Efficacy and safety of topical statins for porokeratosis: a systematic review and practice-guided synthesis

Background Porokeratosis comprises keratinization disorders with few consistently effective, nondestructive treatments. Topical inhibition of the mevalonate pathway with statins is biologically plausible, but the clinical evidence is scattered across small reports. Objectives To consolidate fragmented data into a pragmatic framework for clinicians and to highlight priorities for future controlled trails. Methods We performed a PRISMA-based systematic review of PubMed, Embase, Scopus and ClinicalTrials.gov to 8 December 2025, including all study designs that reported patient-level outcomes with topical statins. Results Thirty-three studies involving 162 patients met the inclusion criteria: three small, randomized trials and predominantly case series and case reports. In nonrandomized studies with analysable data (n = 98), most patients achieved partial improvement (n = 67/98 68.4%), whereas complete or near-complete clearance was less frequent (n = 16/98; 16.3%); disseminated superficial actinic porokeratosis (DSAP) appeared most responsive. Randomized evidence showed clinical improvement with topical statins but did not support routine addition of cholesterol to statin formulations. Topical statins were generally well tolerated, with several patch test-confirmed cases of simvastatin allergic contact dermatitis but no serious systemic adverse events. Certainty of evidence (GRADE) was low for DSAP improvement and serious harms, and very low for other subtypes, reflecting small sample sizes, risk of bias and heterogeneity. Conclusions Overall, topical statin monotherapy emerges as a mechanism-based, field-directed option for porokeratosis, particularly DSAP, most often yielding partial rather than complete clearance with a favourable safety signal.