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Review
. 2016 Sep 27;9(9):CD007917.
doi: 10.1002/14651858.CD007917.pub2.

Light Therapies for Acne

Affiliations
Free PMC article
Review

Light Therapies for Acne

Jelena Barbaric et al. Cochrane Database Syst Rev. .
Free PMC article

Abstract

Background: Acne vulgaris is a very common skin problem that presents with blackheads, whiteheads, and inflamed spots. It frequently results in physical scarring and may cause psychological distress. The use of oral and topical treatments can be limited in some people due to ineffectiveness, inconvenience, poor tolerability or side-effects. Some studies have suggested promising results for light therapies.

Objectives: To explore the effects of light treatment of different wavelengths for acne.

Search methods: We searched the following databases up to September 2015: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase and LILACS. We searched ISI Web of Science and Dissertation Abstracts International (from inception). We also searched five trials registers, and grey literature sources. We checked the reference lists of studies and reviews and consulted study authors and other experts in the field to identify further references to relevant randomised controlled trials (RCTs). We updated these searches in July 2016 but these results have not yet been incorporated into the review.

Selection criteria: We included RCTs of light for treatment of acne vulgaris, regardless of language or publication status.

Data collection and analysis: We used standard methodological procedures expected by Cochrane.

Main results: We included 71 studies, randomising a total of 4211 participants.Most studies were small (median 31 participants) and included participants with mild to moderate acne of both sexes and with a mean age of 20 to 30 years. Light interventions differed greatly in wavelength, dose, active substances used in photodynamic therapy (PDT), and comparator interventions (most commonly no treatment, placebo, another light intervention, or various topical treatments). Numbers of light sessions varied from one to 112 (most commonly two to four). Frequency of application varied from twice daily to once monthly.Selection and performance bias were unclear in the majority of studies. Detection bias was unclear for participant-assessed outcomes and low for investigator-assessed outcomes in the majority of studies. Attrition and reporting bias were low in over half of the studies and unclear or high in the rest. Two thirds of studies were industry-sponsored; study authors either reported conflict of interest, or such information was not declared, so we judged the risk of bias as unclear.Comparisons of most interventions for our first primary outcome 'Participant's global assessment of improvement' were not possible due to the variation in the interventions and the way the studies' outcomes were measured. We did not combine the effect estimates but rated the quality of the evidence as very low for the comparison of light therapies, including PDT to placebo, no treatment, topical treatment or other comparators for this outcome. One study which included 266 participants with moderate to severe acne showed little or no difference in effectiveness for this outcome between 20% aminolevulinic acid (ALA)-PDT (activated by blue light) versus vehicle plus blue light (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.72 to 1.04, low-quality evidence). A study (n = 180) of a comparison of ALA-PDT (activated by red light) concentrations showed 20% ALA was no more effective than 15% (RR 1.05, 95% CI 0.96 to 1.15) but better than 10% ALA (RR 1.22, 95% CI 1.05 to 1.42) and 5% ALA (RR 1.47, 95% CI 1.19 to 1.81). The number needed to treat for an additional beneficial outcome (NNTB) was 6 (95% CI 3 to 19) and 4 (95% CI 2 to 6) for the comparison of 20% ALA with 10% and 5% ALA, respectively.For our second primary outcome 'Investigator-assessed changes in lesion counts', we combined three RCTs, with 360 participants with moderate to severe acne and found methyl aminolevulinate (MAL) PDT (activated by red light) was no different to placebo cream plus red light with regard to change in inflamed lesions (ILs) (mean difference (MD) -2.85, 95% CI -7.51 to 1.81), percentage change in ILs (MD -10.09, 95% CI -20.25 to 0.06), change in non-inflamed lesions (NILs) (MD -2.01, 95% CI -7.07 to 3.05), or in percentage change in NILs (MD -8.09, 95% CI -21.51 to 5.32). We assessed the evidence as moderate quality for these outcomes meaning that there is little or no clinical difference between these two interventions for lesion counts.Studies comparing the effects of other interventions were inconsistent or had small samples and high risk of bias. We performed only narrative synthesis for the results of the remaining trials, due to great variation in many aspects of the studies, poor reporting, and failure to obtain necessary data. Several studies compared yellow light to placebo or no treatment, infrared light to no treatment, gold microparticle suspension to vehicle, and clindamycin/benzoyl peroxide combined with pulsed dye laser to clindamycin/benzoyl peroxide alone. There were also several other studies comparing MAL-PDT to light-only treatment, to adapalene and in combination with long-pulsed dye laser to long-pulsed dye laser alone. None of these showed any clinically significant effects.Our third primary outcome was 'Investigator-assessed severe adverse effects'. Most studies reported adverse effects, but not adequately with scarring reported as absent, and blistering reported only in studies on intense pulsed light, infrared light and photodynamic therapies. We rated the quality of the evidence as very low, meaning we were uncertain of the adverse effects of the light therapies.Although our primary endpoint was long-term outcomes, less than half of the studies performed assessments later than eight weeks after final treatment. Only a few studies assessed outcomes at more than three months after final treatment, and longer-term assessments are mostly not covered in this review.

Authors' conclusions: High-quality evidence on the use of light therapies for people with acne is lacking. There is low certainty of the usefulness of MAL-PDT (red light) or ALA-PDT (blue light) as standard therapies for people with moderate to severe acne.Carefully planned studies, using standardised outcome measures, comparing the effectiveness of common acne treatments with light therapies would be welcomed, together with adherence to the Consolidated Standards of Reporting Trials (CONSORT) guidelines.

Conflict of interest statement

Jelena Barbaric: nothing to declare. Rachel Abbott: nothing to declare. Pawel Posadzki: nothing to declare. Mate Car: nothing to declare. Laura H Gunn: nothing to declare. Alison M Layton: "Over the last five years, the following companies have invited advice, supported educational events, provided unrestricted research grants, or I have acted as CI/PI for their clinical trials: Galderma, GlaxoSmithKline, MEDA, LeoPharma, Indentis, Valeant, Dermira, Pfizer, Novartis, Wyeth and L'Oreal.

I have received remuneration from several different pharmaceutical companies in support of the following:

research projects (funding has been provided as unrestricted educational grants for basic science research);

as an honorarium for lecturing at educational meetings (content of talks unrestricted);

as an honorarium to support work done in an advisory capacity e.g. member of drug monitoring committee or on advisory board.

I am not affiliated to or hold shares in any one specific company." Azeem Majeed: nothing to declare. Josip Car: nothing to declare.

Gloria Sanclemente (an external content expert who peer‐refereed this review) has designed and performed trials with MAL (Metvix®) + Red Light in which Galderma Laboratories has provided the medication and placebo. She has also received honoraria, speaker fees and meeting sponsorship from this pharmaceutical lab.

Brigitte Dréno (an external content expert who also peer‐refereed this review) is a member of an international board for Galderma, and has a grant for clinical studies with drugs in acne and daylight PDT, but no clinical trials with MAL–PDT.

Figures

1
1
Study flow diagram.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Blue‐red light versus placebo, Outcome 1 Participant's and investigator's global assessment of improvement at final treatment.
2.1
2.1. Analysis
Comparison 2 Blue‐red light versus topical benzoyl peroxide, Outcome 1 Participant's and investigator's global assessment of improvement at final treatment.
3.1
3.1. Analysis
Comparison 3 Blue‐red light versus blue light alone, Outcome 1 Participant's and investigator's global assessment of improvement at final treatment.
4.1
4.1. Analysis
Comparison 4 Vehicle + 1000 s blue light versus vehicle + 500 s blue light, Outcome 1 Participant's global assessment of improvement at 6 weeks.
4.2
4.2. Analysis
Comparison 4 Vehicle + 1000 s blue light versus vehicle + 500 s blue light, Outcome 2 Investigator's global assessment of improvement.
5.1
5.1. Analysis
Comparison 5 20% ALA‐PDT versus vehicle plus blue light, Outcome 1 Participant's global assessment of improvement at 6 weeks.
5.2
5.2. Analysis
Comparison 5 20% ALA‐PDT versus vehicle plus blue light, Outcome 2 Investigator's global assessment of improvement at 3 weeks.
5.3
5.3. Analysis
Comparison 5 20% ALA‐PDT versus vehicle plus blue light, Outcome 3 Investigator's global assessment of improvement at 6 weeks.
6.1
6.1. Analysis
Comparison 6 20% ALA‐PDT 30 min incubation plus IPL versus 20% ALA‐PDT 3 h incubation plus IPL, Outcome 1 Participant's and investigator's global assessment of improvement at 12 weeks.
7.1
7.1. Analysis
Comparison 7 20% ALA‐PDT plus 560 nm IPL versus 560 nm IPL alone, Outcome 1 Participant's global assessment of improvement at 8 weeks.
8.1
8.1. Analysis
Comparison 8 20% ALA‐PDT 1000 s versus 500 s, Outcome 1 Participant's global assessment of improvement at 6 weeks.
8.2
8.2. Analysis
Comparison 8 20% ALA‐PDT 1000 s versus 500 s, Outcome 2 Investigator's global assessment of improvement.
9.1
9.1. Analysis
Comparison 9 20% ALA‐PDT versus 15% ALA‐PDT, Outcome 1 Participant's global assessment of improvement at 24 weeks.
9.2
9.2. Analysis
Comparison 9 20% ALA‐PDT versus 15% ALA‐PDT, Outcome 2 Investigator‐assessed severe adverse effects.
10.1
10.1. Analysis
Comparison 10 20% ALA‐PDT versus 10% ALA‐PDT, Outcome 1 Participant's global assessment of improvement at 24 weeks.
10.2
10.2. Analysis
Comparison 10 20% ALA‐PDT versus 10% ALA‐PDT, Outcome 2 Investigator‐assessed severe adverse effects.
11.1
11.1. Analysis
Comparison 11 20% ALA‐PDT versus 5% ALA‐PDT, Outcome 1 Participant's global assessment of improvement at 24 weeks.
11.2
11.2. Analysis
Comparison 11 20% ALA‐PDT versus 5% ALA‐PDT, Outcome 2 Investigator‐assessed severe adverse effects.
12.1
12.1. Analysis
Comparison 12 Yellow light versus no treatment, Outcome 1 Investigator‐assessed change in ILs, NILs and cysts at 12 weeks.
13.1
13.1. Analysis
Comparison 13 Infrared light versus no treatment, Outcome 1 Investigator‐assessed change in ILs, NILs and cysts at 8 weeks.
13.2
13.2. Analysis
Comparison 13 Infrared light versus no treatment, Outcome 2 Investigator‐assessed change in cysts at 8 weeks.
13.3
13.3. Analysis
Comparison 13 Infrared light versus no treatment, Outcome 3 Investigator‐assessed severe adverse effects.
14.1
14.1. Analysis
Comparison 14 585 nm PDL versus 530‐750 nm IPL, Outcome 1 Investigator‐assessed change in ILs and NILs at 8 weeks.
14.2
14.2. Analysis
Comparison 14 585 nm PDL versus 530‐750 nm IPL, Outcome 2 Investigator‐assessed change in ILs and NILS at 8 weeks (normal).
15.1
15.1. Analysis
Comparison 15 1450 nm laser treatments: single pass 13‐14 J/cm2 versus double pass 8–11 J/cm2, Outcome 1 Investigator‐assessed change in ILs at 8 weeks.
15.2
15.2. Analysis
Comparison 15 1450 nm laser treatments: single pass 13‐14 J/cm2 versus double pass 8–11 J/cm2, Outcome 2 Investigator‐assessed change in ILs at 8 weeks (normal).
16.1
16.1. Analysis
Comparison 16 1450 nm laser treatments: 14 J/cm2 versus 16 J/cm2, Outcome 1 Investigator‐assessed change and percentage change in ILs.
16.2
16.2. Analysis
Comparison 16 1450 nm laser treatments: 14 J/cm2 versus 16 J/cm2, Outcome 2 Investigator‐assessed change and percentage change in ILs (normal).
17.1
17.1. Analysis
Comparison 17 80 mg/g MAL plus red light versus placebo cream plus red light at 6 weeks, Outcome 1 Investigator‐assessed change in ILs.
17.2
17.2. Analysis
Comparison 17 80 mg/g MAL plus red light versus placebo cream plus red light at 6 weeks, Outcome 2 Investigator‐assessed percentage change in ILs.
17.3
17.3. Analysis
Comparison 17 80 mg/g MAL plus red light versus placebo cream plus red light at 6 weeks, Outcome 3 Investigator‐assessed change in NILs.
17.4
17.4. Analysis
Comparison 17 80 mg/g MAL plus red light versus placebo cream plus red light at 6 weeks, Outcome 4 Investigator‐assessed percentage change in NILs.
17.5
17.5. Analysis
Comparison 17 80 mg/g MAL plus red light versus placebo cream plus red light at 6 weeks, Outcome 5 Investigator‐assessed severe adverse effects.
17.6
17.6. Analysis
Comparison 17 80 mg/g MAL plus red light versus placebo cream plus red light at 6 weeks, Outcome 6 Investigator's global assessment of improvement.
18.1
18.1. Analysis
Comparison 18 40 mg/g MAL plus red light versus placebo cream plus red light at 6 weeks, Outcome 1 Investigator‐assessed change in ILs.
18.2
18.2. Analysis
Comparison 18 40 mg/g MAL plus red light versus placebo cream plus red light at 6 weeks, Outcome 2 Investigator‐assessed percentage change in ILs.
18.3
18.3. Analysis
Comparison 18 40 mg/g MAL plus red light versus placebo cream plus red light at 6 weeks, Outcome 3 Investigator‐assessed change in NILs.
18.4
18.4. Analysis
Comparison 18 40 mg/g MAL plus red light versus placebo cream plus red light at 6 weeks, Outcome 4 Investigator‐assessed percentage change in NILs.
18.5
18.5. Analysis
Comparison 18 40 mg/g MAL plus red light versus placebo cream plus red light at 6 weeks, Outcome 5 Investigator's global assessment of improvement.
19.1
19.1. Analysis
Comparison 19 80 mg/g MAL plus red light versus placebo cream plus red light at 4 weeks, Outcome 1 Investigator‐assessed change in ILs and NILs.
19.2
19.2. Analysis
Comparison 19 80 mg/g MAL plus red light versus placebo cream plus red light at 4 weeks, Outcome 2 Investigator‐assessed change in ILs and NILs (normal).
20.1
20.1. Analysis
Comparison 20 160 mg/g MAL plus red light versus placebo cream plus red light, Outcome 1 Investigator‐assessed change in ILs.
20.2
20.2. Analysis
Comparison 20 160 mg/g MAL plus red light versus placebo cream plus red light, Outcome 2 Investigator‐assessed percentage change in ILs.
20.3
20.3. Analysis
Comparison 20 160 mg/g MAL plus red light versus placebo cream plus red light, Outcome 3 Investigator‐assessed severe adverse effects.
20.4
20.4. Analysis
Comparison 20 160 mg/g MAL plus red light versus placebo cream plus red light, Outcome 4 Investigator's global assessment of improvement.
21.1
21.1. Analysis
Comparison 21 80 mg/g MAL plus red light versus 40 mg/g MAL plus red light at 6 weeks, Outcome 1 Investigator‐assessed change in ILs.
21.2
21.2. Analysis
Comparison 21 80 mg/g MAL plus red light versus 40 mg/g MAL plus red light at 6 weeks, Outcome 2 Investigator‐assessed percentage change in ILs.
21.3
21.3. Analysis
Comparison 21 80 mg/g MAL plus red light versus 40 mg/g MAL plus red light at 6 weeks, Outcome 3 Investigator‐assessed change in NILs.
21.4
21.4. Analysis
Comparison 21 80 mg/g MAL plus red light versus 40 mg/g MAL plus red light at 6 weeks, Outcome 4 Investigator‐assessed percentage change in NILs.
21.5
21.5. Analysis
Comparison 21 80 mg/g MAL plus red light versus 40 mg/g MAL plus red light at 6 weeks, Outcome 5 Investigator's global assessment of improvement.
22.1
22.1. Analysis
Comparison 22 160 mg/g MAL‐PDT versus IPL alone, Outcome 1 Investigator‐assessed percentage change in ILs and NILs.
22.2
22.2. Analysis
Comparison 22 160 mg/g MAL‐PDT versus IPL alone, Outcome 2 Investigator‐assessed percentage change in ILs and NILs (normal).
23.1
23.1. Analysis
Comparison 23 160 mg/g MAL‐PDT versus adapalene, Outcome 1 Investigator‐assessed percentage change in ILs and NILs.
23.2
23.2. Analysis
Comparison 23 160 mg/g MAL‐PDT versus adapalene, Outcome 2 Investigator‐assessed percentage change in ILs and NILs (normal).
24.1
24.1. Analysis
Comparison 24 ALA plus 420‐950 nm IPL versus IPL alone, Outcome 1 Investigator‐assessed percentage change in ILs and NILs at 12 weeks.
24.2
24.2. Analysis
Comparison 24 ALA plus 420‐950 nm IPL versus IPL alone, Outcome 2 Investigator‐assessed percentage change in ILs and NILs at 12 weeks (normal).
24.3
24.3. Analysis
Comparison 24 ALA plus 420‐950 nm IPL versus IPL alone, Outcome 3 Investigator's global assessment of improvement at 12 weeks.
25.1
25.1. Analysis
Comparison 25 20% ALA‐PDT plus PDL versus no treatment, Outcome 1 Investigator‐assessed change in ILs, NILs and cysts.
25.2
25.2. Analysis
Comparison 25 20% ALA‐PDT plus PDL versus no treatment, Outcome 2 Investigator‐assessed severe adverse effects.
26.1
26.1. Analysis
Comparison 26 Intense pulsed light (IPL) versus no treatment, Outcome 1 Investigator‐assessed severe adverse effects.
26.2
26.2. Analysis
Comparison 26 Intense pulsed light (IPL) versus no treatment, Outcome 2 Investigator‐assessed change in acne severity at 6 months.
26.3
26.3. Analysis
Comparison 26 Intense pulsed light (IPL) versus no treatment, Outcome 3 Investigator‐assessed change in acne severity at 6 months (normal).
27.1
27.1. Analysis
Comparison 27 1450 nm laser treatments: single pass versus double pass, Outcome 1 Investigator‐assessed severe adverse effects.
28.1
28.1. Analysis
Comparison 28 MAL‐PDT with or without occlusion followed by 37 J/cm2 red light, Outcome 1 Investigator‐assessed severe adverse effects.
28.2
28.2. Analysis
Comparison 28 MAL‐PDT with or without occlusion followed by 37 J/cm2 red light, Outcome 2 Investigators' global assessment of improvement at 12 weeks.
29.1
29.1. Analysis
Comparison 29 Single versus multiple treatment of 20% ALA plus 550–700 nm light, Outcome 1 Investigator‐assessed severe adverse effects.
30.1
30.1. Analysis
Comparison 30 585 nm PDL versus BPO plus tretinoin, Outcome 1 Investigator's global assessment of improvement (timepoint unclear).
31.1
31.1. Analysis
Comparison 31 585 nm PDL versus retinoic acid plus TCA peeling, Outcome 1 Investigator's global assessment of improvement (timepoint unclear).
32.1
32.1. Analysis
Comparison 32 Blue‐red light plus topical treatments (TT) versus topical (TT) alone at 4 weeks, Outcome 1 Investigator's global assessment of improvement.
33.1
33.1. Analysis
Comparison 33 400‐410 nm plus 660 nm (blue‐red) light versus 400‐410 nm (blue) light alone, Outcome 1 Investigator's global assessment of improvement at 4 weeks.
34.1
34.1. Analysis
Comparison 34 Blue LED versus red LED, Outcome 1 Investigator's global assessment of improvement.
35.1
35.1. Analysis
Comparison 35 Blue‐red light plus sulfotanshinone (SFT) versus SFT alone, Outcome 1 Investigator's global assessment of improvement at 4 weeks.
36.1
36.1. Analysis
Comparison 36 Blue‐red light plus sulfotanshinone (SFT) versus blue‐red light plus SFT plus prednisolone, Outcome 1 Investigator's global assessment of improvement at 4 weeks.
37.1
37.1. Analysis
Comparison 37 Blue‐red light plus sulfotanshinone (SFT) versus SFT plus prednisolone, Outcome 1 Investigator's global assessment of improvement at 4 weeks.
38.1
38.1. Analysis
Comparison 38 Yinhua decoction (YD) plus electric light versus YD plus blue‐red light, Outcome 1 Investigator's global assessment of improvement at 12w.
39.1
39.1. Analysis
Comparison 39 Blue‐red light plus oral plus topical treatments (OT plus TT) versus OT plus TT alone at 4 weeks, Outcome 1 Investigator's global assessment of improvement.
40.1
40.1. Analysis
Comparison 40 ALA plus red light versus red light alone, Outcome 1 Investigator's global assessment of improvement.

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