April 10, 2018
Journal of the European Academy of Dermatology and Venereology: JEADV
TAKE-HOME MESSAGE
Common nonpharmacological therapies for acne include laser/light-based therapies, chemical peels, and fractional radiofrequency microneedling. Although significant reductions in acne lesions were demonstrated in the majority of 33 studies, only 7 studies had a high methodologic quality. When a best-evidence synthesis was conducted of these 7 trials, strong evidence was found for glycolic acid (10%–40%) and moderate evidence was found for amino fruit acid (20%–60%), intense pulsed light (400–700 and 870–1200 nm), and the diode laser (1450 nm). Conflicting evidence was found for pulsed dye laser (585–595 nm).
Nonpharmacological therapies may be potential alternatives in the treatment of acne vulgaris, but further investigation with high methodological quality is needed.
– InYoung Kim, MD, PhD
Written by Hilary Baldwin MD
Written by Justin Marson
Application of nonpharmacological therapy for the treatment of acne vulgaris
De Vries et al conclude in their systematic review of nonpharmacologic therapies (NPTs) in the treatment of acne vulgaris that there is circumstantial evidence for their use.
As the authors noted, many of the current studies had at least one of the following problems: were underpowered, of insufficient duration, or inadequately blinded or did not have appropriate comparisons. A majority of the reported findings compared different forms of NPT with each other or (for light and laser) showed improvement over no therapy. Few studies have compared the efficacy of NPTs against or in conjunction with standard-of-care topical and oral regimens. As the authors have justly noted, more stringently designed studies are needed to determine the role of NPTs in the therapeutic armamentarium against acne.
In addition, there are also socioeconomic considerations with NPTs. Most of the results measured reflect the outcomes of “a predefined number of clinical assessment visits.” Furthermore, these repeated visits are often not covered by insurance. The burden of time and money may prove insurmountable to access these therapies.
As the authors have outlined, the adverse events associated with NPTs, most of which resolve within hours, are not dissimilar from those associated with pharmacological therapies—such as dryness, erythema, burning, and itching with topical retinoids and benzoyl peroxide—and NPTs are associated with even fewer adverse events than isotretinoin (without need for regular laboratory monitoring). Another major concern underlined by the authors involves development of resistance to antibiotics, a long-time standard of acne therapy. Although concurrent benzoyl peroxide use can partially address the issue, antibiotic stewardship cannot be forgotten, as a majority of oral therapy relies on only two antibiotics.
Given the paucity of new molecules, agents, or mechanisms of action, the recent failure of two promising medications in phase III trials, and no dramatic changes to the standard of care since the advent of isotretinoin in 1982, there is a serious need for novel, non-antibiotic therapies (with minimal adverse events) to treat acne.
Abstract
BACKGROUND
Acne vulgaris is a multifaceted skin disorder, affecting more than 85% of young individuals worldwide. Pharmacological therapy is not always desirable because of the development of antibiotic resistance or the potential risk of adverse effects. Non-pharmacological therapies can be viable alternatives for conventional therapies. However, sufficient evidence-based support in the efficacy and safety of non-pharmacological therapies is lacking.
OBJECTIVE
To assess the efficacy and safety of several non-pharmacological therapies in the treatment of acne vulgaris.
METHODS
A systematic literature review, including a best-evidence synthesis, was performed to identify literature. Three electronic databases were accessed and searched for studies published between January 2000 and May 2017.
RESULTS
Thirty-three eligible studies were included in our systematic review. Three main types of non-pharmacological therapies were identified laser- and light-based therapies, chemical peels and fractional microneedling radiofrequency. The majority of the included studies demonstrated a significant reduction in acne lesions. However, only seven studies had a high methodologic quality. Based on these seven trials, a best-evidence synthesis was conducted. Strong evidence was found for glycolic acid (10-40%). Moderate evidence was found for amino fruit acid (20-60%), intense pulsed light (400-700 and 870-1200 nm) and the diode laser (1450 nm). Initially, conflicting evidence was found for pulsed dye laser (585-595 nm). The most frequently reported side-effects for non-pharmacological therapies included erythema, tolerable pain, purpura, oedema and a few cases of hyperpigmentation, which were in most cases mild and transient.
CONCLUSION
Circumstantial evidence was found for non-pharmacological therapies in the treatment of acne vulgaris. However, the lack of high methodological quality among included studies prevented us to draw clear conclusions, regarding a stepwise approach. Nevertheless, our systematic review including a best-evidence synthesis did create order and structure in resulting outcomes in which a first step towards future research is generated.
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Journal Abstract