Comparative efficacy and safety of chemical peels for acne vulgaris: a systematic review and network metaanalysis of randomized controlled trials

<p><strong>Background: </strong>Chemical peels are widely used for mild-to-moderate acne vulgaris, but comparative evidence is dispersed across small trials and multiple active formulations. This review synthesized the supplied randomized evidence and compared efficacy and tolerability across peel types using network meta-analysis.</p> <p><strong>Methods: </strong>PubMed, the Cochrane Library, Scopus, and Web of Science were searched for randomized active-comparator trials of chemical peels for acne vulgaris up to June 2026. Random-effects network meta-analyses used standardized mean differences (SMDs) for continuous outcomes and risk ratios (RRs) for categorical and safety outcomes, each with 95% confidence intervals (CIs). Salicylic acid was the reference treatment, and treatments were ranked using surface under the cumulative ranking curve (SUCRA) values.</p> <p><strong>Results: </strong>Twenty-three randomized trials with reported enrollment totaling 1,170 participants were included. Most continuous efficacy comparisons were not statistically significant. Relative to salicylic acid, Jessner's solution was associated with a smaller reduction in papule count (SMD 2.49, 95% CI 1.28 to 3.70) and a smaller reduction in Michaelsson acne score (SMD 1.78, 95% CI 0.41 to 3.16). Salicylic plus mandelic acid ranked highest for good improvement (SUCRA 91.9%), but its RR versus salicylic acid was imprecise (RR 1.96, 95% CI 0.75 to 5.13). Trichloroacetic acid was associated with more erythema than salicylic acid (RR 2.74, 95% CI 1.10 to 6.78). Heterogeneity was substantial for non-inflammatory lesion count, papule count, pustule count, and Michaelsson acne score. Treatment-label fragmentation and undocumented handling of split-face correlations limited confidence in rankings.</p> <p><strong>Conclusion: </strong>Our analysis does not establish broad superiority of one chemical peel for acne vulgaris. Salicylic acid performed favorably against Jessner's solution for selected efficacy outcomes and had a lower erythema risk than trichloroacetic acid, but most estimates were imprecise and several networks were heterogeneous. Treatment choice should remain individualized, and the findings require confirmation in rigorously reported head-to-head trials with standardized outcomes.</p>