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NG198 Evidence Review E1

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NG198 Evidence Review E1 1 2 Research recommendations for review question: For people with mild to 3 moderate acne vulgaris what are the most effective treatment options? 4 Research question - physical modalities 5 What is the effectiveness of physical modalities (such as light devices) in the treatment of 6 acne vulgaris or persistent acne vulgaris-related scarring? 7 Why this is important 8 Physical treatments for acne are popular with people because they have the benefit of 9 treating a local area without systemic effects. They can be used in people with co-morbidities 10 or side effects where other treatments are unsuitable. They are currently available in the 11 private sector but there is no standardisation of treatment modalities or duration. Many 12 different physical therapies have been described for acne including: 13 • Comedone extraction 14 • Phototherapy – including UVB, intense pulsed light, blue and red light 15 • Photochemical therapy (e.g. photodynamic therapy) 16 • Laser 17 • Photopneumatic therapy (e.g. intense pulsed light + vacuum) 18 • Photothermal therapy (eg gold nanoparticles +light or laser) 19 Physical treatments are also used for acne scarring. These include: 20 • Punch excision 21 • CO2 laser 22 • Dermabrasion 23 • Radiofrequency (e.g. fractional microneedling, bipolar) 24 Further research is required to determine the most effective physical treatments for acne and 25 acne scarring. This could open the way to wider availability in the NHS. 26 Table 26: Research recommendation rationale Research question What is the effectiveness of physical modalities (such as light devices) in the treatment of acne vulgaris or persistent acne vulgaris-related scarring? Why is this needed Importance to ‘patients’ or the Physical treatments for acne are popular with people because population they have the benefit of treating a local area without systemic effects. They can be used in people with co-morbidities or side effects where other treatments are unsuitable. There is evidence from small studies that physical therapies including various light sources with or without addition of chemical or physical photosensitiser may be effective in all grades of acne. There is also some evidence to support CO2 laser treatment for acne scarring. However, the studies are too small or of insufficient quality to allow recommendations to be made. Relevance to NICE guidance Currently physical treatments for acne vulgaris cannot be recommended. Weak recommendation can be made for CO2 laser for acne scarring, but stronger evidence is required to allow a stronger recommendation. which would lead to wider availability on NHS. 390 Acne Vulgaris: evidence reviews for management options for people with mild to moderate acne vulgaris (NMA) FINAL (June 2021) Research question What is the effectiveness of physical modalities (such as light devices) in the treatment of acne vulgaris or persistent acne vulgaris-related scarring? Relevance to the NHS Acne vulgaris is the most common skin condition affecting the majority of teenagers and young adults. Acne scarring leads to lifelong psychological distress for some people. Physical treatments for acne could provide an alternative for people unwilling or unable to use other treatment modalities. With more evidence of effectiveness and cost effectiveness these treatments may become available on the NHS. Physical treatments for acne scarring may benefit the NHS by reducing psychological morbidity. National priorities There are 2 national priorities, one is to improve young people’s mental health and another is to reduce antibiotic prescribing to prevent resistance. • Improving the mental health of young people is a national priority. Improving acne can have a positive impact on mental health. Rates of depression and suicide are increasing in the under 25-year-old age group, especially amongst men 20-25 years old. (suicides in the UK 2019 ons.gov.uk). In 2018 the government produced a paper ‘Transforming children’s and young people’s mental health provision’, including improving services for those 16-25 years old. This aligns with a need to understand support required for young people with acne vulgaris https://www.gov.uk/government/consultations/transforming- children-and-young-peoples-mental-health-provision-a-green- paper/quick-read-transforming-children-and-young-peoples- mental-health-provision • Acne has traditionally been treated with long courses of antibiotics. If any particular type of physical treatment could be identified as having a positive impact on acne vulgaris then it may lead to a decreased need for antibiotics. Antibiotic resistance is rising in the UK and the government wants to optimise antibiotic prescribing to prevent the development of superbugs. Keeping people well informed would therefore help to address this priority (Tackling antimicrobial resistance 2019–2024 The UK’s five-year national action plan Published 24 January 2019. HM Government) https://assets.publishing.service.gov.uk/government/uploads/s ystem/uploads/attachment_data/file/784894/UK_AMR_5_year _national_action_plan.pdf Current evidence base It is hard to draw conclusions from the current evidence. There are a lack of existing randomised controlled trials in physical treatments for acne and acne scarring, and those which have been done have been variable quality on small numbers of participants. Equality Access to any recommended physical treatments for acne or acne scarring currently differs across the country and according to socioeconomic group. They are mainly available in the private sector. Feasibility Physical treatments need to be supervised, even if they are delivered at home. There would be significant NHS costs associated with setting up provision for physical treatments, but this may be offset by benefits. A time commitment from particpants would be required. Other comments Not applicable 391 Acne Vulgaris: evidence reviews for management options for people with mild to moderate acne vulgaris (NMA) FINAL (June 2021) 1 Table 27: Research recommendation characteristics table - (a) relates to acne 2 management and (b) persistent acne vulgaris-related scarring management Criterion Explanation Population a) Adults with acne vulgaris b) Adults with persistent acne-related scarring Intervention a) any physical intervention for acne, for example: • Blue light therapy weekly for 3 months b) any physical intervention for acne scarring, for example • CO2 laser single or multiple treatments Comparison (a) no treatment or another active treatment. b) no treatment for acne scarring Outcome a) Participant reported improvement, clinician reported improvement in lesion count b) Participant reported improvement, clinician reported improvement in scar appearance a) Recurrence a&b) Side effects: participant and clinician reported, including pigmentary changes and scarring Study design Randomised controlled trial Timeframe a) • 3-6 months (intervention) • 6 month (follow-up) b) • Intervention period • 6 and 12 month follow up Additional information Ideally longer term follow-up data collection would also be useful. 3 4 Research question - chemical peels 5 What is the effectiveness of chemical peels in the treatment of acne vulgaris or persistent 6 acne vulgaris-related scarring? 7 Why this is important 8 Chemical peels are used to remove the surface of the skin. Peels may be ‘superficial’ for 9 treatment of acne vulgaris, removing the dead layer of skin, or ‘deeper’ for atrophic scar 10 management. They are usually applied repeatedly as a course of treatment. Chemical peels 11 are currently not used as standard treatment in the NHS but are available to buy by the 12 public and can be provided by private aesthetic practitioners. The use of chemical peels has 13 potential to change acne and acne scarring management, as an alternative to those who 14 cannot use, tolerate, or are resistant, to other treatments. Therefore, further research is 15 needed to establish its effectiveness. 16 Table 28: Research recommendation rationale Research question What is the effectiveness of chemical peels in the treatment of acne vulgaris or persistent acne vulgaris-related scarring? Why is this needed 392 Acne Vulgaris: evidence reviews for management options for people with mild to moderate acne vulgaris (NMA) FINAL (June 2021) Research question What is the effectiveness of chemical peels in the treatment of acne vulgaris or persistent acne vulgaris-related scarring? Importance to ‘patients’ or The use of chemical peels has potential to change acne and acne the population scarring management, as an alternative to those who cannot use, tolerate, or are resistant, to other treatments. Therefore further research is required to increase the robustness of the evidence Relevance to NICE guidance Chemical peels are currently not routinely offered as a treatment of acne vulgaris or acne associated scarring in the NHS and there is insufficient evidence to make a strong recommendation. Relevance to the NHS Acne vulgaris is the most common skin condition affecting the majority of teenagers and young adults. Acne scarring leads to lifelong psychological distress for some people. Chemical peels for acne could provide an alternative for people unwilling or unable to use other treatment modalities. With more evidence of effectiveness and cost effectiveness these treatments may become available on the NHS. Chemical peels for acne scarring may benefit the NHS by reducing psychological morbidity National priorities • Acne has traditionally been treated with long courses
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