Table2_Benefits and Safety of Chinese Herbal Medicine in Treating Psoriasis: An Overview of Systematic Reviews.DOCX

Background: In recent years, systematic reviews/meta-analyses (SRs/MAs) of Chinese herbal medicine (CHM) for psoriasis have continuously emerged. Their methods and evidence quality, however, are yet to be evaluated, and whether their conclusions can provide clinicians with reliable evidence is still debatable.
Objectives: This overview aims to evaluate the methodological quality, risk of bias, and reporting quality of relevant SRs/MAs, as well as the current evidence of CHM for treating psoriasis.
Methods: We searched nine electronic databases from their respective time of establishment to January 20, 2021, as well as the reference lists of the included SRs/MAs, protocol registries, and gray literature. Two reviewers independently used the following: A Measurement Tool to Assess Systematic Reviews (AMSTAR) 2, Risk of Bias in Systematic Reviews (ROBIS), the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA), and Grades of Recommendations, Assessment, Development and Evaluation (GRADE) to evaluate the methodological quality, risk of bias, reporting quality, and evidence quality of the included SRs/MAs.
Results: This review included 14 SRs/MAs involving 45 outcomes, of which 12 (85.71%) SRs/MAs had a very low quality evaluated by AMSTAR 2 and 7 (50.00%) SRs/MAs had a high risk of bias assessed by ROBIS. The protocol and registration and funding statements were the major reporting flaws according to the PRISMA checklist. The evaluation with the GRADE system demonstrated no outcome of high-quality evidence, and inconsistent efficacy evaluations were found in this overview. Only 15 (33.33%) outcomes were moderate-quality evidence, supporting the claim that CHM plus Western medicine (WM) was superior to WM. Generally low quality of evidence showed no difference in the incidence of adverse events between the combined therapy and WM. However, the conclusion that CHM was superior to WM cannot be drawn due to the inconsistent results.
Conclusion: Despite that CHM has the potential benefit and safety in the adjuvant treatment of psoriasis, the conclusion should be treated with caution because of the generally low quality of methodology and evidence. In the future, high-quality randomized controlled trials (RCTs) should be carried out, and the quality of relevant SRs should also be improved to promote their clinical application.

背景：近年来，针对银屑病（psoriasis）的中草药（Chinese herbal medicine, CHM）系统评价/meta分析（systematic reviews/meta-analyses, SRs/MAs）相关研究持续涌现。然而，此类研究的方法学质量与证据等级尚未得到系统评估，其结论能否为临床医师提供可靠依据仍存在争议。
目的：本伞状综述旨在评估相关SRs/MAs的方法学质量、偏倚风险与报告质量，同时梳理中草药治疗银屑病的现有证据体系。
方法：本研究检索了9个电子数据库自建库至2021年1月20日的全部文献，同时纳入研究的参考文献列表、试验方案注册库及灰色文献。由2名研究者独立采用以下工具开展评价：系统评价方法学评估工具2（A Measurement Tool to Assess Systematic Reviews, AMSTAR 2）、系统综述偏倚风险评价工具（Risk of Bias in Systematic Reviews, ROBIS）、系统综述与meta分析优先报告条目（Preferred Reporting Items for Systematic Reviews and Meta-analyses, PRISMA），以及推荐分级、评估、制定与评价体系（Grades of Recommendations, Assessment, Development and Evaluation, GRADE），分别对纳入SRs/MAs的方法学质量、偏倚风险、报告质量及证据质量进行评估。
结果：本综述共纳入14项SRs/MAs，涉及45个结局指标。经AMSTAR 2评估，其中12项（85.71%）研究的方法学质量为极低水平；经ROBIS评估，7项（50.00%）研究存在高偏倚风险。依据PRISMA清单，研究方案与注册信息、基金资助声明是主要的报告缺陷项。GRADE系统评估结果显示，无任何结局指标属于高质量证据；本次伞状综述中发现疗效评价结果存在不一致性，仅15项（33.33%）结局指标为中等质量证据，支持“中草药联合西药（Western medicine, WM）优于单用西药”的结论。总体而言，不良事件发生率相关证据质量普遍较低，提示联合疗法与单用西药的不良事件发生率无显著差异。但由于研究结果不一致，尚无法得出“中草药优于单用西药”的明确结论。
结论：尽管中草药在银屑病辅助治疗中具备潜在获益与安全性，但鉴于现有研究方法学与证据质量普遍偏低，临床应用相关结论需谨慎对待。未来应开展高质量随机对照试验（randomized controlled trials, RCTs），同时提升相关系统评价的研究质量，以推动其临床转化应用。