Acne and dark marks: setting treatment goals in skin of colour

Acne and the dark marks it leaves need two linked treatment goals: control new lesions and help existing pigmentation improve. Clinical evidence supports treating acne and post-inflammatory hyperpigmentation (PIH) together when appropriate. Gentle supportive skincare and photoprotection help make that plan manageable, while attention to irritation is particularly important in darker skin tones.^{1, 2, 3, 7}

Key messages

• Establish whether the patient is most concerned about active acne, dark marks, discomfort or scars. These need different assessments.^{2, 3, 4}

• Acne often improves before pigmentation. Agree on separate signs of progress without promising a fading deadline.^{3, 5, 6}

• Select acne and pigment-directed treatments by their evidence, formulation, tolerability and relevant precautions.^{3, 10}

• Combine appropriate acne treatment with gentle cleansing, moisturising and practical sun protection. Review irritation, new scars or distress rather than simply adding stronger products.^{3, 5, 7, 8}

What matters to the patient, and what progress should we agree on?

Ask what the patient wants to change: new breakouts, the marks left behind, discomfort, altered texture or several of these. Someone with few current lesions may still have extensive pigmentation that affects confidence or daily life. A 2021 expert consensus on acne in skin of colour recommends including pigmentation and long-term acne control in the treatment goals.²

Review previous treatment, sensitivity and the complete skin and hair-care routine. Agree on what is affordable, available and feasible. Skin of colour encompasses diverse complexions and backgrounds; it does not define one sensitivity level or set of preferences.

Explain the relationship simply: inflammation from a spot can leave extra pigment after the bump settles. The plan can prevent further breakouts while addressing older marks. Invite questions and ask the patient to describe how the routine will work at home. This checks understanding without turning the conversation into a formal assessment score.

Set separate expectations. The American Academy of Dermatology (AAD) advises that initial improvement in breakouts may take at least six to eight weeks. A clinical review of retinoids in acne and pigmentation notes that lesions are likely to improve weeks before PIH resolves.^{3, 6}

For a spot only a few shades darker than the surrounding skin, AAD advice describes fading over six to twelve months once the cause has been identified and stopped. Deeper pigment can last years. These are explanations of the possible course, not an individual deadline.⁵

Agree on visible signs of progress: fewer new inflammatory lesions and marks, gradual change in older pigmentation, and treatment the patient can tolerate. Comparable photographs, with consent, can provide a shared record. At follow-up, check both the skin and whether the original priorities have changed.³

Are the visible changes acne, pigmentation, redness or scars?

Clarify what the patient means by marks. Active lesions, flat colour changes and structural scars can occur together, but improvement in one does not necessarily change the others.^{3, 4}

Inflammation can stimulate pigment-producing melanocytes to make more melanin and transfer it to surrounding skin cells. When the deeper boundary of the outer skin is injured, pigment may also enter the dermis and be taken up by immune cells. This helps explain why a bump and its mark can improve at different rates.¹

PIH can occur in anyone, but pigmentation tends to be more intense and persistent in darker skin. A clinical review also discusses inflammation that is not yet visible as a possible contributor to continuing pigmentation.^{1, 2, 3}

Use history and examination as well as colour. Clinical resources use colour terms differently, and separating pigmentation from erythema can be difficult. Colour alone cannot establish pigment depth or prove that a flat mark contains active acne. Evidence about fading PIH should be applied to that outcome, not automatically to vascular redness or altered skin contour.^{1, 3, 4}

How can acne control and pigment care work together?

Address active acne and existing marks together where appropriate. Effective acne control helps reduce the source of new marks, while suitable pigment-directed care can address the changes already troubling the patient. Match treatment to lesion type, severity, scarring risk, previous response and contraindications.^{3, 7, 8}

Azelaic acid illustrates the value of considering the actual preparation: the retinoid/PIH clinical review describes acne findings with a 15% foam and pigmentation findings from a separate 15% gel study. Those results do not establish identical effects for every concentration or finished formula. L’Oréal Dermatological Beauty Pro offers a professional discussion of azelaic acid in acne management.³

When antibiotics are indicated, AAD guidance recommends limiting systemic antibiotic use and combining systemic antibiotics with benzoyl peroxide and other topical therapies. Benzoyl peroxide is also recommended alongside topical antibiotics to help prevent resistance. Antibiotics address acne management, rather than serving as a generic treatment for residual pigment.^{9, 10}

For severe acne or failure of standard treatment, systemic options need prescribing assessment. Isotretinoin and selected hormonal treatments address acne and its risks, not interchangeable routes to fading old marks. Review maintenance needs as the acne improves.^{3, 10}

How can the plan remain comfortable and safe?

Gentle skincare supports a workable treatment plan. The clinical review recommends pH-balanced cleansing, a non-comedogenic moisturiser and avoiding overly drying toners or astringents. Non-comedogenic means intended not to clog pores. The 2021 skin-of-colour consensus likewise supports suitable cleansers and moisturisers alongside treatment.^{2, 3}

Explain application and introduce potentially irritating changes cautiously where appropriate. Follow the specific medicine’s instructions and individualise adjustments. Irritation can worsen PIH; it is not a sign that a retinoid is working better.³

As one medicine-specific example, AAD patient guidance suggests starting benzoyl peroxide at 2.5% to limit irritation. The appropriate preparation still depends on the clinical situation. Discourage picking, squeezing and abrasive scrubbing; gentle fingertip cleansing is sufficient.⁷

Reassess troublesome burning, pain, peeling or worsening discolouration. AAD advice recommends stopping a skincare product that burns or stings. Changes to prescribed treatment should be discussed with the treating clinician.^{3, 5}

Ask about pregnancy and plans to conceive. Avoid topical retinoids during pregnancy, and arrange professional assessment of the complete regimen rather than relying on an online pregnancy-safe label.^{3, 8}

When might a pigment-directed adjunct or camouflage help?

A separate pigment treatment is optional. Consider the diagnosis, persistence, patient preference and what the skin can tolerate. Some marks fade over time; the purpose is to address unwanted marks rather than change the patient’s natural skin tone.^{1, 3, 5}

Hydroquinone may be considered for selected acne-related PIH. The clinical review advises careful application to affected areas to reduce the risk of unwanted lightening. Selection, supervision and duration should follow the preparation and local prescribing requirements. A combination approved for melasma does not thereby have approval for acne-induced PIH.³

Other ingredients, including niacinamide and vitamin C, occur in clinical lists of pigment-directed options. Such lists support discussion of possible approaches, not equivalent efficacy for every ingredient or a reason to layer them together. The complete formulation and relevant clinical evidence should guide selection.¹

Choose products from dependable sources. AAD reports that some skin-lightening products have contained undeclared steroids or mercury, and advises against liquid bleach on skin. This supports careful selection rather than a judgement that all pigment treatments carry the same risk.⁵

Camouflage can be an optional way to manage appearance while treatment takes effect. It temporarily conceals marks and is distinct from treating pigment or acne. Select tolerated, non-comedogenic make-up and remove it gently.^{1, 7}

What should photoprotection achieve?

Photoprotection helps limit further darkening while acne and pigmentation are addressed. AAD advises broad-spectrum, water-resistant sunscreen with sun protection factor (SPF) 30 or higher; DermNet recommends daily SPF 50+ on exposed areas affected by PIH. Keep these source-specific recommendations in context.^{1, 5}

Visible light deserves separate consideration from ultraviolet (UV) exposure. AAD dark-spot guidance recommends tinted sunscreen containing iron oxide for visible-light protection alongside UV protection. SPF measures UV protection, so a high-SPF, clear or mineral-labelled formula should not automatically be assumed to provide the same visible-light coverage.⁵

Choose a shade and finish the patient can use comfortably, with an appropriate non-comedogenic formulation. AAD guidance includes the ability to blend with skin tone among its selection criteria. Apply to uncovered skin before outdoor exposure and reapply every two hours and after swimming or sweating, alongside shade, clothing and a wide-brimmed hat. Follow the product instructions and exposure context.^{5, 6}

Photoprotection works alongside acne control and gentle care. Review any formula that irritates the skin, and assess gradual pigment improvement without promising a particular fading date.^{3, 5}

When should procedures be discussed?

Define the treatment target before discussing a procedure. Pigmentation near the surface, possible deeper pigment and structural scars need different assessment. Peels and laser approaches may be useful in selected patients, but injury can also worsen pigmentation.^{1, 7}

AAD recommends assessment by a dermatologist experienced with the proposed procedure in skin of colour, including before home versions of chemical peels, microdermabrasion or laser treatment. Discuss the potential for both darker and lighter marks.⁷

Advice about deeper pigment differs between clinical resources. DermNet describes the listed physical treatments as ineffective for dermal pigmentation, while Skin of Color Society information discusses selected procedural options and the risk of worsening pigmentation. This is a reason for specialist diagnosis and individual selection rather than an automatic stronger-laser approach.^{1, 11}

The AAD acne guideline found insufficient evidence to recommend several procedures for acne. That statement should be applied to its acne-management question, not used as a blanket judgement about every PIH or scar procedure. Review active acne and skin tolerance when planning an intervention; these sources do not establish one universal waiting period.¹⁰

What should trigger reassessment or referral?

Seek clinical assessment for deep painful lesions, emerging scars, extensive acne, inadequate response or substantial distress. AAD advice notes that deep painful or scar-forming acne is unlikely to respond adequately to store-bought products alone. National Health Service (NHS) advice also identifies effects on mental health as a reason to seek care.^{8, 12}

Do not make a fixed period of self-treatment a prerequisite when scars are appearing or distress is substantial. Local pathways determine the appropriate clinician and urgency. Persistent or worsening pigmentation, troublesome irritation or diagnostic uncertainty also warrant review.^{1, 8, 12}

At follow-up, return to the linked goals: are fewer lesions and new marks developing, are older marks changing, and does the plan fit the patient’s priorities? If progress differs between acne and pigmentation, review the relevant part of the plan rather than automatically intensifying everything.³

For a broader professional discussion of presentation and supportive care, see LDB Pro’s expert video on acne in skin of colour.

References

1. dermnetnz.org. Postinflammatory hyperpigmentation [Internet]. Accessed 3 November 2026. View source ↗
2. Alexis AF, Woolery-Lloyd H, Williams K, Andriessen A, Callender VD, Kang S, Rodriquez D, Tan J. Racial/Ethnic Variations in Acne: Implications for Treatment and Skin Care Recommendations for Acne Patients With Skin of Color. Journal of Drugs in Dermatology. 2021. View source ↗
3. pmc.ncbi.nlm.nih.gov. Effects of Topical Retinoids on Acne and Post-inflammatory Hyperpigmentation in Patients with Skin of Color: A Clinical Review and Implications for Practice [Internet]. Accessed 3 November 2026. View source ↗
4. American Academy of Dermatology. Acne scars: Signs and symptoms [Internet]. Accessed 3 November 2026. View source ↗
5. American Academy of Dermatology. How to fade dark spots in darker skin tones [Internet]. Accessed 3 November 2026. View source ↗
6. American Academy of Dermatology. Acne: Diagnosis and treatment [Internet]. Accessed 3 November 2026. View source ↗
7. American Academy of Dermatology. 10 tips for clearing acne in darker skin tones [Internet]. Accessed 3 November 2026. View source ↗
8. American Academy of Dermatology. Adult acne treatment dermatologists recommend [Internet]. Accessed 3 November 2026. View source ↗
9. American Academy of Dermatology. Acne clinical guideline [Internet]. Accessed 3 November 2026. View source ↗
10. American Academy of Dermatology. American Academy of Dermatology issues updated guidelines for the management of acne [Internet]. Accessed 3 November 2026. View source ↗
11. skinofcolorsociety.org. Post-Inflammatory Hyperpigmentation (PIH) - Skin of Color Society [Internet]. Accessed 3 November 2026. View source ↗
12. NHS. Acne - NHS [Internet]. Accessed 3 November 2026. View source ↗
13. pubmed.ncbi.nlm.nih.gov. Treatment recommendations for acne-associated hyperpigmentation: Results of the Delphi consensus process and a literature review [Internet]. Accessed 3 November 2026. View source ↗

Evidence note. The 2021 skin-of-colour recommendations and 2023 acne-associated hyperpigmentation recommendations are expert consensus publications; the retinoid/PIH paper is a clinical review. These sources complement graded acne guidance and practical patient information. Pigment efficacy outcomes, acne outcomes and pigment safety observations answer different questions. Read individual findings with their population, formulation, comparator and follow-up intact. In the survey of 208 women cited by the 2021 consensus, 41.6% of the non-White subgroup prioritised PIH clearance; that subgroup result does not establish every patient’s priorities. Consensus authors disclosed industry support and relationships, and the clinical review disclosed industry-supported medical writing.^{2, 3, 10, 13}