Mavranezouli, Ifigneia; Daly, Caitlin H; Welton, Nicky J; Deshpande, Shalmali; Berg, Laura; Bromham, Nathan; Arnold, Stephanie; ... Healy, Eugene; + view all Mavranezouli, Ifigneia; Daly, Caitlin H; Welton, Nicky J; Deshpande, Shalmali; Berg, Laura; Bromham, Nathan; Arnold, Stephanie; Phillippo, David M; Wilcock, Jane; Xu, Jingyuan; Ravenscroft, Jane C; Wood, Damian; Rafiq, Mohammed; Fou, Linyun; Dworzynski, Katharina; Healy, Eugene; - view fewer (2022) A systematic review and network meta‐analysis of topical pharmacological, oral pharmacological, physical and combined treatments for acne vulgaris. British Journal of Dermatology , 187 (5) pp. 639-649. 10.1111/bjd.21739.

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Abstract

BACKGROUND: Various treatments for acne vulgaris exist, but little is known about their comparative effectiveness by acne severity. OBJECTIVES: To identify best treatments for mild-to-moderate and moderate-to-severe acne, as determined by clinician-assessed morphological features. METHODS: We undertook a systematic review and network meta-analysis of randomised controlled trials (RCTs) assessing topical pharmacological, oral pharmacological, physical and combined treatments for mild-to-moderate and moderate-to-severe acne, published up to May 2020. Outcomes included percentage change in total lesion count from baseline, treatment discontinuation for any reason and due to side effects. Risk of bias was assessed using the Cochrane risk-of-bias tool, and bias-adjustment models. We report below effects versus placebo for treatments with ≥50 observations each. RESULTS: We included 179 RCTs with ≈35,000 observations across 49 treatment classes. For mild-to-moderate acne, the most effective options for each treatment type were (mean difference, 95% credible intervals): topical pharmacological - combined retinoid with benzoyl peroxide [BPO] (26.16%, 16.75%-35.36%); physical – chemical peels, e.g. salicylic or mandelic acid (39.70%, 12.54%-66.78%) and photochemical therapy [combined blue/red light] (35.36%, 17.75%-53.08%). Oral pharmacological treatments (e.g. antibiotics, hormonal contraceptives) did not appear to be effective after bias adjustment. BPO and topical retinoids were less tolerated than placebo. For moderate-to-severe acne, the most effective options for each treatment type were: topical pharmacological - combined retinoid with lincosamide [clindamycin] (44.43%, 29.20%-60.02%); oral pharmacological - isotretinoin of total cumulative dose ≥120mg/kg/single course (58.09%, 36.99%-79.29%); physical - photodynamic therapy [light therapy enhanced by a photosensitizing chemical] (40.45%, 26.17%-54.11%); combined - BPO with topical retinoid and oral tetracycline (43.53%, 29.49%-57.70%). Topical retinoids and oral tetracyclines were less tolerated than placebo. Quality of included RCTs was moderate-to-very low, with evidence of inconsistency between direct and indirect evidence. Uncertainty in findings was high, in particular for chemical peels, photochemical and photodynamic therapies. However, conclusions were robust to potential bias in the evidence. CONCLUSIONS: Topical pharmacological treatment combinations, chemical peels and photochemical therapy were most effective for mild-to-moderate acne. Topical pharmacological treatment combinations, oral antibiotics combined with topical pharmacological treatments, oral isotretinoin, and photodynamic therapy were most effective for moderate-to-severe acne. Further research is warranted for chemical peels, photochemical and photodynamic therapies for which evidence was more limited.

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