De bewezen effectiviteit van nietmedicamenteuze. acne vulgaris

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1 De bewezen effectiviteit van nietmedicamenteuze behandelinterventies bij acne vulgaris Femke de Vries MSc Onderzoeker Lectoraat Innovatie van Zorgprocessen in de Farmacie Hogeschool Utrecht Dermatologiecongres mei 2019

2 Inhoud Achtergrond: Acne vulgaris & behandelinterventies Methode: Totstandkoming systematic review & best evidence synthese Effectiviteit van niet-medicamenteuze behandelinterventies Conclusie: Wat betekent dit voor de praktijk?

3 Acne een hot topic Pubmed hits Google hits Barbie met acne Pop-It-Pal Dr. Pimple Popper

4 Acne prevalentie Acne komt voor bij 85% van de adolescenten tussen jaar Na de tienerjaren neemt de prevalentie van acne sterk af Bij vrouwen (12%) komt acne op volwassen leeftijd vaker voor dan bij mannen (3%) Bron: J Clin Aesthetic Dermatology; 2012

5 Pathogenese Toegenomen talgproductie door de talgklier Veranderingen in het keratinisatieproces Folliculaire kolonisatie van P. acnes Vrijkomen van ontstekingsmediatoren in de huid Toegenomen endocrinologische factoren Bron: Williams, 2015 the Lancet

6 Pathogenese (2)

7 Klinisch beeld acne: comedonen Open comedonen: Blackheads Gesloten comedonen: Whiteheads Bron: Toonstra, Dermatologie voor huidtherapeuten, 2012

8 Bron: Toonstra, Dermatologie voor huidtherapeuten, 2012

9 Klinisch beeld acne: Papulopustulosa Bron: Toonstra, Dermatologie voor huidtherapeuten, 2012

10 Bron: Toonstra, Dermatologie voor huidtherapeuten, 2012

11 Nodulair acne en conglobata Bron: Toonstra, Dermatologie voor huidtherapeuten, 2012

12 Bron: Toonstra, Dermatologie voor huidtherapeuten, 2012

13 Varianten van acne(ïforme) erupties Acne excoriée des jeunes filles (knijpen/krabben) Acne neonatorum/acne infantum (baby/kinderacne) Acne fulminans (acute uitbarsting, ziek) Hidradenitis suprativa/ Inversa (inflammatoire afwijking van oksels, liezen en billen) Acne tarda (late-onset acne na het 25e levensjaar) Acne cosmetica Acne mechanica (druk of frictie plaatsen) Mallorca acne (invloed zon, zweten, zonnebrand) Chlooracne (gechloreerde chemicaliën) Geneesmiddelen acne (anabole steroïden, corticosteroïden) Gram-negative folliculitis (bacteriële infectie)

14 Kwaliteit van leven Correlatie met verschillende psychologische factoren: Depressie Schaamte Laag zelfbeeld Frustratie Sociale isolatie Boosheid Angsten Stigmatisering Verminderde QOL correleert niet met ernst acne

15 Behandelinterventies acne Volgens richtlijnen 1e keuze behandelinterventies acne veelal gericht op medicatie Topicale/systemische antibiotica, retinoïden, hormonale therapieën (orale anticonceptiva) of benzoylperoxide. Medicamenteuze behandelinterventies echter niet altijd gewenst: Ontwikkeling van antibiotica resistentie van P acnes en andere bacteriën Risico's op bijwerkingen Bij kinderwens of tijdens zwangerschap Angst/ weerstand tegen medicatie

16 Alternatief: Niet-medicamenteuze interventies Comedonen, papels, pustels verwijdering/incisie Peeling (Jessner, glycolzuur, alpha hydroxy acid, melkzuur, salicylzuur, Trichloorazijnzuur) Microdermabrasie Laser/licht therapie (IPL, PDT, Nd:YAG, blauw licht, rood licht) Microneedling Radio Frequency Echter ontbreekt voldoende evidence based support in de effectiviteit van deze behandelingen!

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19 Methode Systematic review MEDLINE Cochrane library Cinahl (N=33)

20 Methode (2) Kwaliteitscheck a.h.v. Cochrane risk of bias-tool

21 Methode (3) Best evidence synthese Strong: Moderate: Limited: Conflicting: No evidence: Consistent findings among multiple high quality RCTs Consistent findings among multiple low quality RCTs and/or CCTs and/or one high quality RCT One low quality RCT and/or CCT Inconsistent findings among multiple RCTs and/or CCTs No RCTs or CCTs Afkapwaarde voor high quality van 5 bias-vrije domeinen* * Bron: Higgins JP, Altman DG, Gotzsche PC, Juni P, Moher D, Oxman AD, et al. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials.

22 Licht en laser ± ± +++ strong evidence; ++ moderate evidence; + limited evidence; ± conflicting evidence

23 Licht en laser t.o.v. medicatie strong evidence; ++ moderate evidence; + limited evidence; ± conflicting evidence

24 Chemische peeling strong evidence; ++ moderate evidence; + limited evidence; ± conflicting evidence

25 Fractional microneedling radiofrequency strong evidence; ++ moderate evidence; + limited evidence; ± conflicting evidence

26 Conclusie Veel onderzoeken toonden een significante vermindering van acne laesies bij toepassen van niet-medicamenteuze therapieën. Echter, slechts 7/33 studies demonstreren een hoge methodologische kwaliteit voorzichtige interpretatie. Best evidence synthese toonde aan dat: Sterke evidentie gevonden voor glycolic acid (10-40%) Matige evidentie IPL ( nm & nm) en Diode laser (1450 nm) Conflicterende evidentie voor PDL ( nm) Medicatie niet per definitie meer afname van acne dan niet-medicamenteuze interventies. Geen overduidelijke superioriteit voor 1 interventie t.o.v. andere interventie.

27 Conclusie (2) Wat betekent dit voor de praktijk? Indirect bewijs voor de effectiviteit van verschillende nietmedicamenteuze interventies op acne vulgaris. Lage evidentie- onderzoeken niet werkzaam!! Laesie verwijdering (N=0) & (Micro) dermabrasie (N=0) Grote belangstelling voor niet-medicamenteuze interventies benadrukt het belang van meer onderzoek (dubbel geblindeerd, placebogecontroleerd).

28 Take home message: Het Evidence beest

29 Onderzoek patiëntenreis

30 Dank voor uw aandacht.. Femke de Vries MSc Onderzoeker Lectoraat Innovatie van Zorgprocessen in de Farmacie Hogeschool Utrecht

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