Kligman on the state of Rosacea Knowledge

Written by on December 18, 2005 in research with 0 Comments

Some interesting extracts from this scathing assessment of the state of Rosacea Research and Development.

A Personal Critique on the State of Knowledge of Rosacea. Comment. The Third William J. Cunliffe Lecture, Albert M. Kligman, Department of Dermatology, University of Pennsylvania, Philadelphia, Pa., USA, Dermatology 2004 ;208:191-197

This encouragement stands in stark contrast to the indifference of the National Institutes of Health, which with an annual budget of nearly 30 billion dollars, has not seen fit to fund a single grant for the investigation of rosacea.

There are profound disagreements among “experts” who write and talk about rosacea. I state forthrightly that the state of knowledge regarding the classification, pathogenesis, diagnosis and treatment of rosacea is embarrassing, if not scandalous, when compared to the impressive advances in all other fields of dermatologic research.

I have seen many hundreds of rosacea patients enrolled in our experimental efforts over the past ten years. I have not encountered a single one in whom a history of flushing could not be elicited. This is not a moot point, which cannot be waved away as simply a theoretical argument among quarrelsome scholars. I, and others, regard rosacea as fundamentally a vascular disorder which ineluctably begins with episodes of flushing, eventuating in the “red” face.

These and other arguments persist because we have no laboratory tests that will unequivocally establish the diagnosis of rosacea. Moreover, we have no clinical markers that make the diagnosis indisputable. We depend on combining a variety of signs and symptoms to support the diagnosis.

I find it illuminating, even risible that of more than 90 papers which I have reviewed aimed at determining the efficacy of a variety of topical agents, not one concluded that the drug was ineffective. It seems that rosacea is a physician-friendly disorder in which everything works. This brings to mind the old clinical adage that when everything works, nothing works! Of course, we all understand how it happens that industry supported research is unlikely to yield negative results. The choices that doctors make among many competing drugs are largely empirical and arbitrary, that is to say, they do not meet the requirement of evidence-based medicine. This uncomfortable situation furnishes still another reason for raising up funds to settle these issues by the only known pathway, objective, quantifiable research.

To these quandaries we can add another disturbing fact, that we cannot fully explain how some of our most effective drugs actually exert their therapeutic benefits. For example, the high efficacy of oral antibiotics, especially tetracyclines, is beyond doubt, a welcome mainstay of treatment. Yet, no pathogenic organism has been identified as causative. Rosacea is not an infectious disease and there is no evidence that antibiotics work by reducing the native microflora, which do not differ from normals. We have to contrive other explanations;

The National Rosacea Society has gathered a panel of experts who have proposed a new classification which has the highly desirable goal of establishing universal standards for classifying the varied expressions of rosacea.

In my view this is a vast oversimplification which will not solve the diagnostic dilemmas that confront us. I see no reason not to give equal nosologic status to granulomatous rosacea, rosacea conglobata, rosacea inversa (formerly called pyoderma faciale), rosacea fulminans, edematous rosacea (a devastating variety) or combinations with seborrheic dermatitis, lupus erythematosus, acne vulgaris, and still other variants. Reducing the classification to four sub-types does little to clarify and eliminate the inherent complexities of this mysterious disease.

Nevertheless, the new classification is a good beginning since it awakens awareness of the necessity to develop robust diagnostic criteria. This is an area where clinicians and basic researchers can profitably come together to provide internationally approved guidelines.

Nonetheless, I hold that studies of papulo-pustular rosacea has brought in the marketplace too many drugs of marginal efficacy making it almost impossible for clinicians to make rational choices among the offerings, especially when these are backed up by heavy investments in marketing. I have already mentioned that everything seems to work rather well in papulo-pustular rosacea, so that the“active agent is predictably superior to the vehicle control.

Our lack of knowledge regarding many aspects regarding the pathogenesis of rosacea has greatly hampered our obligation to provide internationally agreed-upon guidelines for conducting studies which yield concordant results. This will help clinicians select the most effective drugs and aid manufacturers to create superior ones.

I think Napoleon’s remark is appropriate to demonstrate for the public and the authorities what we desperately need to bring rosacea out of the shadows and to add science to clinical empiricism. When asked what was needed to win a war, he is reputed to have said “Three things – money, money and money”.

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About the Author: David Pascoe started the Rosacea Support Group in October 1998. .

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