The efficacy and safety of minocycline, metronidazole, ivermectin, and azelaic acid in moderate-to-severe papulopustular rosacea: A systematic review and network meta-analysis.

BACKGROUND

There are multiple topical agents for papulopustular rosacea (PPR), but the most effective for the management of moderate-to-severe PPR remains unknown.

OBJECTIVE

To compare the efficacy and safety of topical agents for moderate-to-severe PPR.

METHODS

Medline, Embase, and CENTRAL databases were searched. The efficacy of topical agents was explored through frequentist network meta-analysis using random-effects model. Treatments were ranked using net rank function, yielding P scores.

RESULTS

Nineteen randomized control trials (RCTs) that enrolled and 8208 participants were deemed eligible. Azelaic acid 20% yielded the highest effect size (OR = 8.54, 95% CI: 2.48-29.45) and highest P-score (P score = 0.97) with respect to improvement in investigator global assessment (IGA) score. Azelaic acid 15%, Metronidazole 0.75%, and Ivermectin 1% yielded comparable effect sizes. Azelaic acid 15% yielded statistically significant odds ratio (OR = 1.95, 95% CI: 1.30-2.93, P score = 0.14) for adverse events. Adverse event risk for other topical agents was not significant.

LIMITATION

The sample size was limited for some of the topical agents. Also, many clinically important outcomes were overlooked by most of the included RCTs.

CONCLUSION

Azelaic acid 20% was the most effective in improving IGA score for moderate-to-severe PPR and azelaic acid 15% as having the highest adverse event profile.