Acne in People With Skin of Color: Key Considerations
'We tend to think about what skin care products are being used when caring for patients with acne, and it's less common to review their hair products,' Lester said at the Society for Pediatric Dermatology (SPD) 2025 Annual Meeting. 'But hair products can play a significant role in contributing to acne among patients with skin of color, particularly those with Afro-textured or tightly coiled hair.'
Sebum doesn't easily travel down the hair shaft because of the shape of the hair, and many people of color rely on oils, waxes, and pomades to maintain and style their hair. 'Telling your patients to stop using oil as part of the conversation is not going to be helpful,' Lester said. 'Skin health and hair health can sometimes be at odds with one another, but there are helpful ways to have this conversation.'
Shared decision-making is important, and dermatologists should be asking patients what products they use and discussing how exposure can be minimized, she said. 'Rather than advising patients to stop using these culturally important products, clinicians should ask about hair care routines and recommend strategies such as using water-based formulations — often labeled as milk or lotion — or using oil prior to shampoo,' she explained.
Postinflammatory Hyperpigmentation (PIH)
An important issue in this population is the development of PIH, which is more common and can be more pronounced in individuals with darker skin tones because of the higher concentration of melanin. It is caused by increased production of pigment, which is subsequently transferred to keratinocytes. PIH can occur after inflammatory acne itself or treatment from cutaneous irritation.
PIH can be permanent and is difficult to treat topically. Epidermal hyperpigmentation often responds well to topical interventions, but dermal pigmentation is more resistant. 'Prevention is key here,' Lester said.
However, Lester pointed out that the latest acne guidelines, issued in 2024 by the American Academy of Dermatology, do not adequately address PIH. She explained that the guidelines teach a linear progression of treatment, beginning with topicals and then moving to topicals plus antibiotics and progressing to isotretinoin. But the guidelines recommend that isotretinoin should be reserved for cases involving scarring or psychological distress, and do not mention patients of color, who may not have scarring but have hyperpigmentation. For these patients, 'I have a lower threshold for moving to isotretinoin from topicals,' she said. 'We should consider early initiation of isotretinoin in these patients and think about PIH as a scarring equivalent.'
Disparities and Bullying
Lester also pointed to disparities in acne care. A 2020 study published in JAMA Dermatology found that although Black patients with acne were more likely to be seen by a dermatologist than White patients and had a similar number of visits for acne, they generally received fewer prescriptions for acne medications.
'This is data from dermatologists prescribing these medications,' she said. 'While I think it's important to highlight this, and I have full confidence that everyone is trying to do their best, the best way to begin addressing the issue is to first recognize it.'
PIH needs to be treated as aggressively as acne, and she emphasized that PIH is often more concerning to patients than acne itself.
'My last pearl is to screen for bullying,' Lester said. 'When reviewing the literature, I was struck by how many studies show that children from racial and ethnic minority groups are at a higher risk of bullying.'
She recommended screening patients for bullying by assessing its severity, frequency, and overall impact on the child's health and well-being.
'I think this is an important moment, especially as we get people who treat visible disease and visible differences to assess for this,' Lester said. 'Assessment of severity, frequency, and impact is incredibly important. Clinicians should also collaborate with the patient and parents to encourage communication with school and administrators and bring the primary care physician into the discussion.'
Lester reported having no relevant financial relationships.
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One concern, for example, is soldiers who struggle with post-traumatic stress disorder, or PTSD, might be reluctant to seek help because they fear their treatment history would deprive them of possessing firearms. 'Between the lack of funding to make sure the background check system is effective for those problems and the legal hang ups with advocacy groups who will challenge this, that's a long road ahead,' Eller said. There's a concerted effort by veterans' groups and advocacy organizations like the American Civil Liberties Union to fight against the sharing of mental health records with the National Crime Information Center and local law enforcement, which most states rely on for background checks, according to Eller. 'Groups have been combating that because simply being mentally ill doesn't mean you're mentally incompetent, nor does it mean you're a danger,' he added. 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The Nevada law enforcing background checks for private sales was implemented in January 2020, closing the so-called 'gun show loophole' that gun safety advocates have long criticized as a means for bypassing records checks that can flag past criminal history. Most states conduct background checks through federally licensed dealers relying on the FBI's National Instant Criminal Background Check System (NICS), while some states like Nevada have a designated 'point of contact' system that offers access to state criminal history records. Under federal law, an unlicensed person buying a firearm directly from a gun dealer must also undergo a background check, however, those who already have a concealed carry permit – like Tamura had – may be exempt because they would have already undergone a background check to get the permit. Hours after the shooting in Manhattan, Las Vegas Police Crimestoppers received a tip from a licensed firearms dealer saying he remembered Tamura sought to buy an aftermarket trigger assembly for an M4 rifle at a Las Vegas gun show in June, a senior law enforcement official told CNN. Tamura returned the trigger assembly the next day, saying he needed the money back to buy 500 rounds of .223 ammunition – the same kind of ammunition used in the New York shooting, according to the official. The gun dealer told police Tamura came back the next day with additional funds and re-purchased the trigger assembly, the official said. Tamura's case calls attention to the 'gray area' in the federal regulation and enforcement of private sales that exists when people buy firearms for cash in a private sale, according to Eller. Because a concealed carry permit would exempt an individual for five years from a background check when buying a firearm from a licensed dealer, it creates a 'nuanced area' where a person could obtain a license to carry and then subsequently be convicted or have a mental health prohibitor and might still be able to use their card to purchase a firearm and avoid the background check, Chittum said. Some states recognize this issue and routinely run background checks on licensed holders to determine if their license is still valid, Chittum said. Red flag laws, including the one in Nevada, aim to keep guns out of the hands of those who pose a threat to themselves or others. But such laws are only effective if the individual demonstrated warning signs so that others can alert law enforcement and initiate the process of revoking the person's firearm, Chittum said. It's not clear if Tamura demonstrated any warning signs that would trigger the state's red flag law. The style of weapon Tamura used to slaughter four people has commonly been seen in some of the nation's deadliest mass shootings and has prompted renewed calls by progressive lawmakers for increased regulation. 'In the State of New York, you cannot buy one of these,' Gov. Kathy Hochul told CNN on Tuesday, criticizing what she said were 'much looser laws in the State of Nevada than we have here.' Hochul called on federal lawmakers to pass a national assault weapon ban that would limit access to high-powered guns like the AR-15 style rifle used in Monday's massacre and slammed GOP counterparts whom she accused of being 'intimidated by the gun lobby.' 'We need a national awakening here, people need to be talked about this once again and it shouldn't just happen in the wake of a tragedy like this,' said Hochul. CNN's Mark Morales contributed to this report.
