DN: How do beta-blockers fare at treating flushing?
Dr. Harper: They can help, but I don’t know that they can knock it out completely.
And we should remember that there are no FDA-approved beta-blockers to treat this. Most of the data we have are small case reports or case series. We don’t have a lot of data.
DN: Is there anything that’s used too much in rosacea?
Dr. Harper: Probably metronidazole. I understand why it’s used. It’s not a bad drug. But we have better drugs now.
I think we use metronidazole whenever things aren’t covered by insurance. And we use it to do too many things. Don’t try to make metronidazole do everything.
Metronidazole is FDA-approved for papules and pustules. It wasn’t ever intended to help with flushing and background erythema, and you’ll need to use something else with it.
DN: What’s coming down the line for rosacea?
Dr. Harper: We’ve got a couple new antibiotics: a new topical antibiotic and another oral antibiotic.
DN: Let’s talk about acne. Do you think isotretinoin is underused?
Dr. Harper: We should be using more of it. Why do we hold this drug hostage from our patients? In many people, it will cure their acne if they take it for just 5-6 months.
Are we worried about inflammatory bowel disease? The most recent studies say that’s not really an association. Are we worried about depression? We’ve had a meta-analysis that suggests if you take all that data, depression – if anything – gets better in people who take isotretinoin (; ).
We need to take [the risk with pregnancy] seriously. But we need to be putting more people on the drug and giving them the opportunity to be clear.
DN: What should be used less in acne?
Dr. Harper: We should use less antibiotics and more of everything else – more hormonal treatments, more isotretinoin, more topical retinoids.
That doesn’t mean no antibiotics. But instead of doing three repetitive courses of antibiotics, do one. If acne recurs, go to isotretinoin. Go to an alternative.
DN: What about spironolactone in acne?
Dr. Harper: It’s a blood pressure medicine, but it’s got an antiandrogenic qualities. It blocks the androgen receptor so it’s like getting the benefits of the birth control pill without the estrogen. It can be very beneficial for acne in women.
Its use increased from 2004 to 2013, and people are getting the hang of it. But when you compare it with the number of antibiotics prescribed, antibiotics are written a whole lot more ().
DN: Is there anything that is especially helpful in treating men?
Dr. Harper: Part of the way that birth control and spironolactone work is by decreasing sebum, and we don’t have anything like that for men. But potentially, there may be a topical antiandrogen product that decreases sebum.
DN: How do you deal with patients who are in a lot of distress because of acne or rosacea?
Dr. Harper: You listen to them and tell them you hear what they’re saying. “I understand that you want to be clear, and I’ll help you do that.”