Adolescent acne across skin colours: what a large cohort tells us

Acne assessment in early adolescence should consider pubertal development, active lesions and the young person’s experience together. A large Rotterdam population study found that acne was already common around age 13, with higher measured severity in adolescents at more advanced puberty and in darker skin-colour categories. These findings support attentive, individual assessment across skin colours.¹

The practical value is to ask better questions about current acne, marks, scars and previous care. A group association can inform that conversation without predicting one adolescent’s future course.^{1, 8, 12}

Key messages

• Interpret adolescent prevalence figures with the age, setting and definition of acne visible.^{1, 2, 3}

• Puberty helps explain the Rotterdam findings; skin colour, phototype and ethnicity describe different characteristics.^{1, 5, 6}

• Assess active lesions, post-inflammatory hyperpigmentation, scars and wellbeing separately.^{8, 9, 10}

• Ask directly about previous advice, treatment use and current needs. Parent-reported treatment history does not measure unmet need.^{1, 12}

What did the Rotterdam adolescent study find?

The 2024 acne analysis from Generation R, a population-based study in Rotterdam, included 4,561 adolescents with a median age of 13.5 years; 51% were girls. Researchers graded three-dimensional facial photographs taken in 2016–2019 using the Global Evaluation of Acne Severity (GEA) scale. Although Generation R follows participants over time, this acne analysis assessed them at one stage.¹

The thresholds describe different outcomes: an adolescent with visible acne was not necessarily in the moderate-to-severe group. These figures concern facial acne in a multiethnic Dutch population around age 13, rather than every teenage age or affected body site.¹

Why do prevalence figures differ between populations?

Before comparing percentages, check the age range, pubertal stage, recruitment setting, case definition and assessment method. A photograph, self-report questionnaire, clinical examination and modelled population estimate answer different questions.

A Global Burden of Disease (GBD) analysis used modelled data for people aged 10–24 in 204 countries and territories. Its 2021 global age-standardised prevalence estimate was 9,790.5 per 100,000. Age standardisation adjusts for differences in population age structure. This is a different measure from the observed facial-acne prevalence in Rotterdam’s early-adolescent sample.^{1, 2}

Differences also occur within one population. Among 787 students from 12 secondary schools in Alexandria, Egypt, acne prevalence was 34.7% by self-report and 24.4% on clinical examination. The study demonstrates why the method belongs beside the result, rather than establishing a universal direction of reporting error.³

The GBD analysis reported the highest regional age-standardised rates in Western Europe and the largest increases in North Africa and the Middle East. Geography describes the modelled burden in those settings; it is not an ethnic ranking or an explanation of biological susceptibility.²

How does puberty put the findings into context?

Pubertal androgens, a group of hormones that includes testosterone, stimulate sebaceous glands and sebum production. Together with follicular blockage and inflammation, this helps explain why acne emerges during adolescence. Young people of the same chronological age may be at different developmental stages.⁴

More advanced pubertal development was associated with greater severity in both sexes in Rotterdam. The authors interpreted girls’ higher severity at this age mainly in relation to earlier puberty. This is useful context for the early-adolescent pattern, rather than a rule about which sex has more severe acne throughout the teenage years.¹

Being overweight was associated with greater severity in boys, but the association was not statistically significant in girls. Daily physical activity was associated with lower odds of more severe acne in boys. These observational findings can inform research questions; they do not show that weight loss or exercise treats acne, and should not be used to blame adolescents for their disease.¹

How should the skin-colour association be interpreted?

In the adjusted Rotterdam analysis, darker skin-colour categories V–VI were associated with higher measured acne severity than categories I–II. The adjusted severity odds ratios were 1.90 in girls and 2.43 in boys. The analysis considered ordered severity categories, so these figures describe the odds of a higher acne grade within the model. They are not the proportion who developed acne or an individual prediction.¹

Skin colour, sun-response phototype, ethnicity and ancestry should remain distinct. Fitzpatrick phototype classifies the skin’s reaction to sunlight; it is not an ethnic classification or an acne-risk score. A separate survey of 3,386 people found that race and pigmentary appearance incompletely predicted individual sun sensitivity.^{5, 6}

The association deserves attention because it concerns graded active acne, not simply persistent dark marks. It does not identify pigmentation as the cause. Measured and unmeasured influences, as well as assessment methods, remain relevant when considering why groups differ.¹

For clinical decisions, use the adolescent’s actual lesions, symptoms and history. Neither an ethnic label nor the study’s group association establishes their hormonal state, product exposures, likely course or best treatment.^{1, 12}

What should be recorded beside active acne?

A useful assessment separates active lesions from their aftermath. Record comedones, papules, pustules and deeper lesions; post-inflammatory hyperpigmentation (PIH), or dark marks after inflammation; persistent redness; and depressed or raised structural scars.^{4, 8, 9}

PIH can outlast the lesions that caused it. It can occur in anyone, but tends to be more common, intense and persistent in darker skin. Active acne may improve before the pigment resolves, so the two concerns may require different goals and expectations.^{8, 9}

Colour alone can make assessment difficult. A clinical review of acne and PIH describes challenges distinguishing pigment, redness and active inflammation, supporting separate recording and clinician training. Persistent pigment does not establish severe current acne, while a low lesion count does not make pigment or scar concerns unimportant.⁸

Ask about the chest, back and other sites as well as the face. Facial photographs cannot quantify truncal involvement or the person’s total disease burden.^{1, 4}

How can wellbeing be included in the consultation?

Ask what the young person most wants care to change. Discomfort, confidence, school and social participation can matter alongside visible lesions. For some patients, PIH is more distressing than the acne itself.⁸

In Rotterdam, the psychological symptom measures used were not associated with measured acne severity. A Korean school study of 504 students aged 13–16 found that stress and self-image impairment were more closely related to self-rated severity than objective grading. The populations and measures differed, but together the findings support asking about subjective burden rather than inferring it from a photograph.^{1, 10}

“Which part of your skin problem affects you most?” provides a practical starting point. Follow with questions about embarrassment, avoidance and the young person’s priorities. The UK National Health Service (NHS) includes mental-health impact as a reason to seek clinical help, even when the lesion count appears modest.¹¹

What does treatment history tell us about current needs?

Parents reported that 14% of boys and 19% of girls in Rotterdam had ever received acne treatment; fewer than 1% had received systemic treatment. These historical reports raise useful questions about previous care, but they are not treatment-coverage rates among the adolescents with visible acne at the photographic assessment.¹

Ask what advice was sought, which prescription and non-prescription products were tried, whether they helped, and whether irritation, cost or practical difficulties interrupted use. Review the actual medicines and skin or hair products rather than infer exposures from ethnicity.⁴

Assess the present need directly. Subtracting ever-treatment percentages from current acne prevalence would combine different measures and would not calculate unmet need. The cohort also does not quantify a social, dietary or product-related cause of the skin-colour association.¹

How can the findings guide an individual plan?

Explain the observation in terms the adolescent and family can use: “In this study of young people around 13, acne grades were higher at more advanced puberty and in darker skin-colour groups. That helps us know what to look for, but it does not tell us exactly what will happen to your skin.”¹

Then agree priorities based on active lesions, marks, scars, affected sites, wellbeing and previous care. The American Academy of Dermatology (AAD) describes treatment as an individual decision based on the presentation and the patient’s needs. Persistent, deep, painful, scarring or mentally distressing acne warrants clinical attention through local pathways.^{11, 12}

An inclusive approach to acne keeps individual presentation and priorities at the centre of these decisions.

References

1. Witkam WCAM et al. The epidemiology of acne vulgaris in a multiethnic adolescent population from Rotterdam, the Netherlands: A cross-sectional study. Journal of the American Academy of Dermatology. 2024. View source ↗
2. pubmed.ncbi.nlm.nih.gov. Global, regional and national burdens of acne vulgaris in adolescents and young adults aged 10-24 years from 1990 to 2021: a trend analysis [Internet]. Accessed 3 November 2026. View source ↗
3. pmc.ncbi.nlm.nih.gov. Acne vulgaris: prevalence, severity, and impact on quality of life and self-esteem among Egyptian adolescents [Internet]. Accessed 3 November 2026. View source ↗
4. yalemedicine.org. Acne (Acne Vulgaris) [Internet]. Accessed 3 November 2026. View source ↗
5. dermnetnz.org. Skin phototype (Fitzpatrick skin type) [Internet]. Accessed 3 November 2026. View source ↗
6. pubmed.ncbi.nlm.nih.gov. Self-reported pigmentary phenotypes and race are significant but incomplete predictors of Fitzpatrick skin phototype in an ethnically diverse population [Internet]. Accessed 3 November 2026. View source ↗
7. Dreno B, Dekio I, Baldwin H, Demessant AL, Dagnelie MA, Khammari A, Corvec S. Acne microbiome: From phyla to phylotypes. Journal of the European Academy of Dermatology and Venereology. 2024;38(4):657-664. doi:10.1111/jdv.19540. View source ↗
8. 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 ↗
9. dermnetnz.org. Postinflammatory hyperpigmentation [Internet]. Accessed 3 November 2026. View source ↗
10. anndermatol.org. Psychosocial Aspects of Acne Vulgaris: A Community-based Study with Korean Adolescents - :: AD :: Annals of Dermatology [Internet]. Accessed 3 November 2026. doi:10.5021/ad.2009.21.2.125. View source ↗
11. NHS. Acne - NHS [Internet]. Accessed 3 November 2026. View source ↗
12. American Academy of Dermatology. Acne: Diagnosis and treatment [Internet]. Accessed 3 November 2026. View source ↗

Study note. The Rotterdam acne analysis was cross-sectional within Generation R. It was supported by an unrestricted L’Oréal Research and Innovation grant and included L’Oréal-employed co-authors. The facial severity scale was not validated specifically for darker skin in this analysis. These details inform interpretation alongside the population and outcome definitions.¹