Acne in skin of color: special consideration for diagnosis and management
The basis of acne is clogged pores. When these persist they can become inflamed and result in worsening of acne and the potential for scarring.
The clogged pore stage of acne can be understood by recognizing that whiteheads are closed comedones and can be felt as a small bumps under the skin. Open comedones, traditionally referred to as blackheads, are open pores filled with keratin.
The inflamed stage of acne on lighter skin types can appear pink. In darker skin types the pink hue is not readily apparent. If it worsens it can appear dusky or discolored but the hope is to catch it before it gets to this point. The main reason to catch it early is that if the inflammation persists, its hard to avoid discoloration afterwards that can last for months.
Looking for other clues to inflamed acne? Feel your skin! If those small bumps or clogged pores are enlarging or becoming inflamed they will feel larger, somewhat ‘juicy’ or fluctuant as they often are purulent or filled with pus, and can be tender or sensitive to touch. I encourage medical students and residents to touch or feel the acne to get a sense of how deep it is. This is important to understand the skin on a 3 dimensional level and also to truly understand different skin types and how they present with acne.
The most frustrating aspect of acne in darker skin types is that it often is caught or treated later in its course and can result in significant discoloration that can last months. The key to avoiding this is appropriately diagnosing the stage of acne and starting treatment early. It is also important to integrate topicals that include ingredients that address the potential for discoloration early on such as retinoids and azaleic acid.