Rosacea

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.

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.