Efficacy of tetracyclines in the treatment of acne vulgaris

In general, the inflammation of the pilosebaceous follicle as a response to androgenic hormones is termed as acne (McPhee et al. 2006). Acne vulgaris is a skin disease characterised to have both open and close comedones.  Acne vulgaris can be in the form of pure comedonal variety or can be accompanied with one or more of the following: papular, pustular inflammatory acne, cysts and nodules. It affects the face and the trunk area. Once acne vulgaris is present, a person can suffer from severe scarring, development of cyst and skin pigmentation of the affected areas. Due to this fact, it is highly influential in the physical image of a person, which in turn affects self-image and confidence.

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Acne vulgaris exists across different nations and social structures. It commonly starts to develop during puberty and is considered to more common to men than women (McPhee, 2006). Most attribute the skin disease with genetics while others consider environmental factors. One of the most recommended treatments is through the use of topical and oral antibiotics such as tetracyclines (Petrie and Sabin, 2000). There is no hard evidence that prove that indeed, antibiotics, most especially, tetracyclines, are able to treat the disease (Scholar and Pratt, 2000).

Tetracyclines are generally categorized into two groups . The first-generation cyclines, includes tetracycline HCL and oxytetracylines, while the second-generation includes doxycycline, minocycline and lymecyclines (Simonart et al., 2007). Since tetracyclines are commonly recommended to treat acne (Khanna, 1993), it is important to find out which type is more effective than others. Factors, such as dosage and duration of treatment are also significant markers of the drugs’ efficacy (Simonart et al., 2007).

Introduction

To evaluate the relative efficacy of tetracyclines in the treatment of acne vulgaris, a systematic review of clinical trials, from 1962-2006 are investigated by Simonart and colleagues (2007). The systematic review tries to put together relevant information with regards to a specific health condition, in this case acne vulgarise and tetracyclines (Petrie and Sabin, 2000).

 Given the fact that systemic review requires refinement of a large amount of often-complicated information, the risk of internal bias is in question. Simonart and collegueas (2007) are convinced that the efficacy of tetracyclines is the same on the basis that dosage and duration does not affect its effectiveness. Since the aim of the study focus to create a systemic review of the efficacy of tetracyclines for treatment of moderate to severe acne, it is important to look into the appropriateness of the methods used and the utilization of the literature and evidences.

The Critical Appraisal Skills Programme (Public Health and Resource Unit, 2008) , a methodological approach to look into and identify the validity and the applicability of the results of, in this case, a systemic review, will be used to critically appraise the above mention study made by Simonart and colleagues about the efficacy of tetracycline to treat acne. Through CASP, evidences will be critically analyzed with the use of ten questions that shall evaluate its value. The STROBE statements will also be use to identify whether all relevant structure and ideas of a cross-sectional study are present in the literature.

Methods and Results

The review tries to uncover whether the efficacy should be the basis for using, promoting and/or recommending the use of a specific tetracycline to a patient suffering acne vulgaris.  The data are gathered through electronic research via databases and libraries (mentioned in the article). Simonart and co-researchers (2007) tries to limit the possibility of error and bias through exclusion of duplicates and studies that includes specific forms of acne, combined treatments and small number of patients studied. Non-English studies with no available English version are not included in the systematic review as well.

The researchers used statistical analysis with more than one assessor since they believe that quality scoring yield procedural inadequacy. The variation of treatment –dosage and duration, where assessed by ‘the year of publication and percentage of subjects not evaluated after treatment (Simonart et al, 2007).’ The intention for treatment is also recognize as a component of the analysis. Shearman’s correlation coefficient is used to show the relationship between year of publication and dosage and duration based on the lesions. The reduction of inflammatory and non-inflammatory acne served as basis for the efficacy of treatment of different tetracycline groups, which is measured by multiple regressions.

The researchers try to locate an objective attribute to reveal or show efficacy. They provided tables that show the summary of the qualified studies. Primarily, dosage and duration with regards to the decrease on the number of lesions of those who use first generation and to those who use second-generation tetracycline are compared. In both cases there are no significance change found. The results are expressed in decimal form p-values in the absence of confidence interval. The results precisely identified that there is no significant difference between first generation and second-generation tetracycline’s’ efficacy.

It is a recognizable fact that acne is a skin disease that affects many people across cultures. The population sample covered in the review came from several articles and literature across countries most specifically western countries.

The researchers also elaborated on the fact that the effectiveness of tetracycline does not stem from its antimicrobial property, since even after developing an increased resistance to antibiotic, the efficacy of tetracycline remains the same. Thus, different bacterial strains, as can be concluded, are not a significant factor. Therefore, the results of the study can be applied to any local population experiencing the same skin health problem. The researchers elaborate that first-generation tetracycline has some serious side effects that might have been the reason for its being more preferable.

The study involves a personal or individual point of view and/or preference. It concerns the individual or affected person and at times, his/her family. The article suggests that one should not look into the efficacy of tetracycline in choosing for treatment of acne. Instead, since there are no significant differences between their efficacies, one should focus on practicability and possibility of complications.

With reference to the STROBE statements, the article succeed in presenting an understandable abstract, which contains the gist of the article,’s thought. The title although simple is somehow vague since one will not be able to grasp that the efficacy that will be reviewed refers to the different types of tetracycline and not to tetracycline in general.

The rationale behind the study lies on the fact that second-generation tetracylines, although sold in higher prices, are considered more preferable than first-generation. The review tries to look into dosage and duration of use to identify which tetracycline is most effective after a specific period. The use of a systematic review creates a fusion of several insights and research results.

The underlying trend is the focus of the review. The data collection is done through searching articles from different databases such as PubMed, Medlink and Current Contents. Out of 57 eligible studies and articles, only 35 include inflammatory lesion counts while 23 have non-inflammatory lesion count. The discussion part successfully displays the limitation of the study when restrictions are mentioned and cautious interpretations are applied.

Discussion

A systematic review is suitable to identify the efficacy of tetracycline. A thorough study and comparison of the different articles and literature about tetracycline enlighten the fact that despite their differences– their effects are closely the same. Thus, one tetracycline is no significantly more efficient than another. The systematic review also managed to generalize the interrelated articles that evaluate the effects of different tetracycline. Usually, a study only tries to defend or clarify the efficacy and sometimes the complication of one type of tetracycline. In this article, a general view regarding the effect of tetracycline is explored.

Systematic review reduces the risk of errors since several studies are being used and compared. The authors clarified in each level of analysis that some studies are disregarded due to lack of the criteria to be compared.

A specific target population is not mentioned thus, the direct applicability of the study to local population is hard to validate. Nonetheless, because of the large amount of literature from databases, it follows that the study can be all encompassing (across societal boundaries). According to the researchers, there are no other researches that try to compare the efficacy of tetracycline with each other. This undermines the originality of the work. Simonart and colleagues advise that there should be a study that will uncover the reason behind the treatment of acne through small doses of tetracycline which they suppose lies in its anti-inflammatory property (Simonart et al, 2007).

Conclusion

As a whole the study, demonstrate that there are actually no significant difference between the first-generation tetracycline and the second-generation in terms of efficacy. The problem lies on the possibility of the development of complications in the first-generation which is absent in the second generation. Thus, when choosing between the two, a person should try to weigh between price and possible complications.  The outcome of the study successfully determines that tetracyclines are effective in controlling acne vulgaris. Nonetheless, the relevance and applicability of the study to local community is not extensively discussed since the actual number and profile of the participants are barely incorporated.

References:

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Khanna N. Treatment of acne vulgaris with oral tetracyclines. Indian J Dermatol Venereol Leprol 1993;59:74-6 Retrieved on November 26, 2007 from http://www.ijdvl.com/article.asp?issn=0378-6323;year=1993;volume=59;issue=2;spage=74;epage=76;aulast=Khanna
McPhee, S.J. , Tierney, L.M. and  Papadakis, M.A. Current Medical Diagnosis and Treatment. McGraw-Hill Professional, 2006; 116-17

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Public Health Resource Unit. Critical Appraisal Skills Programme: Systematic Review. Retrieved on November 26, 2008 from http://www.phru.nhs.uk/Pages/PHD/resources.htm

Scholar, E.M. and Pratt, W.B. The Antimicrobial Drugs. Oxford University Press US, 2000;193-194.

Simonart, T., Dramaix, M. and Maertelaert, D.  Efficacy of tetracyclines in the treatment of acne vulgaris: a review. British Association of Dermatology, 2007.
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STROBE statements. Checklist for Cross-Sectional Studies. Retrieved on November 26, 2008, from http://www.strobe-statement.org/Checklist.html