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Summary

  1. Top of page
  2. Summary
  3. Introduction
  4. Causes: mites
  5. Causes: diet, obesity and acne
  6. Effects: quality of life, self-esteem, mood and psychological disorders, and adolescent acne
  7. Treatments: topical
  8. Treatments: oral
  9. Treatments: other
  10. Implications for practice
  11. References
  12. CPD questions
  13. Learning objective
  14. Instructions for answering questions

This review summarizes important clinical developments in acne vulgaris identified from 17 systematic reviews published between February 2011 and August 2012. Regarding causes, Demodex mites have been shown to be associated with both acne vulgaris and rosacea, although it is unclear if their eradication improves either disease. Some weak evidence has emerged that suggests a possible link between dairy produce and acne, which warrants further research. With reference to the effects of acne, there is good evidence that acne negatively affects quality of life, self-esteem and mood in adolescents. Acne is also associated with an increased risk of anxiety, depression and suicidal ideation, highlighting the importance of asking patients with acne directly about psychological issues in order to identify those who might benefit from early psychiatric support. Regarding treatment, there seems to be no additional benefit to using higher strengths of benzoyl peroxide, and lower strengths such as 2.5% have fewer side effects. Despite earlier concerns of increased mortality in those using topical tretinoin for skin cancer prevention, a systematic review on this topic has not found any convincing evidence of a link between such non-cutaneous events and once-daily application of 0.02–0.05% tretinoin. Combined oral contraceptives are of benefit in both inflammatory and non-inflammatory acne. Current surveys suggest that implementation of the pregnancy prevention programme for isotretinoin may not be stringent, and a high level of monitoring and audit is recommended. Ablative and non-ablative laser resurfacing for the treatment of acne scars may be beneficial, but further studies with a longer follow-up period are required.


Introduction

  1. Top of page
  2. Summary
  3. Introduction
  4. Causes: mites
  5. Causes: diet, obesity and acne
  6. Effects: quality of life, self-esteem, mood and psychological disorders, and adolescent acne
  7. Treatments: topical
  8. Treatments: oral
  9. Treatments: other
  10. Implications for practice
  11. References
  12. CPD questions
  13. Learning objective
  14. Instructions for answering questions

This paper summarizes the important systematic reviews dealing with acne, which were indexed in bibliographic databases from February 2011 to August 2012, and included in the full 2012 Annual Evidence Update on Acne Vulgaris, which can be found on the Centre of Evidence Based Dermatology website (http://www.nottingham.ac.uk/research/groups/cebd/index.aspx). Full details of the databases searched along with search terms and excluded studies are to be found there.

Compared with the 2011 acne update, which found only 5 systematic reviews, 17 reviews were identified for the period covered in this paper. Three previous annual evidence updates on acne have been published previously in Clinical and Experimental Dermatology.[1-3] These updates aim to identify important new systematic reviews to pick out clinically important points that may help inform the busy clinician.

Causes: mites

  1. Top of page
  2. Summary
  3. Introduction
  4. Causes: mites
  5. Causes: diet, obesity and acne
  6. Effects: quality of life, self-esteem, mood and psychological disorders, and adolescent acne
  7. Treatments: topical
  8. Treatments: oral
  9. Treatments: other
  10. Implications for practice
  11. References
  12. CPD questions
  13. Learning objective
  14. Instructions for answering questions

Demodex mites are normal colonizers of the skin around the sebaceous glands, and these mites have been associated with several other skin conditions, including rosacea. A systematic review aimed to confirm the link between Demodex and acne vulgaris.[4] Two English databases (MEDLINE and the Institute of scientific information Web of Knowledge) and one Chinese database (China National Knowledge Infrastructure) were searched, resulting in 60 Chinese and 3 English language papers that were then included in the analysis. Of these 63 studies, 43 found an association and 15 found no association. The pooled odds ratio (OR) of an association between Demodex infestation and the development of acne was significant at P = 2.80 (95% CI 2.34–3.36). Data were appropriately presented in forest plots, but there was too much emphasis on quantitative meta-analyses and not enough consideration on the effects of risk of bias of the included observational studies. The tentative finding of an association between Demodex and acne is not the same as claiming that Demodex is playing a causative role, but the review has opened the question as to whether Demodex eradication is worth exploring in acne treatment.

Causes: diet, obesity and acne

  1. Top of page
  2. Summary
  3. Introduction
  4. Causes: mites
  5. Causes: diet, obesity and acne
  6. Effects: quality of life, self-esteem, mood and psychological disorders, and adolescent acne
  7. Treatments: topical
  8. Treatments: oral
  9. Treatments: other
  10. Implications for practice
  11. References
  12. CPD questions
  13. Learning objective
  14. Instructions for answering questions

There has been an influx of studies examining the link between diet and acne over the past decade; the previously published 2010 Acne Evidence update had included one systematic review on the same topic. In a further systematic review in the 2011–2012 update, a PubMed search of articles published in English yielded 23 studies.[5] The papers included were minimally critiqued, and based on objectively limited evidence. The authors concluded that ‘for now, an acne patient could be advised to limit diary intake while supplementing his/her diet with calcium and vitamin D’. However, results should be treated with caution as recommendations were being made on limited observational evidence, which highlights the need to explore the relationship between dairy products or other dietary factors, such as glycaemic load and acne in better longitudinal studies.

Effects: quality of life, self-esteem, mood and psychological disorders, and adolescent acne

  1. Top of page
  2. Summary
  3. Introduction
  4. Causes: mites
  5. Causes: diet, obesity and acne
  6. Effects: quality of life, self-esteem, mood and psychological disorders, and adolescent acne
  7. Treatments: topical
  8. Treatments: oral
  9. Treatments: other
  10. Implications for practice
  11. References
  12. CPD questions
  13. Learning objective
  14. Instructions for answering questions

This important area has lacked systematic reviews, so it was pleasing to see two. The first searched just one database for studies on the psychological effects of acne in adolescents;[6] 16 studies were deemed appropriate for inclusion and of these, 5 dealt with quality of life (QOL), 4 with self-esteem, 2 with personality and mood, and 5 with psychological disorders. The studies were not critiqued individually, and meta-analysis was not possible because of the large variations in study design. The authors concluded that there was good evidence that acne can negatively affect QOL, self-esteem and mood in adolescents, and that acne is associated with an increased risk of anxiety, depression and suicidal ideation. They also concluded that treatment with isotretinoin qualitatively decreases depressive symptoms and improves QOL.

The second study had a more robust search (MEDLINE, PsychINFO, EMBASE and CINHAL were all searched) and stricter inclusion criteria.[7] There was no clear question, and the methodology was not completely transparent. One cohort study and seven cross-sectional studies were identified, confirming that patients with acne have higher levels of depressive symptoms, low self-esteem and reduced QOL compared in to patients without acne.

Despite their flaws, these studies highlight the need for investigations into potential psychological disturbance in patients with acne so that appropriate interventions can be initiated.

Treatments: topical

  1. Top of page
  2. Summary
  3. Introduction
  4. Causes: mites
  5. Causes: diet, obesity and acne
  6. Effects: quality of life, self-esteem, mood and psychological disorders, and adolescent acne
  7. Treatments: topical
  8. Treatments: oral
  9. Treatments: other
  10. Implications for practice
  11. References
  12. CPD questions
  13. Learning objective
  14. Instructions for answering questions

Benzoyl peroxide concentrations

The authors of this review compared different strengths (2.5%, 5% and 10%) of benzoyl peroxide.[8] They searched PubMed, EMBASE and Science Citation Index, and included 10 studies overall. The methodology was incompletely reported. The authors concluded that, as with previous reviews of this topic, there was no justification for using the higher strengths of benzoyl peroxide, and that the 2.5% strength may have a better side-effect profile.[9]

The efficacy of products containing benzoyl peroxide

A systematic review aimed to summarize the effectiveness of products containing benzoyl peroxide.[10] The authors used a thorough and stringent search strategy, which was well documented. However, there was no clear conclusion, and the one provided was contradictory, given the results that were presented. The review added little other than to confirm the efficacy of benzoyl peroxide in treating acne.

Topical antimicrobial treatment of acne

A systematic review published in 2012 addressed topical antimicrobial treatments in general, and which treatment should be used in which situation.[11] A thorough search was undertaken in MEDLINE, EMBASE and the Cochrane Collection. A combination of benzoyl peroxide and adapalene was deemed most efficacious. Although the systematic review was funded by the UK government, we note that one of the authors had previously received an unrestricted grant from a company that makes a benzoyl peroxide/adapalene combination product. Like the review on topical clindamycin and benzoyl peroxide (below), this review supports the notion that combination products work better than monotherapy, and that further independent comparative effectiveness studies are needed.

Combination of topical clindamycin with 2.5% or 5% benzoyl peroxide

A systematic review used data from PubMed and the US Food and Drug Administration (FDA) to compare a combination of 2.5% benzoyl peroxide and clindamycin with a combination of 5% benzoyl peroxide and clindamycin.[12] The authors found that in the 16 included randomized controlled trials (RCTs), the 2.5% benzoyl peroxide/clindamycin group had a greater absolute reduction in lesion count reduction compared with the group treated with 5% benzoyl peroxide/clindamycin. One of the authors worked for Stiefel, which produces the 2.5% benzoyl peroxide/clindamycin combination product. In addition, methods of blinding and randomization of individual studies were not described in the review, nor was any consideration given to the importance of intention-to-treat analysis. Although like other previous reviews, this review had some shortcomings, it does suggest that topical combination products are more effective than monotherapies in acne.[3]

Fixed combination treatment and topical retinoids in the treatment of acne

A systematic review sought to answer the question of whether topical fixed combination products or monotherapy with topical retinoids are a more efficient choice.[13] Only one database was searched. All but one of the studies found fixed combination therapy to be more effective than retinoid monotherapy for inflammatory lesions. Editorial support was provided by a company that produces a fixed combination product but not a topical retinoid, so results should be interpreted with caution. Further work to answer this question is needed.

Topical tretinoin and non-cutaneous adverse events

The aim of the 2005 Veterans Affairs Topical Tretinoin Chemoprevention (VATTC) trial was to investigate if topical tretinoin could prevent non-melanoma skin cancer.[14] The trial was terminated early because of a higher mortality rate in the active group compared with the control group, a result that caused much discussion as to whether this was a real effect or not.[15] A systematic review therefore investigated the noncutaneous adverse effect of topical tretinoin prior to the VATCC trial. EMBASE and MEDLINE were searched, and the authors found that overall there was no evidence of increased mortality from noncutaneous adverse events prior to the VATTC trial. The included studies were limited by the shorter follow-up time (24 months vs. 72 in the VATTC trial), the lower strength of tretinoin (0.02–0.05% vs. 0.1% in the VATTC trial), and the fact that the VATTC trial used a twice-daily application regimen compared with the once-daily regimen used in all of the included studies. The mean age of participants was 71 years in the VATTC study and 44 years in the studies included in the systematic review. This systematic review therefore did not find any evidence to support the findings of the VATTC trial.

Treatments: oral

  1. Top of page
  2. Summary
  3. Introduction
  4. Causes: mites
  5. Causes: diet, obesity and acne
  6. Effects: quality of life, self-esteem, mood and psychological disorders, and adolescent acne
  7. Treatments: topical
  8. Treatments: oral
  9. Treatments: other
  10. Implications for practice
  11. References
  12. CPD questions
  13. Learning objective
  14. Instructions for answering questions

Minocycline for acne

This was an update of a previous Cochrane systematic review investigating use of minocycline in acne.[16] No new conclusions were drawn; minocycline is effective in moderate to severe acne, but it has no superiority to other commonly used therapies. Minocycline is associated with a lupus-like reaction, and also has a worse side-effect profile. It has a more rapid onset of action, but this efficacy is not sustained and the treatment effect does not last longer than that of other tetracyclines.

Combined oral contraceptive pills for the treatment of acne

The authors of this Cochrane review update investigated combined oral contraceptives (COCs).[17] Six new trials were found, giving a total of 31. No new conclusions were drawn; COCs are effective in the treatment of both noninflammatory and inflammatory acne, and there was no evidence that COCs containing cyproterone were more effective than other COCs for acne. More trials comparing COCs are needed, and also trials comparing COCs with other topical and oral treatments.

Compliance of isotretinoin pregnancy prevention programmes in Europe

A systematic review investigated the adherence to a pregnancy prevention programme (PPP) when using isotretinoin in Europe.[18] EMBASE and MEDLINE were searched, and 17 studies of varying design were included. All studies found that implementation of the PPP was not stringent, and the authors concluded that to improve safety, a number of modifications and a greater level of monitoring are required.

Spironolactone for acne

This review investigated the use of spironolactone for acne, and found only one study of 29 patients (8 of whom withdrew), which did not show any evidence of effect.[19]

Treatments: other

  1. Top of page
  2. Summary
  3. Introduction
  4. Causes: mites
  5. Causes: diet, obesity and acne
  6. Effects: quality of life, self-esteem, mood and psychological disorders, and adolescent acne
  7. Treatments: topical
  8. Treatments: oral
  9. Treatments: other
  10. Implications for practice
  11. References
  12. CPD questions
  13. Learning objective
  14. Instructions for answering questions

Fractional laser resurfacing for acne scars

A systematic review compared ablative and nonablative fractionated photothermolysis (FP) in treating acne scars.[20] PubMed and Scopus were searched, and 26 studies were identified, only 4 of which were split-face RCTs. Collation of studies proved difficult because of variations in trial design, but the individual studies were critiqued appropriately. The authors found that there was a short-term improvement in acne scars with both treatments based on both subjective and objective measurements, with an improvement range of 26–83% for ablative and 26–50% for nonablative FP. This was the first review to evaluate FP lasers, so it was an overall useful insight. It summarizes the key side effects of this technique, and highlights the need for future studies with a longer follow-up period to explore whether the short-term benefits are sustained.

Efficacy of superficial chemical peels in active acne management

Chemical peels are used in attempt to smooth out the skin surface and give an even skin tone.[21] Glycolic acid, salicylic acid and pyruvic acid are the main agents used. PubMed was searched between 1990 and 2009 in a systematic review by Dreno et al.; 13 RCTs or open-label studies were included and critiqued, and all 11 review authors declared a conflict of interest. Salicylic acid and glycolic acid had a significant benefit in the treatment of comedonal acne in four studies, with reduction of comedones ranging between 35–50%, although in the majority of these studies, participants were allowed to use other acne medications alongside the peels. The authors did not always specify if this reduction was in terms of appearance, lesion count or symptoms, which made interpretation difficult. It was concluded that peels were safe but there is little data to back this up. Further work is needed to investigate how peels compare with more traditional anti-acne medication, and if there is any synergistic effect.

Clinical evidence – skin disorders: acne vulgaris

This well-conducted review aimed to collate the evidence on topical and oral therapies used in acne vulgaris by searching EMBASE, MEDLINE, the US FDA alerts and the MRHA data.[22] In total, 69 studies were included, and the authors were able to make some useful recommendations such as the use of benzoyl peroxide monotherapy as first-line treatment in non-inflammatory acne. This is a useful independent, evidence-based, well-indexed reference guide for the busy clinician.

Implications for practice

  1. Top of page
  2. Summary
  3. Introduction
  4. Causes: mites
  5. Causes: diet, obesity and acne
  6. Effects: quality of life, self-esteem, mood and psychological disorders, and adolescent acne
  7. Treatments: topical
  8. Treatments: oral
  9. Treatments: other
  10. Implications for practice
  11. References
  12. CPD questions
  13. Learning objective
  14. Instructions for answering questions
  • Acne commonly bears a significant psychological burden and reduced QOL upon some patients, which needs to be elicited during an acne consultation.
  • There is no evidence of any clear benefit of minocycline over tetracyclines or other commonly prescribed acne medications, and some evidence that it may result in more harm.
  • COCs are an effective therapy in acne, but owing to a lack of comparative studies, there is no evidence of superiority of one type over the other or over other standard acne therapies.
  • Despite having a PPP in place for patients receiving isotretinoin, errors can still occur, and more effort should be directed at monitoring compliance with the programme.
  • There is currently no high-quality evidence for efficacy of spironolactone as an effective therapy for acne vulgaris.

References

  1. Top of page
  2. Summary
  3. Introduction
  4. Causes: mites
  5. Causes: diet, obesity and acne
  6. Effects: quality of life, self-esteem, mood and psychological disorders, and adolescent acne
  7. Treatments: topical
  8. Treatments: oral
  9. Treatments: other
  10. Implications for practice
  11. References
  12. CPD questions
  13. Learning objective
  14. Instructions for answering questions

Learning objective

  1. Top of page
  2. Summary
  3. Introduction
  4. Causes: mites
  5. Causes: diet, obesity and acne
  6. Effects: quality of life, self-esteem, mood and psychological disorders, and adolescent acne
  7. Treatments: topical
  8. Treatments: oral
  9. Treatments: other
  10. Implications for practice
  11. References
  12. CPD questions
  13. Learning objective
  14. Instructions for answering questions

To become familiar with the evidence relating to the pathogenesis and treatment of acne vulgaris.

Question 1

Which tetracycline is associated with a lupus-like reaction?

  1. a)
    Lymecycline.
  2. b)
    Minocycline.
  3. c)
    Oxytetracycline.
  4. d)
    Demeclocycline hydrochloride.
  5. e)
    Doxycycline.

Question 2

Which oral contraceptive is the most advantageous in treating female patients with acne vulgaris?

  1. a)
    Drospirenone 3 mg, ethinyloestradiol 30 μg (Yasmin).
  2. b)
    Cyproterone acetate 2 mg (Dianette).
  3. c)
    Desogestrel 750 μg (Cerazette).
  4. d)
    Levonorgestrel 1500 μg, ethinyloestradiol 300 μg (Microgynon).
  5. e)
    None of the above.

Question 3

Which food item may be associated with worsening acne vulgaris?

  1. a)
    Acidic fruit.
  2. b)
    Fava beans.
  3. c)
    Dairy.
  4. d)
    Soya beans.
  5. e)
    Seafood.

Question 4

Demodex is:

  1. a)
    A parasite.
  2. b)
    A bacterium.
  3. c)
    A fungus.
  4. d)
    A virus.
  5. e)
    None of the above.

Question 5

Recommended benzoyl peroxide strength is:

  1. a)
    2.5%.
  2. b)
    5%.
  3. c)
    7.5%.
  4. d)
    10%.
  5. e)
    None of the above.

Instructions for answering questions

  1. Top of page
  2. Summary
  3. Introduction
  4. Causes: mites
  5. Causes: diet, obesity and acne
  6. Effects: quality of life, self-esteem, mood and psychological disorders, and adolescent acne
  7. Treatments: topical
  8. Treatments: oral
  9. Treatments: other
  10. Implications for practice
  11. References
  12. CPD questions
  13. Learning objective
  14. Instructions for answering questions

This learning activity is freely available online at http://www.wileyhealthlearning.com/ced.

Users are encouraged to

  • Read the article in print or online, paying particular attention to the learning points and any author conflict of interest disclosures
  • Reflect on the article
  • Register or login online at www.wileyhealthlearning.com/ced and answer the CPD questions
  • Complete the required evaluation component of the activity

Once the test is passed, you will receive a certificate and the learning activity can be added to your RCP CPD diary as a self-certified entry.