Do tumour necrosis factor-α inhibitors effectively treat acne . . . or cause it?

Tumour necrosis factor-α inhibitors (TNFis)—adalimumab, infliximab and etanercept—are approved to treat several inflammatory diseases such as rheumatoid arthritis and plaque psoriasis. The elevation of cytokines, such as TNF-α, in acne has resulted in consideration of TNFis as a potential treatment option for acne. TNFis are occasionally used off-label to treat severe forms of acne that are refractory to conventional therapies. Use of TNFis for approved indications can also lead to the development of acne, suggesting an association between TNFis and acne. To date, most of the literature consists of case reports and series that have not been systematically reviewed. A recent systematic review examined the use of TNFis to treat acne, as well as acne development following TNFi therapy for other medical conditions. The review included studies reporting on patients of any sex or age who received TNFis and whose treatment was followed by resolution or occurrence of acne. Results showed the following: The systematic review included 53 studies reporting on 64 patients who received TNFis for the treatment of acne (n=47) or those who experienced acne after treatment with TNFis for a different condition (n=17). The mean age of patients was 28.7 years (range 12–64 years); only six female individuals (8.8%) were included. Adalimumab, infliximab and etanercept were the TNFis used in these studies. Among the 47 patients treated for acne with TNFis, most had previously received antibiotics (66.0%) or isotretinoin (68.1%). Most (93.6%) experienced partial improvement (53.2%) or clearance (40.4%) of acne with TNFis, with very few adverse effects reported (6.4%). A total of 17 patients treated with TNFis for a nonacne condition (most commonly Crohn’s disease, psoriasis or a rheumatologic disorder) reported the development of acne. Only one patient (5.9%) had a history of acne. Acne symptoms typically improved when TNFi therapy was discontinued (47.1%) or altered (35.3%); alterations in therapy included the addition of other medications to manage acne (e.g., oral antibiotics or adapalene [29.4%]) or a change in TNFi infusion frequency (5.9%). The authors caution that most cases describing TNFi use to treat acne involved male patients. This may reflect differences between males and females in the prevalence of severe nodulocystic acne. The authors acknowledge that their results may not be generalizable to female patients, and further study is needed. Overall, based on the results of this systematic review, the authors suggest that TNFis can be effective in the treatment of refractory acne, with few adverse events. However, these drugs can also be responsible for inducing acne in some patients being treated for other (nonacne) conditions, necessitating TNFi discontinuation. The authors recommend further clinical trials to clarify the role of TNFis in treating patients with severe acne and in inducing acne. Such trials could provide further evidence to help guide the clinical care of patients with acne that is treated with or induced by TNFis. Reference 1. Sandoval AGW, Vaughn LT, Huang JT, et al. Role of tumor necrosis factor–α inhibitors in the treatment and occurrence of acne. A systematic review. JAMA Dermatol 2023. Published online March 17, 2023. (accessed March 30, 2023).

Do tumour necrosis factor-α inhibitors effectively treat acne . . . or cause it?

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