Management of acne vulgaris: an evidence-based update

Microchanneling and ultrasonic delivery of gold and platinum nanoparticles for selective photothermolysis of sebaceous follicles in the treatment of acne: a pilot study using porcine skin

PURPOSE

Several treatment options for acne vulgaris are limited by their associated adverse effects. An innovative approach involves introducing light-absorbing nanoparticles into sebaceous follicles before destroying the follicles using selective photothermolysis. We aimed to investigate efficient methods for introducing gold and platinum nanoparticles into sebaceous follicles and to identify suitable laser equipment and parameters for the effective destruction of these follicles.

METHODS

We used porcine skin as the experimental model. We compared the efficacies of a thulium laser, ultrasound, and manual massage and evaluated the optimal method for delivering nanoparticles in close proximity to sebaceous follicles. Subsequently, a 1064-nm-wavelength neodymium-doped yttrium aluminum garnet (Nd: YAG) laser was employed to induce selective photothermolysis. We compared different parameters to identify the optimal pulse duration and fluence of the Nd: YAG laser. The extent of penetration and destruction of sebaceous follicles was assessed using hematoxylin and eosin (H&E) staining, and a numerical evaluation was conducted.

RESULTS

H&E staining showed that irradiation with a long-pulsed Nd: YAG laser following a combination of thulium laser and sonophoresis effectively destroyed sebaceous follicles, with destruction rates exceeding 50%. These results were valid with a long pulse duration and a high fluence of the Nd: YAG laser.

CONCLUSION

This study demonstrated that sebaceous follicles can be effectively destroyed through a mixture of gold and platinum nanoparticle delivery by a combination of microchanneling and sonophoresis, followed by selective thermal damage induced by a 1064-nm long-pulsed high-fluence Nd: YAG laser.

Co-occurring ASD Mediates Impact of ADHD on Atopic Dermatitis and Acne: A Retrospective Cohort Study

BACKGROUND

ADHD and ASD are associated with dermatologic manifestations, yet little research investigates co-occurring ADHD/ASD and common dermatologic conditions.

OBJECTIVE

To investigate associations between ADHD, ASD, acne vulgaris, and atopic dermatitis.

METHODS

Using de-identified patient records from the TriNetX database, we created four cohorts on ADHD diagnosis, ASD diagnosis, both, neither. Cohorts were separated into males and females. We balanced each cohort based on age, sex, race, and ethnicity to the baseline cohort with neither ASD or ADHD. Finally, we examined prevalence of acne and eczema.

RESULTS

The cohort sizes varied from 19,764 to 345,626. Compared to matched peers, males with ADHD or ADHD/ASD had increased prevalence of acne, and all neurodivergent males had increased prevalence of eczema. Females with ADHD had an increase in both. Females with ADHD/ASD had no significant differences, and females with ASD had a decreased risk of eczema.

LIMITATIONS

Due to database limitations, we are unable to: analyze symptom severity, skincare routine, or treatment adherence.

CONCLUSIONS

The decreased risk of eczema in females with ASD and lack of significant difference in incidence of acne or eczema in females with ADHD/ASD compared to matched peers suggests research into approaches to skincare in males versus females with ASD may provide clinically relevant insights.

Remodeling of Cornea With Isotretinoin Treatment

OBJECTIVES

To evaluate the change of corneal epithelial thickness (ET) in subjects using isotretinoin with spectral-domain optical coherence tomography and further to explore reflection of changes on corneal topography.

METHODS

Forty eyes of 40 subjects with acne vulgaris scheduled for oral isotretinoin were included in this prospective study. Subjects were examined with RTVue-XR and Pentacam at baseline, 1th, 3rd, and 6th months of treatment, and 3rd month of isotretinoin cessation.

RESULTS

A statistically significant increase was detected in each sector of ET map except inferonasal 7 to 9 mm between baseline and following visits (P<0.05, for all visits). The increase in superior (2-7 mm), inferior (2-7 mm), and maximum values in epithelium statistics and the decrease in superior (2-7 mm), inferior (2-7 mm), minimum, and maximum values in stroma statistics at follow-up visits were significant (P<0.05, for all visits). Central corneal thickness, maximum Ambrosio-relational thickness, average pachymetric-progression index at 1th, 3rd, and 6th months, and thinnest pachymetry, index of surface variance (ISV) at 3rd, and 6th months differed significantly (P<0.05, for specified visits). The regression in parameters was observed at 3rd month of isotretinoin cessation.

CONCLUSIONS

Isotretinoin treatment induces epithelial thickening and stromal thinning. Remodeling of corneal layers causes statistical differences in ISV and pachymetry-related parameters of Pentacam. The pachymetry changes in cornea return to baseline at the 3rd month of discontinuation of treatment.

Effectiveness of a combination of salicylic acid-based products for the treatment of mild comedonal-papular acne: a multicenter prospective observational study

BACKGROUND

The most common therapeutic approach to acne is a combined treatment of retinoid and benzoyl peroxide, with oral antibiotics recommended for moderate-to-severe cases. These kinds of therapies often lead to adverse reactions, leading to the request for new therapeutic options. Recently, the combined use of three salicylic acid-based products for the topical treatment of acne has been related to a significant improvement in acne lesions.

METHODS

A multicenter prospective observational study was carried out on patients with a diagnosis of mild comedonal-papular facial acne to provide new evidence on the clinical effectiveness, tolerability and acceptability of three salicylic acid-based products for the topical treatment of acne in the daily clinical practice. Clinical effectiveness on lesions improvement, the evaluation of personal discomfort related to acne and the assessment of overall clinical outcome were the primary endpoints. Treatment acceptability and tolerability were also evaluated.

RESULTS

The treatment with the three salicylic acid-based products has been related to a significant improvement on acne lesions over 8 weeks of treatment, along with a reduction of personal discomfort related to acne and an improvement on lesions appearance. The products have also shown good acceptability and tolerability.

CONCLUSIONS

The results of this observational study support the effective and well-tolerated use of a combined treatment with three salicylic acid-based products for the topical treatment of acne.

Isotretinoin; A review on the Utilization Pattern in Pregnancy

Purpose: Isotretinoin is the most effective anti-acne drug with a long-term remission. However; it contains severe teratogenic effects with serious adverse drug reactions, which limits the use of medication.

Methods: To review the use of isotretinoin during pregnancy, we carried out a comprehensive search of literature in Google Scholar, Scopus and PubMed/Medline from their inception until April 2015.

Results: Database searching identified 277 records, of which, 38 articles were retrieved according to abstract and title assessment. After full-text review, 17 articles were excluded and finally, a total of 21 studies met the inclusion criteria. Data showed an increased pattern in the use of isotretinoin. In some studies, health care providers were not fully adhered to the risk reduction programs in pregnancy. Exposing to isotretinoin among pregnant women has still occurred due to detrimental adherence to risk reduction programs which resulted in live-born infants with different kinds of abnormalities.

Conclusion: Despite the known serious adverse effect of isotretinoin, the use of drug was not based on the guidelines in some cases, which needs more attentions to prevent the severe drug related problems.

Comparative study of the bactericidal effects of indocyanine green- and methyl aminolevulinate-based photodynamic therapy on Propionibacterium acnes as a new treatment for acne

Acne vulgaris is one of the most common dermatological problems, and its therapeutic options include topical and systemic retinoids and antibiotics. However, increase in problems associated with acne treatment, such as side-effects from conventional agents and bacterial resistance to antibiotics, has led to greater use of photodynamic therapy. The purpose of this study was to compare the bactericidal effects of indocyanine green- and methyl aminolevulinate-based photodynamic therapy on Propionibacterium acnes. P. acnes were cultured under anaerobic conditions; then they were divided into three groups (control, treated with indocyanine green and treated with methyl aminolevulinate) and illuminated with different lights (630-nm light-emitting diode, 805-nm diode laser and 830-nm light-emitting diode). The bactericidal effects were evaluated by comparing each group's colony-forming units. The cultured P. acnes were killed with an 805-nm diode laser and 830-nm light-emitting diode in the indocyanine green group. No bactericidal effects of methyl aminolevulinate-based photodynamic therapy were identified. The clinical efficacy of indocyanine green-based photodynamic therapy in 21 patients was retrospectively analyzed. The Korean Acne Grading System was used to evaluate treatment efficacy, which was significantly decreased after treatment. The difference in the efficacy of the 805-nm diode laser and 830-nm light-emitting diode was not statistically significant. Although the methyl aminolevulinate-based photodynamic therapy showed no bactericidal effect, the indocyanine green-based photodynamic therapy has bactericidal effect and clinical efficacy.

Evaluation the efficacy of trichloroacetic acid (TCA) 33% in treatment of oral retinoid-induced cheilitis compared with placebo (Vaseline): a randomized pilot study

BACKGROUND

Oral Isotretinoin (13-cis-retinoic acid) is a gold standardtreatment for severe forms of acne with cheilitis as a most frequent complication. We designed this novel study to investigate the therapeutic effect of trichloroacetic acid (TCA) 33% as compared with placebo to treat cheilitis.

METHODS

In this pilot study, 90 acne vulgaris patients between 18 and 50 years, who referred dermatologic clinic with cheilitis, were assigned to either case (TCA) or control (Vaseline) group using permuted-block randomization from 2013 to 2015 with data analysis in 2016. Patients had follow-up visits after 2 and 6 weeks, at which their lesions were photographed. Two blinded expert dermatologists recorded physician International global score for each image.

RESULTS

Ninety eligible patients were randomly allocated into two groups. This included 45 patients in each group. At the end of follow-up, 44 patients in the intervention group and 37 patients in control group completed the final assessment. Compared to the control group, the TCA group had a greater reduction in the mean ICGS value from baseline to Week 6 (mean difference 2.59 points, p < .0001).

CONCLUSIONS

TCA can be considered as a good strategy in improvement of cheilitis to isotretinoin therapy.

The blemishes of modern society? Acne prevalence in the Dogon of Mali

BACKGROUND AND OBJECTIVES

Non-communicable diseases may reflect an evolutionary mismatch between our human ancestry and modern environments. To explore the mismatch hypothesis for Acne vulgaris, we studied the prevalence and severity of acne in Dogon adolescents in Mali, West Africa.

METHODOLOGY

We graded the prevalence and severity of acne in 1182 Dogon adolescents aged 11-18 years from nine villages using facial photos taken as part of a prospective cohort study. Eighty-nine (89%) of the individuals in the cohort migrated to the city during adolescence, enabling us to assess the effect of urban migration. Using multivariable logistic regression, we estimated the effect of predictor variables on the presence of acne.

RESULTS

The prevalence of acne in the cohort was 28%, with 90% of cases being mild or very mild. Thus, the prevalence and severity of acne was much lower than for adolescents in high-income countries. Controlling for age, puberty, and body mass index (BMI), the odds of boys developing acne was 85% lower in the city than in the villages (P = 0.002).

CONCLUSION AND IMPLICATIONS

Acne is similar to the 'diseases of civilization' in being promoted by the pro-inflammatory properties of modern diets. The low prevalence and severity of acne in the Dogon supports the mismatch hypothesis and suggests that acne should join the list of diseases of modern lifestyles. However, we also observed an unexpected decrease in acne in urban boys. Future research is needed for a deeper mechanistic understanding of the interplay between diet, inflammation, immune function and other environmental exposures that differ between urban and rural environments.

What's new in acne? An analysis of systematic reviews published in 2011-2012

This review summarizes important clinical developments in acne vulgaris identified from 17 systematic reviews published between February 2011 and August 2012. Regarding causes, Demodex mites have been shown to be associated with both acne vulgaris and rosacea, although it is unclear if their eradication improves either disease. Some weak evidence has emerged that suggests a possible link between dairy produce and acne, which warrants further research. With reference to the effects of acne, there is good evidence that acne negatively affects quality of life, self-esteem and mood in adolescents. Acne is also associated with an increased risk of anxiety, depression and suicidal ideation, highlighting the importance of asking patients with acne directly about psychological issues in order to identify those who might benefit from early psychiatric support. Regarding treatment, there seems to be no additional benefit to using higher strengths of benzoyl peroxide, and lower strengths such as 2.5% have fewer side effects. Despite earlier concerns of increased mortality in those using topical tretinoin for skin cancer prevention, a systematic review on this topic has not found any convincing evidence of a link between such non-cutaneous events and once-daily application of 0.02-0.05% tretinoin. Combined oral contraceptives are of benefit in both inflammatory and non-inflammatory acne. Current surveys suggest that implementation of the pregnancy prevention programme for isotretinoin may not be stringent, and a high level of monitoring and audit is recommended. Ablative and non-ablative laser resurfacing for the treatment of acne scars may be beneficial, but further studies with a longer follow-up period are required.

Non-anti-infective effects of antimicrobials and their clinical applications: a review

Antimicrobial agents are undoubtedly one of the key advances in the history of modern medicine and infectious diseases, improving the clinical outcomes of infection owing to their inhibitory effects on microbial growth. However, many antimicrobial agents also have biological activities stemming from their interactions with host receptors and effects on host inflammatory responses and other human or bacterial cellular biological pathways. These result in clinical uses of antimicrobial drugs that are distinct from their direct bacteriostatic or bactericidal properties. We reviewed the published literature regarding non-anti-infective therapeutic properties and proposed clinical applications of selected antimicrobials, specifically, macrolides, tetracyclines, sulfonamides, and ketoconazole. The clinical applications reviewed were varied, and we focused on uses that were clinically relevant (in terms of importance and burden of disease) and where published evidence exists. Such uses include chronic inflammatory pulmonary and skin disorders, chronic periodontitis, gastrointestinal dysmotility, rheumatoid arthritis, and cancer. Most of these potential therapeutic uses are not Food and Drug Administration approved. Clinicians need to weigh the use of antimicrobial agents for their non-anti-infective benefits, considering potential adverse effects and long-term effect on microbial resistance.

Acute psychosis induced by isotretinoin

Isotretinoin is used for the treatment of severe acne. Psychiatric side-effects, particularly depression, have been well-documented. This dramatic case report is about a young male patient who developed acute psychosis within a few days of starting isotretinoin. Due to his persecutory delusions, the patient, who was an Indian engineer working in Germany, decided to immediately return to India fearing for his life in Germany. Careful history taking established the cause of the psychosis. Isotretinoin was stopped; patient showed rapid improvement, within a week, on a low dose of risperidone. Risperidone was continued as a precaution for 3 months. After a further 8 months, the patient remains well without any psychotropic medication.

A Consensus on Acne Management Focused on Specific Patient Features

Background:

Most treatment guidelines for acne are based on clinical severity. Our objective was to expand that approach to one that also comprised individualized patient features: a case-based approach.

Methods:

An expert panel of Canadian dermatologists was established to develop demographic and clinical features considered to be particularly important in acne treatment selection. A nominal group consensus process was used for inclusion of features and corresponding appropriate treatments.

Results:

Consensus was achieved on the following statements: follicular epithelial dysfunction contributes to acne pathogenesis; inflammation from underlying disease(s) or prior treatment may impact further patient management; management focusing on specific patient features and on addressing psychosocial factors, including impact on quality of life, may improve treatment adherence and outcomes; and case-based scenarios are a practical approach to illustrate the effect of these factors. To address the latter, eight case profiles were developed.

Conclusions:

Management of acne should be based on multifactorial considerations beyond clinically determined acne severity and should include patient-reported impact, gender, skin sensitivity (including preexisting dermatoses), and phototype.

A randomized, double-blind, placebo-controlled study of a novel pantothenic Acid-based dietary supplement in subjects with mild to moderate facial acne

INTRODUCTION

The purpose of this study was to determine the safety, tolerability and effectiveness of daily administration of an orally administered pantothenic acid-based dietary supplement in men and women with facial acne lesions.

METHODS

A randomized, double-blind, placebo-controlled study of adults previously diagnosed with mild to moderate acne vulgaris was performed. Subjects were randomized to the study agent, a pantothenic acid-based dietary supplement, or a placebo for 12 weeks (endpoint). The primary outcome of the study was the difference in total lesion count between the study agent group versus the placebo group from baseline to endpoint. Secondary measurements included differences in mean non-inflammatory and inflammatory lesions, Investigators Global Assessment and Dermatology Life Quality Index (DLQI) scores between the two groups. Investigator assessment of overall improvement and skin photographs were also taken. Safety and tolerability endpoints were the assessment of adverse events and measurement of serum complete blood count and hepatic function.

RESULTS

Forty-eight subjects were enrolled and 41 were evaluable. There was a significant mean reduction in total lesion count in the pantothenic acid group versus placebo at week 12 (P = 0.0197). Mean reduction in inflammatory lesions was also significantly reduced and DLQI scores were significantly lower at week 12 in the pantothenic acid group versus placebo. The study agent was safe and well tolerated.

CONCLUSIONS

The results from this study indicate that the administration of a pantothenic acid-based dietary supplement in healthy adults with facial acne lesions is safe, well tolerated and reduced total facial lesion count versus placebo after 12 weeks of administration. Secondary analysis shows that the study agent significantly reduced area-specific and inflammatory blemishes. Further randomized, placebo-controlled trials are warranted.

Acne vulgaris: A review of causes and treatment options

Acne vulgaris is a disorder of the sebaceous follicle. The cause is multifactorial, and both adolescents and adults can be affected. Acne is associated with a significant financial burden and considerable psychological distress. Treatment options are reviewed, including over-the-counter medications, prescription medications, and in-office procedures.

Mapping systematic reviews on atopic eczema--an essential resource for dermatology professionals and researchers

Background

Many research studies have been published on atopic eczema and these are often summarised in systematic reviews (SRs). Identifying SRs can be time-consuming for health professionals, and researchers. In order to facilitate the identification of important research, we have compiled an on-line resource that includes all relevant eczema reviews published since 2000.

Methods

SRs were searched for in MEDLINE (Ovid), EMBASE (Ovid), PubMed, the Cochrane Database of Systematic Reviews, DARE and NHS Evidence. Selected SRs were assessed against the pre-defined eligibility criteria and relevant articles were grouped by treatment category for the included interventions. All identified systematic reviews are included in the Global Resource of EczemA Trials (GREAT) database (www.greatdatabase.org.uk) and key clinical messages are summarised here.

Results

A total of 128 SRs reviews were identified, including three clinical guidelines. Of these, 46 (36%) were found in the Cochrane Library. No single database contained all of the SRs found. The number of SRs published per year has increased substantially over the last thirteen years, and reviews were published in a variety of clinical journals. Of the 128 SRs, 1 (1%) was on mechanism, 37 (29%) were on epidemiology, 40 (31%) were on eczema prevention, 29 (23%) were on topical treatments, 31 (24%) were on systemic treatments, and 24 (19%) were on other treatments. All SRs included searches of MEDLINE in their search methods. One hundred six SRs (83%) searched more than one electronic database. There were no language restrictions reported in the search methods of 52 of the SRs (41%).

Conclusions

This mapping of atopic eczema reviews is a valuable resource. It will help healthcare practitioners, guideline writers, information specialists, and researchers to quickly identify relevant up-to-date evidence in the field for improving patient care.

Efficacy of 2% metronidazole gel in moderate acne vulgaris

BACKGROUND

Acne vulgaris is an inflammatory disease of the pilosebaceous units. Various systemic and topical options are available for its treatment.

AIMS

This study aimed to evaluate the efficacy of 2% metronidazole gel in acne vulgaris.

MATERIALS AND METHODS

Double-blind, randomized, placebo-controlled, split-face clinical trial. Seventy young adults with moderate acne vulgaris received 2% metronidazole gel on the right side of their face and placebo on the left side of their face twice daily for 8 weeks. The number of inflamed and noninflamed facial lesions and side effects of treatment were documented on weeks 1, 2, 4, and 8. The patients' overall satisfaction was recorded at the end of the study. For statistical analysis we used the repeated-measures analysis, the chi-square test, Fisher's exact test, and the independent-samples t-test as appropriate.

RESULTS

Counts of inflamed and noninflamed facial lesions were comparable between the two sides at baseline. The number of the lesions was significantly lower on the metronidazole-treated side at all follow-up visits. Erythema and oily face decreased by 85.7% and 87.1%, respectively, on the metronidazole-treated side. Mild burning sensation and dryness on the metronidazole-treated side was reported by 3.4% and 22.9% of the patients, respectively. Eighty-eight percent of the patients were satisfied with the results of treatment on the metronidazole-treated side.

CONCLUSIONS

Metronidazole gel (2%) is an effective, safe, and well-tolerated topical medication for moderate acne vulgaris.

Anti-inflammatory effects of a topical preparation containing nicotinamide, retinol, and 7-dehydrocholesterol in patients with acne: a gene expression study

Purpose

Acne vulgaris is a skin disorder of the sebaceous follicles, involving hyperkeratinization and perifollicular inflammation. Aberrant extracellular matrix remodeling due to matrix metalloproteinases (MMPs) has been associated with the presence of acne conditions. Given the complex pathophysiology of acne, novel topical therapies should include combination products that target multiple pathogenetic mechanisms. In this pilot study we investigated the changes in gene expression of extracellular MMPs, the tissue inhibitors of metalloproteinases, and proinflammatory molecules after 45 days of topical application of a combination product containing nicotinamide, retinol, and 7-dehydrocholesterol in 16 patients with inflammatory acne on their back.

Materials and methods

Skin biopsies were obtained before and after treatment for gene expression studies.

Results

Quantitative real-time polymerase chain reaction revealed a significant downregulation of MMP-1, MMP-2, MMP-9, MMP-14, interleukin-6, monocyte chemoattractant protein-1, and macrophage migration inhibitory factor. In contrast, the tissue inhibitors of metalloproteinases and transforming growth factor-β1 were significantly upregulated. The gene expression findings correlated well with the clinical treatment response.

Conclusions

The combination of nicotinamide, retinol, and 7-dehydrocholesterol appears to be effective for acne treatment from both clinical and molecular standpoints.

Flutamide versus a cyproterone acetate-ethinyl estradiol combination in moderate acne: a pilot randomized clinical trial

BACKGROUND

The use of oral flutamide is rarely investigated in acne therapy. The aim of this study was to compare the efficacy of oral flutamide with that of a cyproterone-estradiol combination in treating acne lesions.

METHODS

A randomized clinical trial enrolled patients with moderate acne into two equal groups to receive either oral flutamide or the cyproterone-estradiol combination for 6 months. Lesion count, Acne Severity Index, and Global Acne Grading system (GAGS) scores were used to assess improvement in acne lesions. The dichotomous measurement scale for primary endpoint assessment was defined as improvement from moderate to mild acne based on GAGS score. Patient satisfaction and dermal fat were also assessed. Intention to treat and per protocol analyses were done, reporting related effect sizes.

RESULTS

Both treatments resulted in substantial improvement in acne lesions. Although flutamide seemed to have higher efficacy, an intention to treat analysis did not find the two treatment protocols to be different. The relative risk in intention to treat analysis was 1.8 (95% confidence interval [CI] 0.89-1.6), and was 1.33 (95% CI 1.03-1.72) for the per protocol analysis. The number needed to treat for flutamide compared with the cyproterone-estradiol combination was 7.7 and 4.2 in the intention to treat and per protocol analyses, respectively.

CONCLUSION

Flutamide appears to be more effective than a cyproterone-estradiol combination in some aspects of acne treatment, but this requires confirmation in a larger trial.

What's new in acne? An analysis of systematic reviews published in 2009-2010

This review highlights clinically important findings about acne treatment identified in nine systematic reviews published or indexed in the period March 2009 to February 2010. A systematic review of dietary influences on acne suggested that a possible role of dietary factors in acne cannot be dismissed, as the studies to date have not been sufficiently large or robust. Another review looked at benzoyl peroxide, which may be enjoying a comeback because of increasing bacterial resistance to antibiotics, and suggested that there was a lack of evidence that stronger preparations were more effective than weaker ones. The same team also carried out a systematic review addressing the question of whether topical retinoids cause an initial worsening of acne. They found no evidence to suggest initial worsening of acne severity, although there was evidence of skin irritation that typically settled by 8-12 weeks. A review of oral isotretinoin and psychiatric side-effects reinforced a possible link between the two, although it pointed out that the better-quality primary studies were still inconclusive. An updated Cochrane Review confirmed the efficacy of combined oral contraceptives (COCs) in reducing acne lesion counts. It also found that the evidence to support COCs containing cyproterone acetate over others was very limited. Another Cochrane Review failed to show any benefit of spironolactone for acne, based on limited studies. Three reviews examined laser and light therapies, and found some evidence of superiority only for blue or blue/red light treatment over placebo light, but a general absence of comparisons against other acne treatments. Photodynamic therapy had consistent benefits over placebo but was associated with significant side-effects and was not shown to be better than topical adapalene.

Problems in the reporting of acne clinical trials: a spot check from the 2009 Annual Evidence Update on Acne Vulgaris

In the course of producing the 2009 NHS Evidence--skin disorders Annual Evidence Update on Acne Vulgaris, 25 randomised controlled trials were examined. From these, at least 12 potentially serious problems of trial reporting were identified. Several trials concluded no effect of a treatment yet they were insufficiently powered to exclude potentially useful benefits. There were examples of duplicate publication and "salami publication", as well as two trials being combined and reported as one. In some cases, an incorrect "within-groups" statistical comparison was made and one trial report omitted original efficacy data and included only P values. Both of the non-inferiority studies examined failed to pre-specify a non-inferiority margin. Trials reported as "double-blind" compared treatments that were dissimilar in appearance or had differing adverse effect profiles. In one case an intention-to-treat analysis was not performed and there was a failure to account for all of the randomized participants. Trial results were made to sound more impressive by selective outcome reporting, emphasizing the statistical significance of treatment effects that were clinically insignificant, and by the use of larger-sounding odds ratios rather than rate ratios for common events. Most of the reporting problems could have been avoided by use of the CONSORT guidelines and prospective trial registration on a public clinical trials database.