Research into acne treatments lacking

Acne is a chronic disease which can be painful and disfiguring. Many treatments are publicised as cures for acne, often at considerable expense to the sufferer and the healthcare system.

A new clinical review by experts at The University of Nottingham says there is very little research evidence to show which treatments work best and whether expensive treatments are any better than traditional ones.

The review, led by a team from the Centre for Evidence Based Dermatology (CEBD), at The University of Nottingham, along with colleagues from the University of Colorado, Denver, highlights that the long-term use of antibiotics to treat acne might also contribute to bacterial resistance. As a result they say there is an increasing urgency to test treatments and develop more effective non-antibiotic therapies. The results of their study are published online in The Lancet on Tuesday 30 August 2011.

Hywel Williams, Professor of Dermato-Epidemiology and Director of the CEBD said: "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. As a result, even recent guidelines (including those from the Global Alliance and the American Academy of Dermatology) are based on the opinion of experts. This is of concern because without evidence to support guidelines there is the potential for conflicts of interest. What we would like to see is a great deal more comparative effectiveness research to help reduce the plethora of current therapeutic options for initiation and maintenance treatment."

Acne affects almost all young people to some degree, up to 20% of them are left with facial scarring. The condition can also persist into adulthood, so it needs to be considered as a chronic disease and not just something that clears up after a couple of years. Around 14% of patients with acne experience sufficient distress related to their facial appearance to be diagnosed the with psychological condition dysmorphobia – an excessive pre-occupation with an imaginary or minor defect in a facial feature or localised part of the body.

Relatively little is known about the causes of acne and the treatment for it. Factors such as family history, diet, sunlight, and skin hygiene have all been implicated, but supportive evidence is lacking. So acne sufferers may be going to great lengths to change their lifestyle for not reason at all. A recent study suggested that Western diets might play a role in the disease because of the apparent absence of acne in non-Westernised people in Papua New Guinea and Paraguay, but this has yet to be proven.

Professor Williams said: "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.

"This lack of well-conducted research to test over-the-counter and prescription therapies is putting patients at risk of ineffective treatment and makes treatment decisions for patients and doctors very difficult. This has prompted the Institute of Medicine in the USA to target comparative-effectiveness research on acne therapy as one of the top 100 targets for national research."

The study shows that there is also considerable concern that the overuse of antibiotics to treat acne will lead to the development of antibiotic resistance, especially if they are used for long periods at low doses. The authors suggest restricting the use of antibiotics as maintenance treatment because alternatives such as benzoyl peroxide may work just as well. In the distant future vaccines might hold some promise.

Professor Williams and his team are calling for new research into the comparative effectiveness of common topical and systemic therapies and to improve the understanding of the natural history, specific types, and triggers of acne, and how treatment affects the course of this poorly understood disease.

Professor Willliams said: "Acne has been dismissed as a trivial self-limiting teenage phase for too long. It is chronic condition with significant psychological effects at a critical time of a young person's development. Apart from isotretinoin, which can have some uncommon but serious side effects, I am not convinced that any of the other treatments actually clear acne. What is needed is a whole rethink about acne research into which treatments should be started first, how well do commonly used treatment compare against each other, which treatments should be used for maintaining control and which combinations are best."

(Source: University of Nottingham: The Lancet)