[ORigiNAL ReSeARCH]

Racial Differences in Clinical Characteristics,

Perceptions and Behaviors, and Psychosocial
Impact of Adult Female Acne
a
VALERIE D. CALLENDER, MD; bANDREW F. ALEXIS, MD, MPH;
c
SELENA R. DANIELS, PHARMD, MS; dARIANE K. KAWATA, PhD;
e
CAROLINE T. BURK, PHARMD, MS; dTERESA K. WILCOX, PhD; fSUSAN C. TAYLOR, MD
a
Callender Dermatology & Cosmetic Center, Glenn Dale, Maryland; bSkin of Color Center, Department of Dermatology,
St. Luke’s-Roosevelt Hospital Center, New York, New York; cAllergan, Inc., Irvine, California; dEvidera, Bethesda, Maryland;
e
Health Outcomes Consultant, Laguna Beach, California; fSociety Hill Dermatology, Philadelphia, Pennsylvania

ABSTRACT
Objective: Limited data are available on racial differences in clinical characteristics and burden in adult female acne. The
objective was to describe racial differences in clinical characteristics, psychosocial impact, perceptions, behaviors, and
treatment satisfaction in facial adult female acne. Design: Cross-sectional, web-based survey. Setting: Diverse sample of
United States women. Participants: Women between the ages of 25 and 45 years with facial acne (≥25 visible lesions).
Measurements: Outcomes included sociodemographic characteristics, psychosocial impacts, perceptions, behaviors, and
treatment satisfaction. Racial differences were evaluated using descriptive statistics and t-test/chi-square analyses. Results:
208 females participated (mean age 35±6 years); 51.4 percent were White/Caucasian and 48.6 percent were non-
White/Caucasian women [Black/African American (n=51); Hispanic/Latina (n=23); Asian (n=16); Other (n=11)]. Age of acne
onset (mean 14.8±5 vs. 17.0±8 years, p<0.05) and acne concern occurred earlier (16.6±7 vs. 19.3±9 years, p<0.05) in
White/Caucasian than non-White/Caucasian subjects. Facial acne primarily presented on chin (28.0%) and cheeks (30.8%) for
White/Caucasian women versus cheeks (58.4%) for non-White/Caucasian women. Non-White/Caucasian women experienced
more postinflammatory hyperpigmentation than White/Caucasian women (p<0.0001). Facial acne negatively affected quality
of life (QoL) in both groups, and most participants (>70%) reported some depression/anxiety symptoms. More
White/Caucasian than non-White/Caucasian women were troubled by facial acne (88.8% vs. 76.2%, p<0.05). Lesion clearance
was most important to White/Caucasian women (57.9 vs. non-White/Caucasian 31.7%, p<0.001); non-White/Caucasian females
focused on postinflammatory hyperpigmentation clearance (41.6% vs. Caucasian 8.4%, p<0.0001). Conclusion: Results
highlight racial differences in participant-reported clinical characteristics, attitudes, behaviors, and treatment satisfaction.
These findings may inform clinicians about racial differences in facial adult female acne and guide treatment recommendations
toward improving care. (J Clin Aesthet Dermatol. 2014;7(7):19–31.)

A
cne vulgaris (hereafter referred to as acne) is one of years of age in the United States.1 Acne has typically been
the most frequently encountered externally visible regarded as an adolescent condition, but recent research
skin diseases in dermatology for individuals 15 to 40 and clinical practice experience have shown that it is also

DISCLOSURE: Dr. Daniels is an employee of Allergan Inc. Dr. Burk serves as a consultant for Allergan Inc. Drs. Kawata and Wilcox are employees of
Evidera. Dr. Callender has received honoraria from Allergan, Inc., Galderma, and Valeant and has consultancy agreements with Allergan, Inc.,
Galderma, and Valeant. Dr. Alexis has received honoraria from GSK and has consultancy agreements with Galderma and Allergan, Inc. Dr. Taylor has
consultancy agreements with Allergan, Inc., Beiersdorf, Inc., and Unilever; has served as a speaker for Allergan, Inc., Kao USA, Inc., and Neostrata;
has received research grants from Medicis Pharmaceutical Corp., Noven Pharmaceuticals, Inc., and Pfizer Inc.; and has ownership interest in T2
Skincare, LLC. This study was sponsored by Allergan Inc., Irvine, California. The sponsor and co-authors were involved in study design, statistical
analysis, and interpretation of results. The authors had full access to data and were involved in critical review and editing of the manuscript. All
authors provided approval prior to submission.
ADDRESS CORRESPONDENCE TO: Valerie Callender, MD, Callender Dermatology & Cosmetic Center, 12200 Annapolis Road, Suite 315,
Glenn Dale, MD 20769; E-mail: drcallender@callenderskin.com

[July 2014 • Volume 7 • Number 7] 19

 common in the adult population.1–4 Among adult cases of
acne, women are affected more frequently than men;
approximately 12 to 22 percent of US women have adult
acne,2–4 compared to three percent of men.2 Despite the
higher prevalence of adult female acne (AFA), there has
been limited research investigating the epidemiology,
clinical presentation, and symptom burden in women,
and more specifically potential racial differences that may
exist.
Facial acne is a multifactorial disease with respect to
its pathophysiology as well as its impact on daily
functioning.5–6 A variety of factors have been connected
with AFA, including hormones, genetics, cosmetics, diet,
tobacco use, and stress.7–8 This condition has also been
associated with substantial burden and impairments in
health-related quality of life (QoL).9 Previous studies
have demonstrated that facial acne can impair self-image,
psychological well-being, and the ability to develop social
relationships.5,10–13
Acne is the most common dermatological diagnosis in
non-Caucasian patients.14–19 in a community-based
photographic study, clinical acne was found to be highly
revalent in Black/African American (37%),
Hispanic/Latina (32%), and Asian (30%) women, more so
than in Continental indian (23%) and White/Caucasian
(24%) women.20
Acne characteristics may also vary across racial and
ethnic backgrounds in women. A common facial location
in Black/African American women is the hairline, which
may be impacted by hair grooming products used to
prevent dryness of the hair.19 Furthermore, over two-
thirds of Black/African American women with acne
experience postinflammatory hyperpigmentation (PiH),
a darkening of the skin pigment due to increased amounts
of melanin that usually occurs during the healing process
after acne treatment.5,20 PiH can worsen with persistent
and recurring inflammation.21–22 Keloidal scars are also a
more common potential sequela in non-White/Caucasian
populations, presenting frequently along the jawline and
trunk and often associated with greater acne
severity.19,22,23
Traditionally, acne has been treated homogenously
across all skin types, but special risks in darker skin types,
particularly for development of PiH and keloids, must be
considered.5,24 Strategies to minimize the risk of
pigmentary abnormalities and keloid scarring in skin of
color include the following: avoiding irritation associated
with topical acne therapies, and aggressively reducing
acne-associated inflammation by employing topical
and/or oral agents with anti-inflammatory effects.24
Concurrent management of PiH is also a nuance to
treating acne in non-White/Caucasian skin types.25
There has been limited research comparing the
characteristics of acne among different racial and ethnic
groups, particularly in AFA. However, there is growing
recognition of the nuances and unique challenges of
treating AFA, particularly in darker skin types.20 A
broader understanding of racial/ethnic variations in
20 [July 2014 • Volume 7 • Number 7]
clinical presentation, patient perceptions, and
psychosocial impact of acne in women will help to
improve treatment outcomes in this increasingly diverse
patient population.
The objective of this study was to describe if there are
racial differences in facial AFA. Variation by race was
evaluated for clinical characteristics, psychosocial
impacts, perceptions, behaviors, and treatment
satisfaction in facial AFA.
METHODS
Study design. This was a cross-sectional, electronic
web-based survey conducted with US participants from
October to November 2011. The survey screened for
participant-reported signs consistent with acne and
captured data on sociodemographic and clinical
characteristics, psychosocial impacts, perceptions,
behaviors, and treatment satisfaction. Clinical experts
contributed to development of the acne screening
criteria, survey content, and selection of patient-reported
outcome (PRO) measures. The study design and
materials were approved by a central ethics review board.
Additional details on study design and methodology are
described elsewhere.9
Study population: recruitment and screening. All
participants were recruited through the Yougov Polling
Point Panel in the United States (Palo Alto, California)
from a pool of registered panelists ≥18 years of age.
eligible panelists were women between the ages of 25
and 45 years; had an active e-mail address at the time of
study invitation; were able to read and understand
english; had presence of self-reported acne, defined as
≥25 visible facial lesions using survey-provided
photographs at screening; and fulfilled one of the age
and/or race/ethnicity strata targeted for the sample.
Recruitment aimed to enroll a stratified sample based on
age and race, with a minimum of 200 female participants
with AFA. The stratification goals for age were 50 percent
women ages 25 to 35 years and 50 percent women ages
36 to 45 years; the goals for race/ethnicity were 50
percent White/Caucasian women, 25 percent
Black/African American women, and 25 percent Asian,
Hispanic/Latina, or Other women. Further details about
participant recruitment and screening methods have
been described in a separate paper.9
Study variables. Sociodemographic and clinical data
were collected to understand the characteristics of
women with acne of different racial and ethnic
backgrounds. Acne-related QoL was assessed using the
Acne-specific Quality of Life questionnaire (Acne-QoL),26
a 19-item PRO measure evaluating the impact of facial
acne in the past week across the following four domains:
self-perception, role-social, role-emotional, and acne
symptoms, where higher scores (ranging from 0–30)
indicate better QoL. Psychological status was assessed by
the four-item Patient Health Questionnaire (PHQ-4),27 a
self-administered questionnaire assessing core
depression and anxiety symptoms in the past two weeks;
20
Figure 1. Survey participant disposition. †Arab/Middle Eastern was included as part of the White/Caucasian category; at the time of the
survey, YouGov panelists of Arab/Middle Eastern descent comprised <2% of the panel from which the sample was drawn.

total scores can be interpreted as normal (0–2), mild (3–5),
moderate (6–8), and severe (9–12) depression/anxiety.
Perceptions about acne and behavior patterns of AFA were
assessed by asking participants about the degree of
troublesomeness for specific acne signs and acne overall,
most important aspects of acne clearing, their feelings
about acne, methods used to cope with acne, and myths or
beliefs about acne. Participants who self-identified their
racial background as a group other than White/Caucasian
(i.e., Black/African American, Hispanic/Latina, Asian, and
Other) were considered non-White women. Distinct acne
needs for race, ethnicity, or skin type were assessed among
non-White women, including preferences for acne
treatments, healthcare professional with expertise/
specialty in non-White skin, and treatment effectiveness.
Treatment expectations and satisfaction were assessed by
overall level of acne clearing achieved in the past four
weeks and acne treatment efficacy.
Statistical analyses. Descriptive statistics were used
to evaluate survey data by racial groups (White/Caucasian
vs. non-White/Caucasian women). For continuous
variables, sample size, mean, standard deviation (SD),
median, and minimum and maximum were examined. For
categorical variables, frequencies were reported. Acne-
QoL and PHQ-4 were scored based on guidelines set forth
by the instrument developers. Student’s t-test and chi-
square analyses were used to compare outcomes between
racial groups. Results for the pooled survey sample have
been described in a separate paper.9
RESULTS
Sample characteristics. A flow diagram of study
participants and eligibility by race is presented in Figure 1.
A total of 7,245 female panelists were invited to participate
in the survey, of which 3,702 responded to the e-mail
invitation, provided consent, and completed eligibility
screening. Among those screened, 208 were eligible and
completed the survey. The final sample comprised 51.9
percent 25- to 35-year olds (n=108) and 51.4 percent
White/Caucasian women (n=107). On average, surveys

[July 2014 • Volume 7 • Number 7] 21

TABLE 1. Sociodemographic characteristics

TOTAL SAMPLE WHITE/CAUCASIAN1 NON-WHITE/

p-VALUE3
(N=208) (n=107) CAUCASIAN2 (n=101)

AGE (IN YEARS)

Mean (SD) 35.4 (5.8) 35.6 (5.9) 35.2 (5.7) 0.5934

Median (minimum-maximum) 35.0 (25–45) 35.0 (25–45) 35.0 (25–45)

Employment status (n, %) 0.4977

Employed, full-time (paid) 84 (40.4%) 41 (38.3%) 43 (42.6%)

Employed, part-time (paid) 23 (11.1%) 12 (11.2%) 11 (10.9%)

Unemployed 94 (45.2%) 50 (46.7%) 44 (43.5%)

Other 5 (2.4%) 4 (3.7%) 1 (1.0%)

Prefer not to answer 2 (1.0%) 0 (0%) 2 (2.0%)

Education (n, %) 0.8401

Less than a high school diploma 8 (3.8%) 4 (3.7%) 4 (4.0%)

High school graduate 31 (14.9%) 19 (17.8%) 12 (11.9%)

More than a high school diploma 168 (80.8%) 84 (78.6%) 84 (83.1%)

Prefer not to answer 1 (0.5%) 0 (0%) 1 (1.0%)

Total annual household income (n, %) 0.3712

$0 to $20,000 43 (20.7%) 22 (20.6%) 21 (20.8%)

$20,001 to $50,000 75 (36.1%) 33 (30.8%) 42 (41.6%)

$50,001 to $100,000 64 (30.8%) 38 (35.5%) 26 (25.7%)

$100,001 and over 21 (10.1%) 11 (10.3%) 10 (9.9%)

Prefer not to answer 5 (2.4%) 3 (2.8%) 2 (2.0%)

BMI categories (n, %) 0.7012

Underweight (below 18.5) 7 (3.4%) 4 (3.7%) 3 (3.0%)

Normal (18.5–24.9) 75 (36.1%) 43 (40.2%) 32 (31.7%)

Overweight (25.0–29.9) 42 (20.2%) 19 (17.8%) 23 (22.8%)

Obese (30.0 and above) 66 (31.7%) 33 (30.8%) 33 (32.7%)

Missing 18 (8.7%) 8 (7.5%) 10 (9.9%)

1
Arab/Middle Eastern was included as part of the White/Caucasian category; YouGov race categories align to the US census rather than skin types, and at the
time of the survey, panelists of Arab/Middle Eastern descent comprised <2% of the panel from which the sample was drawn.
2
Non-White/Caucasian group included Black/African American, Hispanic/Latina, Asian, and Other ethnicities.
3
T-test of mean score (for continuous variables) or chi-square/Fisher’s exact test (for categorical responses) by race/ethnicity, with p-value based on comparison
between White/Caucasian and Non-White/Caucasian groups.

22 [July 2014 • Volume 7 • Number 7]

were completed within 25 minutes.
Sociodemographic and clinical characteristics.
Sociodemographic (Table 1) and clinical characteristics
(Table 2) of the study sample were assessed. The sample
was equally distributed between White/Caucasian (51.4%)
and non-White/Caucasian women (48.6%). Non-
White/Caucasian women comprised Black/African
American (24.5%), Hispanic/Latina (11.1%), Asian (7.7%),
and other ethnicities (5.3%). The average age of the
sample was 35.4 years (SD=5.8), with no substantial
difference in age between White/Caucasian and non-
White/Caucasian women (p>0.05; Table 1). Both racial
groups generally had similar sociodemographic
characteristics (all p>0.05; Table 1). More than 80 percent
of women were covered by some type of health insurance
and the majority (77.9%) had prescription drug coverage.
Clinical characteristics are described in Table 2. The
majority of White/Caucasian (82.2%) and non-
White/Caucasian women (78.2%) had 25 to 49 visible facial
lesions (referred to as “pimples”) at the time of survey
completion (p>0.05). Overall, approximately two-thirds of
White/Caucasian (63.6%) and non-White/Caucasian
women (64.4%) reported having 25 to 49 visible facial
lesions over the four weeks prior to the survey (p>0.05).
Mean age of acne onset was significantly earlier for
White/Caucasian (14.8 years, SD=5.3) than non-
White/Caucasian women (17.0 years, SD=7.6; p<0.05), as
was the age at which acne generally began to bother or
concern them (White/Caucasian: 16.6±6.5 years vs. non-
White/Caucasian: 19.3±8.6 years, p<0.05). Adult onset
acne (≥18 years) began around age 25 for both
White/Caucasian (25.7 years, SD=6.1) and non-
White/Caucasian women (25.4 years, SD=6.4; p>0.05). in
terms of acne treatment, approximately half
(White/Caucasian: 54.2% vs. non-White/Caucasian: 44.6%,
p>0.05) had ever (in their lifetime) visited a healthcare
professional (HCP) for acne and one-third
(White/Caucasian: 36.4% vs. non-White/Caucasian: 30.7%,
p>0.05) had previously been diagnosed with adult acne.
Overall patterns of facial acne locations were
significantly different for White/Caucasian and non-
White/Caucasian women (Figure 2; p<0.01). Facial acne
for White/Caucasian women primarily presented on cheeks
(30.8%) and chin (28.0%) versus the cheeks for non-
White/Caucasian women (58.4%). Beyond the face, acne in
the chest area was more common for White/Caucasian
(46.7%) than non-White/Caucasian women (30.7%,
p<0.05). Most women had experienced at least some
erythema (referred to as “redness”) (White/Caucasian:
95.3% vs. non-White/Caucasian: 87.1%) or scarring (86.0%
vs. 91.1%) from facial acne in the past four weeks (p>0.05
for both). Moderate to extensive erythema was slightly
more common for White/Caucasian women (74.8% vs. non-
White/Caucasian: 62.4%) and non-White/Caucasian women
tended to report more scarring (72.3% vs. White: 54.2%).
Non-White/Caucasian women reported substantially more
PiH (referred to as “dark marks”) than White/Caucasian
women (p<0.0001). Nearly half (49.5%) of non-
[July 2014 • Volume 7 • Number 7]
White/Caucasian women reported experiencing “a lot” or
“extensive” PiH, compared to one-fifth (22.5%) of
White/Caucasian women.
Acne-QoL. All women reported low mean scores on
each of the four Acne-QoL domains (mean scores ≤15.0 out
of 30 for self-perception, role-emotional, and acne
symptoms; ≤12.7 out of 24 for role-social), indicating that
facial acne had negatively impacted their overall QoL in the
past four weeks. Although White/Caucasian women had
slightly higher scores (indicating better QoL), these
differences between White/Caucasian and non-
White/Caucasian women were not statistically significant.
Acne Symptoms domain scores (White/Caucasian: 14.3 vs.
non-White/Caucasian: 13.2, p>0.05) suggested active,
progressive acne with limited improvement in acne signs.
Scores from the Self-Perception domain (White/Caucasian:
10.8 vs. non-White/Caucasian: 10.7, p>0.05), indicated that
acne had a negative impact on perception of appearance.
Role-emotional domain scores (White/Caucasian: 12.1 vs.
non-White/Caucasian: 10.9, p>0.05) reflected negative
emotions about having to deal with acne. Lastly, Role-
Social domain scores (White/Caucasian: 12.7 vs. non-
White/Caucasian: 10.8, p>0.05) suggested that acne
negatively affected social functioning.
PHQ-4. The PHQ-4 indicated that participants had
experienced symptoms of depression and/or anxiety within
the past two weeks. The majority of White/Caucasian
(71.0%) and non-White/Caucasian women (73.3%)
reported symptoms reflecting mild, moderate, or severe
levels of depression and anxiety (scores ≥3; mean score
5.3±3.9 out of 12). Overall, no substantial difference
between groups was observed. White/Caucasian women
reported slightly more symptoms of anxiety (48.6% vs.
39.6% score ≥3 on anxiety items, p>0.05) and depression
(37.4% vs. 36.6% score ≥3 on depression items, p>0.05)
than non-White/Caucasian women.
Perceptions and behaviors in AFA. Perceptions
about acne and methods for coping with acne are described
in Table 3. Sweating/perspiration was cited as an acne
breakout trigger by more White/Caucasian (51.4%) than
non-White/Caucasian women (29.7%, p<0.01). The
majority of women attributed breakouts to
hormones/menstrual cycle (White/Caucasian: 63.6% vs.
non-White/Caucasian: 57.4%, p>0.05). Facial acne signs
were troublesome for the majority of females; however, the
overall experience with facial acne signs was described as
troublesome by significantly more White/Caucasian than
non-White/Caucasian women (88.8% vs. 76.2% yes,
p<0.05). The most troublesome signs of facial acne were
also different for White/Caucasian and non-
White/Caucasian women (Figure 3). White/Caucasian
women ranked pustules (referred to as “bumps full of
pus”) (41.1%) and papules (referred to as “bumps”)
(20.6%) as their most troublesome acne signs, while PiH
was rated as the most troublesome acne sign in non-
White/Caucasian women (26.7%), followed by papules
(15.8%) and pustules (15.8%). erythema (referred to as
“redness”) from facial acne was also a more troublesome
23
TABLE 2. Clinical characteristics

TOTAL SAMPLE WHITE/CAUCASIAN1 NON-WHITE/

p-VALUE3
(N=208) (n=107) CAUCASIAN2 (n=101)

Age when acne started (in years)

Mean (SD) 15.9 (6.6) 14.8 (5.3) 17.0 (7.6) 0.0163

Median (minimum-maximum) 14.0 (1–40) 14.0 (2–35) 15.0 (1–40)

Age when acne started (in years), for adult onset acne (age ≥18 years)1

n 51 15 36

Mean (SD) 25.5 (6.2) 25.7 (6.1) 25.4 (6.4) 0.9087

Median (minimum-maximum) 24.0 (18–40) 23.0 (18–35) 24.0 (18–40)

Age when acne began to bother or concern you

Mean (SD) 17.9 (7.7) 16.6 (6.5) 19.3 (8.6) 0.0118

Median (minimum-maximum) 15.0 (7–41) 15.0 (9–37) 17.0 (7–41)

Acne as an adult compared to acne as a teenager (n, %) 0.0036

Not as bad/less severe 42 (20.2%) 24 (22.4%) 18 (17.8%)

The same 70 (33.7%) 43 (40.2%)) 27 (26.7%)

Worse/more severe 45 (21.6%) 25 (23.4%) 20 (19.8%)

Not asked 51 (24.5%) 15 (14.0%) 36 (35.6%)

Facial acne on average over the last 4 weeks (n, %) 0.2559

0–24 visible pimples 49 (23.6%) 24 (22.4%) 25 (24.8%)

25–49 visible pimples 133 (63.9%) 68 (63.6%) 65 (64.4%)

50–75 visible pimples 21 (10.1%) 14 (13.1%) 7 (6.9%)

More than 75 visible pimples 5 (2.4%) 1 (0.9%) 4 (4.0%)

Redness from facial acne in the past 4 weeks (n, %) 0.0578

None 18 (8.7%) 5 (4.7%) 13 (12.9%)

Some 47 (22.6%) 22 (20.6%) 25 (24.8%)

A moderate amount 79 (38.0%) 48 (44.9%) 31 (30.7%)

A lot 54 (26.0%) 25 (23.4%) 29 (28.7%)

Extensive 10 (4.8%) 7 (6.5%) 3 (3.0%)

Scarring from facial acne in the past 4 weeks (n, %) 0.0512

None 24 (11.5%) 15 (14.0%) 9 (8.9%)

Some 53 (25.5%) 34 (31.8%) 19 (18.8%)

A moderate amount 63 (30.3%) 28 (26.2%) 35 (34.7%)

24 [July 2014 • Volume 7 • Number 7]

TABLE 2 continued. Clinical characteristics

TOTAL SAMPLE WHITE/CAUCASIAN1 NON-WHITE/

p-VALUE3
(N=208) (n=107) CAUCASIAN2 (n=101)

A lot 56 (26.9%) 27 (25.2%) 29 (28.7%)

Extensive 12 (5.8%) 3 (2.8%) 9 (8.9%)

Dark marks from facial acne in the past 4 weeks (n,%) <.0001

None 22 (10.6%) 14 (13.1%) 8 (7.9%)

Some 57 (27.4%) 41 (38.3%) 16 (15.8%)

A moderate amount 55 (26.4%) 28 (26.2%) 27 (26.7%)

A lot 56 (26.9%) 22 (20.6%) 34 (33.7%)

Extensive 18 (8.7%) 2 (1.9%) 16 (15.8%)

1
Based on participants who reported acne age of onset as age ≥ 18 years, n=51.
2
Non-White group included Black/African American, Hispanic/Latina, Asian, and Other ethnicities.
3
T-test of mean score (for continuous variables) or chi-square/Fisher's exact test (for categorical responses) by race/ethnicity, with p-value based on
comparison between White and Non-White groups.

Figure 2. Acne location: Prominent areas of facial acne by race

[July 2014 • Volume 7 • Number 7] 25

Figure 3. Most troublesome acne signs by race. Note: N=172; percentage of females by race who assigned a ranking of 1 (most
troublesome) for each acne sign.
acne sign for White/Caucasian women, with 43 percent
describing erythema as “severely” or “very severely”
troublesome compared to one-quarter (26.7%) of non-
White/Caucasian women. PiH was severely troublesome for
nearly half (48.5%) of non-White/Caucasian women.
in addition to being troublesome, acne was associated
with negative self-perceptions. The majority (>75%) of
women “agreed” or “strongly agreed” that acne made them
feel less confident, more self-conscious around other
people, frustrated, and embarrassed (Table 3). More
White/Caucasian women felt self-conscious around other
people (85.0%) than non-White/Caucasian women (68.3%,
p<0.05). Whereas, more non-White/Caucasian than
White/Caucasian women felt that non-acne sufferers could
not relate to experiencing adult acne (66.3% vs. 57.9%,
p<0.05).
White/Caucasian and non-White/Caucasian women
generally used the same methods to cope with acne: using
makeup (58.2%), “popping” or squeezing pimples (52.9%),
and following a strict skin-cleaning routine (41.3%)
(Figure 4). Using makeup to cope with acne was
significantly more common for White/Caucasian women
(67.3%) than non-White/Caucasian women (48.5%,
p<0.05). About half of White/Caucasian (58.9%) and non-
White/Caucasian women (46.5%) reported “popping” or
squeezing pimples to cope with acne. White/Caucasian
women felt less confident in their looks (p<0.05) and less
attractive (p<0.001) without wearing makeup to cover
acne than non-White/Caucasian women (Figure 5). More
White/Caucasian women reported feeling “not at all”
26 [July 2014 • Volume 7 • Number 7]
confident in their looks (42.1%) and “not at all” attractive
(50.5%) without wearing makeup to conceal their acne,
compared to approximately one-quarter of non-
White/Caucasian women (24.8% for confidence, 26.7% for
attractiveness).
Common beliefs or myths about acne were also
assessed. Nearly all women believed that stress causes
acne (White/Caucasian: 96.3% vs. non-White/Caucasian:
93.1%, p>0.05). Non-White/Caucasian women tended to
have more misconceptions about acne. More non-
White/Caucasian than White/Caucasian women believed
that frequent face washing can help clear acne (38.6% vs.
17.8%, p<0.01); eating chocolate gives you acne (43.6% vs.
29.0%, p<0.05); makeup should not be worn if you have
acne (50.5% vs. 30.8%, p<0.01); and that an over-the-
counter (OTC) product (e.g., a good face cream or
cleanser from a cosmetics counter) can effectively clear
acne (59.4% vs. 44.9%, p<0.05). Also, more non-
White/Caucasian women (64.4%) “strongly agreed” that a
good acne medication should reduce PiH compared to
White/Caucasian women (42.1%, p<0.05).
Acne in non-White/Caucasian women. Non-
White/Caucasian women were asked about acne treatment
preferences related to their race, ethnicity, or skin type
and expressed a desire for treatments tailored for their
skin’s distinct needs. Nearly 70 percent felt that their
race/ethnicity/skin type required targeted attention and
two-thirds (66.3%) desired an acne treatment that was
designed to meet the needs of their skin. More than 75
percent would prefer to visit a healthcare professional who
had experience treating acne in non-White/Caucasian
women. in addition, the majority of non-White/Caucasian
women (85.1%) would be interested in an acne treatment
that had been proven effective in treating acne for their
race, ethnicity, or skin type. The types of information
considered most convincing in showing efficacy of an acne
treatment were scientific data or statistics (33.7%),
followed by a recommendation by a dermatologist (17.8%)
or friend/family member (15.8%), photographs (13.9%),
primary care physician recommendation (10.9%), and
other types of information (8.0%).
Treatment satisfaction. Recent acne clearing and
treatment expectations were assessed. Some differences
were identified when women were asked to rank the
importance of seven different acne signs with respect to
acne clearing. More than half (57.9%) of White/Caucasian
women indicated that lesion clearance was the most
important aspect of acne clearing (p<0.001), compared to
one-third (31.7%) of non-White/Caucasian women.
Clearing PiH was most important for many non-
White/Caucasian women (41.6%; p<0.0001); PiH was a
lesser concern for White/Caucasian women (8.4%).
Despite the importance of acne clearing, both
White/Caucasian and non-White/Caucasian women equally
(65.9%) reported having experienced minimal or no acne
clearing in the past four weeks.
Women expected an effective acne treatment to have a
quick onset and immediate results. The majority of
White/Caucasian (68.2% and 70.1%) and non-
White/Caucasian women (78.2% and 74.3%) expected to
see results from an effective prescription or OTC acne
medication within two weeks, respectively (p>0.05 for
both). Furthermore, significantly more non-
White/Caucasian than White/Caucasian women thought
that they should see results even sooner; overnight
improvement was expected for both prescription (18.8%
vs. 6.5%, p<0.05) and OTC (14.9% vs. 3.7%, p<0.05) acne
treatments. A variety of features were considered
important in an effective acne treatment and these differed
by race (Figure 6). Significantly more non-
White/Caucasian than White/Caucasian women rated the
following treatment features to be “very important”: few
side effects, no bleaching/staining or skin dryness, and PiH
efficacy (p<0.05 or lower).
DISCUSSION
This was the first cross-sectional, web-based study
collecting detailed participant-level information on the
characteristics, perceptions, and needs for acne care and
treatment for skin of color in AFA. This study provides a
foundation for describing racial differences in clinical
characteristics and examining burden of AFA as well as
perceived treatment and distinct needs for acne in non-
White/Caucasian women.
Findings from this survey emphasize the varying impact
of AFA in White/Caucasian versus non-White/Caucasian
women. Although acne has traditionally been treated
homogeneously across all skin types, there is evidence that
[July 2014 • Volume 7 • Number 7]
acne in non-White/Caucasian patients is clinically different
and a targeted approach directed to characteristics of
darker skin types could benefit patient care.5,24 Previous
research has demonstrated early onset of puberty in
Black/African Americans compared to other ethnicities,
corresponding to an earlier initial onset of acne.28 These
findings are contradictory to the results of this study, in
which onset of acne in this sample reflected a significantly
earlier acne onset in White/Caucasian women versus non-
White/Caucasian women. With respect to self-reported
clinical characteristics of acne, the location of facial acne in
White/Caucasian women presented primarily on chin and
cheek areas, while in non-White/Caucasian females, it
presented on the cheeks, with more frequent PiH. This
finding of greater PiH incidence in non-White/Caucasian
women was consistent with previous research, which has
shown that 65 to 75 percent of Black/African American
women suffer from PiH; PiH can endure for several weeks
to months.5,20–22
in this study sample, acne was shown to be burdensome
and associated with low QoL and negative self-
perceptions. Both White/Caucasian and non-
White/Caucasian women with AFA exhibited low QoL
specific to acne and symptoms of depression/anxiety. Poor
QoL in acne patients has been documented in the
literature. Levels of social and emotional problems in acne
patients were similar to that of psoriasis patients,29 and
also comparable with that of patients with severe chronic
disabling diseases, such as arthritis and diabetes.13 Facial
acne overall, as well as individual acne signs, were
considered troublesome by most women. For
White/Caucasian women, papules, pustules, and erythema
were the most troublesome acne signs, while PiH was
especially problematic for non-White/Caucasian women.
The majority of women reported feelings of low self-
confidence, high self-consciousness, frustration, and
embarrassment as result of facial acne. White/Caucasian
women generally felt both less self-confident and
attractive without makeup and more self-conscious due to
facial acne than non-White/Caucasian women. This finding
in adult women may be related to racial differences in
body image that have been observed in adolescent girls;
Black/African American adolescent girls have reported
greater body esteem and perceived sexual attractiveness
than White/Caucasian female adolescents and more
generally, adolescent girls with acne have lower body
esteem scores than adolescents without acne.30 in addition,
more non-White/Caucasian women tended to endorse
common lay perceptions about acne causation and
treatment (e.g., frequent face washing/OTC treatment will
clear acne; chocolate contributes to acne) that are
generally unsupported by acne research, despite
similarities in socioeconomic and educational status
between the two groups. These beliefs are common among
acne patients across different ages and gender.31,32
important aspects of acne treatments and treatment
expectations of AFA also varied with race. Clearing lesions
was important in acne clearing for White/Caucasian
27
 TABLE 3. Acne perceptions

TOTAL SAMPLE WHITE/CAUCASIAN1 NON-WHITE/

P-VALUE3
(N=208) (n=107) CAUCASIAN2 (n=101)

Considering your overall experience with

facial acne, are your acne symptoms 172 (82.7%) 95 (88.8%) 77 (76.2%) 0.0168
troublesome to you? (n, % yes)

How troublesome are your symptoms

0.1301
overall? (n, %)

Very severely 21 (10.1%) 13 (12.1%) 8 (7.9%)

Severely 60 (28.8%) 32 (29.9%) 28 (27.7%)

Moderately 72 (34.6%) 38 (35.5%) 34 (33.7%)

Mildly 18 (8.7%) 12 (11.2%) 6 (5.9%)

Not at all troublesome 1 (0.5%) 0 (0%) 1 (1.0%)

Not applicable1 36 (17.3%) 12 (11.2%) 24 (23.8%)

Feelings about acne 0.0748

My acne makes me feel less confident (n, %)

Strongly disagree/disagree 19 (9.1%) 4 (3.7%) 15 (14.8%)

Neutral 29 (13.9%) 14 (13.1%) 15 (14.9%)

Agree/strongly agree 160 (76.9%) 89 (83.2%) 71 (70.3%)

My acne makes me feel self-conscious around other people (n, %) 0.0111

Strongly disagree/disagree 20 (9.6%) 3 (2.8%) 17 (16.8%)

Neutral 28 (13.5%) 13 (12.1%) 15 (14.9%)

Agree/strongly agree 160 (76.9%) 91 (85.0%) 69 (68.3%)

I feel like no one understands what it’s like to have adult acne (n, %) 0.0119

Strongly disagree/disagree 42 (20.2%) 24 (22.4%) 18 (17.8%)

Neutral 37 (17.8%) 21 (19.6%) 16 (15.8%)

Agree/strongly agree 129 (62.0%) 62 (57.9%) 67 (66.3%)

I get very frustrated when I see or think about my acne (n, %) 0.2795

Strongly disagree/disagree 17 (8.2%) 5 (4.6%) 12 (11.9%)

Neutral 33 (15.9%) 17 (15.9%) 16 (15.8%)

Agree/strongly agree 158 (76.0%) 85 (79.5%) 73 (72.3%)
I get very embarrassed when I see or think about my acne (n, %) 0.0937
Strongly disagree/disagree 20 (9.6%) 5 (4.6%) 15 (14.8%)
Neutral 27 (13.0%) 12 (11.2%) 15 (14.9%)
Agree/strongly agree 161 (77.4%) 90 (84.2%) 71 (70.3%)
1
Participants who previously reported that acne symptoms were not troublesome were classified as Not Applicable.
2
Non-White/Caucasian group included Black/African American, Hispanic/Latina, Asian, and Other ethnicities.
3
T-test of mean score (for continuous variables) or chi-square/Fisher’s exact test (for categorical responses) by race/ethnicity, with p-value based on
comparison between White/Caucasian and Non-White/Caucasian groups.

28 [July 2014 • Volume 7 • Number 7]

Figure 4. Acne coping behaviors by race. *p<0.05 for comparisons of White/Caucasian vs. non-White/Caucasian female subjects

Figure 5. Confidence and attractiveness without makeup to cover acne by race

women, while eliminating PiH was of primary importance
for non-White/Caucasian women. All women expected to
see results quickly (within 2 weeks) from an effective acne
treatment, with rapid resolution of acne signs for
prescription and OTC acne treatments alike. These
unrealistic expectations for quick resolution of acne signs
may indicate that further patient education and
consultation on speed of treatment efficacy may be
warranted.24 The negative psychosocial impact and
negative perceptions associated with facial AFA observed
in this sample may contribute to their desire for acne
treatments to produce results very quickly. Behaviors
engaged in by participants to help cope with the presence
of acne included makeup use (particularly among
White/Caucasian women) as well as “popping” or squeezing
lesions and instituting a strict skin cleansing regimen. The
lower frequency of make-up use among non-
White/Caucasian women observed in this study may relate
to more limited make-up options for darker skin tones
(particularly when concealing PiH is desired).
Consistent with the recent literature, this study
demonstrates that there are racial differences in acne.
Findings from the survey show that non-White/Caucasian
women feel their acne requires targeted attention and
expressed interest in acne treatments tailored to the
unique needs of their skin. This finding was consistent with

[July 2014 • Volume 7 • Number 7] 29

Figure 6. Important features of an acne treatment by race. Note: Percentage of female subjects by race who rated each feature of an acne
treatment as “Very important.” *p<0.05; **p<0.01; ***p<0.0001 for comparisons of White/Caucasian vs. non-White/Caucasian female
subjects
previous research that has emphasized the importance of
considering race-related clinical characteristics when
prescribing acne treatments for acne, such as focusing on
treatments targeting PiH in people with skin of color.22
Products used by non-White/Caucasian women may also
contribute to the presence of acne, such as hair oil or
pomade, and has been shown to be highly correlated with
the presence of forehead acne in Black/African American
women.33
The design of this study was unique in that it focused on
a subpopulation of acne sufferers that has not been studied
extensively, allowing for a more critical comparison of acne
clinical characteristics, treatment preferences, and burden
among different racial and ethnic groups. Additional
advantages of this web-based study included stratified
recruitment to generate data on a diverse sample of female
participants of different ages and races. This approach also
offered access to a large pool of US panelists, a high level
of control in survey programming (e.g., pre-programmed
skip patterns, automated data checks for quality control),
and rapid data collection. Further details on the overall
strengths and limitations of web-based surveys have been
described elsewhere.34
LIMITATIONS
This study was not without limitations. The sample size
for non-White/Caucasian women was limited by the pool of
preregistered female panelists in the United States.
30 [July 2014 • Volume 7 • Number 7]
Stratification of the sample into more granular
race/ethnicity subgroups was not possible due to limited
sample size. However, additional studies are planned that
will allow further assessment of subgroups in a larger pool
of non-White/Caucasian women. Additional limitations
included selection bias due to web-based data collection
methodology, use of self-reported clinical information
(unconfirmed by physician records or diagnostic
information), and potential response bias due to current
acne severity (overall acne severity may have differed
from time of screening). Lastly, enrollment was limited to
women who self-reported ≥25 visible facial lesions,
thereby excluding milder cases with fewer lesions and
limiting the conclusions that can be drawn about the AFA
population as a whole or differences between women of
different races.
CONCLUSION
in conclusion, AFA in skin of color are a unique and
under-studied patient population. Acne therapies have
typically not recognized the variation in clinical
presentation and impact of acne as a function of
race/ethnicity, gender, and age. The findings from this
study emphasize the diversity in AFA and help to
characterize AFA in non-White/Caucasian women. This
study contributes to the body of knowledge about racial
differences in AFA and highlights the multifaceted impacts
of acne for White and non-White women. These findings
may aid the clinical community in recognizing the
substantial burden associated with acne. informing
clinicians about racial differences in clinical presentation of
facial AFA and increasing awareness about the
psychosocial impacts of AFA and specific needs of non-
White women may help guide treatment recommendations
for improving care in AFA populations.
ACKNOWLEDGMENT
The authors would like to acknowledge the following
individuals for their contributions to the study: emil A.
Tanghetti (The Center for Dermatology and Laser
Surgery) for his contributions to survey design; Karen
Yeomans (UBC) for her contributions to survey design and
execution; Krista A. Payne (UBC) for survey design; Ren
Yu (evidera) for data analysis and statistical support;
Marielle Bassel, Sunning Tao, and irene Pan (UBC) for
project support; Sepideh F. Varon (Allergan) for strategy
support in refocusing subject recruitment; Samantha Luks,
Ashley grosse, and Jason Cowden (Yougov) for web
survey management and implementation; and Purvi Mody
(Allergan) for editorial support in the preparation and
styling of this manuscript.
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