Miny Samuel, Rebecca Brooke, Sally Hollis, Christopher EM Griffiths

Photodamage describes skin changes such as fine and coarse wrinkles, roughness, freckles and pigmentation changes that occur as a result of prolonged exposure to the sun. Many treatments are available to reverse the damage, but it is unclear which work and at what cost in terms of unwanted side effects. To assess the effects of topically applied treatments, tablet treatments, laser and surgical procedures for photodamaged skin. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, Issue 1 2002, MEDLINE (1966-June 2002), EMBASE (1974-June 2002), Health Periodicals (1976-June 2002). We checked references of articles and communicated with authors and the pharmaceutical industry. Randomised controlled trials which compared drug or surgical interventions with no treatment, placebo or another drug, in adults with mild, moderate or severe photodamage of the face or forearms. Two reviewers independently extracted data and assessed trial quality. Thirty studies of variable quality were included.Eight trials showed that topical tretinoin cream, in concentrations of 0.02% or higher, was superior to placebo for participants with mild to severe photodamage on the face and forearms (although losses to follow up were relatively high in most studies). For example, the relative risk of improvement for 0.05% tretinoin cream, compared to placebo (3 studies), at 24 weeks, was 1.73 (95% confidence interval 1.39 to 2.14). This effect was not seen for 0.001% topical tretinoin (1 study) or 0.01% (3 studies). A dose-response relationship was evident for both effectiveness and skin irritation.One small within-patient study showed benefit from topical ascorbic acid compared with placebo.Tazarotene (0.01% to 0.1%) and isotretinoin (0.1%) both showed significant improvement over placebo for moderate photodamage (one study each).There is limited evidence (one trial), to show that the effectiveness of 0.05% tretinoin, is equivalent to the effects of 0.05% and 0.1% tazarotene.One small study showed greater improvement in upper lip wrinkles with CO2 laser technique compared to Baker's phenol chemical peel, at six months.Three small RCTs comparing CO2 laser with dermabrasion found no difference in wrinkle score at four to six months, suggesting that both methods are equally efficacious, but more erythema was reported with the laser.The effectiveness of other interventions such as hydroxy acids and natural polysaccharides was not clear. There is conclusive evidence that topical tretinoin improves the appearance of mild to moderate photodamage on the face and forearms, in the short-term. However erythema, scaling/dryness, burning/stinging and irritation may be experienced initially.There is limited evidence that tazarotene and isotretinoin benefit patients with moderate photodamage on the face: both are associated with skin irritation and erythema. The effectiveness of other interventions remains uncertain.