Guideline Recommendations for Acne and Post‑Inflammatory Hyperpigmentation in Patients with Darker Skin Types

Evidence Gaps in Skin‑of‑Color Research

The 2024 American Academy of Dermatology (AAD) guidelines note that only 4 of 55 acne studies included participants with Fitzpatrick skin types IV‑VI, highlighting a major lack of data for Black, African‑American, and Afro‑Caribbean patients. 1

Topical retinoids are strongly recommended as first‑line treatment for acne in patients of color because they address both active lesions and post‑inflammatory hyperpigmentation (PIH). [1][2]4

Combining topical agents with different mechanisms of action is endorsed by good‑practice statements to enhance efficacy and reduce resistance. [1][2][3][4]
Benzoyl peroxide receives a strong recommendation and should be used together with retinoids to improve lesion clearance. [1][2][3][4]
Topical antibiotics are strongly recommended but must be paired with benzoyl peroxide or a retinoid to limit the development of antibiotic resistance. [1][2][3][4]

Azelaic acid receives a conditional recommendation for patients of color owing to its combined anti‑acne and depigmenting effects. [1][2][3][4]
Salicylic acid and topical clascoterone also receive conditional recommendations for use in this population. [1][2][3][4]

Oral doxycycline is strongly recommended for moderate‑to‑severe acne in patients of color. [1][2][3][4]
Oral isotretinoin is strongly recommended for severe acne, acne causing psychosocial burden or scarring, or acne refractory to standard therapy. [1][2][3][4]
Oral minocycline, sarecycline, combined oral contraceptives, and spironolactone receive conditional recommendations for appropriate patients. [1][2][3][4]
Systemic antibiotics must be combined with topical therapies and limited in duration according to good‑practice statements. [1][2][3][4]

Intralesional corticosteroid injections for larger acne lesions are recommended as part of good‑practice statements. [1][2][3][4]

Evidence regarding low‑glycemic‑index diets or dairy restriction for acne control remains conflicting and insufficient, preventing formal guideline recommendations. [1][2][4][5]