At Skin of Color Update 2025, Michelle Henry, MD, FAAD, discussed new evidence behind the future of acne scar treatments and reviewed the safety and efficacy of microneedling in skin of color.
Acne is highly prevalent in skin of color (SOC) populations, with studies reporting acne in 37% of African American women, 32% of Hispanic women, and 30% of Asian women, compared with 24% of Caucasian women. Importantly, 84.4% of acne patients with SOC develop scarring, compared with a 47% global average, demonstrating a significantly greater risk of permanent sequelae. Additionally, African American patients are 7.1 times more likely to develop keloids than Caucasian patients, and some studies suggest a 15-20x increased risk.
Given the high likelihood of scarring in SOC, Dr. Henry emphasized the importance of early, proactive intervention to prevent permanent disfigurement and reduce psychosocial burden.
Evidence for Energy-Based Devices in SOC
Dr. Henry highlighted a 2023 systematic review evaluating 35 clinical studies using radiofrequency (RF) and RF microneedling (RFM) in Fitzpatrick III–VI skin. Across studies, there was consistent improvement in rhytids, acne scarring, skin texture, and photoaging, with a largely favorable safety profile and transient PIH when present. Limitations included small sample sizes, heterogeneous endpoints, and inconsistent energy parameters. Despite these limitations, RF-based devices remain a moderately effective and low-risk option for acne scars in SOC when performed with conservative settings and appropriate aftercare.
Fractional RF Microneedling: Atrophic Scars
Fractional RFM delivers controlled dermal heating with minimal epidermal disruption, reducing the risk of PIH, which is a major advantage in darker skin tones. Dr. Henry emphasized that rolling and boxcar scars show the most consistent improvement, while icepick scars also benefit, particularly when RFM is combined with other treatment modalities. She noted that pairing RFM with fractional lasers offers the greatest degree of scar remodeling and supports a precision-based, multimodal strategy tailored to scar morphology. Because of its versatility and strong efficacy record, RFM remains a cornerstone therapy in acne scar management for skin of color.
755-nm Picosecond Laser in Skin Types V-VI
Dr. Henry reviewed clinical data evaluating the 755-nm picosecond Alexandrite laser (PSAL) with a diffractive lens array, demonstrating promising outcomes in patients with deeper skin tones. In the reviewed study, 100% of patients showed clinician-rated improvement, 88% were very much improved at three months, and 94% reported high satisfaction. Treatment was well-tolerated with mild-to-moderate discomfort (average pain score 4.9/10) and no serious adverse events, including no persistent PIH, necrosis, or scarring. These results support PSAL as a safe and effective option for acne scarring in Fitzpatrick V–VI when SOC-appropriate parameters are used.
Combination Picosecond Laser + RF Microneedling
Dr. Henry reviewed a prospective, evaluator-blinded, split-face randomized trial comparing 755-nm picosecond Alexandrite laser (PSAL) plus radiofrequency microneedling (RFM) versus RFM alone for moderate-to-severe atrophic acne scars. Both treatment sides demonstrated statistically significant improvement in validated scar assessments (ECCA and GAIS).
While formal grading scales did not show a statistically significant difference between the two treatment arms, blinded evaluators correctly identified the combination-treated side in 87.5% of patients, supporting a clinically noticeable enhancement in texture with dual-modality treatment.
Safety outcomes were excellent, with no PIH, hypopigmentation, scarring or other serious adverse effects.
Dr. Henry noted that RFM remains highly effective on its own, particularly for rolling and boxcar scars, but adding PSAL may provide incremental dermal remodeling benefits. Larger trials will be required to validate synergy, determine ideal sequencing, and standardize treatment parameters in skin of color.
Non-Ablative Fractional Laser Safety in Skin of Color
Dr. Henry highlighted a foundational retrospective review evaluating 1550-nm erbium-doped non-ablative fractional laser resurfacing for acne scarring in Fitzpatrick IV–VI patients. The treatment demonstrated a low incidence of post-inflammatory hyperpigmentation (PIH) of 4%, and all cases resolved, with the majority occurring within one month.
The study found that higher fluence, rather than the number of passes, was the primary factor associated with increased PIH. SOC-specific protocols, including 4% hydroquinone pretreatment and post-treatment, intraoperative cooling, and strict photoprotection, were thought to enhance treatment tolerance and minimize pigmentary complications.
This data supports non-ablative fractional resurfacing as a safe and effective option for acne scarring in skin of color when conservative energy settings and pigment-protective measures are employed by experienced clinicians.
Case Example: Laser Burn Rehabilitation
Dr. Henry shared a case involving a laser-induced burn that occurred outside a medical setting. She treated the patient with three weekly PRFM sessions combined with silicone-based regenerative scar therapy. The patient demonstrated marked improvement in both texture and pigmentation, highlighting the important role of regenerative adjunctive therapies in managing complications and restoring skin quality in skin of color.
PIH Prevention Strategies
To reduce complication risk in SOC, Dr. Henry briefly highlighted evidence showing the importance of broad-spectrum photoprotection, which remains the most reliable preventive measure against post-inflammatory hyperpigmentation (PIH). She also noted that post-procedure topical corticosteroids may help reduce the severity of PIH. The evidence for pretreatment depigmenting agents is mixed, and tranexamic acid remains promising, though current data are still inconclusive. Ultimately, optimized device parameters and diligent postoperative care remain the most important strategies for minimizing PIH in skin of color.
Adjunctive Topical and Injectable Therapies
To further support dermal remodeling while controlling inflammation, Dr. Henry incorporates several adjunctive treatments into her acne scar management approach. These include PRP, recombinant PDGF, and topical agents such as hydroquinone, tranexamic acid, and cysteamine. For hypertrophic or keloid scars, intralesional kenalog (ILK) may be used as needed. She also employs topical steroids and silicone-based scar therapy following procedures. Together, these supportive measures help enhance healing and reduce both fibrotic and pigmentary complications.
Key Principles
Dr. Henry emphasized that acne scarring is more prevalent and often more severe in skin of color, making early recognition and treatment particularly critical. Because different scar subtypes respond differently to treatment, careful scar morphology assessment is essential to selecting the most effective device or technique for each patient.
There is no single gold-standard modality for acne scarring in SOC. Instead, multimodal, combination-based treatment plans offer superior clinical outcomes by addressing both textural and pigmentary components of scarring. Among available options, fractional lasers, RF microneedling, microneedling, and regenerative therapies such as PRP/PRFM currently have the strongest evidence base in SOC.
Achieving meaningful improvement while minimizing risk requires strict SOC-specific safety protocols, including:
- Conservative fluence and energy selection
- Maximizing epidermal protection through cooling and interface shields
- Rigorous pre- and post-procedure photoprotection
- Close monitoring and early management of PIH when present
Looking ahead, Dr. Henry highlighted that the future of acne scar treatment in skin of color lies in increasingly personalized and inclusive approaches, optimizing efficacy without compromising pigmentary safety.
This summary was prepared by Dr. Courtney Hanna, dermatology resident, who attended the session. The content reflects the resident’s notes and interpretations, may contain errors, and is provided for educational purposes only. It does not constitute official faculty endorsement and should not replace original sources or clinical judgment.
References:
Clark, C. M., Silverberg, J. I., & Alexis, A. F. (2013). A retrospective chart review to assess the safety of nonablative fractional laser resurfacing in Fitzpatrick skin types IV to VI. Journal of Drugs in Dermatology: JDD, 12(4), 428-431.
Darji, K., Zarbafian, M., Ishii, L., Zubair, R., Cho, S., Zhou, X., … & Loyal, J. (2025). Evaluating the Picosecond 755-nm Alexandrite Laser With Diffractive Lens Array and Radiofrequency Microneedling for the Treatment of Atrophic Acne Scarring. Dermatologic Surgery, 51(9S), S69-S76.
Niaz, G., Ajeebi, Y., Alshamrani, H. M., Khalmurad, M., & Lee, K. (2025). Fractional radiofrequency microneedling as a monotherapy in acne scar management: A systematic review of current evidence. Clinical, Cosmetic and Investigational Dermatology. Advance online publication
Sanyal, R. D., & Fabi, S. G. (2024). Energy-based devices for the treatment of facial skin conditions in skin of color. Journal of Clinical and Aesthetic Dermatology, 17(6), 22–32. PubMed Central
Tao, J., Hashemi, D. A., Bajaj, S., Wang, J. V., & Geronemus, R. G. (2025). 755-nm Picosecond Laser With Diffractive Lens Array for Acne Scars in Fitzpatrick Skin Types V and VI. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.], 51(2), 171–174. https://doi.org/10.1097/DSS.0000000000004398
Tran, A., Klein, R., & Robinson, D. (2021). Evaluation of Picosecond 755-nm Alexandrite Laser With a Diffractive Lens Array on Pore Size Reduction. Journal of drugs in dermatology : JDD, 20(12), 1302–1306. https://doi.org/10.36849/jdd.6199
Wong, I. T. Y., & Richer, V. (2021). Prophylaxis of Post-Inflammatory Hyperpigmentation From Energy-Based Device Treatments: A Review. Journal of cutaneous medicine and surgery, 25(1), 77–86. https://doi.org/10.1177/1203475420957633
