Hi,

I found the interview below in the September 2004 issue of
Dermatology Times.

URL that will break:

http://www.dermatologytimes.com/dermatologytimes/article/articleDetail
.jsp?id=119838

Shortcut to above URL:

http://tinyurl.com/3zzuv

Dialogue with a Mentor
Sep 1, 2004


Albert Kligman, M.D., Ph.D., has devoted his career to challenging
the status quo, and to this day continues to play an active role in
the ever-changing arena of dermatology. Even as he celebrates his
88th birthday this month, Dr. Kligman remains a strong example of the
power behind research and continues to shed light on some of the more
perplexing dermatologic dilemmas.

In this, the first installment in a sponsored series
entitled, "Dialogue with a Mentor," where long-time veterans of
dermatology share their experience, insights, and what they believe
will have the most impact on future practice, Dr. Kligman sets his
sights on what he views as still uncharted territory — the diagnosis
and treatment of rosacea.

A pioneer in dermatology, Dr. Kligman is noted for the development of
tretinoin, ground-breaking work in the advancement of acne
management, and is the physician who coined the term "cosmeceutical"
when referring to his use of retinoids in anti-aging. Dr. Kligman has
a wealth of experience, and in this interview outlines some of his
opinions and findings as they relate to rosacea treatment.

Q What are your thoughts about the pathogenesis of rosacea?

It appears the answer to that question is not a simple one because
rather than having a single cause, rosacea probably develops as a
result of multiple interacting factors, some of which include genetic
determination and perhaps the presence of demodectic mites in some
individuals. The pathogenesis of rosacea is a subject that has been
debated and disagreed on for many years, and I consider it a real
scandal that our knowledge remains so poor. Consider that rosacea and
acne vulgaris are related disorders, and while we have a good
understanding about the causes of acne and how to treat it, we remain
as ignorant today about rosacea as we were about acne 50 years ago.

Q What have been some of the major milestones in treatment of rosacea?

There are many different treatments that have been introduced and
talked about as helpful for rosacea, but I believe there are only a
few medications that offer unassailable efficacy. Among oral agents,
I think nobody will deny antibiotics are important therapy,
particularly the tetracyclines, 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 severe cases. At the topical
treatment level, metronidazole has become a mainstay, but there are a
number of other topical agents being used according to prescriber
personal preference. I don't believe there is sufficient good science
backing the purported activity of some of the topical drugs for
reducing the features of rosacea that can devastate quality of life.

Q What impact do you believe the National Rosacea Society
classification system will have on the understanding, recognition,
and diagnosis of rosacea?

It's an excellent start, but I think it is too simplified because I
believe there are many more varieties of rosacea in addition to the
four subtypes listed in that system. However, the goal of developing
a standard classification for enabling research and communication is
a good one, and the system was developed as a provisional one.

Q For 10 years, an oral antibiotic plus topical metronidazole has
been the foundation for treating rosacea. Do you agree that it is
the "ideal regimen?"

For most patients, it is a good idea to initiate therapy with such a
combination systemic and topical treatment. However, the treatment
has to be tailored to the manifestations of the individual patient.
For example, there is an under-recognized form of rosacea with hard
edema, and in that situation I add massage as a physical therapy,
while I prescribe isotretinoin if I see a patient with severe
inflammatory rosacea.

Q Are there situations where you would prescribe monotherapy instead
of combination treatment?

Probably 95 percent of the time, I initiate treatment with the
combination of an oral antibiotic and a topical agent. I might
consider topical metronidazole treatment as monotherapy for a patient
presenting with very early, mild rosacea. In general, however,
medical management of rosacea should be multimodal. Rosacea is a
serious disease with potentially significant psychosocial
consequences, and there are many patients who are finally receiving
treatment after suffering for 20 years without a diagnosis.

Q To reduce the development of drug-resistant bacterial strains, the
FDA has mandated new statements appear on the physician labeling for
all systemic antibacterial drugs. Do you think that will affect
prescribing patterns for rosacea?

I don't think those concerns are particularly relevant to rosacea and
I don't expect them to have much impact on our reliance on oral
antibiotics. In theory, use of antibiotics for the treatment of
rosacea could contribute to the emergence of resistant bacteria.
However, there does not appear to be an important bacterial cause of
rosacea that we need to be concerned about, and we've been using oral
antibiotics for 35 years with a great safety record.

Q What experience do you have with some of the more recently
introduced therapies for rosacea?

My own impression of azelaic acid is that its efficacy is being
overstated. Similarly, while there are some people who think the
topical immunomodulators tacrolimus and pimecrolimus work, I have not
seen good supporting evidence for those claims. Through my own
limited experience, I have been unimpressed with the benefits of the
topical immunomodulators.

Q A recent report suggests topical metronidazole has an antioxidant
effect. Do you think that might encourage patient compliance?

"Antioxidant" has become an important buzzword in the popular lexicon
and is a term that is being widely used for marketing purposes.
Therefore, the idea that use of metronidazole provides antioxidant
benefits might motivate some patients to adhere better to treatment.
However, we still haven't the faintest idea about the real mechanism
of metronidazole's efficacy in the treatment of rosacea.

Q Some information suggests that only 10 percent of patients with
rosacea are receiving treatment. Does that surprise you and what can
be done to improve the situation?

I think that statistic may understate the situation, but certainly
more than 50 percent of affected persons are not receiving care
because they have not been properly diagnosed. That is another piece
of the scandal about rosacea I referred to earlier. However, the
National Rosacea Society (NRS) is doing an invaluable and effective
job in spreading the word to raise awareness and bring forward better
treatment.

Q Do you foresee any new developments in treatment occurring over the
next five to 10 years?

We have begun to do some research on the use of topical retinoids,
and I think as we collect more information, they will emerge as a
first order treatment. There is a good rationale for using topical
retinoids recognizing that patients with rosacea have severely
photodamaged skin even at the time of disease onset. Therefore, I
think topical retinoids are indicated and effective because of their
benefits for restoring the dermal matrix.

Otherwise, more basic research is needed to elucidate the
pathogenesis of rosacea because only with that information will we be
able to identify targeted therapies. We can continue to pick at the
problem with recommendations about avoiding triggers and our current
empirical approaches to drug treatment. However, we need to support
some serious basic research because that will provide a foundation
for developing rational therapy.