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Management of acne vulgaris-associated scarring
Evidence review M
NICE Guideline, No. 198
National Guideline Alliance (UK).
Management of acne vulgaris-associated scarring
Review question
What are the most effective treatment options for acne vulgaris-associated scarring?
Introduction
There is a lot of evidence that people with severe acne scarring can suffer life-long psychological problems and their quality of life is reduced. There is also some evidence of stigmatisation and prejudice towards people with acne. Treatments for acne scarring are available in a few NHS centres but there is uncertainty regarding which intervention is the most effective and there is geographical variation in availability of treatments. Therefore, the aim of this review is to determine the most effective treatment options for acne vulgaris-associated scarring.
Summary of the protocol
Please see Table 1 for a summary of the Population, Intervention, Comparison and Outcome (PICO) characteristics of this review.
Table 1
Summary of the protocol.
For further details see the review protocol in appendix A.
Methods and process
This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual. Methods specific to this review question are described in the review protocol in appendix A and the methods document (supplementary document 1).
Declarations of interest were recorded according to NICE’s conflicts of interest policy.
Clinical evidence
Included studies
Overall 30 studies were included in this review. These are divided according to the study design, that is split-face randomised controlled trials (RCTs) and parallel-group RCTs.
Atrophic acne vulgaris scars
Split-face studies
Overall 19 split-face RCTs were included in this review. Five studies were conducted in Egypt (Abdel-Magiod 2019, Galal 2019, Gawdat 2014, Hassan 2019, Osman 2017), 4 in Iran (Faghihi 2015, Fahgihi 2016, Faghihi 2017, Nilforoushzadeh 2017), 3 in Thailand (Khamthara 2018, Manuskiatti 2012, Rongsaard 2014), 2 in Korea (Cho 2010, Lee 2009), 2 in the USA (Sage 2011, Tanzi 2004), 1 in Denmark (Hedelund 2012), 1 in Germany (Reinholz 2015) and 1 in China (Zhang 2013). The sample size of the studies ranged from 8 to 42 participants.
Studies included participants with different severities of atrophic facial acne vulgaris scars: 7 studies included participants with moderate to severe acne scars (Abdel-Maguid 2019, Faghihi 2015, Faghihi 2016, Faghihi 2017, Hassan 2019, Hedelund 2012, Khamthara 2018), 4 studies with mild, moderate or severe acne scars (Cho 2010, Gawdat 2014, Osman 2017, Zhang 2013), 2 with mild to moderate acne scars (Lee 2009, Tanzi 2004); one study included participants with severe acne scars only (Reinholz 2015) and 5 studies did not report the severity of acne scarring (Galal 2019, Manuskiatti 2012, Nilforoushzadeh 2017, Rongsaard 2014, Sage 2011).
Included studies evaluated the effectiveness of different interventions with carbon dioxide laser (CO2) being the most common intervention:
- ablative fractional CO2 laser with platelet-rich plasma intradermal administration versus CO2 laser with saline intradermal administration (Faghihi 2016, Gawdat 2014) or platelet-rich plasma topical administration (Gawdat 2014), or versus CO2 laser alone (Galal 2019),
- ablative fractional CO2 laser with platelet-rich plasma topical administration versus CO2 with stem cell-conditioned medium topical administration (Abdel-Maguid 2019),
- ablative fractional CO2 laser with stem cell-conditioned medium topical administration versus CO2 laser with saline topical administration (Abdel-Maguid 2019),
- ablative fractional CO2 laser with punch elevation (Faghihi 2015) or subcision (Nilforoushzadeh 2017) versus CO2 laser,
- 2940-nm Er:YAG laser plus silicone gel versus 2940-nm Er:YAG laser plus hydrophilic cream (Khamthara 2018),
- 2940-nm Er:YAG laser versus CO2 laser (Manuskiatti 2012, Reinholz 2015),
- 585-nm pulsed dye laser versus 1064-nm long-pulsed Nd:YAG laser (Lee 2009),
- 1550-nm erbium-doped fractional photothermolysis laser versus ablative fractional CO2 laser (Cho 2010),
- 1320-nm Nd:YAG laser versus 1450-nm diode laser (Tanzi 2004),
- 2940-nm ER:YAG laser versus microneedling (Osman 2017),
- ablative fractional CO2 laser versus no treatment (Hedelund 2012),
- fractional micro-plasma radiofrequency versus ablative fractional CO2 laser (Zhang 2013),
- fractional bipolar radiofrequency versus 1550-nm fractional erbium-doped glass laser (Rongsaard 2014).
The effectiveness of the following interventions not involving laser treatment was also assessed:
- fractionated microneedle frequency plus subcision versus fractionated microneedle frequency (Faghihi 2017),
- subcision plus autologous platelet-rich plasma intradermal administration versus autologous platelet-rich plasma intradermal administration (Hassan 2019),
- subcision versus collagen filler intradermal administration (Sage 2011).
Evidence was identified for the majority of outcomes such as improvement in scarring (investigator or participant reported), participant satisfaction with treatment and side effects.
No evidence was identified for serious adverse events, skin-related quality of life and participant’s mood. The included split-face studies are summarised in (Table 2).
Parallel-group studies
Overall 11 parallel-group RCTs were included in this review. One study was conducted in Brazil (Cachafeiro 2016), 5 studies were conducted in Egypt (Ahmed 2014, Leheta 2011, Leheta 2014, Mohammed 2013, Nofal 2014), 1 study was conducted in India (Anupama 2016), 1 study was conducted in Iran (Asilian 2011), 1 study was conducted in Korea (Chae 2015), 1 study was conducted in Turkey (Erbagci 2000), and 1 study was conducted in USA (Bhargava 2019). The sample size of the studies ranged from 28 to 50 participants.
Studies included participants with different severities of atrophic facial acne vulgaris scars. Three studies included participants with mild, moderate, or severe acne scars (Anupama 2016, Erbagci 2000, Nofal 2014); 3 studies included participants with moderate to severe acne scars (Asilian 2011, Cachafeiro 2016, Mohammed 2013); 1 study included participants with severe acne scars (Bhargava 2019); and 4 studies did not report the severity of acne scarring (Ahmed 2014, Chae 2015, Leheta 2011, Leheta 2014).
Included studies evaluated the effectiveness of different interventions with laser therapy being the most common intervention:
- Trichloroacetic acid (TCA) CROSS 100% versus carbon dioxide (CO2) laser (Ahmed 2014);
- CO2 laser with subcision versus CO2 laser (Anupama 2016);
- 1064 nm Q-switched Nd:YAG laser versus CO2 laser (Asilian 2011);
- 1340 nm non-ablative fraction erbium laser versus microneedling (Cachafeiro 2016);
- 1550 nm Er:Glass fractional laser versus microneedling (Chae 2015);
- 1540 nm fractional photothermolyis versus percutaneous collagen induction (PCI) and TCA 20% versus alternating treatment of both interventions (Leheta 2014);
- CO2 laser and needling versus CO2 laser (Mohammed 2013).
The effectiveness of the following interventions not involving laser treatment was also assessed:
- Subcision and needling and platelet-rich plasma versus subcision and needling (Bhargava 2019);
- Glycolic acid peel versus 15% glycolic acid cream versus placebo (Erbagci 2000);
- PCI versus TCA CROSS 100% (Leheta 2011);
- Intradermal PRP versus TCA CROSS 100% versus needling and topical PRP (Nofal 2014)
Evidence was identified for the majority of outcomes such as improvement in scarring (investigator or participant reported), participant satisfaction with treatment and side effects.
No evidence was identified for serious adverse events, skin-related quality of life and participant’s mood. The included parallel-group studies are summarised in (Table 2).
Hypertrophic and keloid acne vulgaris scars
No relevant evidence was identified for hypertrophic or keloid scars.
See the literature search strategy in appendix B and study selection flow chart in appendix C.
Excluded studies
Studies not included in this review with reasons for their exclusions are provided in appendix K.
Summary of clinical studies included in the evidence review
Summaries of the studies that were included in this review are presented in Table 2.
Table 2
Summary of included studies.
See the full evidence table in appendix D. No meta-analysis was conducted (and so there are no forest plots in appendix E).
Quality assessment of included studies in the evidence review
See the evidence profiles in appendix F.
Economic evidence
Included studies
A single economic search was undertaken for all topics included in the scope of this guideline but no economic studies were identified which were applicable to this review question. See the literature search strategy in appendix B and economic study selection flow chart in appendix G.
Excluded studies
Economic studies not included in this review are listed, and reasons for their exclusion are provided, in appendix K.
Economic model
Although this review question was prioritised for economic modelling due to its potentially significant resource implications, no formal economic modelling was possible to undertake, because the available clinical effectiveness data were too limited to inform a meaningful economic analysis of good quality. Instead, a simple cost analysis was carried out to estimate intervention costs of treatments with some evidence of effectiveness, so that clinical effectiveness could be considered alongside intervention costs in a simplistic cost-consequence analysis, to enable the committee to formulate potential recommendations after taking into account both effectiveness and cost considerations.
According to the guideline systematic review, 3 treatments showed some evidence of effectiveness in the management of acne vulgaris-associated scaring: CO2 laser treatment; punch elevation; and glycolic acid peels. Intervention costs for each treatment option were estimated by combining resource use reported in the RCTs included in the guideline systematic review, modified based on the committee’s expert opinion to reflect UK routine practice, with respective national unit costs.
Clinical effectiveness and intervention cost of CO2 laser treatment
Evidence on the effectiveness of CO2 laser treatment in the management of acne vulgaris-associated scarring was obtained from Hedelund 2012, which was a split-face trial that compared CO2 laser treatment with no treatment tested on 13 people. Participants received 3 sessions of laser treatment at 4-5 week intervals. The measure of outcome was the change in the level of scarred skin texture and atrophy. Effect was assessed using numerical scales ranging from 0 (even skin texture without scarring/atrophy) to 10 (worst possible scarring/atrophy). CO2 laser treatment resulted in higher improvements in both scarred skin texture (MD −1.33, 95% CI −2.35 to −0.31) and scarred skin atrophy (MD −1.33, 95% CI −2.31 to −0.35) compared with no treatment.
The committee advised that, in routine clinical practice, a course of treatment of acne vulgaris-associated scarring with CO2 laser comprises a range of 1-4 laser sessions (day-case specialist appointments) and 1-2 nurse-led follow-up outpatient visits. Usually, treatment consists of 3 laser sessions and one separate follow-up session, since some follow-up monitoring of a laser treatment session occurs at the same time with the next day-case appointment for laser treatment.
In order to attach appropriate unit costs to the resource use associated with CO2 laser treatment, the committee advised that CO2 laser treatment corresponds to ‘major skin procedures’ Healthcare Resource Group (HRG), as listed in the national schedule of NHS costs. However, it was noted that HRQ ‘intermediate skin procedures’ had a higher unit cost than ‘major skin procedures’, and therefore NHS unit costs for both major and intermediate skin procedures were used in costing, to provide low and high estimates for intervention costs associated with CO2 laser treatment for acne vulgaris-associated scarring.
Table 3 shows the resource use and unit costs relating to a course of CO2 laser treatment for the management of acne vulgaris-associated scarring, as well as the range of the estimated total intervention cost, depending on the assumptions on the number of CO2 laser treatment sessions and the number of follow-up outpatient visits required, as well as the related HRG unit cost used. The cost of a course of CO2 laser treatment is likely to lie between £938 and £4,465. At the usual resource use (3 laser sessions and 1 follow-up visit) the estimated intervention cost is likely to range from £2,619 to £3,300.
Table 3
Estimation of the intervention cost of a course of CO2 laser treatment for the management of acne vulgaris-associated scarring.
Clinical effectiveness and intervention cost of punch elevation
Evidence on the effectiveness of punch elevation in the management of acne vulgaris-associated scarring was obtained from Faghihi 2015, which was a split-face trial that compared punch elevation provided in advance to CO2 laser treatment versus CO2 laser treatment alone tested on 42 people. Participants received either 1 session of punch elevation 24 hours prior to 2 sessions of CO2 laser treatment (which were provided 4 weeks apart) or 2 sessions of CO2 laser treatment alone. The measure of outcome was the clinician-rated improvement in acne vulgaris-associated scarring, graded as follows: ‘excellent’ improvement: >75% improvement; ‘good’ improvement: 51-75% improvement, and ‘moderate’ improvement: 25-50% improvement. Treatment with punch elevation added on laser treatment produced better effect than laser treatment alone at 4 months after treatment, with a risk ratio for excellent improvement of 6 (95% CI 1.43 to 25.19). However, the risk ratio for either excellent or good improvement was 1.19 (95% CI 0.89 to 1.61).
The committee advised that, in routine clinical practice, in more than 80% of cases, punch elevation is provided as one extra session prior to laser treatment. In 20% of cases, punch elevation may be provided as a separate intervention, in a range of 1-4 sessions (day-case specialist appointments) and 1-2 nurse-led follow-up outpatient visits.
The committee advised that punch elevation corresponds to ‘intermediate skin procedures’ HRG, as listed in the national schedule of NHS costs. However, because HRQ ‘major skin procedures’ had a lower unit cost than ‘intermediate skin procedures’, NHS unit costs for both major and intermediate skin procedures were used in costing, to provide low and high estimates for the intervention cost associated with punch elevation for the management of acne vulgaris-associated scarring.
Table 4 shows the resource use and unit costs relating to a course of punch elevation for the management of acne vulgaris-associated scarring, as well as the range of the estimated total intervention cost, depending on the assumptions on the number of sessions and follow-up outpatient visits required, as well as the related HRG unit cost used. The cost of a course of punch elevation, if provided as a stand-alone intervention (20% of cases), is likely to lie between £938 and £4,465. At the usual resource use (1 session of punch elevation prior to laser treatment – 80% of cases) the estimated intervention cost is likely to range from £841 to £1,068.
Table 4
Estimation of the intervention cost of a course of punch elevation for the management of acne vulgaris-associated scarring.
Clinical effectiveness and intervention cost of glycolic acid peels
Evidence on the effectiveness of glycolic acid peels in the management of acne vulgaris-associated scarring was obtained from Erbagci 2000, which was a parallel group trial that compared glycolic acid peels with glycolic acid cream and with placebo cream tested on 48 people with atrophic acne scars. Peels were applied in 2-weekly intervals. The glycolic acid cream and the placebo cream were applied once or twice daily. Treatment lasted 24 weeks. The measure of outcome was improvement on a 10-point scale, with ‘good improvement’ being defined as a change of more than 60% from baseline, whereas partial improvement was defined as a change of 30%-60% from baseline. At 24 weeks, glycolic acid peels showed the highest level of good improvement, with a peto odds ratio of 9.64 (95% CI 1.65 to 56.19) versus placebo cream and 12.24 (95% CI 2.15 to 69.74) versus glycolic acid cream. When good and partial improvement were combined, then the peto odds ratio of glycolic acid peels became 12.49 (95% CI 2.80 to 55.73) versus placebo cream and 4.21 (95% CI 0.74 to 24.00) versus glycolic acid cream. The authors concluded that glycolic acid peels were effective for the treatment of atrophic acne scars, but repetitive peels (at least 6 times) with 70% concentration are necessary to obtain evidence of improvement.
The committee advised that, in routine clinical practice, around 6 glycolic acid peels are applied in a course of treatment, in consultant-led, multi-professional outpatient visits, as the presence of a specialist nurse is very helpful. It was noted, though, that in the RCT that provided clinical evidence on the effectiveness of glycolic acid peels these were applied 12 times.
Table 5 shows the resource use and unit costs relating to a course of glycolic acid peels for the management of acne vulgaris-associated scarring, as well as the range of the estimated total intervention cost, depending on the assumptions on the number of sessions required, as well as the related drug ingredient cost. The cost of 6 glycolic acid peels, which represent routine practice, ranges between £845 and £873; the cost of 12 glycolic acid peels, which reflect resource use in the only RCT that provided evidence on the effectiveness of the intervention in the management of acne vulgaris-associated scarring, ranges between £1,672 and £1,728.
Table 5
Estimation of the intervention cost of a course of glycolic acid peels for the management of acne vulgaris-associated scarring.
The committee’s discussion of the evidence
Interpreting the evidence
The outcomes that matter most
The committee agreed that permanent severe acne scarring has a significant and profound life-long impact on the psychological well-being of people affected by it thus investigator-assessed and participant-reported improvement in scarring were prioritised as critical outcomes. Serious adverse events were chosen as a critical outcome and side effects (local and general) as an important outcome because they indicate safety of a particular intervention. Participant satisfaction with treatment, skin-related quality of life and participant’s mood were important outcomes as they indicate acceptability of the intervention and its impact on psychological well-being.
The quality of the evidence
Overall, the quality of the evidence from split-face and parallel-group trials ranged from high to very low quality, with most being of very low quality. This was predominately due to risk of bias of individual studies and imprecision in the effect estimates. Many included studies were small in terms of sample size, especially split-face studies, which may have yielded a less reliable or precise effect estimate leading to uncertainty abouth the actual effect size. Most studies also did not clearly describe or carry out any allocation concealment which may have inflated the effects. The process of blinding was also not possible due to the type of scarring treatment used or compared which may have also influenced the subjectively rated outcomes. It was also not possible to meta-analyse the results due to the heterogeneity of the populations, the interventions and the reported outcomes. Therefore, the confidence in the evidence base was low.
Benefits and harms
Based on experience and knowledge the committee noted that it is important to talk with the person affected by acne related scarring to explore the impact that acne related scarring has on them and provide information tailored to their needs. The committee discussed that people with acne-related scarring might experience psychological distress, stigmatisation and experience low self-esteem or depression. Treatment options for ongoing acne that could help prevent further scarring as well as potential treatment options for scarring should also be discussed. A common concern of people is to find out what may have caused their scars so that future scarring may be avoided. The committee also noted that the appearance of scars can change over time because tissue remodelling and healing process takes a long time so they recommended that this should also be explained to the person.
Based on their experience and expertise, the committee recommended considering a referral to a dermatology consultant-led team with expertise in scarring management because they noted that some of these treatments could potentially have lasting effects on the skin (such as hyperpigmentation) if used incorrectly. The committee agreed that it is important to not substantially increase the number of referrals for the management of scarring since this is not current practice (and would have a significant resource impact) and therefore restricted this to a specific subgroup of people who would benefit most from such treatment. The committee therefore specified based on the available evidence and clinical expertise that those with persistent severe scarring are likely to have the greatest benefit. The committee discussed that in their experience, tissue remodelling and healing process occurs for up to about a year after the acne has cleared and management of acne scarring should be considered after this timeframe.
There was a considerable amount of evidence that met the inclusion criteria. However, most of the trials compared different types of treatment to each other rather than a treatment to no treatment. Since there is uncertainty about the effectiveness of some of the treatments without this basic knowledge it is difficult to interpret comparisons of one treatment with another. Despite there being a large number of studies included in this review, it was not possible to meta-analyse the results due to the heterogeneity of the populations, the interventions and the reported outcomes. The pattern of findings was therefore difficult to interpret. Three treatments were recommended based on evidence of effectiveness. These treatment options were glycolic acid peels or CO2 laser treatment (alone or after a session of punch elevation). The committee recommended these as they demonstrated some evidence of effectiveness for improving atrophic acne-related scarring. In terms of glycolic acid peels the evidence came from a parallel-group RCT that compared the use of glycolic acid peels with glycolic acid cream and with placebo cream. The study showed that after 24 weeks of treatment glycolic acid peels showed the highest level of good improvement in scarring when compared to glycolic acid cream or placebo cream. The evidence on the effectiveness of CO2 laser treatment came from a split-face RCT that compared CO2 laser treatment with no treatment, and showed that CO2 laser treatment was more effective in terms of improvement of scarred skin texture and atrophy when compared to no treatment. The effectiveness of punch elevation on atrophic acne-related scarring was shown in a split-face RCT which compared punch elevation given before CO2 laser treatment with CO2 laser treatment only. Since the committee had already established a possible benefit of CO2 laser treatment (based on the study by Hedelund 2012 comparing CO2 laser treatment versus no treatment) it made the interpretation of this comparison easier. The combination of punch elevation and CO2 laser treatment showed a better improvement in scarring than CO2 laser treatment alone. However, they noted that punch elevation would usually be added only for a particular type of deep scarring which would need to be elevated. The committee stressed that the choice of treatment procedures would depend on the particular types of acne scarring. However, they did not want to be prescriptive about which option to recommend for which particular type of scar because scars can vary between people but also in the same person.
The committee noted that overall the evidence base was small (only 3 studies) for the use of any of these treatments with small participant numbers (13 to 48) and not particularly high level of evidence quality using the GRADE assessment. Although this lowered their confidence in the findings, the committee were aware, from their knowledge and experience, that these interventions show clinical effectiveness for some people with acne-related scarring. They therefore decided the chance of potential benefit outweighs the harm of adverse psycholocal impact.
The committee also discussed that acne scarring treatments are widely available in the private sector but they are rarely, if at all, commissioned in NHS centres. They agreed to make a weak recommendation for the treatment of acne associated scarring which would leave the decision to individual commissioning bodies. Having a stronger recommendation would have a substantial impact on resource and would change clinical practice and the committee decided that the evidence was not strong enough to support such a change.
Due to the small number of participants in the studies and other uncertainties that the systematic review identified (such as the heterogenous patterns of findings), the committee discussed whether the topic should be prioritised for a research recommendation. They decided that the psychological impact of scarring can be significant and therefore justifies this as a topic for further research (see appendix L for details). Since the evidence pointed to the effectiveness of peels and laser treatment the committee decided to make one recommendation for physcial treatments and another for chemical peels.
Cost effectiveness and resource use
No economic evidence was identified for this review question. A simple cost analysis was undertaken to estimate the costs associated with management options for acne-related scarring. The committee considered these costs alongside the limited clinical evidence on the effectiveness of scarring management options versus no treatment and concluded that there is a significant uncertainty around the cost-effectiveness of these interventions. The committee agreed that the clinical experience on such interventions within the NHS is currently very limited, and therefore scarring management interventions should only be offered within consultant dermatologist-led teams with expertise in scarring management.
The committee considered the benefits of specialist dermatology care for various sub-groups of people with acne-related scarring and agreed that, for people with severe acne-related scarring that persists a year after acne has cleared, referral to a consultant dermatologist-led team with expertise in scarring management is essential for symptom improvement, since in this group non-specialist care has failed to manage scarring effectively (despite of the effective management of acne). The committee was aware that referral to specialist care requires use of additional healthcare resources at extra costs, but decided to make recommendations based on their expertise because they expressed the view that benefits of referral to specialist care are likely to outweigh associated costs for this specific subgroup of people.
Based on the available limited clinical and economic evidence, and considering its uncertainty, the committee decided to make a weak (‘consider’) recommendation for scarring management interventions (glycolic acid peel or CO2 laser treatment alone or after a session of punch elevation), delivered within the consultant-led specialist dermatology setting, for people with acne-related scarring that persists a year after acne has cleared. The committee expressed the view that such interventions are likely to be beneficial for this sub-group of people with persistent scarring, with benefits outweighing costs. They also argued that if people with long-term persistent scarring are not offered effective, specialist management for their scarring, they may try other ineffective and potentially harmful treatments outside healthcare settings, which may do harm and increase the need for resource intensive management further down the care pathway.
As the availability of such interventions for the management of acne-related scarring is variable across the NHS, the committee expected that making scarring management interventions available may have some resource impact; however, this is not excepted to be substantive as the recommendation is weak (“consider”) and is relevant only to a small sub-group of people, who have acne-related scarring that persists one year after acne has cleared.
The recommendation to provide information to people with severe scarring and discuss their concerns is expected to have only a small impact on resources relating to health professionals’ additional time required.
Recommendations supported by this evidence review
This evidence review supports recommendations 1.8.1 and 1.8.2 and research recommendations on the effectivenss of chemical peels and effectiveness of physical modalities in the treatment of acne related scarring in the guideline.
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Appendices
Appendix A. Review protocol
Appendix B. Literature search strategies
Appendix C. Clinical evidence study selection
Appendix D. Evidence tables
Appendix E. Forest plots
Forest plots for review question: What are the most effective treatment options for acne vulgaris-associated scarring?
This section includes forest plots only for outcomes that are meta-analysed. No meta-analysis was conducted for this review question and so there are no forest plots. The quality assessment for the outcomes is provided in the GRADE profiles in appendix F.
Appendix F. GRADE tables
Appendix G. Economic evidence study selection
Appendix H. Economic evidence tables
Economic evidence tables for review question: What are the most effective treatment options for acne vulgaris-associated scarring?
No economic evidence was identified which was applicable to this review question.
Appendix I. Economic evidence profiles
Economic evidence profiles for review question: What are the most effective treatment options for acne vulgaris-associated scarring?
No economic evidence was identified which was applicable to this review question.
Appendix J. Economic analysis
Economic analysis for review question: What are the most effective treatment options for acne vulgaris-associated scarring?
No economic analysis was conducted for this review question.
Appendix K. Excluded studies
Excluded clinical and economic studies for review question: What are the most effective treatment options for acne vulgaris-associated scarring?
Clinical studies
Download PDF (488K)
Economic studies
Download PDF (110K)
Appendix L. Research recommendations – full details
Final
Evidence review underpinning recommendations 1.8.1 and 1.8.2 and two research recommendations in the NICE guideline
These evidence reviews were developed by the National Guideline Alliance which is a part of the Royal College of Obstetricians and Gynaecologists
Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.
NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.
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