Taipei, Taiwan—Most of the estimated $5 billion market for acne treatment products is spent on OTC products, but the cost of prescription medications also is significant. The skin condition affects more than 50 million people in the United States each year, according to the American Academy of Dermatology.

The question with pharmacologic treatment is a straightforward one: What works? A new study published in Annals of Family Medicine sought to answer that question.

National Taiwan University Hospital researchers and colleagues reviewed randomized, controlled trials comparing the efficacy of pharmacologic therapies for acne vulgaris in patients of any age and sex and with a treatment duration of at least 2 weeks. The study team searched PubMed and Embase databases from inception until February 2022. Prespecified primary endpoints included mean percentage reduction in total, inflammatory, and noninflammatory lesions.

The analysis included 210 articles describing 221 trials and 37 interventions, with more than 65,000 patients involved in the studies. Across all trials, the mean age was 20.4 years, the median duration of treatment was 12 weeks, and the median total, inflammatory, and noninflammatory lesion counts were 72, 27, and 44, respectively.

The study found that the most effective treatment was oral isotretinoin (mean difference [MD] = 48.41; P = 1.00), followed by triple therapy containing a topical antibiotic, a topical retinoid, benzoyl peroxide (BPO; MD = 38.15; P = .95), and by triple therapy containing an oral antibiotic, a topical retinoid, and BPO (MD = 34.83; P = .90).

In terms of monotherapies, the authors advised that “oral or topical antibiotics or topical retinoids have comparable efficacy for inflammatory lesions, while oral or topical antibiotics have less effect on noninflammatory lesions.”

The authors wrote that their network meta-analysis is the largest study to date providing broad and detailed comparative efficacy of pharmacologic interventions in acne vulgaris based on the reduction of inflammatory or noninflammatory acne lesions.

“Oral isotretinoin is the most effective treatment, followed by combination therapies consisting of an oral or topical antibiotic, topical retinoid, and BPO,” they pointed out. “In general, oral antibiotics, topical antibiotics, and topical retinoids as monotherapies have comparable efficacy on inflammatory lesion counts. For noninflammatory lesions, topical retinoids are significantly more effective, and oral antibiotics alone are inadequate treatments.”

They added that the efficacies of different combined oral contraceptives are usually modest, adding, “The combination of a topical retinoid and BPO is at least equally effective as an oral antibiotic with a topical retinoid in reducing inflammatory lesion counts. This information may change treatment strategies by reducing the need of oral antibiotic treatment in inflammatory acne, thus minimizing the risk of antibiotic resistance.”

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