Rick,

Good comments below. Understood. But, it is bits and pieces work.
Many physicians do not have time to read the entire article, they
focus on the title, abstract and end of discussion.

1. The title is extremely iimportant. So, "Topical Metronidazole
Remains Remission in rosacea" should never have passed peer review
of any major article.

2. First, the title says nothing about papulopustular rosacea. Just
as important is that this title is the most refereced rosacea
article to date if you look it up in the library referencing
catalogue. So, that title itself rings out in the ears of general
physicians and general dermatologists.

3. Second, when you look at the results, they do not support the
conclusions becase Dr. Dahl states that patients must continue to
avoid all triggers. This is not emphasized (only one sentence) and
there is once again, no mention about this in the title. I could
never get any of my articles passed based on the title -- it must
support the results. If you need a topical treatment and complete
avoidance of triggers, there is no way that you can title the
article to suggest that the medication is responsible for remission.

4. If you thoroughly analyze the results a significant portion of
rosacea sufferers on metronidazole relapse by 50% to 100%, once
again not supporting the title -- p>0.05 in relapse. This is
significant, so you cannot state that it remains remission in
rosacea.

5. I believe that I am being extremely generous and caring in my
presentation because since the article was published, hundreds of
dermatologists who I chat with as friends or at meetings, etc. quote
that title. In their minds remission equals cure for rosacea. So,
this article really hurts the rosacea patient.

6. You brought up the sponsorship of Dr. Dahl by Galderma. Good
point, well taken. I dont believe there is any conspiracy theory.
But, there is a clear conflict of interest at the very least. This
does make a difference in all the articles and recent publications --
there will be a tendency to mention Galderma products first. Even
if not done on purpose. However, when you add that up with his
being the top notcho on the NRS Grant Committee (Galderma), this
throws the conflict of interest into a total tailspin. We would
never be allowed to be on the board of any pharmaceutical company
that we were doing independent studies for. Never. Now for the
last layer which should completely open up everyone's eyes and
clearly defines conflict of interest and borders unethical. Dr.
Dahl is on the Medical Advisory Committee/board of the NRS
responsible for funding grants that we (the rosacea sufferers) have
donated money to. No one on the Medical Advisory Committee or the
board can ever receive or apply for a grant in any formal
organization. This is never done. Ever. Yet, Dr. Dahl submitted a
grant and received money for the study and also approved two grants
by two other board members on that same committee. This is unheard
of. If one of my mentors from 10 years ago, twice removed submits a
grant to the NIH where I am reviewing grants, I have to leave the
room for the day. We certainly could never even think of sitting in
the NIH grant processing room and pass each others grants to each
other and approve them. Absolutely past the line on so many
levels. So, I feel qualified to critique this sort of inappropriate
behavior by professionals.

7. You bring up an excellent point about the use of the term cure.
Remission does not mean cure. However, remission does equal cure
when you talk to pharmaceutical companies or University researchers
who see no reason to create better treatments if there is a topical
product that puts rosacea into remission. There is no financial
payback. Remission equals cure to 17 straight pharmaceutical
companies that I spoke to over the last two months. I spoke to the
physician MD directors of 17 Pharmaceutical companies about the need
for better treatments (Research and Development). 17 out of 17
stated they had no interest because rosacea had been "cured"
or "basically cured" with metronidazole == "as quoted by the indepth
study performed by Dr. Dahl" and then they quoted the title in most
cases to see if I knew of the article "Topical Metronidazole Remains
Remission in Rosacea".


This is where we stand with this. Rick, are you satisfied with
this? Has metronidazole remained remission in your case. Have the
more recent studies suggesting that metronidazole also relieves
chronic facial redness and burning sensations impressed you? I hope
not. Are you happy with the status quo -- I know this group is
not. Am I picking on Dr. Dahl for any particular reason or am I
trying to get to the top of the hill and waive the red rosacea flag
and say, "Everybody, hold on........we are not even close to
remission in any form of the disorder once you have passed the mild
stages of any subtype." Does it not send shivers down your spine
that 17 pharmaceutical companies that specialize in inflammatory
skin disorders have no interest in our disorder because of this
paper in large part. That is the absolute truth of how much effect
one major title/abstract can have on a disease.

This is probably the third time we have had this same discussion.
You are extremely bright. Don't you think it would be of better use
to focus on better treatments, contacts, derm talks, medical papers
than critique me for the third time on trivial points that I
actually treat with great fairness. You mention that the problem is
not with Dr. Dahl, but the community as a whole. This is where you
are wrong. Dr. Dahl's paper influences the community as a whole,
so, he is a part of the great rosacea stall. You also fail to grasp
that Dr. Dahl is currently considered the number one, foremost
dermatologist expert in the field of rosacea, so, once again his
papers influence the medical community as a whole more than any
other single derm. When Dr. Wilkin was the head rosacea expert, you
saw real scientific testing of the flushing response and
iontophoresis or agents to test blood vessel sensitivity, in-depth
talks about the neurovascular aspects of the disorder, papers about
severe burning and how rosacea can ruin lives, and no slew of papers
or research supported by the same pharmaceutical company.

Regards,

Geoffrey
______________________________

Dr. Geoffrey Nase
Ph.D. Neurovascular Physiologist
http://www.drnase.com
______________________________




> Geoffrey,
>
> You mentioned these points in a previous post about Dr Dahl, and I
> was a bit surprised then, but felt that it was not worth making a
> big deal about.
>
> First, below are his rosacea publications as returned by Medline
> (Dahl + rosacea). I suspect you are right that 1998 and 2001
> publications on topical metronidazole were funded by Galderma. It
> is unfair to say that the "results always support Galderma's
> products". (As you know, the majority of clinical dermatological
> studies are funded by entities with a strong interest in the
> outcome -- look no further than the IPL literature.) The NRS
> classification system discussed in his more recent publications is
> an excellent first start, but the linkage with Galderma is
secondary
> via their support of NRS.
>
> Second, while I understand your comments on the use of the
> word "remission" in his infamous paper, but it is clear in the
full-
> length paper that he addressing only patients with papules and
> pustules. 113 such patients entered the open phase (usual
systemic
> antibiotics + topical metronidazole), and 88 responded positively
> based on achieving a 70% reduction in p&p. The remission statement
> refers only to the 88 who entered the second phase, with half
> receiving topical metronidazole and the other half a placebo gel.
> My reading of this is that he is merely stating that IF your p&p
can
> be reduced by conventional treatment with oral antibiotics, THEN
you
> have a good chance of sustaining this with topical metronidazole.
> Nothing more. Certainly, there is no suggestion whatsoever that
> this is a "cure", or indeed that this will work for ALL rosacea
> patients. The conclusions are only for a subset of sufferers, one
> that we all know is much more easily controlled that the
problematic
> erythematic/flushing subset that probably includes the majority of
> people on this Board.
>
> The problem is not with Dahl, but rather with the community as a
> whole. And this is where you come in ...
>
> Rick
>
> --------------------------
> Items 1 - 7 of 7 One page.
> 1: Dahl MV. Related Articles, Links
> Rosacea subtypes: a treatment algorithm.
> Cutis. 2004 Sep;74(3 Suppl):21-7, 32-4. Review.
> PMID: 15499755 [PubMed - indexed for MEDLINE]
> 2: Wilkin J, Dahl M, Detmar M, Drake L, Liang MH, Odom R, Powell
F;
> National Rosacea Society Expert Committee. Related Articles,
Links
> Standard grading system for rosacea: report of the National
Rosacea
> Society Expert Committee on the classification and staging of
> rosacea.
> J Am Acad Dermatol. 2004 Jun;50(6):907-12. No abstract available.
> PMID: 15153893 [PubMed - indexed for MEDLINE]
> 3: Dahl MV, Ross AJ, Schlievert PM. Related Articles, Links
> Temperature regulates bacterial protein production: possible role
> in rosacea.
> J Am Acad Dermatol. 2004 Feb;50(2):266-72.
> PMID: 14726884 [PubMed - indexed for MEDLINE]
> 4: Wilkin J, Dahl M, Detmar M, Drake L, Feinstein A, Odom R,
Powell
> F. Related Articles, Links
> Standard classification of rosacea: Report of the National
Rosacea
> Society Expert Committee on the Classification and Staging of
> Rosacea.
> J Am Acad Dermatol. 2002 Apr;46(4):584-7. No abstract available.
> PMID: 11907512 [PubMed - indexed for MEDLINE]
> 5: Dahl MV. Related Articles, Links
> Pathogenesis of rosacea.
> Adv Dermatol. 2001;17:29-45. No abstract available.
> PMID: 11758120 [PubMed - indexed for MEDLINE]
> 6: Dahl MV, Jarratt M, Kaplan D, Tuley MR, Baker MD. Related
> Articles, Links
> Once-daily topical metronidazole cream formulations in the
> treatment of the papules and pustules of rosacea.
> J Am Acad Dermatol. 2001 Nov;45(5):723-30.
> PMID: 11606923 [PubMed - indexed for MEDLINE]
> 7: Dahl MV, Katz HI, Krueger GG, Millikan LE, Odom RB, Parker F,
> Wolf JE Jr, Aly R, Bayles C, Reusser B, Weidner M, Coleman E,
> Patrignelli R, Tuley MR, Baker MO, Herndon JH Jr, Czernielewski
JM.
> Related Articles, Links
> Topical metronidazole maintains remissions of rosacea.
> Arch Dermatol. 1998 Jun;134(6):679-83.
> PMID: 9645635 [PubMed - indexed for MEDLINE]
> ---------------------
> --- In rosacea-support@yahoogroups.com, "Dr. Geoffrey Nase, PhD"
> <drnase1000@h...> wrote:
> >
> >
> > Hello Group,
> >
> > First of all, I want to thank you for all your caring emails and
> > posts. I was not looking for them or the overwhelming responses
> > that I received upon posting that I may need to cut back, pace
> > myself or possibly move on due to career decision time. But,
> thank
> > you.
> >
> > I finished my Post-Doctoral Fellowship four years ago. Upon
> > completion of this, one usually becomes a Tenure Track Professor
> at
> > a Medical University or heads up a division at a Pharmaceutical
> > company. I rejected all offers because rosacea boiled in my
> blood –
> > I lived it and now it has become my passion. Just as important
> was
> > the fact that there are NO dermatology rosacea experts since Dr.
> > Wilkin retired 8 years ago and none are waiting in the wing.
That
> > is the absolute sad truth. Rosacea has stalled and another
decade
> > could very easily pass by with out a single major advance in any
> > area of rosacea research or treatment.
> >
> > I thought Dr. Dahl would step up to the plate because he is very
> > smart, a great guy, has rosacea, etc. Not only has he not
filled
> > the void, but he has single handedly moved rosacea backwards
five
> or
> > six years. Most of his publications are funded by Galderma and
> the
> > results always support Galderma's products. But, most important
> is
> > that at all the National Dermatology Meetings I attend, all the
> > pharmaceutical companies I call, the SAME exact statement comes
to
> > the forefront……."Why are you talking about rosacea, it has been
> > cured. Dr. Dahl wrote a huge paper titled, "Metronidazole
Remains
> > Remission in Rosacea". That has to be placed in the Hall of
Shame
> > as the single worst, misrepresentative rosacea paper ever
> published.
> >
> > Anyway, back to my career. I have been in neutral for four
> years.
> > This is hard to do when you are pressured on a daily basis to
grab
> > the offers that are given to you and at faculty meetings
everyone
> > looks at you like you are Forest Gump – maybe I should just buy
a
> > shrimp boat. I am big enough of a man to take all of this, but
it
> > is time for me to make a decision that has some form of security
> to
> > it. If I take any career in my field I am literally out of
> rosacea,
> > because in my specialty there is no such thing as a 40 hour
week……
> or
> > as a matter of fact an 80 hour week. So, this looms heavily on
my
> > mind.
> >
> > On the other hand, many wonderful avenues and opportunities have
> > opened up on the rosacea arena.. Publishing in medical journals
> > that NEVER allow anyone other than Dermatologists to publish in,
> > presenting posters at Dermatology meetings, co-founding the
> Rosacea
> > Research Foundation with the most amazing Board Members anyone
> could
> > ask for and 6 of the most well known doctors on our Medical
> Advisory
> > Committee. However, it seems that I am a pitiful business man
> > because everything I am doing is for free and all these
fantastic
> > opportunities cost me a bundle – submitting an article to a
major
> > dermatology journal costs at least $2,000 bucks per article (7
> > articles submitted) and about 6 weeks of work on my part.
> Attending
> > all these meetings is about $4,000 a pop (10 Meetings this year)
> and
> > all my other adventures in rosacea.
> >
> > I appreciate the offers for reimbursement and such, but I could
> > never accept them. That is not what I am about. People should
do
> > things for others for free and out of the pure generosity to
help
> > those who are suffering.
> >
> > I saw a lot of interesting ideas and suggestions that I will
look
> > into. My hopes are that I can somehow find a 40 hour a week job
> in
> > my trained area – this would allow me enough time to do
everything
> I
> > wanted without knocking over dumpsters looking for food scraps –
> if
> > you are not a writer, you will never appreciate the saying, "A
> > starving writer". It's true in most cases.
> >
> > I had a great conversation with David Pascoe. I am certainly
> still
> > part of the board and probably will be until a cure is found. I
> > just need to find the proper pace to set. Private emails is a
> tough
> > one due to sheer volume and time to answer each individual one;
I
> > roughly receive 250 to 400 emails every single day. I have
been
> > trying to answer 25 a day but even that is too much (7 minutes
per
> > email to read, analyze, type in and send comes out to be 2.5
hours
> > every day) and that does not even make a dent in the emails I
> > receive. Part of my top priorities must be changing the
> dermatology
> > industry through constant publications and full dedication to
the
> > non-profit Rosacea Research Foundation to finally get some real
> > research and treatments. Avoidance of triggers is not a
> treatment.
> > Dermatologists are dumfounded when I tell them this. Most come
> back
> > with the three layers of green and yellow makeup. Well……also
not
> a
> > treatment and does not help the burning or uncomfortable
> flushing.
> > Very bluntly, dermatologists need to unlearn, stop reading the
> same
> > old cookie cutter articles, stop spending 8 minutes with each
> > patient (US average dermatology appointment) and re-educate
them.
> > Some should be gracefully forced into early retirement.
> >
> > So, I will find a pace with the support group, with the private
> > emails and continue to look for something that will allow me
> > security and growth – all humans need this.
> >
> > I enjoyed seeing your posts evolve and people realize that they
> are
> > worthy enough, smart enough and dedicated enough to make a
> > difference on the Support Group. You guys and gals don't need
me
> as
> > much as you think you do. I am constantly amazed at the level
of
> > questions, the professional responses, the ability to
> read/decipher
> > medical literature, the gentle debates and so on. Don't ever
> become
> > dependent on anyone or anything. I am simply a rosacea support
> > member who is notorious for his long run on sentences.
> >
> > I will be taking a break and going to some job interviews. I
will
> > talk to everyone soon.
> >
> > My Best Regards to Everyone,
> >
> >
> > Geoffrey
> > ______________________________
> >
> > Dr. Geoffrey Nase
> > Ph.D. Neurovascular Physiologist
> > http://www.drnase.com
> > ______________________________