Topical acne treatment combinations, chemical peels, and photochemical therapy are the most effective treatments for mild to moderate acne, according to data from a systematic review and network meta-analysis (NMA) published in the British Journal of Dermatology.

Investigators conducted a systematic review of randomized controlled trials (RCTs) of topical pharmacological, oral pharmacological, physical, and combined treatments for mild to moderate and moderate to severe acne vulgaris and performed separate analyses by acne severity. They also conducted separate analyses for men and women in the case of treatment with hormonal contraceptives. Patients of all ages were included except for those with neonatal acne.

Investigators only included drug classes and interventions available in the UK, and a fixed class effects model was used across analyses. All control groups were included under a broader “placebo” control class. Using NMA techniques, investigators analyzed 3 endpoints: efficacy, treatment discontinuation for any reason (acceptability), and treatment discontinuation due to side effects (tolerability).


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A total of 173 publications reporting on 179 RCTs were included in the NMA analysis, with 112 for mild to moderate acne and 67 for moderate to severe acne. RCTs for mild to moderate acne had small sample sizes and therefore had bias-adjusted results.

For mild to moderate acne, topical retinoids, benzoyl peroxide and their combination had higher rates of discontinuation due to side effects compared with placebo. Topical and physical treatments (chemical peels and photochemical therapy) showed efficacy compared with placebo. Among topical treatments, combinations with clindamycin, benzoyl peroxide with a retinoid, benzoyl peroxide with a macrolide, clindamycin with a retinoid, and a microlide with an antifungal showed greater efficacy compared with single topical treatments and placebo.

For moderate to severe acne (bias-adjusted analysis), topical retinoids alone or combine with oral tetracycline, oral cocyprindiol alone or combined with oral tetracycline, and oral tetracycline alone showed higher rates of discontinuation due to side effects compared with placebo. The most effective treatments included oral isotretinoin, oral tetracyclines combined with topical treatments (azelaic acid, retinoid, or combined retinoid with benzoyl peroxide), and topical treatment combinations. Photodynamic and photochemical therapies also showed efficacy compared with placebo. Monotherapies of oral tetracyclines or topical treatments had lower efficacy compared with combination treatments.

There was no evidence of an effect on treatment discontinuation for any reason by any treatment class compared with placebo at either acne severity level, investigators found. There was no evidence for the effectiveness of hormone-modifying agents; however, patients with polycystic ovary syndrome were excluded from the analysis.

The study was limited by the moderate-very low quality of evidence from the RCTs included in the analysis.

Despite limited evidence, the study authors wrote that azelaic acid combined with oral tetracycline was considered “a good alternative for people with moderate-to-severe acne who have irritation to topical retinoids,” and it also has a “possible side effect” which reduces the risk for hyperpigmentation in acne patients with darker skin.

Reference

Mavranezouli I, Daly CH, Welton NJ, et al. A systematic review and network meta-analysis of topical pharmacological, oral pharmacological, physical and combined treatments for acne vulgaris. Br J Dermatol. Published online July 5, 2022. doi:10.1111/bjd.21739