Authors Jordan, Kristiana M Famisan, Demi O Myer, Summer N et al.
Publication Date 2024
DOI 10.5070/D330363861
Copyright Information Copyright 2024 by the author(s).This work is made available under the terms of a Creative Commons Attribution-NonCommercial-NoDerivatives License, available at https://creativecommons.org/licenses/by-nc-nd/4.0/
Peer reviewed
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University of California Volume 30 Number 3|May/June 2024| Dermatology Online Journal || Original 30(3):1
Acne vulgaris in black pediatric patients: clinical presentation,
treatment patterns, and unique needs Kristiana M Jordan1,2 BA, Demi O Famisan1,2 BS, Summer N Myer1,2 BS, Jeffrey Fine3 MPH, Yunyi Ren2 MS, Danielle M Tartar1 MD PhD Affiliations: 1Department of Dermatology, University of California Davis, Sacramento, USA, 2School of Medicine, University of California Davis, Sacramento, USA, 3Department of Biostatistics, Epidemiology, and Research Design, University of California Davis, Sacramento, USA Corresponding Author: Danielle Tartar MD PhD, Department of Dermatology, University of California Davis, 3301 C Street, Suite 1400, Sacramento, CA 95819, Tel: 916-734-6111, Email: DTartar@ucdavis.edu
Introduction Abstract Acne vulgaris is among the most common Acne vulgaris is a common dermatological diagnosis dermatologic diagnoses in patients with skin of color observed in pediatric patients with skin of color, [1]. Previous research has suggested that there are often resulting in scarring, keloid formation, and post-inflammatory hyperpigmentation, significantly racial and ethnic differences in the clinical impacting their quality of life. This exploratory presentation and sequela of acne vulgaris but this retrospective chart review included 77 black research is limited [2]. Although peak prevalence is in pediatric patients seen at a tertiary care center for ages 15-20 years, acne is now presenting earlier and acne vulgaris between 2018 and 2023. We analyzed lasting longer [1]. The clinical presentation of acne demographics, acne descriptors, and treatment vulgaris often includes open and closed comedones, modalities. The most common acne morphology was inflammatory papules, pustules, nodules, and cysts. comedonal acne (83.6%), with 71% of the patients The presence of erythema is often harder to being female. Significant age differences were recognize in darker skin types [2]. Various treatment observed particularly for acne at the chin and overall regimens exist, though topical therapies such as face. Treatment regimens commonly prescribed tretinoin, adapalene, benzoyl peroxide, and azelaic included combinations of adapalene and benzoyl peroxide (22%), topical antibiotics, tretinoin, and acid remain first line [3]. Common sequelae from benzoyl peroxide (34%). Given the higher risk of acne vulgaris in the pediatric skin of color population sequelae for patients with darker skin, it is crucial to includes scarring, keloid formation, and post- address their unique treatment needs. This study inflammatory hyperpigmentation. The risk of post- highlights the distinctive characteristics of acne in inflammatory hyperpigmentation increases with black pediatric patients and calls for further research recurrent inflammation [4]. There is growing to enhance our understanding and treatment of this recognition that these sequelae may present population. Limitations include the lack of direct challenges that impact the quality of life for the patient interactions and reliance on chart data. pediatric skin of color population. Therefore, it is Further studies are needed to compare acne important to better understand acne vulgaris in our presentation in skin of color of other populations, skin of color pediatric population to guide clinicians refining our knowledge of acne clinical presentation, complications, and treatment modalities for diverse in recognizing and treating acne and associated patient populations. complications. Our study specifically aims to elucidate patterns in clinical presentation and treatment plans for black pediatric patients—a Keywords: (single-word alphabetized list): acne, pediatrics, historically underrepresented group in dermatologic pigmentation, skin of color research. We aim to add insight to an evolving
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understanding of acne vulgaris in this population to those with comedonal acne and those without guide clinicians in recognizing and treating acne and (P=0.271). A total of 46 patients (59.7%) were associated complications. diagnosed with inflammatory acne and there was no difference between male (68.2%) and female (56.4%) patients (P=0.443). There were no differences in the Methods diagnosis of inflammatory acne based on age in our This study was approved by the University of population (P=0.185). California (UC) Davis Institutional Review Board. This The least common acne morphology diagnosed in is a retrospective chart review study examining sex, this population was cystic acne. A total of 5 patients age at first appointment, acne descriptors, and were diagnosed with cystic type acne and there was treatment modalities in black pediatric patients seen no difference between male (4.5%) and female at the UC Davis dermatology clinic for acne vulgaris (7.3%) patients (P>0.99). Additionally, there were no (International Classification of Diseases, Tenth differences in diagnosis of cystic acne based on age Revision codes: L70.0, L70.8, L70.9) between 2018 in our pediatric population (P=0.511). and 2023. Patients over the age of 18 as well as those diagnosed and treated for acne outside of the UC Acne location and severity Davis dermatology department were excluded from In our study of black pediatric patients seeking this study. An age cutoff of 11 years was made to treatment for acne in our dermatology office, there separate pre-pubertal from post-pubertal patients to was no association between patient age and acne investigate trends in age. We reviewed clinical notes location on the forehead, cheek, nose, ears, neck, for descriptions of acne severity, indicated by notes chest, shoulders, arms, and back. Interestingly, including descriptors such as “mild,” “moderate,” and however, patients with acne location at the chin “severe.” (P=0.015) and the general face (P=0.028) had a significantly higher age compared to patients Results were analyzed using R version 4.2.2. Two- without acne at those locations. The average age for sample t-test or ANOVA were used for normally patients without acne on the chin in our study was distributed continuous variables; Fisher’s exact test 13.8±2.4 years, whereas the average age for patients was used for categorical variables. Hypothesis tests with acne on the chin was 15.2±2.0 years. Average were two-sided and evaluated at a significance level age for patients without acne on the general face of 0.05. was 14.6±2.3 years, whereas the average age for patients with acne on the general face was 13.2±2.2. There was no significant difference between acne Results location and self-identified sex in our study. Demographics A total of 77 patients met inclusion criteria, aged 10- Acne severity descriptors were documented in 18 years old (average 14.3 years). Strikingly, 71.4% clinical notes in 27 patients and we found no (55) of black pediatric patients seeking care at a significant trends between severity and age dermatology office for acne were female, whereas (P=0.396) in our population. Thirteen patients were only 28.6 (22) were male. All patients self-identified diagnosed with mild acne, with an average age of as Black or African American (Table 1). Table 1. Demographics of Black pediatric patients seeking care for acne in a dermatology office. Acne type The most common acne morphology diagnosed in Demographic Value (%) N=77 Sex our black pediatric population was comedonal acne. Female 55 (71.4%) In fact, 83.6% of patients in our study were Male 22 (28.6%) diagnosed with comedonal acne. Male (86.4%) and Age (years) female (83.6%) patients were equally likely to be Median (Q1, Q3) 14.0 (13.0, 16.0) diagnosed with comedonal acne (P>0.99). There was Mean (SD) 14.3 (2.3) no significant difference in average age between Range 10.0-18.0
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13.7 years and a standard deviation of 2.6 years. Table 2. Acne treatments by frequency. Thirteen patients were diagnosed with moderate Treatment Frequency acne, with an average age of 13.8 years and standard Topical benzoyl peroxide 78% deviation of 2.1 years. One patient in our study was Tretinoin 75% diagnosed with severe acne (age 12). Topical antibiotics 62% Adapalene 44% Scarring and post-inflammatory hyperpigmen- Oral antibiotics 30% tation Azelaic acid 23% In total, 29 patients were diagnosed with post- Salicylic acid 14% inflammatory and 13 patients had documented Topical dapsone 9% scarring. We examined the association of acne Isotretinoin 9% Oral contraceptives 8% scarring and post-inflammatory hyperpigmentation Sulfur wash 4% by sex and age. In our population, no significant Spironolactone 3% difference was seen between female (82.8%) and Total percentages presented in the study exceed 100% due to the male (17.2%) patients for post-inflammatory inclusion of patients who underwent multiple acne treatments pigmentary changes (P=0.120). Likewise, no simultaneously. significant difference was seen between female (61.5%) and male (38.4%) patients and scarring in our prescribed treatment regimens and sex. It is study (P=0.502), though sample size likely important to note that this manuscript presents an contributed to this result of statistical insignificance. exploratory analysis, aiming to generate hypotheses rather than confirm them. We conducted multiple Treatment comparisons, necessitating attention to the false In this study, topical benzoyl peroxide was the most positive rate. common treatment modality prescribed, followed by tretinoin, topical antibiotics, adapalene, oral One of the most striking findings of this study is that, antibiotics, azelaic acid, salicylic acid, topical among the black pediatric population, 71.4% of our dapsone, isotretinoin, oral contraceptives, sulfur patients were female compared to only 28.6% male. wash, and spironolactone (Table 2). Six female It is not clear that this represents more severe acne patients were prescribed an oral contraceptive. burden in female patients in this cohort or if female There were no statistical differences in age or sex for patients were more motivated to seek treatment any treatment modality other than topical dapsone, based on societal pressures. Although we did not though this was prescribed to a small sample group discover significant results in scarring and post- (females N=2 [3.6%]), (males N =5 [22.7%]), (P=0.018). inflammatory hyperpigmentation between sexes, sample size may have affected these results. Further Combination treatment study into gender roles in acne treatment and Combination therapies were used frequently in our outcomes in the black pediatric population is cohort. The most commonly prescribed combination warranted. We also found that patients with acne at therapy was adapalene and benzoyl peroxide (34%) the chin and overall face were higher in age in whereas topical antibiotics plus benzoyl peroxide comparison to patients without acne at those was prescribed in 22%. locations. In fact, the median age for patients with acne documented on the chin was 15.2 years compared to 13.8 years for patients who did not have Discussion chin involvement. We hypothesize that this may This single-center retrospective cohort study relate to hormonal influence. During puberty, describes the clinical presentation and treatment sebaceous glands enlarge, and sebum output modalities for acne vulgaris in black pediatric increases significantly. Several studies have patients from 2018 to 2023. We identified trends in demonstrated that certain hormones regulate acne location and age, as well as commonly sebaceous gland secretions—namely androgens,
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estrogens, growth hormone, and insulin [5,6]. in black pediatric patients and highlights the need Sebaceous glands are notably larger and more for further study to better meet the needs of this numerous on the cheeks, forehead, scalp, and chin. population. Thus, it comes to no surprise that patients This study is limited by the lack of direct patient experiencing puberty often present with hormonal interactions by the majority of investigators and acne specifically at those locations. Although we did reliance on chart data. Further studies comparing not discover significant results in other hormonally acne presentation in skin of color to other impacted locations (i.e., cheeks, forehead), it is populations will be necessary to refine knowledge of important to recognize that our smaller dataset may acne clinical presentation, complications, and have had an impact on our findings. treatment modalities in a diverse patient population. Prior studies have shown that a combination of topical antibiotics and/or retinoids with benzoyl peroxide can also be effective at treating acne Conclusion vulgaris and unique challenges with skin of color, Acne vulgaris is one of the most common skin including hyperkeratinization, inflammation, and disorders observed in pediatric patients with skin of dyspigmentation [2]. Similarly, Alexis et al. evaluated color. Black patients are at risk of acne complications the efficacy and safety of adapalene 0.1%/benzoyl including post-inflammatory hyperpigmentation, peroxide 2.5% gel in 238 African American hypertrophic and keloidal scarring, and prolonged individuals and found that this combination was well subclinical inflammation. Given the higher risk of tolerated; no cases of treatment-related post- sequelae for patients with more pigmented skin, it is inflammatory hyperpigmentation were observed [7]. important to recognize that this population has In our cohort, combination therapies were used unique treatment needs. frequently; 22% of black pediatric patients received adapalene and benzoyl peroxide whereas 34% Acknowledgments: The project described was received topical antibiotics, tretinoin, and benzoyl supported by the National Center for Advancing peroxide. These combination regimens are known to Translational Sciences, National Institutes of Health, be well-tolerated in skin of color and successfully through grant number UL1 TR001860. The content is treat post-inflammatory hyperpigmentation [4]. For solely the responsibility of the authors and does not this population, it is important to consider a regimen necessarily represent the official views of the NIH. that is efficacious enough to eradicate the acne while avoiding irritation, as post-inflammatory hyperpigmentation may be a complication from Potential conflicts of interest topical treatments that are not well-tolerated. This The authors declare no conflicts of interest. study highlights some of the unique features of acne
References 1. Layton AM, Ravenscroft J. Adolescent acne vulgaris: current and Acne Patients With Skin of Color. J Drugs Dermatol. 2021;20:716- emerging treatments. Lancet Child Adolesc Health. 2023;7:136-44. 25. [PMID: 34232006]. [PMID: 36525984]. 5. Arora MK, Yadav A, Saini V. Role of hormones in acne vulgaris. Clin 2. Maymone MBC, Watchmaker JD, Dubiel M, Wirya SA, Shen LY, Biochem. 2011;44:1035-40. [PMID: 21763298]. Vashi NA. Common Skin Disorders in Pediatric Skin of Color. J 6. Rao A, Douglas SC, Hall JM. Endocrine Disrupting Chemicals, Pediatr Health Care. 2019;33:727-37. [PMID: 31655787].. Hormone Receptors, and Acne Vulgaris: A Connecting 3. Eichenfield DZ, Sprague J, Eichenfield LF. Management of Acne Hypothesis. Cells. 2021;10. [PMID: 34207527]. Vulgaris: A Review. JAMA. 2021;326:2055-67. [PMID: 34812859]. 7. Alexis AF, Johnson LA, Kerrouche N, Callender VD. A subgroup 4. Alexis AF, Woolery-Lloyd H, Williams K, Andriessen A, Callender analysis to evaluate the efficacy and safety of adapalene-benzoyl VD, Kang S, Rodriquez D, Tan J. Racial/Ethnic Variations in Acne: peroxide topical gel in black subjects with moderate acne. J Drugs Implications for Treatment and Skin Care Recommendations for Dermatol. 2014;13:170-4. [PMID: 24509968].
