Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational & Health Psychology, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK.
National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK.
Br J Dermatol. 2022 Nov;187(5):639-649. doi: 10.1111/bjd.21739. Epub 2022 Aug 22.
Various treatments for acne vulgaris exist, but little is known about their comparative effectiveness in relation to acne severity.
To identify best treatments for mild-to-moderate and moderate-to-severe acne, as determined by clinician-assessed morphological features.
We undertook a systematic review and network meta-analysis of randomized 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 discontinuation owing to side-effects. Risk of bias was assessed using the Cochrane risk-of-bias tool and bias adjustment models. Effects for treatments with ≥ 50 observations each compared with placebo are reported below.
We included 179 RCTs with approximately 35 000 observations across 49 treatment classes. For mild-to-moderate acne, the most effective options for each treatment type were as follows: topical pharmacological - combined retinoid with benzoyl peroxide (BPO) [mean difference 26·16%, 95% credible interval (CrI) 16·75-35·36%]; physical - chemical peels, e.g. salicylic or mandelic acid (39·70%, 95% CrI 12·54-66·78%) and photochemical therapy (combined blue/red light) (35·36%, 95% CrI 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 well tolerated than placebo. For moderate-to-severe acne, the most effective options for each treatment type were as follows: topical pharmacological - combined retinoid with lincosamide (clindamycin) (44·43%, 95% CrI 29·20-60·02%); oral pharmacological - isotretinoin of total cumulative dose ≥ 120 mg kg per single course (58·09%, 95% CrI 36·99-79·29%); physical - photodynamic therapy (light therapy enhanced by a photosensitizing chemical) (40·45%, 95% CrI 26·17-54·11%); combined - BPO with topical retinoid and oral tetracycline (43·53%, 95% CrI 29·49-57·70%). Topical retinoids and oral tetracyclines were less well tolerated than placebo. The 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 therapy and photodynamic therapy. However, conclusions were robust to potential bias in the evidence.
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 therapy and photodynamic therapy for which evidence was more limited. What is already known about this topic? Acne vulgaris is the eighth most common disease globally. Several topical, oral, physical and combined treatments for acne vulgaris exist. Network meta-analysis (NMA) synthesizes direct and indirect evidence and allows simultaneous inference for all treatments forming an evidence network. Previous NMAs have assessed a limited range of treatments for acne vulgaris and have not evaluated effectiveness of treatments for moderate-to-severe acne. What does this study add? For mild-to-moderate acne, topical treatment combinations, chemical peels, and photochemical therapy (combined blue/red light; blue light) are most effective. For moderate-to-severe acne, topical treatment combinations, oral antibiotics combined with topical treatments, oral isotretinoin and photodynamic therapy (light therapy enhanced by a photosensitizing chemical) are most effective. Based on these findings, along with further clinical and cost-effectiveness considerations, National Institute for Health and Care Excellence (NICE) guidance recommends, as first-line treatments, fixed topical treatment combinations for mild-to-moderate acne and fixed topical treatment combinations, or oral tetracyclines combined with topical treatments, for moderate-to-severe acne.
各种痤疮的治疗方法都有，但对于根据临床医生评估的形态特征与痤疮严重程度相关的治疗方法的比较效果知之甚少。
确定轻度至中度和中度至重度痤疮的最佳治疗方法，这些方法是根据临床医生评估的形态特征来确定的。
我们对截至 2020 年 5 月评估轻度至中度和中度至重度痤疮的局部药理学、口服药理学、物理和联合治疗的随机对照试验（RCT）进行了系统评价和网络荟萃分析。结果包括总病变计数从基线的变化百分比、任何原因的治疗停药和因副作用停药。使用 Cochrane 偏倚风险工具和偏倚调整模型评估偏倚风险。与安慰剂相比，每种治疗方法的治疗效果均在观察到≥50 例的情况下进行了报告。
我们纳入了 179 项 RCT，涉及 49 种治疗类别，大约有 35000 个观察结果。对于轻度至中度痤疮，每种治疗类型的最佳选择如下：局部药理学 - 联合维甲酸与过氧化苯甲酰（BPO）[平均差异 26.16%，95%可信区间（CrI）16.75-35.36%]；物理疗法 - 化学换肤，例如水杨酸或扁桃酸（39.70%，95%CrI 12.54-66.78%）和光化学疗法（联合蓝/红光）（35.36%，95%CrI 17.75-53.08%）。口服药理学治疗（例如抗生素、激素避孕药）在偏倚调整后似乎没有效果。BPO 和局部维甲酸的耐受性比安慰剂差。对于中度至重度痤疮，每种治疗类型的最佳选择如下：局部药理学 - 联合维甲酸与林可酰胺（克林霉素）（44.43%，95%CrI 29.20-60.02%）；口服药理学 - 总累积剂量≥120mg/kg 的异维 A 酸单疗程（58.09%，95%CrI 36.99-79.29%）；物理疗法 - 光动力疗法（光敏化学增强的光疗法）（40.45%，95%CrI 26.17-54.11%）；联合 - BPO 与局部维甲酸和口服四环素（43.53%，95%CrI 29.49-57.70%）。局部维甲酸和口服四环素的耐受性比安慰剂差。纳入 RCT 的质量为中等到非常低，证据显示直接证据和间接证据之间存在不一致。发现的不确定性很高，特别是对于化学换肤、光化学疗法和光动力疗法。然而，在证据中存在潜在偏倚的情况下，结论是稳健的。
局部药理学联合治疗、化学换肤和光化学疗法对轻度至中度痤疮最有效。局部药理学联合治疗、口服抗生素联合局部药理学治疗、口服异维 A 酸和光动力疗法对中度至重度痤疮最有效。对于化学换肤、光化学疗法和光动力疗法，证据更为有限，因此需要进一步研究。关于这个话题已经知道了什么？痤疮是全球第八大常见疾病。有几种局部、口服、物理和联合治疗痤疮的方法。网络荟萃分析（NMA）综合了直接和间接证据，并允许同时对形成证据网络的所有治疗方法进行推断。以前的 NMA 评估了有限范围的痤疮治疗方法，并且没有评估中重度痤疮治疗方法的有效性。本研究增加了哪些新内容？对于轻度至中度痤疮，局部治疗联合、化学换肤和光化学疗法（联合蓝/红光；蓝光）最有效。对于中重度痤疮，局部治疗联合、口服抗生素联合局部治疗、口服异维 A 酸和光动力疗法（光敏化学增强的光疗法）最有效。根据这些发现，以及进一步的临床和成本效益考虑，英国国家卫生与保健优化研究所（NICE）指南建议，对于轻度至中度痤疮，首选固定局部联合治疗；对于中度至重度痤疮，首选固定局部联合治疗或口服四环素联合局部治疗。
