Alternative acne treatments not to suggest

But be prepared to discuss complementary acne treatments with your patients.

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Only four alternative oral acne treatments have any evidence backing them, and many others are likely unsafe, according to a systematic review of 42 studies. 

The analysis of more than 3300 participants revealed that good quality studies only showed efficacy for vitamin D, green tea extract, probiotics and cheongsangbangpoong-tang (a herbal formula also known as CBT).  

“While many topical and systemic prescription options are available for the treatment of acne, some patients may be interested in natural and complementary therapies as either an adjunctive or an alternative to prescription medications,” the authors wrote in JAMA Dermatology. 

Several treatments had fair quality studies indicating efficacy and limited adverse effects, including pantothenic acid (vitamin B5), w-3 and w-6 fatty acids and probiotics. 

Nevertheless, the studies were often small scale, and few of these nutraceuticals were assessed in more than one study.  

The report concluded that vitamin D may be a low-risk option for acne treatment. Dosages were similar to the recommended daily allowance in clinical trials and there were no adverse effects reported. 

Supplementing with 1000IU daily of cholecalciferol led to inflammatory lesions in 35% of the group compared to 6% of the placebo group after eight weeks. Total and noninflammatory lesion counts were similar between groups though. 

After 12 weeks taking w-3 and w-6 fatty acids, patients had an average of six inflammatory lesions compared to more than 10 in the control group. They also had 19 noninflammatory lesions, while the no treatment group had 22. Acne grade was 1.7 in the treatment group compared to 2.3 in the no treatment group, with limited adverse effects reported. 

Green tea extract and CBT are commonly used alternative medicines and are likely low-risk options, the authors said. A small and not statistically significant improvement in acne reduction was found over four weeks between the decaffeinated green tea extract treatment group and the placebo group in one study. Gastrointestinal side effects were also seen in a small number of participants. 

Patients in the CBT study had a significant reduction in inflammatory lesions compared with the placebo group but their global assessment of acne scores were similar – and some minor digestive discomfort was reported. 

Probiotics were studied by the greatest number of trials, but these were small, did not reach statistical significance and had possible publication bias.  

The authors also noted that the dose of pantothenic acid studied was significantly higher than the recommended daily allowance. While not necessarily unsafe, when used for extended periods there may be potential risk of toxicity which needed to be investigated before it could be considered a safe acne treatment, they wrote. 

Zinc was the most studied alternative acne treatment, and just over half of the studies suggested it was effective – but usually when the dose was far greater than recommended. 

Moreover, most studies were small, of poor quality, and had short follow-up. There was substantial diversity in dosages, formulations and results between the studies.  

Zinc was also tied to the most adverse effects, with gastrointestinal complaints such as vomiting and abdominal pain. However, some of these studies compared these gastrointestinal effects to those of antibiotics and found them to be experienced at a similar rate. 

The vitamin A studies were found to be outdated and of poor quality, and the known potential for teratogenicity, neuropsychiatric disturbances and mucocutaneous adverse effects suggested that the high dosage often indicated for acne treatment may be unsafe. 

“The findings of this systematic review suggest a possible role for nutraceutical supplements in the treatment of acne,” the authors concluded. 

“However, available evidence is limited, and larger trials are needed to better understand the efficacy of these treatments. Physicians should be prepared to discuss the evidence for nutraceuticals with patients.” 

JAMA Dermatology 2023, online October 25