Assessing the 5-year persistence in positive clinical response with innovative psoriasis treatments: a network meta-analysis of pasi score.

BACKGROUND: Psoriasis is a chronic skin condition, for which the approval of several biologics has made a dramatic impact. Despite their initial treatment effectiveness, the challenge lies in understanding the long-term responses, as they may diminish over time. Limitations of the drug survival analysis warrant the application of additional outcomes to fully capture the performance of a biologic. We aimed to provide a broader perspective on the global landscape of biologic agents' persistence in positive clinical response by comparing innovative therapies over a 5-year period through a systematic review and network meta-analysis (NMA). METHODS: We comprehensively identified studies in Pubmed, EMBASE, Scopus and clinicaltrial.gov. We defined two outcomes: 1) "persistence at optimal response" (POR) or "clinical remission", and 2) "persistence at suboptimal response" (PSR) or "low disease activity" as the proportion of patients with continuous exposition to a biologic who achieved a PASI 100 or PASI 90 responses, respectively, at the end of the predefined 5-year follow-up period. RESULTS: Eleven publications, comprising 18 RCTs and 11,202 patients met inclusion criteria and were included in the NMA. In the ranking analysis, guselkumab exhibited the highest cumulative (0.8397250), followed by ixekizumab (0.8185545), and risankizumab (0.7643864). Conversely, etanercept (0.4152295), brodalumab (0.3633977), apremilast (0.2452136), and placebo (0.0263) showed the lowest cumulative probability of POR. For PSR, guselkumab (0.86083636), ixekizumab (0.74931136), and risankizumab (0.71293182) also held the top ranks, while brodalumab (0.41740227), secukinumab (0.231575), etanercept (0.192775), and placebo (0.01934545) presented the lowest PSR probabilities. CONCLUSION: The highest rates of persistence with clear or almost clear skin can be expected with guselkumab, ixekizumab and risankizumab compared to other biologics. The proposed proxy definitions of long-term persistence (POR and PSR) are reliable measures of patients being successfully treated that warrant further exploration and validation.

Comparative efficacy and therapeutic positioning of biologics in hidradenitis suppurativa: A systematic review with network meta-analysis of randomised trials.

Background Hidradenitis suppurativa (HS) is a challenging inflammatory skin condition. Recently, many different biologics have been tested for HS, but the paucity of head-to-head comparative trials makes it difficult to determine the real value of each biological intervention. We aimed to determine the relative efficacy among biologics in treating moderate-to-severe HS throughout a network meta-analysis (NMA) and, to identify which pathogenetic pathways may be the most appropriate to target. Methods We comprehensively identified studies in 3 databases and clinicaltrials.gov. The eligibility criteria included randomised controlled trials (RCTs) reporting data on the efficacy of moderate-to-severe HS. Results The NMA comprised 13 studies comprising 14 interventions on 2,748 participants in the network. The NMA showed the odds of achieving the clinical response were significantly superior with adalimumab (RR: 0.37, 95% CI = 0.06-0.63), adalimumab QW (RR: 0.63, 95% CI = 0.43-0.87), MAB1p (RR: 1.33, 95% CI = 0.03-3.12), secukinumab (RR: 0.25, 95% CI = 0.11-0.47) and secukinumabQ2W (RR: 0.24, 95% CI = 0.1-0.46) compared to placebo. Conclusion Based on the NMA, inhibiting tumour necrosis factor (TNF)-a with adalimumab appears to be the best strategy, followed by the blockade of IL--17 with secukinumab. Data for bimekizumab and CJM112 are promising. Infliximab has inconsistent clinical response, and more data are necessary to confirm this molecule as a potential third-line therapy in HS. The blockade of IL-23 and CD5a pathways is not relevant, or at least the current evidence is insufficient to recommend further investigation of guselkumab, risankizumab, and vilobelimab in phase III trials.

Comparative efficacy of oral Janus kinase inhibitors and biologics in adult alopecia areata: A systematic review and Bayesian network meta-analysis.

Alopecia areata (AA) is an autoimmune disorder that affects the hair follicles, resulting in patchy recurrent hair loss. A large body of evidence has demonstrated the favourable clinical response of the Janus kinase (JAK) inhibitors and biologics, but a lack of comprehensive comparison among these therapies exists in the current literature. This study aimed to compare their efficacy. A systematic review and meta-analysis were performed including randomized trials that report the outcomes of the Severity of Alopecia Tool (SALT)50 and/or the mean change in SALT. These articles were pooled and a network meta-analysis (NAM) was conducted. Based on the surface under the cumulative ranking curve estimates obtained for the mean change in SALT score, baricitinib_4 mg (0.7949656) had the best probability of being the most effective therapy, followed by ritlecitinib_200_50 mg (0.7391906) and ivarmacitinib_4 mg (0.7292594). In contrast, dupilumab, secukinumab, tralokinumab and apremilast were less likely to be effective. Targeting the JAK signalling pathway holds great potential for restoring hair regrowth, albeit the contribution of JAK1, JAK2, JAK3 and TYK2 inhibition to the therapeutic effect on AA is apparently different. Baricitinib_4 mg and ritlecitinib 200_50 mg demonstrated notable efficacy, and both molecules displayed a dose-dependent effect, which is not observed with ivarmacitinib. Further investigations into the specific mechanisms of action of these JAK inhibitors are warranted to elucidate the reasons behind these differences.

A Systematic Review and Bayesian Network Meta-Analysis of Medical Therapies for Lichen Planopilaris.

BACKGROUND: Lichen planopilaris (LPP) is a primary chronic lymphocytic cutaneous disorder that selectively destroys the hair follicles, resulting in scarring alopecia. Unfortunately, current available treatments are not fully effective to stop hair loss, and the level of evidence for medical interventions is weak. OBJECTIVES: The present article aimed to determine the efficacy of the different medical interventions in LPP through a network meta-analysis (NMA). METHODS: A systematic review and meta-analysis were performed including randomized trials that report the outcomes of lichen planopilaris activity index (LPPAI). These articles were pooled and a NMA was conducted. RESULTS: A total of seven studies were identified and included in meta-analysis, comprising 251 LPP patients. The NMA showed the mean difference in LLPAI was significantly superior with the combination of clobetasol plus N-acetylcysteine (mean difference: -2.0, 95% CI = -3.43 to -0.51) and the combination of clobetasol plus pentoxifylline (mean difference: -1.62, 95% CI = -3.0 to -0.25) compared to the treatment of reference (clobetasol). The NMA showed cyclosporine (mean difference: 2.05 95% CI = 0.68-3.49), methotrexate (mean difference: 1.95 95% CI = 1.23-3.17), the combination of methotrexate plus prednisolone (mean difference: 1.56 95% CI = 0.25-2.96) were significantly worse than hydroxychloroquine according to the differences in LLPAI. CONCLUSION: This work is the first NMA in LPP and hence, it can be helpful in serving as an initial step toward better evidence-based decisions in the treatment of this challenging condition. We propose a triple-combined approach consisting of topical clobetasol, hydroxychloroquine, and N-acetylcysteine as resulted in the most effective approach. Considering the poor outcomes observed with pioglitazone, mycophenolate mofetil, and cyclosporine, it is advisable to contemplate the use of these medications in patients who have not responded adequately to more efficacious alternatives.

Effects of probiotic supplementation in adult with atopic dermatitis: a systematic review with meta-analysis.

BACKGROUND: Atopic dermatitis (AD) is one of the most common chronic inflammatory skin diseases. The effect of probiotic administration on the severity of AD in adults has shown inconsistent results. OBJECTIVES: To determine the effectiveness of probiotic supplementation as a therapeutic tool for adult AD. METHODS: PubMed, Scopus and Embase were systematically searched to collect data from studies in which probiotics were administered to treat adult AD. RESULTS: Out of 413 publications, 9 papers were included in the meta-analysis. Significant differences in the ScORing Atopic Dermatitis tool favouring probiotics were observed [relative risk (RR) -5.93, 95% confidence interval (CI) -8.43 to -3.43]. Lactobacillus salivarius presented with largest effect size (RR -9.79, 95% CI -13.04 to -6.54), followed by L. acidophilus (RR -5.77, 95% CI -10.82 to -0.72) and L. plantarum (RR -3.76, 95% CI -6.36 to -1.16). No benefit was observed with L. fermentum. Based on the severity of AD, probiotics showed better results in people with moderate-to-severe AD (RR -9.12, 95% CI -12.17 to -6.08) than in individuals with mild disease (RR -2.67, 95% CI -4.67 to -0.66). Serum levels of IgE and eosinophil count remained significantly unchanged after the probiotic intervention (RR 0.25, 95% CI -0.10 to 0.60; RR -0.27, 95% CI -0.68 to 0.13, respectively). CONCLUSIONS: Current evidence supports a role for some probiotics as a therapeutic tool for the treatment of adult AD, particularly in patients with severe AD. The efficacy of probiotics is strain specific, with L. salivarius and L. acidophilus having the largest clinical benefit. Such benefit is apparently independent of IgE levels and eosinophil count. Despite these encouraging results, the decrease in AD severity did not translate into a clinically meaningful better quality of life as assessed by the Dermatology Life Quality Index. There currently is not enough reliable data to reach conclusions about the optimal dose and duration for probiotic treatment.

Meta-analysis on preventive and therapeutic effects of probiotic supplementation in infant atopic dermatitis.

Despite a large body of research, the effect of probiotic administration on the incidence and severity of atopic dermatitis (AD) shows conflicting results. We aimed to investigate whether probiotic supplementation reduces the incidence and severity of AD. Three databases were systematically searched. A 22% lower incidence of AD was found in the probiotic group. The reduction in incidence was 49% when probiotics were given to pregnant and lactating mothers, and 27% when they were given to pregnant mothers and infants. A 39% reduction of AD incidence was achieved when administered to pregnant-breastfeeding mothers and infants. Significant differences in SCORAD (SCORing Atopic Dermatitis) favoring probiotics were observed, but the IDLQI remained unchanged. Lactobacillus (L.) rhamnosus was the most documented strain, but it turned out to be ineffective in reducing SCORAD. Conversely, L. paracasei and L. sakei showed a significant decrease in SCORAD. Probiotics are effective in the prevention of AD, but the effect is less conclusive for the treatment of AD, especially in infants <1 year. The intake of probiotics by breastfeeding mothers is an important measure and may become a novel preventive strategy. The preventive effect of probiotics against AD is not associated with family background or AD risk. L. paracasei and L. sakei show the greatest reduction in SCORAD.

Bayesian network meta-analysis of head-to-head trials for complete resolution of nail psoriasis.

BACKGROUND: Almost 50% of patients with skin psoriasis have concomitant nail involvement. The comparative effectiveness of the available biologics for nail psoriasis (NP) is still an area of contention because of limited data on nails. OBJECTIVES: We conducted a systematic review and network meta-analysis (NMA) to compare the efficacy of biologics in achieving complete resolution of NP. METHODS: We identified studies in PubMed, EMBASE and Scopus. The eligibility criteria included randomized controlled trial (RCTs) or cohort studies for psoriasis or psoriatic arthritis with at least two arms of active comparator of biologic reporting at least one efficacy outcome of interest: that is the Nail Psoriasis Severity Index (NAPSI), the modified NAPSI or the Physician's Global Assessment of Fingernail Psoriasis with a score of 0. RESULTS: Fourteen studies comprising seven treatments met the inclusion criteria, and were included in the NMA. The NMA showed the odds of complete NP resolution were superior with ixekizumab [risk ratio (RR) 1.4, 95% confidence interval (CI) 0.73-3.10] compared with the treatment of reference (adalimumab). Brodalumab (RR 0.92, 95% CI 0.14-7.40), guselkumab (RR 0.81, 95% CI 0.40-1.80), infliximab (RR 0.90, 95% CI 0.19-4.60) and ustekinumab (RR 0.33, 95% CI 0.08-1.60) demonstrated worse therapeutic effect compared with adalimumab. According to the surface under the cumulative ranking curve, ixekizumab 80 mg every 4 weeks had the highest probability of being the best treatment. CONCLUSIONS: The interleukin-17A inhibitor ixekizumab has the highest rate of complete nail clearance and it can be considered the best-ranked therapy from the present evidence. This study is relevant to daily practice as it facilitates the decision when choosing between the wide variety of available biologics in patients for whom clearance of nail symptoms is the first concern.

Real-world experience and long-term evaluation of tofacitinib in refractory alopecia areata: A prospective, open-label, single-center study in Asian Arab population.

Tofacitinib is a pan-janus kinase inhibitor (JAK) which has been tested off-label in alopecia areata (AA) with promising results. However, evidence of tofacitinib in real-life setting is still poor. We evaluated long-term efficacy and safety of tofacitinib for refractory AA. This is a prospective, open-label, observational, single-center cohort study conducted between January 2018 and December 2020. Primary end-point was the percent change in Severity of Alopecia Tool (SALT) at the basal visit and at the most recent follow-up visit. Three categories of treatment response were analyzed. Data on 47 participants of Arab-Asian heritage were analyzed. A complete and partial regrowth was observed in 18 patients (41.86%) and 11 patients (25.58%), respectively. In 12 patients (27.9%), no response was obtained. Most of the non-responders belonged to the alopecia universalis group (66.67%). No statistical differences were observed in rates of regrowth between pediatric and adult individuals (p = 0.52), nor between women and men. Significant differences in the average duration of tofacitinib treatment were obtained among the three categories of regrowth (p < 0.003), notably duration of AA did not impact the clinical regrowth (p = 0.62). To the best of our knowledge, this is the first prospective, observational, long-term study using tofacitinib in refractory AA. Rates of regrowth and side effects are analogous to previous works. Length of tofacinitib therapy should last for 12 months before considering any discontinuation or change, since early cessation can lead to treatment failures or incomplete regrowth. Maintenance therapy after complete regrowth has demonstrated to be safe and effective to prevent recurrences of hair loss.

Bullous pemphigoid induced by biologic drugs in psoriasis: a systematic review.

INTRODUCTION: Several therapies for psoriasis have been described as triggers of biologic-induced bullous pemphigoid (BIBP). The real incidence of BIBP in psoriatic patients is still unknown. Hence, we compilated and analyzed current literature to identify the frequency and burden of this adverse event for psoriasis patients treated with biologics. MATERIAL AND METHOD: We systematically searched literature records involving psoriatic patients developing BIBP. Electronic searches were conducted in Pubmed, EMBASE and Scopus in April 2021. To assess the causal relationship between BP and the biologic drug, we applied the Naranjo adverse reaction probability scale and the Karch-Lasagna algorithm. RESULTS: Our systematic review identified 586 records through the three electronic databases. We identified 15 case reports of BIBP. These cases implicated two cases induced by adalimumab, three by efalizumab, three by etanercept, six by ustekinumab, and one case by secukinumab. Mean period of latency until the BIBP developed was time 5.12 ± 3.44 weeks for TNF-α blockers, and 28.66 ± 26.27 weeks for ustekinumab (p = .09). Most of the cases were assessed as "probable" consistently in both the Naranjo scale and the Karch-Lasagna algorithm. CONCLUSION: This work presents an accurate estimation on the frequency and burden of BIBP. Ustekinumab presents with the largest evidence of BIBP, especially in patients with previous failure to TNF-α agents. Distinct patterns in the cytokinic pathways and clinical course exist between the BP induced by TNF-α blockers and ustekinumab. A close monitoring of skin condition is highly advisable in patients receiving biologic therapies for psoriasis. Knowledge of BIBP is of great importance to determine the preventive measures and select optimal treatment options.What's already known about this topic?The widespread use of biologic drugs has led dermatologists to encounter increasing situations of biologic-induced BP (BIBP).A lack of data exists on the real incidence of BIBP in psoriatic patients.BIBP is an important adverse event to know when managing patients with psoriasis using biologics.What does this study add?This work presents an accurate estimation on the raised burden of BIBP.Ustekinumab presents with the largest evidence of BIBP, especially in patients with previous failure to TNF-α agents.Mean period of latency until the BIBP developed was time 5.12 ± 3.44 weeks for TNF-α blockers, and 28.66 ± 26.27 weeks for ustekinumab.Distinct patterns in the cytokine pathways and clinical course exist between the BP induced by TNF-α blockers and ustekinumab.A careful screening of previous history of bullous diseases and a baseline immunologic study in psoriatic patients should be advisable prior to commencing any biologic therapy.A close monitoring of skin condition is highly advisable in patients receiving biologic therapies for psoriasis.

Dupilumab in prurigo nodularis: a systematic review of current evidence and analysis of predictive factors to response.

INTRODUCTION: Dupilumab has been shown effective for prurigo nodularis (PN). However, precise data about efficacy of dupilumab as off-label use in PN is missing. We aggregated current evidence to assess efficacy of dupilumab in PN and to identify possible response predictors. MATERIAL AND METHODS: Five electronic databases were searched. Our primary outcome was improvement in pruritus measured by numerical rating scale (NRS). We collected data on NRS before (NRSpre) and after (NRSpost) the dupilumab therapy and designed two categorical variables: 'NRS_50' and 'NRS_100' defined as whether one patient reaches 50% and 100% reduction of the NRSpre. Secondary outcomes included: time until patient perceived any improvement (Time_First) and time until patient reported absence of pruritus (Time_Final). RESULTS: Data on 45 patients from eleven articles were analyzed. The NRSpre was 8.58 ± 1.89 and the NRSpost was 1.78 ± 2.29. Time_First was 10.15 ± 10.56 weeks, while Time_Final was 19.28 ± 13.71 weeks. 22/45 patients (48.88%) presented with complete resolution (NRS_100) and 37/45 patients (82.22%) had itch half dropped (NRS_50). Time_First was significantly longer in subjects that did not reach NRS_100 (13.13 ± 13.77) than in subjects that did (7.34 ± 7.86, p= .05). Time_First was significantly longer in atopic dermatitis (AD) patients (16.08 ± 16.18) than in subjects without AD (7.02 ± 5.69, p=.01). NRS_50 and NRS_100 presented with a significant association (p=.05). CONCLUSION: Dupilumab is an effective target-to-treat agent. In comparison with AD, the clinical response to dupilumab initiates later and, two months of therapy are required until significant itch relieves. Complete remission is rarely observed before 4 months of therapy. Notably, AD-related PN patients need longer treatment than non-AD related PN patients to find any relief. Two early signs of improvement are promising predictors of response to dupilumab: The Time_First and NRS_50. What's already known about this topic?Dupilumab has been shown to be an efficacious treatment for prurigo nodularis (PN)However, literature data on this topic are scattered. What does this study add?This work presents the largest cohort of PN patients treated with dupilumab.Our findings demonstrate dupilumab is a novel and effective choiceIn comparison with atopic dermatitis, the clinical response to dupilumab initiates later.Two months of therapy are required until the itch relieves. Complete remission is rarely observed before 4 months of therapy.Atopic dermatitis-related PN patients need more weeks of treatment than non-atopic dermatitis-related PN patients.

Efficacy and predictive factors of cyclosporine A in alopecia areata: a systematic review with meta-analysis.

INTRODUCTION: Drugs for alopecia areata (AA) can induce hair regrowth, but do not change the disease course. Dual properties of cyclosporine A (CsA) as hypetrichotic and immunosuppressive agent have encouraged use in AA. We aimed to determine the most meaningful efficacy of CsA and reveal features helping enhance its efficacy and reduce relapses. METHOD: Efficacy of CsA and predictive factors were investigated. Cochrane, MEDLINE, Pubmed and Embase databases were searched. RESULTS: 2,189 papers were retrieved. Based on 344 patients, mean proportion of responders was 73%. CsA monotherapy showed proportion of hair regrowth of 66%, whereas CsA combined with systemic corticosteroids yielded 78%. Overall efficacy in studies with duration of CsA treatment <6 months was: 74% (53-88%), while in those with duration ≥6 months was: 73% (47-89%). Recurrence with CsA monotherapy was 55% (6-96%) whereas when CsA was combined with systemic corticosteroids it was 28% (6-72%). CONCLUSION: CsA confers a favorable therapeutic effect and concomitant use of steroids slightly enhances efficacy, but it dramatically decreases relapses. Longer treatments seem to lead to less relapse likelihood, but daily dose does not influence recurrence. Optimal CsA dosage is 5 mg/kg/day in single therapy regimen, whereas it is 3 mg/kg/day in the steroid-associated regimen. KEY POINTSWhat is already known about this subject? Most treatments for alopecia areata have not been critically evaluated. Current outcomes about the efficacy and relapse rate of cyclosporine A (CsA) are inconsistent and predictive factors about the clinical response are lacking.What this study adds? CsA confers a favorable therapeutic hair regrowth. Longer treatment seems to lead to less likelihood of relapse of AA, but the daily dose does not exert any effect on the recurrence of the disease. The concomitant use of corticosteroids broadly decreases relapses, and it also enhances efficacy.Impact on clinical practice The combination with corticosteroids is the most predictive feature to prevent relapse of AA, followed by the duration of CsA therapy. The daily dose of CsA is the feature with the least or null impact on the clinical course of AA.

Effectiveness of ustekinumab in patients with atopic dermatitis: analysis of real-world evidence.

INTRODUCTION: Atopic dermatitis (AD) is a common chronic inflammatory condition. Ustekinumab is a human monoclonal antibody approved for psoriasis, that targets the interleukin (IL)-12 and IL-23, and it may also play a role in AD. Administration of ustekinumab in AD is presented in anecdotal reports with conflicting results. Our aim was to evaluate the precise value of ustekinumab on AD. MATERIAL AND METHOD: We systematically reviewed published data involving AD treated with ustekinumab. The main outcome was clinical improvement. We classified this in three categories: 'complete response,' 'partial response,' and 'no response.' A multivariant model was used to assess the effectiveness and the following potential predictive factors: gender, age, duration of AD, asthma, previous use of biologics, previous systemic therapies,levels of IgE and duration of ustekinumab therapy. RESULTS: Data on 23 patients were analyzed. Complete AD remission was reported in 8 patients (34.8%), while the absence of response was observed also in 8 patients (34.8%). Partial response was reported in 7 patients (30.4%). No differences were observed with the predictive factors. CONCLUSION: The IL-12/23 pathway is likely not an attractive target for AD. Other effective treatments are available and should be prioritized with a good safety profile. WHAT'S ALREADY KNOWN ABOUT THIS TOPIC?Administration of ustekinumab in AD (atopic dermatitis) has been presented in anecdotical reports with conflicting results.WHAT DOES THIS STUDY ADD?This work presents the largest cohort of AD patients treated with ustekinumab in a real-world setting.Ustekinumab resulted in similar rates of complete, partial, and negative responses.Our findings demonstrate the IL-12/23 pathway is not an attractive target in AD.More novel and effective treatments for AD are available and should be prioritized.The impact of anti-IL-12/IL-23p40 therapy in AD is still unclarified due to limited controlled trials.

Light-based therapies in the management of rosacea: a systematic review with meta-analysis.

BACKGROUND: The current scenario and position of laser and light-based therapies (LLBT) in the therapeutic rosacea scheme are lacking evidence-based recommendations and comparisons on efficacy and tolerability among different devices. This article aimed to systematically compare the efficacy, acceptability, and tolerability of the pulsed dye laser (PDL) versus other devices. METHOD: A literature search was conducted in March 2020. Four domains were analyzed throughout the following six outcomes: Spectrophotometer erythema index and percentage of reduction for background erythema, telangiectasia grading scale for telangiectasias, visual analog scale for pain, and physician's assessment and patient's satisfaction for treatment success. RESULTS: Our search yielded 423 potentially relevant studies. After removing the excluded and duplicated records, 12 records were assessed for eligibility in the meta-analysis. Erythema (RR:0.38 95%CI: -0.20-0.95), telangiectasias (RR:0.54 95%CI: -0.87-1.94), and the treatment success throughout the physician's assessment (RR:1.23 95%CI: 0.74-2.04) and the patient's satisfaction (RR:1.15 95%CI: 0.73-1.82) were not significantly different between pulsed dye laser and other LLBT. In the pain domain, PDL was as painful as other LLBT (RR:-0.23 95%CI: -0.96-0.49) but more painful than neodymium: yttrium-aluminum-garnet laser (RR:0.84 95%CI: 0.53-1.14) and less than intense pulsed light (RR:-1.18 95%CI: -1.56-0.80). CONCLUSION: This work based on previously published literature demonstrates that the quality of evidence to support any recommendation on LLBT in rosacea is low-to-moderate. Among all the available devices, PDL holds the most robust evidence, although in the meta-analysis the effectiveness was comparable to other LLBT, such as neodymium: yttrium-aluminum-garnet laser (Nd-YAG) or IPL.

Comparative appraisal with meta-analysis of erbium vs. CO2 lasers for atrophic acne scars.

Recent advances in laser technology allowed the development of systems that improve texture, appearance and pliability of skin in acne scars (AS). Currently, comprehensive comparative studies on the efficacy of the most commonly used fractional systems in AS are lacking. Thus, the aim of this work was to appraise and compare the clinical response to erbium versus CO2 lasers in AS in the form of a meta-analysis. The databases MEDLINE, EMBASE, Cochrane library were searched. Main clinical outcomes were investigator-reported scar improvement and participant-reported scar improvement. Five studies were included in this meta-analysis. Scar improvement was similar for both types of laser in terms of investigator-reported scar improvement (RR: 0.60 95 % CI: 0.35-1.02) and participant-reported scar improvement (RR: 0.99 95 % CI: 0.79-1.25). A sensitivity analysis that excluded studies with high risk of bias found the CO2 lasers to be superior to the erbium lasers (RR: 0.47 95 % CI: 0.24-0.93): However, the subgroup analysis showed the CO2 laser not to be significantly different from either the non-ablative erbium (RR: 0.65 95 % CI: 0.34-1.24) or the ablative erbium laser (RR: 0.60 95 % CI: 0.35-1.02). The CO2 laser produced a slightly greater clinical response compared to the erbium lasers based on the physician's assessment. Overall, the two devices do not differ largely in terms of efficacy but may be complementary, with each resurfacing laser better suited for different clinical tasks.

Laser and light-based therapies in the management of rosacea: an updated systematic review.

Unlike other rosacea therapies which need daily takings or applications over long periods, the edge of lasers and light-based therapies (LLBT) is the limited number of sessions to achieve improvement. The proper selection of the adequate physical device in accordance with the patients' skin features and rosacea-related signs and symptoms should be considered and the management with physical sources should be updated as new data become available. This article reviews and discusses the current use of lasers and light-based therapies in rosacea with reference to all the available literature.This systematic review demonstrates the quality of evidence to support any recommendation on LLBT in rosacea is low-to-moderate. Among all the available devices, PDL holds the most robust evidence. Treatments options should be tailored for each specific clinical scenario as it is unlike that single modality results in complete resolution. Platforms that include two or more devices and combined therapies with topical agents are suitable and they warrant further investigations.

Evaluation of the efficacy of subantimicrobial dose doxycycline in rosacea: a systematic review of clinical trials and meta-analysis.

BACKGROUND: Low-dose doxycycline (SDD) is an antimicrobial agent that appears to improve common inflammatory skin diseases. Few data are available regarding the overall effectiveness, appropriate length of treatment and optimal patient selection for rosacea. We therefore reviewed the efficacy of sub-antimicrobial doses of SDD in papulopustular rosacea (PPR) and aimed to determine the most suitable patients for this approach. METHODS: From July to September 2019, we carried out a comprehensive search of literature from five databases, using a combination of "rosacea" AND "doxycycline". RESULTS: Our search yielded 532 potentially relevant studies. Our meta-analysis showed no significant difference between SDD and a comparator (RR: 1.12, 95 % CI: 0.78-1.62, I2 =  86 %). Subgroup analysis of studies comparing doxycycline with placebo yielded a clear difference in favor of doxycycline (RR: 1.45, 95 % CI: 1.22-1.72, I2 =  31 %), while subgroup analysis of studies comparing active drugs revealed no difference between interventions (RR: 0.52, 95 % CI: 0.17-1.63, I2 =  90 %). CONCLUSIONS: There is strong evidence that SDD is more effective than placebo. However, other drugs such as minocycline or isotretinoin have shown outcomes at least similar to that of SDD. We suggest that the anti-inflammatory properties of SDD may be of more value for mild cases of rosacea than for moderate to severe cases, for which higher (antimicrobial) doses of doxycycline may be a more suitable choice.