Clinical Question

What are the most effective therapies for acne vulgaris?

Bottom Line

Oral isotretinoin was the most effective therapy for decreasing the number of lesions in patients with acne. However, oral isotretinoin is not considered first-line therapy. Topical retinoids and benzoyl peroxide combined with oral or topical antibiotics were comparably effective in achieving the assessment of treatment success. Another analysis suggested starting treatment with adapalene (Differin) plus benzoyl peroxide, clindamycin plus benzoyl peroxide, or adapalene alone. (Level of Evidence = 1a−)

Synopsis

The ambitious, data-laden network meta-analysis sought to identify the most effective therapies for a condition that many think of as trivial or a rite of passage for adolescents. However, the psychological and cosmetic impacts make acne vulgaris an important condition for primary care physicians to properly manage. The authors searched PubMed and Embase to identify randomized trials that assessed the effectiveness of therapies for acne. They included 210 papers with 65,601 patients. The median duration of the studies was 12 weeks (range = 2 to 48 weeks). The studies evaluated six oral antibiotics, five topical antibiotics, oral isotretinoin, five topical retinoids, six combined oral contraceptives, topical clascoterone (Winlevi), 10 combination therapies, benzoyl peroxide, azelaic acid, and placebo. The most common outcomes were disease-oriented inflammatory and noninflammatory lesion counts, but 69 studies reported the investigators' global assessment of success. No study reported patients' self-assessments. Overall, the studies were of decent quality. Oral isotretinoin was the most effective agent at decreasing the number of lesions (relative reduction = 48.4%), followed by combination therapy (i.e., oral antibiotic, topical retinoid, and benzoyl peroxide; relative reduction = 38.2%). For patients with inflammatory lesions, oral isotretinoin was also the most effective (relative reduction = 54.2%), followed by a combination of topical antibiotics plus azelaic acid (relative reduction = 43.6%). The effectiveness of combined oral contraceptives was inconsistent, possibly due to studies that included patients without hormonally sensitive acne. Using the investigators' assessment of treatment success, topical retinoids and benzoyl peroxide combined with oral or topical antibiotics were comparable (odds ratio = 6.04 and 6.76, respectively). Patients taking topical trifarotene (Aklief) had the greatest odds of discontinuing treatment due to adverse events (odds ratio = 11.4). There were moderate to high degrees of heterogeneity among the data (I² range = 61% to 79%). There was no strong evidence of publication bias.