Further acne treatment studies necessary: Experts

By Dr. Ananya Mandal, MDAug 31 2011

Researchers writing in the journal The Lancet suggest further research that is urgently needed for effective non-antibiotic treatments for acne, because of concerns regarding long-term antibiotic use and its contribution to bacterial resistance. Pharmacies are well stocked with a wide range of acne medications. However, evidence regarding their efficacy and which treatments work best for whom are limited, the authors added.

Leading author Hywel Williams from the Centre of Evidence-Based Dermatology at University of Nottingham in Nottingham, UK explains, “The large number of products and product combinations, and the scarcity of comparative studies, has led to disparate guidelines with few recommendations being evidence-based.”

Authors write that guidelines including recent ones and those from the Global Alliance to Improve Outcomes in Acne and the American Academy of Dermatology are solely based on the opinion of experts. This raises concern due to potential conflicts of interest without evidence to support practice recommendations.

Relatively little knowledge exists about causes and treatments of acne, despite the fact, that nearly all young people suffer it to some degree. Even though factors, such as diet, sunlight and skin hygiene have been associated with the condition, there is no supportive evidence. 
The seminar revealed that, “Almost half of recently published acne trials contain serious flaws that could be overcome by better reporting. . . . The absence of trials with active comparators is a significant handicap to shared clinical decision making. Clinical trials of cost-effectiveness of different strategies for initial treatment and maintenance therapy of acne are needed.”

The IOM (Institute of Medicine), USA, would like more comparative studies on acne medications and therapies as one of the top 100 targets for national research. The IOM says that the lack of extensive studies makes it difficult for doctors to know what to say for their patients. Patients also risk wasting a lot of time and money on ineffective therapies.

Long-term low-dose antibiotic usage may lead to the proliferation of antibiotic-resistant bacteria. The authors suggest using benzoyl peroxide as an alternative maintenance treatment, which may be equally effective and to restrict the use of antibiotics.

In a concluding statement, the authors emphasize the need for new research into the comparative effectiveness of common topical and systemic therapies and to improve knowledge of the natural history, specific types, and triggers of acne together with how treatment affects the course of this disease which is not well understood.

Medications, including retinoids, bezoyl peroxide, topical dapsone, hormonal medications like birth control pills and antibiotics, are the most common treatments for varying degrees of acne. Experts have discouraged doctors in recent years from prescribing long-term antibiotics for treatment out of fear that patients will develop resistance to the medications.

But, Dr. Kevin Cooper, professor and chair of dermatology at University Hospitals Case Medical Center in Cleveland, defended the research of many over-the-counter and prescribed acne-fighting products. “There are many clinical trials published which demonstrate that the treatment being studied is better than placebo and has reasonable or minimal side effects,” said Cooper. “This is necessary to obtain FDA approval of the medication or the medication combination. In some cases the company may have compared the combination against the individual ingredients alone.” The study's reference to “lack of research,” refers to comparative effectiveness research, where two competitive products are tested head-to-head to see if one is better than the other, Cooper noted.

While the best scientific evidence for most kinds of research comes from double-blind, prospective, randomized, placebo-controlled trials, Dr. John Messmer, associate professor of family and community medicine at Penn State Hershey College of Medicine, noted that those “are hard to do with acne.”

Acne is the most common skin disorder in the United States, affecting 40 to 50 million Americans according to the American Academy of Dermatology, and is usually caused by three common occurrences: the overproduction of oil, blockage of hair follicles that release oil and growth of bacteria within the follicles. Almost all teenagers will suffer from at least a mild acne, and about 40 to 60 percent of adults well into their 20s and 30s will suffer from some acne, according to a 2001 German study published in the British Journal of Dermatology.