From: "drnase2000"
Date: Mon Nov 11, 2002 11:15 pm
Excellent questions to each point I made. I will do my best over the next week
to find the references and summarize them -- as well as send you some of the
papers for your review. I did want to quickly comment on your question
concerning Dr. Dahl.
First of all, since we lost our best advocate (Dr. Wilkin), he has never been
replaced. He was primarily interested in attacking the heart of the beast -
flushing and vascular abnormalities. Dr. Dahl seems to have been pushed up to
the top of the foam. While I think his credentials as a derm are impressive,
his studies are flawed and his conclusions are erroneous -- especially with the
"Great" article titled "Metronidazole Remains Remission in Rosacea". This
double blind, placebo controlled, multicenter study had enough holes in it that
it should have never passed by the review board.
Below is a short excerpt about metronidazole from my book that puts its use
into perspective. This is followed by Dr.Dahl's article and his erroneous
conclusions that make it seem that we have a near-cure with metronidazole. This
is more harmful than good -- if derms think we have a near cure......than why
do anymore research. Anyway here goes:
Limitations of topical metronidazole
For the record, I think that metronidazole-based topicals such as noritate and
metrogel have an important place in rosacea therapy. These topicals are very
effective in mild cases, and are usually able to reduce some of the superficial
symptoms in moderate to severe cases. However, while patients are often
grateful for reduced symptoms, it must be stressed that topical metronidazole
does not treat the heart of the vascular disorder and does not result in
clearance of rosacea and facial flushing. In fact, there are numerous medical
reports suggesting that rosacea sufferers in the moderate to severe stages may
only experience minor improvements while on topical metronidazole, or may not
respond at all:
• In a recent clinical article, topical metronidazole was found to be
ineffective in the treatment of 20 different rosacea sufferers. (52)
• In a review of 27 rosacea patients, oral antibiotics and topical
metronidazole were not effective in treating the vascular heart of the disorder
such as facial redness, inflammation, flushing, and telangiectasia. (18)
• Consistent with the above, Dr. Grousshans states, "Tetracycline and
metronidazole are very useful for therapy, but they only influence the
cutaneous and ocular complications and do not act upon the basic vascular
trouble." (22)
• In a recent 1998 review of rosacea treatments, Dr. Greaves stresses, "It is
important to explain to patients that none of the above measures (i.e., oral or
topical antibiotics) will significantly suppress the troublesome flushing,
burning, redness and telangiectasia which underlie the disease." (103)
• In a 1999 medical review, Dr. Larry Millikan, a Dermatologist at the
Department of Dermatology, Tulane University Medical School, emphasizes,
"Metronidazole has been the most extensively studied therapy for rosacea, but
not all patients show a response to it." (15)
• Several medical reports indicate that topical metronidazole is effective for
superficial papules and pustules, but is not effective on the facial flushing,
redness, or telangiectasia that are key to rosacea. (8, 21, 104)
• Two in-depth case reports documented that these rosacea sufferers did not
respond at all to topical metronidazole. (23)
• Other experts have documented that topical metronidazole is not effective at
reducing facial flushing or telangiectasia, and is only mildly effective at
decreasing redness in some rosacea sufferers. (19)
Medical articles should include benefits and limitations of topical
metronidazole so that gener-al physicians and rosacea sufferers know what to
reasonably expect from treatment
In a very recent medical article in the Archives of Dermatology (1998), medical
physicians boldly titled their study, "Topical Metronidazole Maintains
Remissions of Rosacea". (89) While this study was well designed and performed
by top-notch dermatologists, I humbly suggest that the article's title, and
some of the basic conclusions are innocently misleading – both to general
physicians and rosacea sufferers. The title, abstract, and general conclusions
of this medical article are written in such a way that it honestly looks like
we have found a near-cure for rosacea in topical metronidazole. This just isn't
the case. Some of the rosacea sufferers did not improve at all, a significant
percentage of sufferers relapsed while on topical metronidazole, many still had
papules and pustules, others showed no improvement or only minimal improvement
in facial redness; and facial flushing, facial telangiectasia, facial burning,
and trigger avoidance were not even evaluated. More specifically: (89)
• 10% of the rosacea sufferers did not improve enough in the beginning stages
of the study to be included. They dropped out of the study.
• 23% of the sufferers relapsed completely while on topical metronidazole.
• 47% of the sufferers still had papules and pustules at the end of the study.
• 26% did not show any improvement in facial redness, while many others only
demonstrated mild improvement.
• Facial flushing, telangiectasia, swelling, and burning sensations were not
evaluated at all.
• Most importantly, avoidance of flushing triggers (a very important part of
rosacea treatment), was not even addressed in this study. These medical
researchers only included half a sentence on this very important topic,
stating, ".....others frequently stay well by avoiding trigger factors.....".
So, "Topical Metronidazole Maintains Remissions of Rosacea" may not be the most
accurate description of the medical findings. A more accurate title might be,
"Topical Metronidazole with Avoidance of All Flushing Triggers Reduces
Superficial Symptoms in Some Rosacea Sufferers".
In a more recent article in the Archives of Dermatology (1999), Dr. Wilkin
also voices his concerns over the conclusions of this medical article. (105) In
fact, he states, "Limiting one's clinical regimen literally to the treatment
evaluated by these medical investigators (Dr. Dahl) could shortchange patients
with rosacea, and be hazardous to those with ocular involvement."
Please remember that topical metronidazole has benefits and limitations.