Review Article Acupuncture for Acne Vulgaris: A Systematic Review and Meta-Analysis

13 Pages·2017·1.86 MB·English

Hindawi
Evidence-Based Complementary and Alternative Medicine
Volume 2018, Article ID 4806734, 12 pages
https://doi.org/10.1155/2018/4806734
Review Article
Acupuncture for Acne Vulgaris: A Systematic
Review and Meta-Analysis
SuziS.Y.Mansu ,1HaiyingLiang ,2SheftonParker,1
MeaghanE.Coyle ,1KaiyiWang,1AnthonyL.Zhang ,1XinfengGuo ,2
ChuanjianLu ,2andCharlieC.L.Xue 1,2
1China-AustraliaInternationalResearchCentreforChineseMedicine,SchoolofHealthandBiomedicalSciences,
RMITUniversity,P.O.Box71,Bundoora,VIC3083,Australia
2GuangdongProvincialHospitalofChineseMedicine,GuangdongProvincialAcademyofChineseMedicalSciencesand
TheSecondClinicalCollege,GuangzhouUniversityofChineseMedicine,Guangzhou,China
CorrespondenceshouldbeaddressedtoChuanjianLu;[email protected]
andCharlieC.L.Xue;[email protected]
Received 15 September 2017; Accepted 21 January 2018; Published 12 March 2018
AcademicEditor:DawnM.Bellanti
Copyright©2018SuziS.Y.Mansuetal.ThisisanopenaccessarticledistributedundertheCreativeCommonsAttributionLicense,
whichpermitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.
Purpose.Toconductasystematicreviewandmeta-analysistodeterminethecurrentbestavailableevidenceoftheefficacyand
safetyofacupunctureandrelatedtherapiesforacnevulgaris.Methods.ElevenEnglishandChinesedatabasesweresearchedto
identifyrandomizedcontrolledtrials(RCTs)ofacnevulgariscomparedtopharmacotherapies,notreatment,andshamorplacebo
acupuncture.MethodologicalqualitywasassessedusingCochraneCollaboration’sriskofbiastool.Meta-analysiswasconducted
usingRevMansoftware.Results.TwelveRCTswereincludedinthequalitativereviewand10RCTswereincludedinmeta-analysis.
Methodologicalqualityoftrialswasgenerallylow.Thechanceofachieving≥30%changeinlesioncountintheacupuncturegroup
was no different to the pharmacotherapy group (RR: 1.07 [95% CI 0.98, 1.17]; 𝐼2 = 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]; 𝐼2 = 50%).
Conclusions.Whilecautionshouldbeexercisedduetoqualityoftheincludedstudies,acupunctureandauricularacupressurewere
notstatisticallydifferenttoguidelinerecommendedtreatmentsbutwerewithfewersideeffectsandmaybeatreatmentoption.
FuturetrialsshouldaddressthemethodologicalweaknessesandmeetstandardreportingrequirementsstipulatedinSTRICTA.
1.Introduction imbalances[7]caninfluencesebaceousglandlipidsynthesis.
Exacerbationcanresultfromsingleormultiplefactorssuch
Acnevulgaris(acne)isachronicandself-limitingcondition as P. acnes, menstruation, occupation, personal sweating,
thatbeginsinadolescenceandcanlastover10years[1].Acne diet,orstress[2,8].
is characterized by inflamed and noninflamed comedones, Treatmentofacneincludestopicalbenzoylperoxideand
oily skin, and cysts [2]. The mechanisms for the initial topical retinoids or antibiotics for mild to moderate acne
development of comedones are not fully understood [3]. and oral antibiotics combined with either topical benzoyl
Four factors have been identified which contribute to acne peroxide or topical or oral retinoids for severe acne [4].
lesions and are the main targets of treatment. These factors Acupuncture is an umbrella term for traditional Chinese
include follicular keratinization, sebum production, Propi- medicine techniques that stimulate acupuncture points.
onibacterium acnes (P. acnes), and inflammatory mediator Techniques include acupuncture (insertion of fine needles
release [4]. Acne lesions may involve cellular inflammation at specific loci typically for a period of 20 to 30 minutes),
causing hyperkeratinization of follicular ducts [5]. P. acnes auricular acupuncture (insertion of needles in specific loci
caninducekeratinocytestoproducecytokineswhichrupture of the auricle), auricular acupressure (placement of blunt
ducts, causing comedones [3]. Genetics [6] and androgen instruments such as small metallic ball bearings at specific
2 Evidence-BasedComplementaryandAlternativeMedicine
locioftheauricle),electroacupuncture(mildelectricstimu- Search terms included acne vulgaris, papulo-pustular acne,
lationofacupunctureneedles)[9],andmoxibustion(burning acupuncture, acupressure, moxibustion, auricular acupunc-
of Artemisia argyi Levl. et Vant or Artemisia vulgaris leaf tureandauricularacupressure,electro-acupuncture,electro
in a processed form) [10]. Several studies have suggested a stimulation,andvariants.Moxibustionandacupressurewere
potential role of acupuncture techniques in acne. Auricular included as they are commonly used techniques to directly
acupressure and surrounding needle (where two to four stimulate acupuncture points. Moxibustion in particular is
needles are inserted superficially around the acne lesion) commonly combined with acupuncture, and the Chinese
havebeenshowntoreduceserumexcretionrate(SER)and termforacupuncture“zhenjiu”literallymeansacupuncture
testosterone [11]. When acupuncture was combined with and moxibustion. Search terms for study design included
benzoyl peroxide, SER in women was reduced compared randomizedcontrolledtrials,controlledclinical trials,drug
to benzoyl peroxide alone [12]. In animal studies, auricular therapy,placebo,andvariants.
acupuncture, auricular electroacupuncture, body acupunc-
Titles and abstracts of identified citations were scanned
ture,andelectro-acupuncturehavebeenshowntodecrease
to identify potentially eligible randomized controlled trials
inflammation [13–16]. Auricular acupuncture may reduce
(RCTs).Fulltextwasretrievedwheneligibilitycouldnotbe
acneinflammationthroughperipheralmuscarinicreceptors
ascertainedfromthetitleandabstract.RCTsofacupuncture,
[13]andinnateandadaptiveimmuneresponses[14,17,18],
acupressure, auricular acupuncture, moxibustion, and elec-
therebypossiblyreducingacneinflammation.
troacupuncture compared to no treatment, sham acupunc-
Several reviews have examined the potential benefits
ture,placebo,orconventionalpharmacotherapyforacnevul-
of acupuncture techniques in clinical studies. A Cochrane
gariswereincludedinthereview.Noage,gender,ethnicity,
review on complementary therapies for acne [19] evaluated
or language limitations were applied. Trials that included
efficacy of herbal medicine, acupuncture, cupping therapy,
othermodalities,ascointervention,suchaspharmacotherapy
dietary modifications, purified bee venom, and tea tree oil.
or Chinese medicine techniques other than those specified
The review found there was a lack of evidence to support
abovewereexcluded.
the use of herbal medicine and acupuncture. Two system-
The primary outcome was the change in lesion count
atic reviews of acupuncture for acne have been published,
measured by therapeutic effective rate (TER). Chinese
one in English [20] and one in Chinese [21]. Cao et al. medicine guidelines recommend reporting the TER ≥50%
[20] included trials which used acupuncture, cupping, and
basedonlesioncountaloneoracombinationoflesioncount
otherherbalmedicines.Whilethenumberof“cured”cases and severity [22]. Many of the studies used a TER of ≥30%
increased when acupuncture was combined with cupping,
as an improvement based on Chinese medicine guidelines
or oral or topical herbal medicines, no benefit was found
from 1994 [23]. The criteria for therapeutic effective rate
whenacupuncturewascomparedwithpharmacotherapy.The
from the 1994 guideline were based on a change in lesion
reviewersdescribedthemethodologicalqualityofthepapers
count and associated symptoms. For analysis, we included
aspoor.Lietal.[21]includedtrialsofmanualacupuncture
dataforpeoplewhoachieved30%orgreateronlesioncount,
compared to routine conventional medicine (isotretinoin
irrespectiveoftheminimumthresholdusedbythestudyfor
andantibiotics)ormultipleChinesemedicinetherapies.The
effectiveness.Secondaryoutcomesincludedseveritygrading,
authorswereunabletoprovideconclusionsduetothepoor
physician’s overall grading (physician’s assessment or self-
qualityoftheincludedtrials.
reporting),photographicgrading,qualityoflifeinstruments,
Thesereviewsincludedherbalmedicinesandtechniques
andadverseevents(AE)reports.
notcommonlyusedoutsideofChina.Acupunctureiscom-
Data extracted included patient demographics, sample
monlyusedinclinicalpracticeforskinconditions,yetagap
size,dropoutrate,detailsoftheinterventionandcomparator,
existsintheevaluationofefficacyandsafetyofacupuncture
outcomemeasures,results,andadverseevents.Authorswere
for acne vulgaris. This review will analyze acupuncture
contactediftherewasmissingdata.Verificationofdatawas
comparedtopharmacotherapies,notreatment,andshamor
conductedbyanindependentresearcher(IZ).
placebo acupuncture to evaluate the efficacy and safety of
Two researchers (KW, IZ) independently assessed
acupunctureandacupressureforacnevulgaris.
methodological quality using Cochrane Collaboration’s
risk of bias tool [24]. Trials were judged as low, unclear, or
2.Methods
high risk of bias for the domains of sequence generation,
allocation concealment, blinding of participants, blinding
ElevendatabasesweresearchedfrominceptiontoMay2013,
of outcome assessors, incomplete outcome data, selective
withanupdateinMay2016.FiveEnglish(PubMed,Embase,
reporting, and other forms of bias such as conflicts of
Allied and Complementary Medicine Database (AMED),
interest. For acupuncture studies, it is not feasible to blind
the Cumulative Index to Nursing and Allied Health Liter-
personnel (practitioner) [25]. Disagreements in judgments
ature (CINAHL), and Cochrane Central Register of Con-
wereresolvedbyconsultinganotherreviewer(TZ).
trolledTrials(CENTRAL))andsixChinesedatabases(Chi-
neseNationalKnowledgeInfrastructure(CNKI),Chongqing Statistical analyses were performed using Review Man-
VIP Information Company (CQVIP), Wanfang Data, Chi- ager5.3.5[26].Dichotomousdataarepresentedasriskratio
nese Biomedical Literature Database (CBM)) as well as (RR)andcontinuousdataasmeandifference,with95%confi-
China’sConferencePapersDatabaseandChinaDissertation denceintervals(CIs).Datawereanalyzedforavailablecases.
databaseweresearched.Therewerenolanguagerestrictions. A random effects model was used. Statistical heterogeneity
Evidence-BasedComplementaryandAlternativeMedicine 3
n Records identified through Additional records identified
o
ficati databa(sne = s e1a5r,c3h0i6n)g through o(tnh e=r 1so)urces
nti
e
d
I
Records after duplicates removal
(n = 10,158)
g
n
ni
e
e
cr
S
Records screened Records excluded
(n = 10,158) (n = 7,673)
Full-text articles assessed Full-text articles excluded,
for eligibility with reasons (n = 2,473)
bility (n = 2,485) Not acne vulgaris = 97
gi Not acupuncture = 566
Eli Not a clinical study = 25
Not meeting inclusion
criteria = 1,733
Not usable data = 17
Studies included in
Duplicates = 23
qualitative synthesis
(n = 12) Reviews = 10
Unable to locate full text = 2
d
e
d
u
ncl
I
Studies included in
quantitative synthesis
(meta-analysis)
(n = 10)
Figure1:Studyselectionflowchart.
wasconsideredsubstantialwhenthe𝐼2 statisticwasgreater database searches. After removalof duplicates, screening of
than 50%. We planned to perform sensitivity analysis with titlesandabstractsexcluded7,673papers,and2,485fulltexts
studiesassessedaslowriskofbiasforsequencegeneration. werereviewed(Figure1).
Subgroupanalyseswerealsoconductedon≥50%and≥30%
TER. Exploration of publication bias was planned if more
3.2. Characteristics of Studies. Twelve RCTs involving 1,026
thantenstudieswereincludedinanymeta-analysis.Dueto
participants met the inclusion criteria [27–38]. Ten RCTs
thenumberofincludedtrialsandmethodologicalquality,not
with 975 participants were included in the meta-analysis.
allplannedanalysescouldbeperformed.
The datapresented fromtwo trialscould notbe reanalyzed
due to data not being available for individual groups; these
3.Results wereexcludedfromquantitativeanalysis[37,38].Theauthors
werecontactedforadditionalinformation;howeverthiswas
3.1. Search Results. A total of 15,306 records with one unsuccessful.Alltrialsrecruitedmaleandfemaleparticipants
additional record sourced elsewhere were identified from exceptK.S.KimandY.-B.Kim[37]whorecruitedonlymale
4 Evidence-BasedComplementaryandAlternativeMedicine
subjects.Participantagerangedfrom13to37withamedian as)
ofmeanageof23.1years.Detailsoftriallocation,treatment bi
e
times,follow-upperiods,andparticipantstageandduration nc
a
o(s[bSaaaliteinw3sulrcl.ufseoi6mcutrxocscKnle]tpouThtsciteirunt(oa,dmro,ortninndeenweoaaaddciatlcnnatio[strtniu3unde)moooittpn4rdlnner[.oeeou]2ire..antnfanYv7OhlThrtThete,c.saei-rnn)t2sBaciwulepta8e[ruy.iars2lrhm,opeenceK93euntuosasw,thr1ise,nmhl–em3meeyhncr30adspitheto3uicd]eu2ease.,shadra.rr0rtciO3gtaebcw1Miau5frtn2uanroo]peaelclefurrTual[fqoKsoemo3pranturner7lbcsaceleiea]eoolrattdwnec,euhmwleiitue1rnceloutde.prypeicndseneaaualeucesuerlccnbdc.osedoucyrewmod2eempitdfb0uldaatubepoue0srwhincedan4trtpecachirrercotsleiaor[daubnumde3naacarle8dccweeaTlwb]uubritaiimnppaotaribtahenurhuueclecamecrdnnuodmtailmcccpun2iwwcttourwd.tuueierixlaneKtnaarrosiihdeeesr--ttl. Random sequence generation (selection bias) Allocation concealment (selection bias) Blinding of participants and personnel (perform Blinding of outcome assessment (detection bias) Incomplete outcome data (attrition bias) Selective reporting (reporting bias) Other bias
groups, sham auricular acupuncture, and sham auricular Han 2010 [27] + ? ? ? + ? +
electroacupuncture,respectively.
He 2009 [28] − ? ? ? + ? +
There was large variation in acupuncture points used
(Table 2). Three studies [27, 28, 34] used CV13 Shang- K. S. Kim and Y.-B. Kim 2012 [37] + + ? + + − +
wan, CV12 Zhongwan, CV4 Guanyuan, CV6 Qihai, ST24 Li et al. 2002 [29] − ? ? ? + ? +
Huaroumen,ST26Wailing,ShangFengShiDian(anabdom-
inal point 0.5 cun lateral to ST 24 Huaroumen), and KI13 Liu 2011 [30] ? ? ? ? + ? +
Qixue. Most of the studies used a standardized set of Liu and Shi 2015 [31] + ? ? ? ? ? +
acupuncturepointswithonestudyusingasemistandardized
McKee et al. 2004 [38] ? ? ? + + − ?
approach[30].FourstudiesusedAshipoints[28,29,33,34]
where the location was not specified and two used needles Mo and Jin 2005 [32] − ? ? ? + ? +
aroundacnelesions(surroundingacupuncture[29,33]).
Tang and Quan 2011 [33] ? ? ? ? + ? +
Onetrial[29]reportedontherapeuticeffectiveratebased
on lesion count and severity and also reported on serum Wu 2011 [34] + ? ? ? + ? +
testosterone and recurrence rate. Four trials [27, 31, 34, 35]
You and Liu 2014 [35] − ? ? ? + ? +
reportedontherapeuticeffectiverateaccordingtothe2002
Chinese medicine research guidelines [22]. One trial [33] Zhang et al. 2014 [36] + + ? ? − ? +
used the Chinese medicine research guidelines from 1997
[39] and three trials [28, 32, 36] used the 1994 Chinese Figure2:Riskofbiassummary.
medicine research guidelines [23]. One trial did not refer
toaguidelineforjudgmentoftherapeuticeffectiveratebut
indicated an improvement of lesion of 95% was a cure and
trialswereassessedaslowriskforincompletedata.Twotrials
60%wasasignificantimprovement;thesedatawereincluded
were assessed as high risk for selective outcome reporting.
inthemeta-analysis[30].Thecriteriafordeterminingclinical
McKeeetal.[38]statedtheywouldincludedataonadverse
effectaredescribedinSupplementaryTable 1.Onlyonetrial
eventsbutnodatawerepresented.K.S.KimandY.-B.Kim
reportedmeasuringqualityoflife,usingSkindex29[37].
2011indicatedintheirprotocol[40]theuseofVASscalebut
nodatawasreported.Theremainingtentrialswereassessed
3.3. Risk of Bias. Methodological quality of the trials was
asunclearastherewerenotrialprotocolspublishedortrial
generally low (Figure 2). Four trials [28, 29, 32, 35] were
registrationsidentified[27–36].
assessed as high risk of bias in the domain of sequence
generationastheyusedsequenceofvisitforrandomization.
Five trials [27, 31, 34, 36, 37] were assessed as low risk 3.4. Primary Outcome: Therapeutic Effective Rate. Figure 3
as random number generators were used. Three trials were presentstheforestplotforTER≥30%changeinsymptoms.
assessedasunclearastherewasinsufficientinformation[30, Inthemeta-analysisofthetrialsthatdefinedtheTER≥30%
33,38].Alltrialswereassessedasunclearriskinblindingof as improvement, the chance of achieving a 30% or greater
participants.Twotrialswereassessedaslowriskforblinding change in lesion count in the acupuncture group was not
ofoutcomeassessors[37,38]andtenwereatunclearriskdue differenttothecombinedpharmacotherapygroup(retinoids,
toinsufficientinformation.Onetrialwasassessedasunclear antibiotics, and other supplements) (four studies, RR: 1.07
riskforincompletedata[31]astheydidnotreportdropout [95% CI 0.98, 1.17] and 𝐼2 = 8%) [28, 32, 33, 36] with
data.Onetrial,Zhangetal.[36],reportedondropoutbutdata low heterogeneity. Subgroup analysis of studies where the
wasreportedonlyforthosewhocompletedthetrialandthus comparator was antibiotics plus other supplements showed
wasassessedashighriskforincompleteoutcomedata.Ten thechanceofa30%orgreaterchangeinlesioncountwasnot
Evidence-BasedComplementaryandAlternativeMedicine 5
e); NSNSNSNS
Age(mean(SD)orranggender(M/F) ±I:25.835.25;18/28±C:24.684.36;14/33 I:25.2;NSC:23.6;NS I1:13–37;NSI2:14–35;NSC:14–33;NS I:14–41;6/34C:13–30;7/33 NSNS NS;11/31NS;7/35 ±I:24.314.08;13/23±C:23.913.83;13/22 I:23.2;27/33C:24;27/31 I:18–23;2/17C:18–24;5/15 ±I:255;17/13±C:255;15/14 I1:F16(2.1)M15(0.7);I2:F21(3.4)M16(3.6);C1:F19(4.2)M17(1.9);C2:F21(1.5)M15(1.2); I:M21.5(3.6);NSC:M23.3(4.1);NS
mberofparticipantsdomized/assessed;outsorwithdrawals I:50/46;4C:50/47;3 I:24/24;0C:22/22;0 I1:200/200;0I2:60/60;0C:60/60;0 I:40/40;0C:40/40;0 I:42/42;0C:38/38;0 I:42/42;0C:42/42;0 I:40/36;4C:40/35;5 I:60/50;10C:58/50;8 I:20/19;1C:20/20;0 I:30/30;0C:30/30;0 I1:6/6;2I2:11/11;6C1:6/6;1C2:6/6;0 I:11/11,3C:11/11,2
np
uao
Nrr
d
nt
bycou
acialsion >(10
Table1:Characteristicsofstudies. Stage,severity,anddurationofcondition Stage:NSSeverity:PillsburyI,II2.35±0.86±Duration:I:;C:2.150.82Stage:NSSeverity:slighttosevereDuration:I:20dto16y;C:1mto17yStage:NSSeverity:Samuelson1–9Duration:I1:14d–15y,I2:7d–13y;C:4d–14yStage:NSSeverity:NSDuration:I:1w–14y;C:1w–10yStage:NSSeverity:NSDuration:NSStage:NSSeverity:NSDuration:1w–9yStage:NSSeverity:NS±±Duration:I:11.928.93;C:12.779.58Stage:NSSeverity:NSDuration:I:6.5m;C:6.1mStage:NSSeverity:NSDuration:I:6m–5y;C:6m–4.5yStage:NSSeverity:NSDuration:I:23.36m;C:22.81mStage:NSSeverity:gradeI&IImild-to-moderatenonscarringfdermatologist;photographsgradingbyCook1979andleDuration:NSStage:NSSeverity:KoreanAcneGradingSystemgrades2–4<papules,20nodulesonface);>Duration:3months(chronicstage) weeks;m:months;y:years.
w:
on,on ys;
atiati da
mentdurw-updur 8w,1m 3w,NS 6d,1m 2w,6m 2w,NS 10d,NS 8w,2m 8w,NS 4w,NS 30d,NS 20w,NS 4w,NS M:male;d:
Treatfollo male;
e
f
Triallocation China,hospital,outpatients China,hospital,outpatients NS NS NS NS NS NS NS NS USA,outpatientclinic Korea,outpatientclinic ention;C:control;F:
v
Firstauthor,publicationyear Han;2010[27] He;2009[28] Li;2002[29] Liu;2011[30] Mo;2005[32] Tang;2011[33] Wu;2011[34] Liu;2015[31] Zhang;2014[36] You;2014[35] McKee;2004[38] Kim;2012[37] NS:notstated;I:inter
6 Evidence-BasedComplementaryandAlternativeMedicine
Controltreatmentfrequency 10mgb.i.d.(firstmonth);10mgq.d.(secondmonth) b.i.d. 0.5g,q.i.d. b.i.d. Viaminate0.25mgt.i.d.;VitB6,2pillst.i.d.Erythromycin0.2gb.i.d.;zincsulfate0.2gb.i.d.;sulphur(topical)q.d. 10mgb.i.d. 10mgb.i.d.-t.i.d. b.i.d.
Controldetails Isotretinoincapsules(oral) Metronidazole(topical) Tetracycline(oral) Benzamycin(oral) Viaminatecapsules,VitB6(oral)Erythromycin,zincsulfate(oral);sulphur(topical) Isotretinoincapsules(oral) Isotretinoin(oral) Tretinoin(topical)
y 3
dcomparators. erventiontreatmentfrequenc 30mins,3timesperweek 30mins:bodypoints;5–20mins:headpointsAshiointsq.d.(firstweek),every2days(2ndand3rdweeks) A:30minq.d.;AA:3–5min,b.i.d. AA:5–10min,t.i.d. -5hrs/treatment,5timesperweek 30minq.d. upunctureandmoxibustion:timesperweek q.d.(totalof56treatments) Twiceperweek(totalof15treatments)
an nt 1p S 4 Ac
s I
n
Table2:Interventio Acupuncturepoints CV13Shangwan,CV12Zhongwan,CV4Guanyuan,CV6Qihai;ST24Huaroumen,ST26Wailing;ShangfengShidian(abdominalpoint0.5cunlateralandsuperiortoST24);KI13Qixue,M-CA-23Sanjiaojiu(Qipang)CV13Shangwan,CV12Zhongwan,CV4Guanyuan,CV6Qihai;ST24Huaroumen,ST26Wailing;ShangfengShidian(abdominalpoint0.5cunlateralandsuperiortoST24);KI13Qixue,M-CA-23Sanjiaojiu(Qipang),M-HN-3Yintang,SI18Quanliao,ST4Dicang,M-HN-9Taiyang,AshipointsSA:Ashipoints,AA:endocrine,lung,sympathetic,stomach,largeintestine,earShenMen,internalgenitalsLung,endocrine,adrenalgland,earShenMen,subcortex,cheek;largeintestine(windandheatinlungmeridian);spleen,stomach,largeintestine(heatanddampinspleenandstomach);liver,kidney(penetratingandconceptionmeridiandisharmony) Governormeridian Manual:ST36Zusanli,ST40Fenglong,ST45Lidui,LI11Quchi,LI10Shoushanli,LI4Hegu;SA:AshipointsAcupuncture:CV11Shangwan,CV12Zhongwan,CV4Guanyuan,CV6Qihai;ST24Huaroumen,ST26Wailing;ShangfengShidian(abdominalpoint0.5cunlateralandsuperiortoST24);KI13Qixue;Moxa:CV4Guanyuan,CV6QihaiGB14Yangbai,SI18Quanliao,GV14Dazhui,LI4Hegu,LI11Quchi,ST44NeitingGovernormeridians,Jiajiandbladderthroughthefirstlateralline,lung,largeintestine,stomach
e A
p S +
nterventionty Acupuncture Acupuncture I1AA+SAI2:AA AA Acupuncture cupuncture+ Acupuncturemoxibustion Acupuncture EA
I A
Firstauthor,publicationyear Han,2010[27] He,2009[28] Li,2002[29] Liu,2011[30] Mo,2005[32] Tang,2011[33] Wu,2011[34] Liu,2015[31] Zhang,2014[36]
Evidence-BasedComplementaryandAlternativeMedicine 7
c:
e
s
ntroltreatmentfrequency q.n. 0minweekly surroundneedle;
o 2 A:
C S
e;
ur
ess
pr
Controldetails Tretinoin(topical) C1:9shampointsonhelixauricularridgeC2:9shampointsonelixauricularridgeasC1plusEA8–16sec,10–40Hz Waitlist(notreatment) ghtly;AA:auricularacu
h ni
e
c
n
y o
ntinued. Interventiontreatmentfrequenc q.d.(totalof15treatments) 20minweekly Twiceweeklyfor4weeks esdaily;q.i.d.:fourtimesdaily;q.n.:
o m
C ti
Table2: Acupuncturepoints M-HN-3Yintang,SI18Quanliao,CV24Chengjiang,BL13Feishu,BL19Ganshu,BL20Pishu,BL23Shenshu,CV12Zhongwan,CV10Xiawan,CV4Guanyuan,CV6Qihai,ST25Tianshu,GV14Dazhui,LI11Quchi,LI4Hegu,ST36Zusanli,KI3Taixi,LU9Taiyuan I1:Oleson’sShenMen,allergypoint,skindisorderpointF,pointzero,lungs1and2,endocrinepoint,genitalcontrolpoint,facepointbilateralears;I2:pointsasI1plusEA8–16secon5–80Hz ST2Sibai,ST6Jiache,ST36Zusanli,LI20Yingxiang,LI11Quchi,PC6Neiguan,HT8Shaofu,SP3Taibai,SP6Sanyinjiao,SP10Xuehai,LR3Taichong,and/orAshipointsrandomlyselectedatpapulesandnodulesonthefacebyacupuncturepractitioner q.d.:onetimeperday;b.i.d.:twicedaily;t.i.d.:three
e;
ur
A ct
e E n
p u
nterventionty Acupuncture Auricularupunctureand Acupuncture EA:electroacup
I ac ol;
ntr
] o
Firstauthor,publicationyear You,2014[35] McKee,2004[38 Kim,2012[37] I:intervention;C:cseconds;Hz:hertz.
8 Evidence-BasedComplementaryandAlternativeMedicine
Intervention Control Risk ratio Risk ratio
Study or subgroup Weight
Events Total Events Total M-H, random, 95% CI M-H, random, 95% CI
1.1.1 Acupuncture versus antibiotics & other supplements
He 2009 [28] 23 24 19 22 21.5% 1.11 [0.92, 1.34]
Tang and Quan 2011 [33] 37 42 38 42 32.6% 0.97 [0.84, 1.13]
Subtotal (95% CI) 66 64 54.1% 1.03 [0.91, 1.16]
Total events 60 57
Heterogeneity:2=0.00;2=1.17, df =1(P=0.28);I2=14%
Test for overall effect:Z=0.41(P=0.68)
1.1.2 Acupuncture versus retinoids
Mo and Jin 2005 [32] 40 42 33 38 35.6% 1.10 [0.95, 1.26]
Zhang et al. 2014 [36] 18 19 15 20 10.3% 1.26 [0.96, 1.66]
Subtotal (95% CI) 61 58 45.9% 1.13 [1.00, 1.28]
Total events 58 48
Heterogeneity:2=0.00;2=0.86, df = 1 (P=0.35);I2=0%
Test for overall effect:Z=1.90(P=0.06)
Total (95% CI) 127 122 100.0% 1.07 [0.98, 1.17]
Total events 118 105
Heterogeneity:2=0.00;2=3.24, df =3(P=0.36);I2=8%
0.5 0.7 1 1.5 2
Test for overall effect:Z=1.55(P=0.12)
Test for subgroup differences:2=1.11, df = 1 (P=0.29);I2=9.9% Control Acupuncture therapy
Figure3:ForestplotofTER≥30%changeinsymptoms.
different between acupuncture and topical/oral antibiotics using Skindex 29 score. The data were not presented in a
andsupplementsgroup(twostudies,RR:1.03[95%CI0.91, waythatpermittedreanalysis,sotheeffectsremainunclear.
1.16] and 𝐼2 = 14%) [28, 33] with low heterogeneity. In a The study authors concluded that the use of acupuncture
subgroupanalysisofthechanceofachangeof30%orgreater andChineseherbalmedicineKeigai-rengyo-tocouldbeused
inlesioncountacupuncturewasaseffectiveastheretinoids for inflammatory acne lesions but further research was
groups(viaminateandtretinoin)(twostudies,RR:1.13[95% required.
CI1.00,1.28],𝑃 = 0.06,and𝐼2 = 0%)withnoheterogeneity Atotalof127adverseeventswerereportedinthreetrials
[32,36]. [27, 33, 34]. The other nine did not mention any adverse
Figure 4 presents the forest plot for TER ≥50% change events.Thereweremoreadverseeventsinthecontrolgroup
in symptoms. In the meta-analysis of the data from the (98 in the controlgroup and 29 in the interventiongroup).
trials that used ≥50% TER, the chance of a greater than Adverse events in the intervention group included painful
50% change in lesion count in the acupuncture group was sensation (11 cases), ecchymosis (nine cases), flushing (five
not statistically different to the pharmacotherapy group cases), and itchy sensation after needle withdrawal (four
(retinoidsandantibiotics)(sixstudies,RR:1.07[95%CI0.98, cases) which are common adverse events seen after needle
1.17] and 𝐼2 = 50%) [27, 29–31, 34, 35]; however there penetration and acupressure [41, 42]. In the control group,
was moderate-to-substantial heterogeneity. In a subgroup adverseeventsthatincludeddrymouth(75cases),dryskin
analysis,thechanceofa50%orgreaterchangeinlesioncount anddesquamation(17cases),andgastrointestinaldiscomfort
in the acupuncture group was not different to the retinoid (sixcases)arealsocommonadverseeventsfollowingtopical
group (isotretinoin and topical tretinoin) in four studies benzoylperoxideandretinoidtreatment[4,43].Noserious
(four studies, RR: 1.05 [95% CI 0.93, 1.17] and 𝐼2 = 59%) adverseeventswerereportedintheincludedtrials.
with moderate-to-substantial heterogeneity [27, 31, 34, 35].
Two auricular acupressure trials were not combined due to
4.Discussion
differencesincomparatortypes(onecomparatorwasanoral
pharmaceutical and the other was a topical preparation). Thissystematicreviewshowedthatthechanceof≥30%and
Auricular acupressure was more effective compared to oral ≥50%improvementinacnesymptomswithbodyacupunc-
tetracyclineforTER≥50%(onestudy,RR:1.15[95%CI1.02, ture,electroacupuncture,andauricularacupressurewasnot
1.31])[29];howevertherewerefourtimesmoreparticipants statistically different from that of pharmaceuticals for acne
intheinterventiongroupcomparedtothecomparatorgroup vulgaris.Interestingly,themagnitudeofthetreatmenteffect
with no reasons provided. Another study of auricular acu- andthe95%CIswerethesamefortheprimarymeta-analyses,
pressure found no benefit compared to topical benzamycin regardless of which criteria were used to measure clinical
(onestudy,RR:1.12[95%CI0.88,11.43])[30]. change.Thereweremoreadverseeventsinthepharmacother-
apy/control group than in the acupuncture/intervention
3.5. Secondary Outcomes. The paper by K. S. Kim and Y.- group.Basedontheincludedstudies,acupuncturewaswell
B. Kim [37] was the only trial to report on quality of life toleratedbyparticipantswithacnevulgaris.
Evidence-BasedComplementaryandAlternativeMedicine 9
Intervention Control Risk ratio Risk ratio
Study or subgroup Weight
Events Total Events Total M-H, random, 95% CI M-H, random, 95% CI
1.2.1 Acupuncture versus retinoids
Han 2010 [27] 42 46 44 47 21.5% 0.98 [0.87, 1.10]
Liu and Shi 2015 [31] 48 50 41 50 18.2% 1.17 [1.02, 1.35]
Wu 2011 [34] 32 36 33 35 18.2% 0.94 [0.82, 1.09]
You and Liu 2014 [35] 28 30 24 30 12.2% 1.17 [0.95, 1.43]
Subtotal (95% CI) 162 162 70.2% 1.05 [0.93, 1.17]
Total events 150 142
Heterogeneity:2=0.01;2=7.24, df =3(P=0.06);I2=59%
Test for overall effect:Z=0.80(P=0.43)
1.2.2 Auricular acupressure versus tetracycline
Li et al. 2002 [29] 245 260 49 60 20.5% 1.15 [1.02, 1.31]
Subtotal (95% CI) 260 60 20.5% 1.15 [1.02, 1.31]
Total events 245 49
Heterogeneity: not applicable
Test for overall effect:Z=2.27(P=0.02)
1.2.3 Auricular acupressure versus benzamycin
Liu 2011 [30] 32 40 30 42 9.3% 1.12 [0.88, 1.43]
Subtotal (95% CI) 40 42 9.3% 1.12 [0.88, 1.43]
Total events 32 30
Heterogeneity: not applicable
Test for overall effect:Z=0.90(P=0.37)
Total (95% CI) 462 264 100.0% 1.07 [0.98, 1.17]
Total events 427 221
Heterogeneity:2=0.01;2=10.05, df =5(P=0.07);I2=50%
Test for overall effect:Z=1.59(P=0.11) 0.5 0.7 1 1.5 2
Test for subgroup differences:2=1.31, df = 2 (P=0.52);I2=0% Control Acupuncture therapy
Figure4:ForestplotofTER≥50%changeinsymptoms.
Whilenotvalidated,TERisacommonmeasureofeffect be an option for those wanting an alternative treatment to
in Chinese medicine trials. The TER for acne vulgaris is a pharmaceuticals.Treatmenttimesvariedconsiderablyacross
subjective outcome that includes a change in lesion count thetrials.Suchvariationsoftreatmenttimescouldintroduce
or severity. The Chinese research guidelines for acne from clinical heterogeneity. The typical treatment duration for
2002[22]suggesta≥50%changeinlesioncountorseverity body acupuncture is 20 to 30 minutes for each treatment
whereasthe1994guidelines[23]suggested≥30%changein and treatment frequency may vary from one to five times
lesioncountandsymptoms.Inthisreview,acupuncturewas per week depending on the local clinical practice environ-
aseffectiveasantibioticsintrialsthatusedtheTERcriteriaof ment.Fibromyalgiaandtensionheadachestudieshavefound
a≥30%improvementinsymptoms.Inthetrialsthatuseda 20- to 30-minute needle retention, repeated stimulation on
≥50%improvementinsymptoms,auricularacupressurewas acupuncture points (de-qi sensation), and daily or twice
aseffectiveasantibioticsandacupuncturewasaseffectiveas weeklytreatmenttohavebetterclinicaloutcomescompared
topicalandoralretinoids.Thereiscurrentlynoconsensuson to less needle retention time and once-per-week treatment
outcomemeasuresforacnethoughthereareeffortsunderway [47,48].
to standardize them [44]. There was only one trial that The findings of this review are similar to previous
reportedonqualityoflifemeasureSkindex29eventhough reviews [20, 21]; however previous reviews included trials
thereismountingevidencethatsufferersofacnevulgarismay thatcomparedChinesemedicineinterventionsagainsteach
experienceconsiderablepsychologicalandemotionalburden other such as acupuncture compared to herbal medicines.
[45]. Thisreviewfacedthesamelimitationsasothersintermsof
All trials in the quantitative analysis used retinoids themethodologicalqualityofincludedtrials.Methodological
or antibiotics as the comparator. Retinoids and antibiotics quality of included studies was low, with four of the twelve
havedemonstratedefficacyforacne[4];howeverlongterm studiesassessedashighriskofbiasandthreeunclearinthe
antibiotic use can contribute to antibiotic resistance [46]. domain of sequence generation. There was also insufficient
Retinoids have severe adverse effects such as teratogenicity information on blinding of outcome assessors and partici-
and should be used with caution in people of childbearing pants.
age[46].Acupunctureandauricularacupressurewereshown Samplesizesweresmall,andnoneoftheincludedstudies
in this analysis not to be statistically different to guideline reportedsamplesizecalculations.Notalltrialsreportedon
recommendedtreatmentsbutwithfewersideeffectsandmay theseverityoflesions.Therewerenofollow-upassessments
10 Evidence-BasedComplementaryandAlternativeMedicine
in the included trials. Statistical heterogeneity was also SupplementaryMaterials
detected in several subgroup analyses which were not able
SupplementaryTable 1:therapeuticeffectiveratecriteriaand
to be explored due to small numbers of studies. Detailed
secondary outcomes. Supplementary Table 2: assessment of
reportingoftrialinformationwaslacking;noneofthetrials
reportingofSTRICTAitems.(SupplementaryMaterials)
addressedallitemsfromConsolidatedStandardofReporting
Trials (CONSORT) [49] or Standards for Reporting Inter-
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