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Chuanjian Lu: moc.anis.piv@888naijnauhcul; Charlie C. L. Xue: ua.ude.timr@eux.eilrahc Academic Editor: Dawn M. Bellanti Received 2017 Sep 15; Accepted 2018 Jan 21. Copyright © 2018 Suzi S. Y. Mansu et al.This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Supplementary Materials: Supplementary Table 1: therapeutic effective rate criteria and secondary outcomes. Supplementary Table 2: assessment of reporting of STRICTA items.
GUID: 977BA564-2C16-4E78-A3EB-11F44EFB186CTo conduct a systematic review and meta-analysis to determine the current best available evidence of the efficacy and safety of acupuncture and related therapies for acne vulgaris.
Eleven English and Chinese databases were searched to identify randomized controlled trials (RCTs) of acne vulgaris compared to pharmacotherapies, no treatment, and sham or placebo acupuncture. Methodological quality was assessed using Cochrane Collaboration's risk of bias tool. Meta-analysis was conducted using RevMan software.
Twelve RCTs were included in the qualitative review and 10 RCTs were included in meta-analysis. Methodological quality of trials was generally low. The chance of achieving ≥30% change in lesion count in the acupuncture group was no different to the pharmacotherapy group (RR: 1.07 [95% CI 0.98, 1.17]; I 2 = 8%) and ≥50% change in lesion count in the acupuncture group was not statistically different to the pharmacotherapy group (RR: 1.07 [95% CI 0.98, 1.17]; I 2 = 50%).
While caution should be exercised due to quality of the included studies, acupuncture and auricular acupressure were not statistically different to guideline recommended treatments but were with fewer side effects and may be a treatment option. Future trials should address the methodological weaknesses and meet standard reporting requirements stipulated in STRICTA.
Acne vulgaris (acne) is a chronic and self-limiting condition that begins in adolescence and can last over 10 years [1]. Acne is characterized by inflamed and noninflamed comedones, oily skin, and cysts [2]. The mechanisms for the initial development of comedones are not fully understood [3]. Four factors have been identified which contribute to acne lesions and are the main targets of treatment. These factors include follicular keratinization, sebum production, Propionibacterium acnes (P. acnes), and inflammatory mediator release [4]. Acne lesions may involve cellular inflammation causing hyperkeratinization of follicular ducts [5]. P. acnes can induce keratinocytes to produce cytokines which rupture ducts, causing comedones [3]. Genetics [6] and androgen imbalances [7] can influence sebaceous gland lipid synthesis. Exacerbation can result from single or multiple factors such as P. acnes, menstruation, occupation, personal sweating, diet, or stress [2, 8].
Treatment of acne includes topical benzoyl peroxide and topical retinoids or antibiotics for mild to moderate acne and oral antibiotics combined with either topical benzoyl peroxide or topical or oral retinoids for severe acne [4]. Acupuncture is an umbrella term for traditional Chinese medicine techniques that stimulate acupuncture points. Techniques include acupuncture (insertion of fine needles at specific loci typically for a period of 20 to 30 minutes), auricular acupuncture (insertion of needles in specific loci of the auricle), auricular acupressure (placement of blunt instruments such as small metallic ball bearings at specific loci of the auricle), electroacupuncture (mild electric stimulation of acupuncture needles) [9], and moxibustion (burning of Artemisia argyi Levl. et Vant or Artemisia vulgaris leaf in a processed form) [10]. Several studies have suggested a potential role of acupuncture techniques in acne. Auricular acupressure and surrounding needle (where two to four needles are inserted superficially around the acne lesion) have been shown to reduce serum excretion rate (SER) and testosterone [11]. When acupuncture was combined with benzoyl peroxide, SER in women was reduced compared to benzoyl peroxide alone [12]. In animal studies, auricular acupuncture, auricular electroacupuncture, body acupuncture, and electro-acupuncture have been shown to decrease inflammation [13–16]. Auricular acupuncture may reduce acne inflammation through peripheral muscarinic receptors [13] and innate and adaptive immune responses [14, 17, 18], thereby possibly reducing acne inflammation.
Several reviews have examined the potential benefits of acupuncture techniques in clinical studies. A Cochrane review on complementary therapies for acne [19] evaluated efficacy of herbal medicine, acupuncture, cupping therapy, dietary modifications, purified bee venom, and tea tree oil. The review found there was a lack of evidence to support the use of herbal medicine and acupuncture. Two systematic reviews of acupuncture for acne have been published, one in English [20] and one in Chinese [21]. Cao et al. [20] included trials which used acupuncture, cupping, and other herbal medicines. While the number of “cured” cases increased when acupuncture was combined with cupping, or oral or topical herbal medicines, no benefit was found when acupuncture was compared with pharmacotherapy. The reviewers described the methodological quality of the papers as poor. Li et al. [21] included trials of manual acupuncture compared to routine conventional medicine (isotretinoin and antibiotics) or multiple Chinese medicine therapies. The authors were unable to provide conclusions due to the poor quality of the included trials.
These reviews included herbal medicines and techniques not commonly used outside of China. Acupuncture is commonly used in clinical practice for skin conditions, yet a gap exists in the evaluation of efficacy and safety of acupuncture for acne vulgaris. This review will analyze acupuncture compared to pharmacotherapies, no treatment, and sham or placebo acupuncture to evaluate the efficacy and safety of acupuncture and acupressure for acne vulgaris.
Eleven databases were searched from inception to May 2013, with an update in May 2016. Five English (PubMed, Embase, Allied and Complementary Medicine Database (AMED), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Cochrane Central Register of Controlled Trials (CENTRAL)) and six Chinese databases (Chinese National Knowledge Infrastructure (CNKI), Chongqing VIP Information Company (CQVIP), Wanfang Data, Chinese Biomedical Literature Database (CBM)) as well as China's Conference Papers Database and China Dissertation database were searched. There were no language restrictions. Search terms included acne vulgaris, papulo-pustular acne, acupuncture, acupressure, moxibustion, auricular acupuncture and auricular acupressure, electro-acupuncture, electro stimulation, and variants. Moxibustion and acupressure were included as they are commonly used techniques to directly stimulate acupuncture points. Moxibustion in particular is commonly combined with acupuncture, and the Chinese term for acupuncture “zhen jiu” literally means acupuncture and moxibustion. Search terms for study design included randomized controlled trials, controlled clinical trials, drug therapy, placebo, and variants.
Titles and abstracts of identified citations were scanned to identify potentially eligible randomized controlled trials (RCTs). Full text was retrieved when eligibility could not be ascertained from the title and abstract. RCTs of acupuncture, acupressure, auricular acupuncture, moxibustion, and electroacupuncture compared to no treatment, sham acupuncture, placebo, or conventional pharmacotherapy for acne vulgaris were included in the review. No age, gender, ethnicity, or language limitations were applied. Trials that included other modalities, as cointervention, such as pharmacotherapy or Chinese medicine techniques other than those specified above were excluded.
The primary outcome was the change in lesion count measured by therapeutic effective rate (TER). Chinese medicine guidelines recommend reporting the TER ≥50% based on lesion count alone or a combination of lesion count and severity [22]. Many of the studies used a TER of ≥30% as an improvement based on Chinese medicine guidelines from 1994 [23]. The criteria for therapeutic effective rate from the 1994 guideline were based on a change in lesion count and associated symptoms. For analysis, we included data for people who achieved 30% or greater on lesion count, irrespective of the minimum threshold used by the study for effectiveness. Secondary outcomes included severity grading, physician's overall grading (physician's assessment or self-reporting), photographic grading, quality of life instruments, and adverse events (AE) reports.
Data extracted included patient demographics, sample size, dropout rate, details of the intervention and comparator, outcome measures, results, and adverse events. Authors were contacted if there was missing data. Verification of data was conducted by an independent researcher (IZ).
Two researchers (KW, IZ) independently assessed methodological quality using Cochrane Collaboration's risk of bias tool [24]. Trials were judged as low, unclear, or high risk of bias for the domains of sequence generation, allocation concealment, blinding of participants, blinding of outcome assessors, incomplete outcome data, selective reporting, and other forms of bias such as conflicts of interest. For acupuncture studies, it is not feasible to blind personnel (practitioner) [25]. Disagreements in judgments were resolved by consulting another reviewer (TZ).
Statistical analyses were performed using Review Manager 5.3.5 [26]. Dichotomous data are presented as risk ratio (RR) and continuous data as mean difference, with 95% confidence intervals (CIs). Data were analyzed for available cases. A random effects model was used. Statistical heterogeneity was considered substantial when the I 2 statistic was greater than 50%. We planned to perform sensitivity analysis with studies assessed as low risk of bias for sequence generation. Subgroup analyses were also conducted on ≥50% and ≥30% TER. Exploration of publication bias was planned if more than ten studies were included in any meta-analysis. Due to the number of included trials and methodological quality, not all planned analyses could be performed.
A total of 15,306 records with one additional record sourced elsewhere were identified from database searches. After removal of duplicates, screening of titles and abstracts excluded 7,673 papers, and 2,485 full texts were reviewed ( Figure 1 ).