Under its Evidence-based Practice Program, the Agency for Healthcare Research and Quality (AHRQ) is developing scientific information for other agencies and organizations on which to base clinical guidelines, performance measures, and other quality improvement tools. Contractor institutions review all relevant scientific literature on assigned clinical care topics and produce evidence reports and technology assessments, conduct research on methodologies and the effectiveness of their implementation, and participate in technical assistance activities.
Overview / Reporting the Evidence / Methodology / Findings / Future Research / Availability of Full Report
It is estimated that 45 million people in the United States have acne vulgaris, with a prevalence of approximately 85 percent in the population 15-24 years of age. The disease is more common and more severe in males than in females. Morbidity primarily comes from the lesions themselves, which may be painful and tender, as well from scars left by nodules and cysts. Morbidity may be generated by adverse effects of treatments as well. Psychological morbidity has been noted.
It is estimated that consumers spend $100 million per year in over-the-counter remedies. Coupled with loss of productivity and unemployment, the direct cost of acne may exceed $1 billion per year in the United States.
Three questions were addressed in literature abstraction:
Evidence was sought for several subpopulations:
Working with our partners, the American Academy of Dermatology and the American Academy of Pediatrics, as well as with the American Pharmaceutical Association, the Departments of Dermatology and Pediatrics at Johns Hopkins School of Medicine, the Cochrane Collaboration, and the Society for Investigational Dermatology, we assembled a team of technical experts.
The questions for consideration were developed through discussions with our technical experts, as well as through preliminary searches of MEDLINE® and MicroMedex and a review of consumers' questions submitted to a major consumer health Internet Web site (InteliHealthTM).
The following reference databases were searched:
The CENTRAL search strategy was (acne-vulgaris*.me OR acne*.tw). Similar strategies were used for the other databases. The search strategy for PubMed combined, using a Boolean AND, a topic-specific strategy (acne vulgaris[mh] OR acne*[tw]) with a strategy designed to retrieve all controlled trials.
Reference lists from key articles were reviewed by hand. All unique controlled trials of acne therapy were sought that presented original, human data and were written in English.
Identified articles were screened by independent reviewers in an abstract review process to determine eligibility for full article review. Eligible articles were reviewed serially by two or more abstracters who sought methodological and outcome data.
Studies were qualitatively assessed in terms of methodological strengths and weaknesses. Studies were also classified by the level of acne severity in study patients at enrollment. A combined acne severity classification was created that integrated the 25 schemes found in the literature.
The unit of analysis was the comparison between pairs of treatment arms. Comparisons were qualitatively assessed by addressing methodological issues, by addressing commonality of outcomes across studies, and by addressing results and their statistical significance between arms. The evidence was assessed in terms of strength at Levels A, B, or C as follows:
There is still much work to be done to define the best approach to management of acne in an individual patient based upon his or her specific characteristics. Until this work is done, the process of care for patients with acne vulgaris will remain highly individualized, based upon the experience of the patient and the treating physician. The effectiveness of a more evidence-based, stepwise approach that incorporates several therapies at different points in time still needs to be documented.
Future research on the treatment of acne vulgaris would benefit from:
This report was developed using accepted evidence-based techniques. However, as in other areas of research, the methodology was necessarily constrained by issues of feasibility and practicality so that, for example, the analysis was limited to clinical trials reported in the English language. Nonetheless, this report is a systematic effort to collect and summarize the available evidence on the management of acne and represents a potentially powerful resource for the field. As with any systematic review, to be accurate and comprehensive, the generation of guidelines requires additional information, such as expert opinion, to put the evidence into context.
The full evidence report from which this summary was taken was prepared for the Agency for Healthcare Research and Quality by the Johns Hopkins University under contract No. 290-97-006. Print copies may be obtained free of charge from the AHRQ Publications Clearinghouse by calling 1-800-358-9295. Requestors should ask for Evidence Report/Technology Assessment No. 17, Management of Acne (AHRQ Publication No. 01-E019).
The Evidence Report is also online on the National Library of Medicine Bookshelf (select for Volume I and Volume II). The report can also be downloaded as a zipped file.
AHRQ Publication No. 01-E018
Current as of March 2001
Internet Citation:
Management of Acne. Summary, Evidence Report/Technology Assessment: Number 17. AHRQ Publication No. 01-E018, March 2001. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/epcsums/acnesum.htm
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