Among patients with severe acne that is refractory to conventional treatments, tumor necrosis factor-α inhibitors (TNFis) are effective with low rates of adverse events, although they also can be associated with the occurrence of acne. These are among the study findings published in JAMA Dermatology.
Researchers conducted a systematic review to evaluate the use of TNFis in the treatment and occurrence of acne and followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline checklist.
Eligible studies included those in which participants who received TNFi treatment for acne or developed acne in response to TNFi therapy for another condition. A systematic literature search of relevant studies was performed in PubMed and Web of Science from inception through October 17, 2022.
A total of 53 articles that reported individual clinical data from 64 participants were included in the final analysis. Use of TNFis for acne treatment was reported in 39 studies with 47 patients, who were grouped based on whether acne manifested in an inflammatory syndrome.
The 17 participants without an inflammatory syndrome had a mean (SD) age of 28.8 (15.8) years, and all were boys or men. Nearly all patients were previously prescribed antibiotics or isotretinoin. A majority of the participants had either partial improvement (53% [n=9]) or clearance (41% [n=7]), with no adverse effects. A participant in each TNFi treatment group was in remission without treatment for an extended period.
The participants who had acne as part of a syndrome were a mean (SD) age of 24.2 (10.6) years, and 90 (n=30) were men. Fewer of these participants were previously prescribed antibiotics or isotretinoin vs those in the acne-alone group. Most also had partial improvement (53% [n=16]) or clearance (40% [n=12]). Use of etanercept was associated with hyperuricemia in 2 participants and pyoderma gangrenosum in 1 participant, which resolved after switching to infliximab. Also, 1 participant switched from infliximab to adalimumab due to lack of efficacy.
Of the 14 studies with 17 participants in which TNFis therapy was followed by the occurrence of acne, the participants were a mean (SD) age of 36.6 (12.8) years, and 64.7% (n=17) were men. The diseases for which TNFis were most frequently prescribed were Crohn disease, followed by psoriasis or rheumatologic disorders, with 1 participant reporting a history of acne. Acne occurrence was commonly associated with treatment discontinuation of TNFis (47.1% [n=8]), addition of other medications for acne, such as oral antibiotics or adapalene (29.4% [n=5]), or change in infusion frequency (5.9% [n=1]). A positive dechallenge or rechallenge response with etanercept occurred in 1 participant, suggesting an association, and another patient switched from infliximab to adalimumab without acne recurrence.
Limitations of the analysis include the fact that most cases of TNFis used to treat acne were boys or men, which may limit the generalizability of the results. Other limitations include potential publication bias, lack of standardized reporting methods, and small sample sizes.
“The results of this systematic review suggest that while TNFis can be an effective treatment for refractory acne, they also have the potential to induce acne, highlighting the association between TNFis and acne,” conclude the researchers.
Disclosure: One of the study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.
Sandoval AGW, Vaughn LT, Huang JT, Barbieri JS. Role of tumor necrosis factor–α inhibitors in the treatment and occurrence of acne: a systematic review. JAMA Dermatol. Published online March 17, 2023. doi:10.1001/jamadermatol.2023.0269