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Blue-Light Therapy for Acne Vulgaris: a Systematic Review and Meta-Analysis

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Blue-Light Therapy for Acne Vulgaris: a Systematic Review and Meta-Analysis Blue-Light Therapy for Acne Vulgaris: A Systematic Review and Meta-Analysis 1 Anna Mae Scott, PhD ABSTRACT 1 Paulina Stehlik, PhD PURPOSE Antibiotic use in acne treatment raises concerns about increased Justin Clark, BA1 resistance, necessitating alternatives. We assessed the effectiveness of blue-light therapy for acne. Dexing Zhang, PhD2 METHODS We analyzed randomized controlled trials comparing blue light with 3 Zuyao Yang, PhD nonlight interventions. Studies included people of any age, sex, and acne sever- Tammy Hoffmann, PhD1 ity, in any setting, and reported on investigator-assessed change in acne severity, 1 patients’ assessment of improvement, change in inflammatory or noninflamma- Chris Del Mar, MD tory lesions, and adverse events. Where data were sufficient, mean differences Paul Glasziou, PhD1 were calculated. 1Centre for Research in Evidence-Based RESULTS Eighteen references (14 trials) including 698 participants were included. Practice, Bond University, Robina, Most of the trials were small and short (<12 weeks) and had high risk of bias. Queensland, Australia Investigator-assessed improvement was quantitatively reported in 5 trials, of 2Division of Family Medicine and Primary which 3 reported significantly greater improvement in blue light than compara- Health Care, Jockey Club School of Public tor, and 2 reported improvement. Patients’ assessments of improvement were Health and Primary Care, The Chinese quantitatively reported by 2 trials, favoring blue light. Mean difference in the University of Hong Kong, Shatin, Hong mean number of noninflammatory lesions was nonsignificant between groups at Kong weeks 4, 8, and 10-12 and overall (mean difference [MD] = 3.47; 95% CI, -0.76 3Division of Epidemiology, Jockey Club to 7.71; P = 0.11). Mean difference in the mean number of inflammatory lesions School of Public Health and Primary Care, was likewise nonsignificant between groups at any of the time points and overall The Chinese University of Hong Kong, (MD = 0.16; 95% CI, -0.99 to 1.31; P = 0.78). Adverse events were generally mild Shatin, Hong Kong and favored blue light or did not significantly differ between groups. CONCLUSION Methodological and reporting limitations of existing evidence limit conclusions about the effectiveness of blue light for acne. Clinicians and patients should therefore consider the balance between its benefits and adverse events, as well as costs. Ann Fam Med 2019;17:545-543. https://doi.org/10.1370/afm.2445. INTRODUCTION Conflicts of interest: No funding or other material pproximately 50 million Americans have acne vulgaris1; it is the support was sought or received to perform this work eighth most prevalent disease globally2 and one of the most com- specifically; however, several of the authors (T.H., mon reasons for clinical consultations,3 including among primary C.D.M., P.G.) are recipients of funding from the A National Health and Medical Research Council care physicians and general practitioners (GPs). Among respondents to Centre for Research Excellence in Minimising the James Lind Alliance’s Acne Priority Setting Partnership survey, for Antimicrobial Resistance from Acute Respiratory example, 65% reported having sought help for acne from their GP or fam- Infections (CREMARA), within whose remit the ily doctor (higher than from a dermatologist, 45%; a pharmacist, 34%; or present review was conducted; 2 of the authors’ any other source).4 salaries (A.M.S., J.C.) are partially funded by CREMARA. Several effective pharmacological treatments for acne exist, such as topical benzyl peroxide and topical or oral retinoids and antibiotics. With antibiotics, however, there is increasing concern about the global CORRESPONDING AUTHOR development of resistance from the use of topical and oral antibiotics. Anna Mae Scott, PhD The incidence of resistance in Proprionibacterium acnes has been increasing: Centre for Research in Evidence-Based more than 50% of P acnes strains are resistant to erythromycin in Egypt, Practice, Bond University 14 University Drive France, Greece, Italy, Spain, and the United Kingdom and to clindamycin 5,6 Robina, QLD 4226, Australia in Egypt, Greece, Hong Kong, Italy, and Spain. This resistance not only [email protected] reduces the effectiveness of antibiotic treatment for acne but also can ANNALS OF FAMILY MEDICINE ✦ WWW.ANNFAMMED.ORG ✦ VOL. 17, NO. 6 ✦ NOVEMBER/DECEMBER 2019 ANNALS OF FAMILY MEDICINE ✦ WWW.ANNFAMMED.ORG ✦ VOL. 17, NO. 6 ✦ NOVEMBER/DECEMBER 2019 PB 545 BLUE LIGHT THERAPY spread to untreated contacts and hence affect greater Included Studies population antibiotic resistance patterns. We included randomized controlled trials of any Alternatives to antibiotics for acne treatment are design (eg, parallel, crossover), in which randomiza- thus desirable. One recent option is the use of various tion was by individual or by body part (eg, split face forms of light therapy, particularly blue-light therapy. studies); participants of any age, sex, and severity of Light in the 407- to 420-nm wavelength range has acne were included. Included studies investigated light been shown to have a bactericidal effect on P acnes.7 treatment of restricted wavelength, in which blue light The proposed mechanism is the excitation of bacterial was a major component. The comparator could be porphyrins (coproporphyrin III and protoporphyrin any intervention other than light (including placebo; IX) leading to the release of singlet oxygen and reac- topical agents such as retinoids, benzoyl peroxide, or tive free radicals that exert bactericidal effects.3,8 antibiotics; or oral antibiotics or isotretinoin). Nonran- The US Food and Drug Administration (FDA) has domized study designs were excluded. approved light-emitting diode (LED) devices (blue, The primary outcome was investigator-assessed red, and blue/red light devices) for at-home use,9 and change in acne severity. Secondary outcomes included the market for light therapy devices for acne is grow- patient’s global assessment of improvement, changes ing: the first device received FDA approval in 2009, in inflammatory lesions (papules, pustules, nodules), and 35 devices are on the market now.10 Patient inter- changes in noninflammatory lesions (open and closed est in these devices is correspondingly increasing, comedones), and adverse events. with “Which physical therapies, including lasers and other light-based treatments, are safe and effective in Search Strategy treating acne?” being the top acne treatment uncer- We searched PubMed, the Cochrane Central Register tainty identified by patients responding to the James of Controlled Trials (via Wiley), Embase (via Elsevier), Lind Alliance survey, at 35% of respondents.4 Given CINAHL (via EBSCO), and the Web of Science Core the increased availability over-the-counter treatments, Collection (via Clarivate Analytics) from inception patient interest, and decreasing price—as well as the to March 5, 2018; we searched the clinical trial reg- concerns about adverse events and antibiotic resis- istries (clinicaltrials.gov and the World Health Orga- tance caused by present treatments—interest is likely nization’s who.int) on August 7, 2018 (Supplemental to keep increasing. Appendix, available at http://www.AnnFamMed.org/ Application of blue light does require consider- content/17/6/545/suppl/DC1/). We also did forward able commitment by the user, however, with typical and backward citation searches of the included studies at-home devices being used twice a day for 30 to 60 (on August 7, 2018). No date or language restrictions minutes for 4 to 5 weeks. Therefore, evidence of the were applied. size and sustainability of any effect would be impor- tant to potential users. A 2016 Cochrane review of Screening and Data Extraction all types of light therapy for acne found 71 trials, Screening of the literature was conducted by 2 authors with little evidence for most, but low certainty of evi- independently, first by title/abstract and subsequently dence for green or blue lights.11 Further trials of blue in full text. Discrepancies were resolved by consensus light have been published since, however. We there- or referring to a third author if necessary. Three data fore undertook a systematic review of randomized extraction forms were predesigned and piloted for this controlled trials examining the effects of blue-light review: Table of Characteristics form, Primary and Sec- therapy for acne compared with any other nonlight ondary Outcomes data form, and Risk of Bias form. Data therapy, in people of any age, sex, and acne sever- from included studies were extracted independently in ity. The present systematic review will also underpin pairs into the data extraction forms. Discrepancies were a proposed entry for blue-light therapies for acne in resolved by discussion or by reference to a third author. the Handbook of Non-Drug Interventions (HANDI), which aims to promote effective nondrug treatments for gen- Risk of Bias eral practice or primary care.12 The risk of bias was assessed with the Cochrane Col- laboration’s Risk of Bias tool,13 by 2 authors indepen- dently, with discrepancies resolved by discussion. METHODS Protocol Statistical Analysis The protocol for this systematic review was registered A meta-analysis was conducted where data were suffi- on PROSPERO: http:// www. crd. york. ac. uk/ PROSPERO/ cient to pool. The results are presented as mean differ- display_ record. php? ID=CRD42018090053. ences with 95% CIs via a random effects model; there ANNALS OF FAMILY MEDICINE ✦ WWW.ANNFAMMED.ORG
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