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ROSACEA
Dialogue
with a Mentor
Albert Kligman, M.D., Ph.D., is a pioneer who continues
to break new ground in dermatology.
knowledge remains so poor. Consider that rosacea his career to challenging the status quo, and acne vulgaris are related disorders, and while Aand to this day continues to play an active we have a good understanding about the causes of
role in the ever-changing arena of dermatology.
acne and how to treat it, we remain as ignorant Even as he celebrates his 88th birthday this today about rosacea as we were about acne 50 month, Dr. Kligman remains a strong example of the power behind research and continues toshed light on some of the more perplexing der- Q What have been some of the major mile-
stones in treatment of rosacea?
In this, the first installment in a sponsored There are many different treatments that have series entitled, “Dialogue with a Mentor,” where been introduced and talked about as helpful for long-time veterans of dermatology share their rosacea, but I believe there are only a few med- experience, insights, and what they believe will ications that offer unassailable efficacy. Among have the most impact on future practice, Dr.
oral agents, I think nobody will deny antibiotics Kligman sets his sights on what he views as still are important therapy, particularly the tetracy- uncharted territory — the diagnosis and treat- clines, but they must be given in full doses. In addition, there is no question that isotretinoin, even at moderate doses, is very effective for more noted for the development of tretinoin, ground- severe cases. At the topical treatment level, breaking work in the advancement of acne man- metronidazole has become a mainstay, but there agement, and is the physician who coined the are a number of other topical agents being used term “cosmeceutical” when referring to his use according to prescriber personal preference. I of retinoids in anti-aging. Dr. Kligman has a don’t believe there is sufficient good science wealth of experience, and in this interview out- backing the purported activity of some of the lines some of his opinions and findings as they topical drugs for reducing the features of rosacea Q What are your thoughts about the
Q What impact do you believe the National
pathogenesis of rosacea?
Rosacea Society classification system will
It appears the answer to that question is not a have on the understanding, recognition, and
simple one because rather than having a single diagnosis of rosacea?
cause, rosacea probably develops as a result of It’s an excellent start, but I think it is too simplified multiple interacting factors, some of which because I believe there are many more varieties of include genetic determination and perhaps the rosacea in addition to the four subtypes listed in presence of demodectic mites in some individu- that system. However, the goal of developing a als. The pathogenesis of rosacea is a subject that standard classification for enabling research and has been debated and disagreed on for many communication is a good one, and the system was years, and I consider it a real scandal that our have not seen good supporting evidence for those Q For 10 years,an oral antibiotic plus topi- claims. Through my own limited experience, I
cal metronidazole has been the foundation
have been unimpressed with the benefits of the for treating rosacea. Do you agree that it is
the “ideal regimen?”
For most patients, it is a good idea to initiate
Q A recent report suggests topical metron-
therapy with such a combination systemic and idazole has an antioxidant effect. Do you think
topical treatment. However, the treatment has to that might encourage patient compliance?
be tailored to the manifestations of the individual “Antioxidant” has become an important buzz- patient. For example, there is an under-recog- word in the popular lexicon and is a term that is nized form of rosacea with hard edema, and in being widely used for marketing purposes.
that situation I add massage as a physical therapy, Therefore, the idea that use of metronidazole while I prescribe isotretinoin if I see a patient with provides antioxidant benefits might motivate some patients to adhere better to treatment.
However, we still haven’t the faintest idea about Q Are there situations where you would
the real mechanism of metronidazole’s efficacy prescribe monotherapy instead of combina-
tion treatment?
Probably 95 percent of the time, I initiate treat-
Q Some information suggests that only 10
ment with the combination of an oral antibiot- percent of patients with rosacea are receiv-
ic and a topical agent. I might consider topical ing treatment. Does that surprise you and
metronidazole treatment as monotherapy for a what can be done to improve the situation?
patient presenting with very early, mild rosacea.
I think that statistic may understate the situa- In general, however, medical management of tion, but certainly more than 50 percent of rosacea should be multimodal. Rosacea is a seri- affected persons are not receiving care because ous disease with potentially significant psy- they have not been properly diagnosed. That is chosocial consequences, and there are many another piece of the scandal about rosacea I patients who are finally receiving treatment after referred to earlier. However, the National suffering for 20 years without a diagnosis.
Rosacea Society (NRS) is doing an invaluableand effective job in spreading the word to raise Q To reduce the development of drug-
awareness and bring forward better treatment.
resistant bacterial strains, the FDA has man-
dated new statements appear on the physi-
Q Do you foresee any new developments
cian labeling for all systemic antibacterial
in treatment occurring over the next five to
drugs. Do you think that will affect prescrib-
10 years?
ing patterns for rosacea?
We have begun to do some research on the use of I don’t think those concerns are particularly rele- topical retinoids, and I think as we collect more vant to rosacea and I don’t expect them to have information, they will emerge as a first order much impact on our reliance on oral antibiotics.
treatment. There is a good rationale for using In theory, use of antibiotics for the treatment of topical retinoids recognizing that patients with rosacea could contribute to the emergence of rosacea have severely photodamaged skin even at resistant bacteria. However, there does not appear the time of disease onset. Therefore, I think top- to be an important bacterial cause of rosacea that ical retinoids are indicated and effective because we need to be concerned about, and we’ve been of their benefits for restoring the dermal matrix.
using oral antibiotics for 35 years with a great safe- Otherwise, more basic research is needed to elucidate the pathogenesis of rosacea because Dialogue
only with that information will we be able to with a Mentor
Q What experience do you have with some identify targeted therapies. We can continue to
of the more recently introduced therapies
for rosacea?
about avoiding triggers and our current empiri- My own impression of azelaic acid is that its effi- cal approaches to drug treatment. However, we cacy is being overstated. Similarly, while there are need to support some serious basic research some people who think the topical immunomod- because that will provide a foundation for devel- ulators tacrolimus and pimecrolimus work, I

Source: http://rosacea.iinet.net.au/kligman.pdf