To the Editor: More than 5.2 million people (1.7% of the US population) identify as having American Indian or Alaskan Native heritage.1United States Census BureauThe American Indian and Alaska Native population: 2010.https://www.census.gov/prod/cen2010/briefs/c2010br-10.pdfDate accessed: March 24, 2018Google Scholar Approximately 59% of the total Native American population receives care at an Indian Health Service (IHS) or tribal health care facility, with limited access to specialists such as dermatologists.2Indian Health ServiceA quick look.https://www.ihs.gov/newsroom/includes/themes/responsive2017/display_objects/documents/factsheets/QuickLook.pdfDate accessed: March 26, 2018Google Scholar According to IHS officials, there is only 1 Commissioned Corps dermatologist currently employed in a national health care system serving 2.2 million patients (Christopher Bengson, MD, MHS personal communication, March 29, 2018).2Indian Health ServiceA quick look.https://www.ihs.gov/newsroom/includes/themes/responsive2017/display_objects/documents/factsheets/QuickLook.pdfDate accessed: March 26, 2018Google Scholar Research on Native American–focused dermatology is particularly limited. A search of PubMed for articles on dermatology and acne dealing specifically with Native Americans or American Indians resulted in a total of 31 articles published from 1996 to 2018. As a result, there is a significant knowledge gap in the epidemiology, presentation, and outcomes of dermatologic conditions in Native Americans, even in cases involving common dermatoses such as acne. Between 2017 and 2018, an anonymous questionnaire was administered to Native Americn participants both in person at a local powwow and via email listservs and Facebook groups, including Indians into Medicine, Native American Student Affairs, the American Indian Science and Engineering Society, and the Native Research Network. The questionnaire's content explored the demographics, prevalence, symptoms, lesion locations, severity, scarring, quality of life measures, treatment modalities, and satisfaction. Inclusion criteria for participation were age older than 18 years, self-identification as a Native American member of a federally recognized tribe, and history of living on a reservation. This study was approved and exempted by the University of Arizona's institutional review board. There were 158 participants (mean age, 32 ± 10.3 years; female participants, n = 137 [86.7%]). All participants reported a history of living on a reservation (mean time on a reservation, 20 ± 11 years) and status as an enrolled member of a federally recognized tribe. Most participants (79% [n = 125]) reported a history of acne and 55.1% (n = 87) reported having acne scarring. In all, 31% of participants (n = 49; mean age, 27 ± 7.7 years) reported active acne lesions, with an average severity of 4.8 on a scale from 1 to 10. Almost half of them (46.9% [n = 23]) reported seeking treatment from a health care professional, with 52.2% (n = 12) managed by an IHS or tribal health care clinic provider. Of these patients, only 1 (8%) reported seeing a dermatologist. The lifetime prevalence of acne among our participants was 79.1%, which is similar to the rate among the US general population.3Thiboutot D.M. Dreno B. Abanmi A. et al.Practical management of acne for clinicians: an international consensus from the Global Alliance to Improve Outcomes in Acne.J Am Acad Dermatol. 2018; 78: S1-S23.e21Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar In a 2011 study of 2895 women (age, 10-70 years), Perkins et al4Perkins A.C. Cheng C.E. Hillebrand G.G. Miyamoto K. Kimball A.B. Comparison of the epidemiology of acne vulgaris among Caucasian, Asian, Continental Indian and African American women.J Eur Acad Dermatol Venereol. 2011; 25: 1054-1060Crossref PubMed Scopus (90) Google Scholar examined acne epidemiology by ethnicity and found that African Americans had both the highest rate of active acne (37%) and the highest rate of combined hypertrophic and atrophic acne scarring (34%) when compared with other groups. In our study, 31% of participants reported active acne, suggesting a prevalence similar to that found in other ethnic groups from the 2011 study (Fig 1). However, 1 notable difference in our Native American cohort was the elevated rate of acne scarring (55.1%), which could signify an even higher rate than previously observed in other ethnic groups (Fig 2).Fig 2Prevalence of acne scarring by ethnicity. A, Prevalence of acne scarring among Native Americans, as reported by participants in the present study. B, Combined rates of atrophic and hypertrophic acne scarring observed in other ethnic groups in the 2011 study by Perkins et al.4Perkins A.C. Cheng C.E. Hillebrand G.G. Miyamoto K. Kimball A.B. Comparison of the epidemiology of acne vulgaris among Caucasian, Asian, Continental Indian and African American women.J Eur Acad Dermatol Venereol. 2011; 25: 1054-1060Crossref PubMed Scopus (90) Google ScholarView Large Image Figure ViewerDownload Hi-res image Download (PPT) The high prevalence of acne scarring in Native Americans highlights a health care disparity in terms of the access to treatment and care of a common dermatosis. According to the Global Alliance to Improve Outcomes in Acne,3Thiboutot D.M. Dreno B. Abanmi A. et al.Practical management of acne for clinicians: an international consensus from the Global Alliance to Improve Outcomes in Acne.J Am Acad Dermatol. 2018; 78: S1-S23.e21Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar early and effective treatment of acne is the best method to prevent the formation of scarring. Therefore, the high prevalence of acne scarring in Native Americans may be due to a lack of access to early treatment. Only 1 participant seeking care at an IHS or tribal health care clinic reported seeing a dermatologist for acne. For comparison, the 2012 National Ambulatory Medical Care Survey reported a rate of acne-related dermatologist visits of 69.3%,5Patel V.M. Schwartz R.A. Disparities in access to a dermatologist for acne care in the United States.Int J Dermatol. 2017; 56: e131-e133Crossref PubMed Scopus (3) Google Scholar further highlighting the limited access to dermatologic specialty care within the Native American health care system. Several potential interventions may help to alleviate the acne burden among Native American communities. In the immediate future, federal, state, or even local programs could incentivize dermatologists to spend time working with underserved tribes. Additionally, dermatology workshops and CME could be offered to better prepare IHS and tribal health care primary care providers, who may not be as well versed in treating complicated, recalcitrant skin conditions. Furthermore, telemedicine is a promising intervention for underserved communities, with the potential to bridge the dermatologic health care gap for Native Americans.