Re: another editorial by Wilkin

[Guest guest]

> Here is another, more recent 1999 editorial by Jonathon Wilkin. It

> discusses the use of topicals to maintain remission:

>

> http://archderm.ama-assn.org/issues/v135n1/fpdf/ded8021.pdf

>

> Again, the derm literature is a bit weird. Only here can someone

> (Wilkin) totally trash someone else's study (in this case, Mark

Dahl,

> who, like Wilkin, is a prominent rosacea researcher an member of

the

> National cea Society advisory board) in an editorial (as

opposed

> to letter to the editor), with no opportunity for the criticized

> party to respond.

Rick, I had a different take on the article. In 1999 evidence-based

medicine was making significant inroads, and from Wilkin's comments

he doesn't sound like a believer in that approach. Dahl's study,

published a year earlier, may well have been suggested as a model for

evidence-based protocol. (This was exactly the time when all of

medicine was going protocol-happy. <g>)

Wilkins feels that rosacean care needs to be more individualized that

treatment protocols allow. That's not dissing Dahl's study. Plus,

it's an editorial, so Wilkin is free to voice his opinion. If he

cared to, Dahl may respond in a Letter to the Editor to the Archives

of Dermatology journal, or by writing his own editorial. But I don't

see why he would, unless Dahl was a strong supporter of evidence-

based medicine.

To me, this is how physicians and/or researchers always talk to one

another about each other's work. I'm not picking up any ad hominem

comments, esp since Dahl's results support his own clinical approach.

> Second, note that Wilkin carefully inquires of his patients which

> season is typically " best " for their rosacea (summer seems to be

the

> most popular choice), and then deliberately starts the remission

> program to coincide with what would otherwise be the most benign

> period for each patient. Assuming he followed this statitically

> biased approach in his 1994 editorial (where he bragged about his

> superior success rate in weaning patients off of systemic

> anitbiotics

> to topicals), it certainly raises questions about the conduct of

> his studies (and his rather remarkable ego.)

Oh, I didn't read it that way at all! It's good medical care to taper

medications when remission is most likely to take place, for the

longest period of time. As long as he treated all patients the same,

I don't see the bias.

I don't know anything about Wilkin or Dahl, so you may have the

advantage there. But in my ignorance, I'm not reading any ego or

bragging or dissing. To me Wilkin is communicating his clinical

experiences in a straightforward manner, there's no reason to be

modest if he's had success.

Of course, if his results can't be verified by others, then his

success remains his own. But it sounds like Dahl's study confirmed

his own (prolonged remission in more patients with continuing topical

after course of oral antibiotics), as have subsequent studies.

What am I missing? We usually agree more than this (although

disagreeing can also be fun). <g>

Marjorie

Marjorie Lazoff, MD

[Guest guest]

> Here is another, more recent 1999 editorial by Jonathon Wilkin. It

> discusses the use of topicals to maintain remission:

>

> http://archderm.ama-assn.org/issues/v135n1/fpdf/ded8021.pdf

>

> Again, the derm literature is a bit weird. Only here can someone

> (Wilkin) totally trash someone else's study (in this case, Mark

Dahl,

> who, like Wilkin, is a prominent rosacea researcher an member of

the

> National cea Society advisory board) in an editorial (as

opposed

> to letter to the editor), with no opportunity for the criticized

> party to respond.

Rick, I had a different take on the article. In 1999 evidence-based

medicine was making significant inroads, and from Wilkin's comments

he doesn't sound like a believer in that approach. Dahl's study,

published a year earlier, may well have been suggested as a model for

evidence-based protocol. (This was exactly the time when all of

medicine was going protocol-happy. <g>)

Wilkins feels that rosacean care needs to be more individualized that

treatment protocols allow. That's not dissing Dahl's study. Plus,

it's an editorial, so Wilkin is free to voice his opinion. If he

cared to, Dahl may respond in a Letter to the Editor to the Archives

of Dermatology journal, or by writing his own editorial. But I don't

see why he would, unless Dahl was a strong supporter of evidence-

based medicine.

To me, this is how physicians and/or researchers always talk to one

another about each other's work. I'm not picking up any ad hominem

comments, esp since Dahl's results support his own clinical approach.

> Second, note that Wilkin carefully inquires of his patients which

> season is typically " best " for their rosacea (summer seems to be

the

> most popular choice), and then deliberately starts the remission

> program to coincide with what would otherwise be the most benign

> period for each patient. Assuming he followed this statitically

> biased approach in his 1994 editorial (where he bragged about his

> superior success rate in weaning patients off of systemic

> anitbiotics

> to topicals), it certainly raises questions about the conduct of

> his studies (and his rather remarkable ego.)

Oh, I didn't read it that way at all! It's good medical care to taper

medications when remission is most likely to take place, for the

longest period of time. As long as he treated all patients the same,

I don't see the bias.

I don't know anything about Wilkin or Dahl, so you may have the

advantage there. But in my ignorance, I'm not reading any ego or

bragging or dissing. To me Wilkin is communicating his clinical

experiences in a straightforward manner, there's no reason to be

modest if he's had success.

Of course, if his results can't be verified by others, then his

success remains his own. But it sounds like Dahl's study confirmed

his own (prolonged remission in more patients with continuing topical

after course of oral antibiotics), as have subsequent studies.

What am I missing? We usually agree more than this (although

disagreeing can also be fun). <g>

Marjorie

Marjorie Lazoff, MD

[Guest guest]

> Here is another, more recent 1999 editorial by Jonathon Wilkin. It

> discusses the use of topicals to maintain remission:

>

> http://archderm.ama-assn.org/issues/v135n1/fpdf/ded8021.pdf

>

> Again, the derm literature is a bit weird. Only here can someone

> (Wilkin) totally trash someone else's study (in this case, Mark

Dahl,

> who, like Wilkin, is a prominent rosacea researcher an member of

the

> National cea Society advisory board) in an editorial (as

opposed

> to letter to the editor), with no opportunity for the criticized

> party to respond.

Rick, I had a different take on the article. In 1999 evidence-based

medicine was making significant inroads, and from Wilkin's comments

he doesn't sound like a believer in that approach. Dahl's study,

published a year earlier, may well have been suggested as a model for

evidence-based protocol. (This was exactly the time when all of

medicine was going protocol-happy. <g>)

Wilkins feels that rosacean care needs to be more individualized that

treatment protocols allow. That's not dissing Dahl's study. Plus,

it's an editorial, so Wilkin is free to voice his opinion. If he

cared to, Dahl may respond in a Letter to the Editor to the Archives

of Dermatology journal, or by writing his own editorial. But I don't

see why he would, unless Dahl was a strong supporter of evidence-

based medicine.

To me, this is how physicians and/or researchers always talk to one

another about each other's work. I'm not picking up any ad hominem

comments, esp since Dahl's results support his own clinical approach.

> Second, note that Wilkin carefully inquires of his patients which

> season is typically " best " for their rosacea (summer seems to be

the

> most popular choice), and then deliberately starts the remission

> program to coincide with what would otherwise be the most benign

> period for each patient. Assuming he followed this statitically

> biased approach in his 1994 editorial (where he bragged about his

> superior success rate in weaning patients off of systemic

> anitbiotics

> to topicals), it certainly raises questions about the conduct of

> his studies (and his rather remarkable ego.)

Oh, I didn't read it that way at all! It's good medical care to taper

medications when remission is most likely to take place, for the

longest period of time. As long as he treated all patients the same,

I don't see the bias.

I don't know anything about Wilkin or Dahl, so you may have the

advantage there. But in my ignorance, I'm not reading any ego or

bragging or dissing. To me Wilkin is communicating his clinical

experiences in a straightforward manner, there's no reason to be

modest if he's had success.

Of course, if his results can't be verified by others, then his

success remains his own. But it sounds like Dahl's study confirmed

his own (prolonged remission in more patients with continuing topical

after course of oral antibiotics), as have subsequent studies.

What am I missing? We usually agree more than this (although

disagreeing can also be fun). <g>

Marjorie

Marjorie Lazoff, MD

[Guest guest]

> Here is another, more recent 1999 editorial by Jonathon Wilkin. It

> discusses the use of topicals to maintain remission:

>

> http://archderm.ama-assn.org/issues/v135n1/fpdf/ded8021.pdf

>

> Again, the derm literature is a bit weird. Only here can someone

> (Wilkin) totally trash someone else's study (in this case, Mark

Dahl,

> who, like Wilkin, is a prominent rosacea researcher an member of

the

> National cea Society advisory board) in an editorial (as

opposed

> to letter to the editor), with no opportunity for the criticized

> party to respond.

Rick, I had a different take on the article. In 1999 evidence-based

medicine was making significant inroads, and from Wilkin's comments

he doesn't sound like a believer in that approach. Dahl's study,

published a year earlier, may well have been suggested as a model for

evidence-based protocol. (This was exactly the time when all of

medicine was going protocol-happy. <g>)

Wilkins feels that rosacean care needs to be more individualized that

treatment protocols allow. That's not dissing Dahl's study. Plus,

it's an editorial, so Wilkin is free to voice his opinion. If he

cared to, Dahl may respond in a Letter to the Editor to the Archives

of Dermatology journal, or by writing his own editorial. But I don't

see why he would, unless Dahl was a strong supporter of evidence-

based medicine.

To me, this is how physicians and/or researchers always talk to one

another about each other's work. I'm not picking up any ad hominem

comments, esp since Dahl's results support his own clinical approach.

> Second, note that Wilkin carefully inquires of his patients which

> season is typically " best " for their rosacea (summer seems to be

the

> most popular choice), and then deliberately starts the remission

> program to coincide with what would otherwise be the most benign

> period for each patient. Assuming he followed this statitically

> biased approach in his 1994 editorial (where he bragged about his

> superior success rate in weaning patients off of systemic

> anitbiotics

> to topicals), it certainly raises questions about the conduct of

> his studies (and his rather remarkable ego.)

Oh, I didn't read it that way at all! It's good medical care to taper

medications when remission is most likely to take place, for the

longest period of time. As long as he treated all patients the same,

I don't see the bias.

I don't know anything about Wilkin or Dahl, so you may have the

advantage there. But in my ignorance, I'm not reading any ego or

bragging or dissing. To me Wilkin is communicating his clinical

experiences in a straightforward manner, there's no reason to be

modest if he's had success.

Of course, if his results can't be verified by others, then his

success remains his own. But it sounds like Dahl's study confirmed

his own (prolonged remission in more patients with continuing topical

after course of oral antibiotics), as have subsequent studies.

What am I missing? We usually agree more than this (although

disagreeing can also be fun). <g>

Marjorie

Marjorie Lazoff, MD

[Guest guest]

Marjorie,

My only real point concerning the editorial policy here is that it is

somewhat different than other technical literature, where comments

such as those made by Wilkin about other work would have required

communication (and possible rebuttal) with the other author prior to

publication. But I understand and appreciate your comments about the

medical literature.

The slightly more substantive comment has to do with his assertion,

both here and in the 1994 article, that he has a higher rate of

remission maintenance than other published studies. This has nothing

to do with his " technique " , since all we're really talking about is

slapping on Metronidozale (sp?) and seeing if it retains remission

after a course of systemic antibiotics. Hence, statistics becomes an

essential part of the analysis. (BTW, I build predictive

mathematical models against very noisy data like internet purchase

behavior and stock-market tick data, so I'm a bit over-sensitive when

I see casual statements made in the medical literature about these

sorts of things ...).

Hence, my major issue is that if (as an extreme) you select a bunch

of rosaceans whose rosacea subsides (by itself) during the summer,

subject them to a clinical study, and then conclude that your

" technique " has retained remission for 3 months, you've simply

conducted a biased experiment that would should be rejected (IMHO) as

serious science. The sample has to be drawn randomly, i.e. starting

people on this regiment independent of when their rosacea would be

expected to improve. This may well be what Dahl etal have done (I'm

not sure on this ...), and indeed the Noritate clinical study

(summarized very nicely in the little foldout you get with Noritate)

carries no indication that it followed the Wilkin approach.

Having, gotten this far, I will also pose the following gedanken

experiment. Suppose that, left to their own skin-care regimen, 10%

of rosaceans observe some improvement in their rosacea over the next

6 months. Now, select a sample from this group, and treat them with

photoderm (or whatever). Now, if 10% get better over the next 6

months, does this mean the treatment is effective? I mention this,

because it is my crude estimate from reading this forum for 2 years

that around 10% of people undegoing photoderm have noticed any

*significant* improvement. And this could, in principle, be what

physicists simply call a background effect: it could have happened in

the absence of the postulated theory.

Thanks as always for your informed comments - I don't read this forum

that often any more, but always check out your posts ...

Rick

> > Here is another, more recent 1999 editorial by Jonathon Wilkin.

It

> > discusses the use of topicals to maintain remission:

> >

> > http://archderm.ama-assn.org/issues/v135n1/fpdf/ded8021.pdf

> >

> > Again, the derm literature is a bit weird. Only here can someone

> > (Wilkin) totally trash someone else's study (in this case, Mark

> Dahl,

> > who, like Wilkin, is a prominent rosacea researcher an member of

> the

> > National cea Society advisory board) in an editorial (as

> opposed

> > to letter to the editor), with no opportunity for the criticized

> > party to respond.

>

> Rick, I had a different take on the article. In 1999 evidence-based

> medicine was making significant inroads, and from Wilkin's comments

> he doesn't sound like a believer in that approach. Dahl's study,

> published a year earlier, may well have been suggested as a model

for

> evidence-based protocol. (This was exactly the time when all of

> medicine was going protocol-happy. <g>)

>

> Wilkins feels that rosacean care needs to be more individualized

that

> treatment protocols allow. That's not dissing Dahl's study. Plus,

> it's an editorial, so Wilkin is free to voice his opinion. If he

> cared to, Dahl may respond in a Letter to the Editor to the

Archives

> of Dermatology journal, or by writing his own editorial. But I

don't

> see why he would, unless Dahl was a strong supporter of evidence-

> based medicine.

>

> To me, this is how physicians and/or researchers always talk to one

> another about each other's work. I'm not picking up any ad hominem

> comments, esp since Dahl's results support his own clinical

approach.

>

> > Second, note that Wilkin carefully inquires of his patients which

> > season is typically " best " for their rosacea (summer seems to be

> the

> > most popular choice), and then deliberately starts the remission

> > program to coincide with what would otherwise be the most benign

> > period for each patient. Assuming he followed this statitically

> > biased approach in his 1994 editorial (where he bragged about his

> > superior success rate in weaning patients off of systemic

> > anitbiotics

> > to topicals), it certainly raises questions about the conduct of

> > his studies (and his rather remarkable ego.)

>

> Oh, I didn't read it that way at all! It's good medical care to

taper

> medications when remission is most likely to take place, for the

> longest period of time. As long as he treated all patients the

same,

> I don't see the bias.

>

> I don't know anything about Wilkin or Dahl, so you may have the

> advantage there. But in my ignorance, I'm not reading any ego or

> bragging or dissing. To me Wilkin is communicating his clinical

> experiences in a straightforward manner, there's no reason to be

> modest if he's had success.

>

> Of course, if his results can't be verified by others, then his

> success remains his own. But it sounds like Dahl's study confirmed

> his own (prolonged remission in more patients with continuing

topical

> after course of oral antibiotics), as have subsequent studies.

>

> What am I missing? We usually agree more than this (although

> disagreeing can also be fun). <g>

>

> Marjorie

>

> Marjorie Lazoff, MD

[Guest guest]

Marjorie,

My only real point concerning the editorial policy here is that it is

somewhat different than other technical literature, where comments

such as those made by Wilkin about other work would have required

communication (and possible rebuttal) with the other author prior to

publication. But I understand and appreciate your comments about the

medical literature.

The slightly more substantive comment has to do with his assertion,

both here and in the 1994 article, that he has a higher rate of

remission maintenance than other published studies. This has nothing

to do with his " technique " , since all we're really talking about is

slapping on Metronidozale (sp?) and seeing if it retains remission

after a course of systemic antibiotics. Hence, statistics becomes an

essential part of the analysis. (BTW, I build predictive

mathematical models against very noisy data like internet purchase

behavior and stock-market tick data, so I'm a bit over-sensitive when

I see casual statements made in the medical literature about these

sorts of things ...).

Hence, my major issue is that if (as an extreme) you select a bunch

of rosaceans whose rosacea subsides (by itself) during the summer,

subject them to a clinical study, and then conclude that your

" technique " has retained remission for 3 months, you've simply

conducted a biased experiment that would should be rejected (IMHO) as

serious science. The sample has to be drawn randomly, i.e. starting

people on this regiment independent of when their rosacea would be

expected to improve. This may well be what Dahl etal have done (I'm

not sure on this ...), and indeed the Noritate clinical study

(summarized very nicely in the little foldout you get with Noritate)

carries no indication that it followed the Wilkin approach.

Having, gotten this far, I will also pose the following gedanken

experiment. Suppose that, left to their own skin-care regimen, 10%

of rosaceans observe some improvement in their rosacea over the next

6 months. Now, select a sample from this group, and treat them with

photoderm (or whatever). Now, if 10% get better over the next 6

months, does this mean the treatment is effective? I mention this,

because it is my crude estimate from reading this forum for 2 years

that around 10% of people undegoing photoderm have noticed any

*significant* improvement. And this could, in principle, be what

physicists simply call a background effect: it could have happened in

the absence of the postulated theory.

Thanks as always for your informed comments - I don't read this forum

that often any more, but always check out your posts ...

Rick

> > Here is another, more recent 1999 editorial by Jonathon Wilkin.

It

> > discusses the use of topicals to maintain remission:

> >

> > http://archderm.ama-assn.org/issues/v135n1/fpdf/ded8021.pdf

> >

> > Again, the derm literature is a bit weird. Only here can someone

> > (Wilkin) totally trash someone else's study (in this case, Mark

> Dahl,

> > who, like Wilkin, is a prominent rosacea researcher an member of

> the

> > National cea Society advisory board) in an editorial (as

> opposed

> > to letter to the editor), with no opportunity for the criticized

> > party to respond.

>

> Rick, I had a different take on the article. In 1999 evidence-based

> medicine was making significant inroads, and from Wilkin's comments

> he doesn't sound like a believer in that approach. Dahl's study,

> published a year earlier, may well have been suggested as a model

for

> evidence-based protocol. (This was exactly the time when all of

> medicine was going protocol-happy. <g>)

>

> Wilkins feels that rosacean care needs to be more individualized

that

> treatment protocols allow. That's not dissing Dahl's study. Plus,

> it's an editorial, so Wilkin is free to voice his opinion. If he

> cared to, Dahl may respond in a Letter to the Editor to the

Archives

> of Dermatology journal, or by writing his own editorial. But I

don't

> see why he would, unless Dahl was a strong supporter of evidence-

> based medicine.

>

> To me, this is how physicians and/or researchers always talk to one

> another about each other's work. I'm not picking up any ad hominem

> comments, esp since Dahl's results support his own clinical

approach.

>

> > Second, note that Wilkin carefully inquires of his patients which

> > season is typically " best " for their rosacea (summer seems to be

> the

> > most popular choice), and then deliberately starts the remission

> > program to coincide with what would otherwise be the most benign

> > period for each patient. Assuming he followed this statitically

> > biased approach in his 1994 editorial (where he bragged about his

> > superior success rate in weaning patients off of systemic

> > anitbiotics

> > to topicals), it certainly raises questions about the conduct of

> > his studies (and his rather remarkable ego.)

>

> Oh, I didn't read it that way at all! It's good medical care to

taper

> medications when remission is most likely to take place, for the

> longest period of time. As long as he treated all patients the

same,

> I don't see the bias.

>

> I don't know anything about Wilkin or Dahl, so you may have the

> advantage there. But in my ignorance, I'm not reading any ego or

> bragging or dissing. To me Wilkin is communicating his clinical

> experiences in a straightforward manner, there's no reason to be

> modest if he's had success.

>

> Of course, if his results can't be verified by others, then his

> success remains his own. But it sounds like Dahl's study confirmed

> his own (prolonged remission in more patients with continuing

topical

> after course of oral antibiotics), as have subsequent studies.

>

> What am I missing? We usually agree more than this (although

> disagreeing can also be fun). <g>

>

> Marjorie

>

> Marjorie Lazoff, MD

[Guest guest]

Marjorie,

My only real point concerning the editorial policy here is that it is

somewhat different than other technical literature, where comments

such as those made by Wilkin about other work would have required

communication (and possible rebuttal) with the other author prior to

publication. But I understand and appreciate your comments about the

medical literature.

The slightly more substantive comment has to do with his assertion,

both here and in the 1994 article, that he has a higher rate of

remission maintenance than other published studies. This has nothing

to do with his " technique " , since all we're really talking about is

slapping on Metronidozale (sp?) and seeing if it retains remission

after a course of systemic antibiotics. Hence, statistics becomes an

essential part of the analysis. (BTW, I build predictive

mathematical models against very noisy data like internet purchase

behavior and stock-market tick data, so I'm a bit over-sensitive when

I see casual statements made in the medical literature about these

sorts of things ...).

Hence, my major issue is that if (as an extreme) you select a bunch

of rosaceans whose rosacea subsides (by itself) during the summer,

subject them to a clinical study, and then conclude that your

" technique " has retained remission for 3 months, you've simply

conducted a biased experiment that would should be rejected (IMHO) as

serious science. The sample has to be drawn randomly, i.e. starting

people on this regiment independent of when their rosacea would be

expected to improve. This may well be what Dahl etal have done (I'm

not sure on this ...), and indeed the Noritate clinical study

(summarized very nicely in the little foldout you get with Noritate)

carries no indication that it followed the Wilkin approach.

Having, gotten this far, I will also pose the following gedanken

experiment. Suppose that, left to their own skin-care regimen, 10%

of rosaceans observe some improvement in their rosacea over the next

6 months. Now, select a sample from this group, and treat them with

photoderm (or whatever). Now, if 10% get better over the next 6

months, does this mean the treatment is effective? I mention this,

because it is my crude estimate from reading this forum for 2 years

that around 10% of people undegoing photoderm have noticed any

*significant* improvement. And this could, in principle, be what

physicists simply call a background effect: it could have happened in

the absence of the postulated theory.

Thanks as always for your informed comments - I don't read this forum

that often any more, but always check out your posts ...

Rick

> > Here is another, more recent 1999 editorial by Jonathon Wilkin.

It

> > discusses the use of topicals to maintain remission:

> >

> > http://archderm.ama-assn.org/issues/v135n1/fpdf/ded8021.pdf

> >

> > Again, the derm literature is a bit weird. Only here can someone

> > (Wilkin) totally trash someone else's study (in this case, Mark

> Dahl,

> > who, like Wilkin, is a prominent rosacea researcher an member of

> the

> > National cea Society advisory board) in an editorial (as

> opposed

> > to letter to the editor), with no opportunity for the criticized

> > party to respond.

>

> Rick, I had a different take on the article. In 1999 evidence-based

> medicine was making significant inroads, and from Wilkin's comments

> he doesn't sound like a believer in that approach. Dahl's study,

> published a year earlier, may well have been suggested as a model

for

> evidence-based protocol. (This was exactly the time when all of

> medicine was going protocol-happy. <g>)

>

> Wilkins feels that rosacean care needs to be more individualized

that

> treatment protocols allow. That's not dissing Dahl's study. Plus,

> it's an editorial, so Wilkin is free to voice his opinion. If he

> cared to, Dahl may respond in a Letter to the Editor to the

Archives

> of Dermatology journal, or by writing his own editorial. But I

don't

> see why he would, unless Dahl was a strong supporter of evidence-

> based medicine.

>

> To me, this is how physicians and/or researchers always talk to one

> another about each other's work. I'm not picking up any ad hominem

> comments, esp since Dahl's results support his own clinical

approach.

>

> > Second, note that Wilkin carefully inquires of his patients which

> > season is typically " best " for their rosacea (summer seems to be

> the

> > most popular choice), and then deliberately starts the remission

> > program to coincide with what would otherwise be the most benign

> > period for each patient. Assuming he followed this statitically

> > biased approach in his 1994 editorial (where he bragged about his

> > superior success rate in weaning patients off of systemic

> > anitbiotics

> > to topicals), it certainly raises questions about the conduct of

> > his studies (and his rather remarkable ego.)

>

> Oh, I didn't read it that way at all! It's good medical care to

taper

> medications when remission is most likely to take place, for the

> longest period of time. As long as he treated all patients the

same,

> I don't see the bias.

>

> I don't know anything about Wilkin or Dahl, so you may have the

> advantage there. But in my ignorance, I'm not reading any ego or

> bragging or dissing. To me Wilkin is communicating his clinical

> experiences in a straightforward manner, there's no reason to be

> modest if he's had success.

>

> Of course, if his results can't be verified by others, then his

> success remains his own. But it sounds like Dahl's study confirmed

> his own (prolonged remission in more patients with continuing

topical

> after course of oral antibiotics), as have subsequent studies.

>

> What am I missing? We usually agree more than this (although

> disagreeing can also be fun). <g>

>

> Marjorie

>

> Marjorie Lazoff, MD

[Guest guest]

Marjorie,

My only real point concerning the editorial policy here is that it is

somewhat different than other technical literature, where comments

such as those made by Wilkin about other work would have required

communication (and possible rebuttal) with the other author prior to

publication. But I understand and appreciate your comments about the

medical literature.

The slightly more substantive comment has to do with his assertion,

both here and in the 1994 article, that he has a higher rate of

remission maintenance than other published studies. This has nothing

to do with his " technique " , since all we're really talking about is

slapping on Metronidozale (sp?) and seeing if it retains remission

after a course of systemic antibiotics. Hence, statistics becomes an

essential part of the analysis. (BTW, I build predictive

mathematical models against very noisy data like internet purchase

behavior and stock-market tick data, so I'm a bit over-sensitive when

I see casual statements made in the medical literature about these

sorts of things ...).

Hence, my major issue is that if (as an extreme) you select a bunch

of rosaceans whose rosacea subsides (by itself) during the summer,

subject them to a clinical study, and then conclude that your

" technique " has retained remission for 3 months, you've simply

conducted a biased experiment that would should be rejected (IMHO) as

serious science. The sample has to be drawn randomly, i.e. starting

people on this regiment independent of when their rosacea would be

expected to improve. This may well be what Dahl etal have done (I'm

not sure on this ...), and indeed the Noritate clinical study

(summarized very nicely in the little foldout you get with Noritate)

carries no indication that it followed the Wilkin approach.

Having, gotten this far, I will also pose the following gedanken

experiment. Suppose that, left to their own skin-care regimen, 10%

of rosaceans observe some improvement in their rosacea over the next

6 months. Now, select a sample from this group, and treat them with

photoderm (or whatever). Now, if 10% get better over the next 6

months, does this mean the treatment is effective? I mention this,

because it is my crude estimate from reading this forum for 2 years

that around 10% of people undegoing photoderm have noticed any

*significant* improvement. And this could, in principle, be what

physicists simply call a background effect: it could have happened in

the absence of the postulated theory.

Thanks as always for your informed comments - I don't read this forum

that often any more, but always check out your posts ...

Rick

> > Here is another, more recent 1999 editorial by Jonathon Wilkin.

It

> > discusses the use of topicals to maintain remission:

> >

> > http://archderm.ama-assn.org/issues/v135n1/fpdf/ded8021.pdf

> >

> > Again, the derm literature is a bit weird. Only here can someone

> > (Wilkin) totally trash someone else's study (in this case, Mark

> Dahl,

> > who, like Wilkin, is a prominent rosacea researcher an member of

> the

> > National cea Society advisory board) in an editorial (as

> opposed

> > to letter to the editor), with no opportunity for the criticized

> > party to respond.

>

> Rick, I had a different take on the article. In 1999 evidence-based

> medicine was making significant inroads, and from Wilkin's comments

> he doesn't sound like a believer in that approach. Dahl's study,

> published a year earlier, may well have been suggested as a model

for

> evidence-based protocol. (This was exactly the time when all of

> medicine was going protocol-happy. <g>)

>

> Wilkins feels that rosacean care needs to be more individualized

that

> treatment protocols allow. That's not dissing Dahl's study. Plus,

> it's an editorial, so Wilkin is free to voice his opinion. If he

> cared to, Dahl may respond in a Letter to the Editor to the

Archives

> of Dermatology journal, or by writing his own editorial. But I

don't

> see why he would, unless Dahl was a strong supporter of evidence-

> based medicine.

>

> To me, this is how physicians and/or researchers always talk to one

> another about each other's work. I'm not picking up any ad hominem

> comments, esp since Dahl's results support his own clinical

approach.

>

> > Second, note that Wilkin carefully inquires of his patients which

> > season is typically " best " for their rosacea (summer seems to be

> the

> > most popular choice), and then deliberately starts the remission

> > program to coincide with what would otherwise be the most benign

> > period for each patient. Assuming he followed this statitically

> > biased approach in his 1994 editorial (where he bragged about his

> > superior success rate in weaning patients off of systemic

> > anitbiotics

> > to topicals), it certainly raises questions about the conduct of

> > his studies (and his rather remarkable ego.)

>

> Oh, I didn't read it that way at all! It's good medical care to

taper

> medications when remission is most likely to take place, for the

> longest period of time. As long as he treated all patients the

same,

> I don't see the bias.

>

> I don't know anything about Wilkin or Dahl, so you may have the

> advantage there. But in my ignorance, I'm not reading any ego or

> bragging or dissing. To me Wilkin is communicating his clinical

> experiences in a straightforward manner, there's no reason to be

> modest if he's had success.

>

> Of course, if his results can't be verified by others, then his

> success remains his own. But it sounds like Dahl's study confirmed

> his own (prolonged remission in more patients with continuing

topical

> after course of oral antibiotics), as have subsequent studies.

>

> What am I missing? We usually agree more than this (although

> disagreeing can also be fun). <g>

>

> Marjorie

>

> Marjorie Lazoff, MD

[Guest guest]

> My only real point concerning the editorial policy here is that it

is

> somewhat different than other technical literature, where comments

> such as those made by Wilkin about other work would have required

> communication (and possible rebuttal) with the other author prior

> to publication. But I understand and appreciate your comments

> about the medical literature.

That is the policy in medical literature too, Rick, but in reverse:

when someone critiques an already published study (or editorial), it

is published in the Letters or Correspondence section and the

original author is invited to publicly reply.

Rather than do the same with original contributions, the better

medical journals pride themselves on the peer review process --

experts in the field without bias to any agenda read the original

study or article and reveal or eliminate biases before it gets

publication. Original contributions are to contribute objective data

to the medical community, not subjective opinion.

Obviously editorials and other think pieces aren't subjected to peer

review, but traditionally these are reserved for leaders or experts

in various fields and aren't used to bash anyone. Again, I just don't

see where Wilkin is bashing Dahl at all, quite the contrary, but more

on that below.

All that's the ideal, anyway. <g>

> The slightly more substantive comment has to do with his assertion,

> both here and in the 1994 article, that he has a higher rate of

> remission maintenance than other published studies. This has

> nothing to do with his " technique " , since all we're really talking

> about is slapping on Metronidozale (sp?) and seeing if it retains

> remission after a course of systemic antibiotics. Hence,

> statistics becomes an essential part of the analysis. (BTW, I

build predictive

> mathematical models against very noisy data like internet purchase

> behavior and stock-market tick data, so I'm a bit over-sensitive

when

> I see casual statements made in the medical literature about these

> sorts of things ...).

>

> Hence, my major issue is that if (as an extreme) you select a bunch

> of rosaceans whose rosacea subsides (by itself) during the summer,

> subject them to a clinical study, and then conclude that your

> " technique " has retained remission for 3 months, you've simply

> conducted a biased experiment that would should be rejected (IMHO)

> as serious science. The sample has to be drawn randomly, i.e.

> starting

> people on this regiment independent of when their rosacea would be

> expected to improve. This may well be what Dahl etal have done

(I'm

> not sure on this ...), and indeed the Noritate clinical study

> (summarized very nicely in the little foldout you get with

Noritate)

> carries no indication that it followed the Wilkin approach.

I agree with you completely regarding the necessary rigors of

statistics.

Here's where I think our differences lie: I don't interprete Wilkin's

private practice results as a personal achievement over Dahl's study

results (and I don't believe he does either). Instead, I read this as

Wilkin's declaration against evidence-based medicine. Wilkin is

taking the side that individual nuisances in patient presentation and

physician care account for *significant* improvement in results

beyond the results promised by the aggregated data in studies.

Advocates of evidence based-medicine would agree, esp those who

adhere closely to Cochrane, EBM's founder. But the majority in the

late 1990s were paying only lip-service to the private practitioner,

concentrating instead on data collection and dissemination based on

well-controlled studies, and the creation of practice guidelines

based on this data. Wilkin's is right: individualized attention to

the patient by an individual physician is characteristic of patient

care, the hallmark of the healing arts in tangible and intangible

ways that cannot be measured by the group averages and tendencies

characteristic of clinical trials.

Wilkin lists some of the nuisances he has identified for rosacea care

in bullet form, if I recall. One of them is individualizing a

patient's tapering schedule according to their particular

manifestion, for example, what season they are least likely to

exacerbate. Another bullet, I recall, involved attention to ocular

rosacea not just skin features, unlike Dahl's study.

So I hear Wilkin's implicit argument in this editorial as follows:

like Dahl's, even the best designed and conducted studies --the

database of evidence-based medicine -- will underestimate a patient's

likely response when cared for as an individual by a skilled

practitioner -- not just for his patients, but all patients.

> Having, gotten this far, I will also pose the following gedanken

> experiment. Suppose that, left to their own skin-care regimen, 10%

> of rosaceans observe some improvement in their rosacea over the next

> 6 months. Now, select a sample from this group, and treat them

with

> photoderm (or whatever). Now, if 10% get better over the next 6

> months, does this mean the treatment is effective? I mention this,

> because it is my crude estimate from reading this forum for 2 years

> that around 10% of people undegoing photoderm have noticed any

> *significant* improvement. And this could, in principle, be what

> physicists simply call a background effect: it could have happened

in

> the absence of the postulated theory.

This sounds to me like a placebo-controlled research, in which case I

agree with you. Placebo-control is essential in studying conditions

characterized by exacerbations and remissions such as rosacea.

What strikes me about the laser therapy posts I've read here is the

variety of results from what sounds like very reasonable, educated

people. Some clearly believe they have improved because of

phototherapy, others who are as certain that phototherapy has made

their condition worse, and a third group believing that phototherapy

hasn't significantly changed their condition one way or the other.

I don't see any pattern, so it's hard for me to either advocate

photoderm or reject it out of hand. I suspect it needs technological

advancement, and more and better studies conducted by independent

researchers following a placebo-controlled, double-blinded, random

and multi-centered design.

> Thanks as always for your informed comments - I don't read this

> forum that often any more, but always check out your posts ...

Thanks for the kind words. I hope you'll post more often, I very much

enjoy discussions like this.

Marjorie

Marjorie Lazoff, MD

>

> > > Here is another, more recent 1999 editorial by Jonathon

Wilkin.

> It

> > > discusses the use of topicals to maintain remission:

> > >

> > > http://archderm.ama-assn.org/issues/v135n1/fpdf/ded8021.pdf

> > >

> > > Again, the derm literature is a bit weird. Only here can

someone

> > > (Wilkin) totally trash someone else's study (in this case, Mark

> > Dahl,

> > > who, like Wilkin, is a prominent rosacea researcher an member

of

> > the

> > > National cea Society advisory board) in an editorial (as

> > opposed

> > > to letter to the editor), with no opportunity for the

criticized

> > > party to respond.

> >

> > Rick, I had a different take on the article. In 1999 evidence-

based

> > medicine was making significant inroads, and from Wilkin's

comments

> > he doesn't sound like a believer in that approach. Dahl's study,

> > published a year earlier, may well have been suggested as a model

> for

> > evidence-based protocol. (This was exactly the time when all of

> > medicine was going protocol-happy. <g>)

> >

> > Wilkins feels that rosacean care needs to be more individualized

> that

> > treatment protocols allow. That's not dissing Dahl's study. Plus,

> > it's an editorial, so Wilkin is free to voice his opinion. If he

> > cared to, Dahl may respond in a Letter to the Editor to the

> Archives

> > of Dermatology journal, or by writing his own editorial. But I

> don't

> > see why he would, unless Dahl was a strong supporter of evidence-

> > based medicine.

> >

> > To me, this is how physicians and/or researchers always talk to

one

> > another about each other's work. I'm not picking up any ad

hominem

> > comments, esp since Dahl's results support his own clinical

> approach.

> >

> > > Second, note that Wilkin carefully inquires of his patients

which

> > > season is typically " best " for their rosacea (summer seems to

be

> > the

> > > most popular choice), and then deliberately starts the

remission

> > > program to coincide with what would otherwise be the most

benign

> > > period for each patient. Assuming he followed this

statitically

> > > biased approach in his 1994 editorial (where he bragged about

his

> > > superior success rate in weaning patients off of systemic

> > > anitbiotics

> > > to topicals), it certainly raises questions about the conduct

of

> > > his studies (and his rather remarkable ego.)

> >

> > Oh, I didn't read it that way at all! It's good medical care to

> taper

> > medications when remission is most likely to take place, for the

> > longest period of time. As long as he treated all patients the

> same,

> > I don't see the bias.

> >

> > I don't know anything about Wilkin or Dahl, so you may have the

> > advantage there. But in my ignorance, I'm not reading any ego or

> > bragging or dissing. To me Wilkin is communicating his clinical

> > experiences in a straightforward manner, there's no reason to be

> > modest if he's had success.

> >

> > Of course, if his results can't be verified by others, then his

> > success remains his own. But it sounds like Dahl's study

confirmed

> > his own (prolonged remission in more patients with continuing

> topical

> > after course of oral antibiotics), as have subsequent studies.

> >

> > What am I missing? We usually agree more than this (although

> > disagreeing can also be fun). <g>

> >

> > Marjorie

> >

> > Marjorie Lazoff, MD

[Guest guest]

> My only real point concerning the editorial policy here is that it

is

> somewhat different than other technical literature, where comments

> such as those made by Wilkin about other work would have required

> communication (and possible rebuttal) with the other author prior

> to publication. But I understand and appreciate your comments

> about the medical literature.

That is the policy in medical literature too, Rick, but in reverse:

when someone critiques an already published study (or editorial), it

is published in the Letters or Correspondence section and the

original author is invited to publicly reply.

Rather than do the same with original contributions, the better

medical journals pride themselves on the peer review process --

experts in the field without bias to any agenda read the original

study or article and reveal or eliminate biases before it gets

publication. Original contributions are to contribute objective data

to the medical community, not subjective opinion.

Obviously editorials and other think pieces aren't subjected to peer

review, but traditionally these are reserved for leaders or experts

in various fields and aren't used to bash anyone. Again, I just don't

see where Wilkin is bashing Dahl at all, quite the contrary, but more

on that below.

All that's the ideal, anyway. <g>

> The slightly more substantive comment has to do with his assertion,

> both here and in the 1994 article, that he has a higher rate of

> remission maintenance than other published studies. This has

> nothing to do with his " technique " , since all we're really talking

> about is slapping on Metronidozale (sp?) and seeing if it retains

> remission after a course of systemic antibiotics. Hence,

> statistics becomes an essential part of the analysis. (BTW, I

build predictive

> mathematical models against very noisy data like internet purchase

> behavior and stock-market tick data, so I'm a bit over-sensitive

when

> I see casual statements made in the medical literature about these

> sorts of things ...).

>

> Hence, my major issue is that if (as an extreme) you select a bunch

> of rosaceans whose rosacea subsides (by itself) during the summer,

> subject them to a clinical study, and then conclude that your

> " technique " has retained remission for 3 months, you've simply

> conducted a biased experiment that would should be rejected (IMHO)

> as serious science. The sample has to be drawn randomly, i.e.

> starting

> people on this regiment independent of when their rosacea would be

> expected to improve. This may well be what Dahl etal have done

(I'm

> not sure on this ...), and indeed the Noritate clinical study

> (summarized very nicely in the little foldout you get with

Noritate)

> carries no indication that it followed the Wilkin approach.

I agree with you completely regarding the necessary rigors of

statistics.

Here's where I think our differences lie: I don't interprete Wilkin's

private practice results as a personal achievement over Dahl's study

results (and I don't believe he does either). Instead, I read this as

Wilkin's declaration against evidence-based medicine. Wilkin is

taking the side that individual nuisances in patient presentation and

physician care account for *significant* improvement in results

beyond the results promised by the aggregated data in studies.

Advocates of evidence based-medicine would agree, esp those who

adhere closely to Cochrane, EBM's founder. But the majority in the

late 1990s were paying only lip-service to the private practitioner,

concentrating instead on data collection and dissemination based on

well-controlled studies, and the creation of practice guidelines

based on this data. Wilkin's is right: individualized attention to

the patient by an individual physician is characteristic of patient

care, the hallmark of the healing arts in tangible and intangible

ways that cannot be measured by the group averages and tendencies

characteristic of clinical trials.

Wilkin lists some of the nuisances he has identified for rosacea care

in bullet form, if I recall. One of them is individualizing a

patient's tapering schedule according to their particular

manifestion, for example, what season they are least likely to

exacerbate. Another bullet, I recall, involved attention to ocular

rosacea not just skin features, unlike Dahl's study.

So I hear Wilkin's implicit argument in this editorial as follows:

like Dahl's, even the best designed and conducted studies --the

database of evidence-based medicine -- will underestimate a patient's

likely response when cared for as an individual by a skilled

practitioner -- not just for his patients, but all patients.

> Having, gotten this far, I will also pose the following gedanken

> experiment. Suppose that, left to their own skin-care regimen, 10%

> of rosaceans observe some improvement in their rosacea over the next

> 6 months. Now, select a sample from this group, and treat them

with

> photoderm (or whatever). Now, if 10% get better over the next 6

> months, does this mean the treatment is effective? I mention this,

> because it is my crude estimate from reading this forum for 2 years

> that around 10% of people undegoing photoderm have noticed any

> *significant* improvement. And this could, in principle, be what

> physicists simply call a background effect: it could have happened

in

> the absence of the postulated theory.

This sounds to me like a placebo-controlled research, in which case I

agree with you. Placebo-control is essential in studying conditions

characterized by exacerbations and remissions such as rosacea.

What strikes me about the laser therapy posts I've read here is the

variety of results from what sounds like very reasonable, educated

people. Some clearly believe they have improved because of

phototherapy, others who are as certain that phototherapy has made

their condition worse, and a third group believing that phototherapy

hasn't significantly changed their condition one way or the other.

I don't see any pattern, so it's hard for me to either advocate

photoderm or reject it out of hand. I suspect it needs technological

advancement, and more and better studies conducted by independent

researchers following a placebo-controlled, double-blinded, random

and multi-centered design.

> Thanks as always for your informed comments - I don't read this

> forum that often any more, but always check out your posts ...

Thanks for the kind words. I hope you'll post more often, I very much

enjoy discussions like this.

Marjorie

Marjorie Lazoff, MD

>

> > > Here is another, more recent 1999 editorial by Jonathon

Wilkin.

> It

> > > discusses the use of topicals to maintain remission:

> > >

> > > http://archderm.ama-assn.org/issues/v135n1/fpdf/ded8021.pdf

> > >

> > > Again, the derm literature is a bit weird. Only here can

someone

> > > (Wilkin) totally trash someone else's study (in this case, Mark

> > Dahl,

> > > who, like Wilkin, is a prominent rosacea researcher an member

of

> > the

> > > National cea Society advisory board) in an editorial (as

> > opposed

> > > to letter to the editor), with no opportunity for the

criticized

> > > party to respond.

> >

> > Rick, I had a different take on the article. In 1999 evidence-

based

> > medicine was making significant inroads, and from Wilkin's

comments

> > he doesn't sound like a believer in that approach. Dahl's study,

> > published a year earlier, may well have been suggested as a model

> for

> > evidence-based protocol. (This was exactly the time when all of

> > medicine was going protocol-happy. <g>)

> >

> > Wilkins feels that rosacean care needs to be more individualized

> that

> > treatment protocols allow. That's not dissing Dahl's study. Plus,

> > it's an editorial, so Wilkin is free to voice his opinion. If he

> > cared to, Dahl may respond in a Letter to the Editor to the

> Archives

> > of Dermatology journal, or by writing his own editorial. But I

> don't

> > see why he would, unless Dahl was a strong supporter of evidence-

> > based medicine.

> >

> > To me, this is how physicians and/or researchers always talk to

one

> > another about each other's work. I'm not picking up any ad

hominem

> > comments, esp since Dahl's results support his own clinical

> approach.

> >

> > > Second, note that Wilkin carefully inquires of his patients

which

> > > season is typically " best " for their rosacea (summer seems to

be

> > the

> > > most popular choice), and then deliberately starts the

remission

> > > program to coincide with what would otherwise be the most

benign

> > > period for each patient. Assuming he followed this

statitically

> > > biased approach in his 1994 editorial (where he bragged about

his

> > > superior success rate in weaning patients off of systemic

> > > anitbiotics

> > > to topicals), it certainly raises questions about the conduct

of

> > > his studies (and his rather remarkable ego.)

> >

> > Oh, I didn't read it that way at all! It's good medical care to

> taper

> > medications when remission is most likely to take place, for the

> > longest period of time. As long as he treated all patients the

> same,

> > I don't see the bias.

> >

> > I don't know anything about Wilkin or Dahl, so you may have the

> > advantage there. But in my ignorance, I'm not reading any ego or

> > bragging or dissing. To me Wilkin is communicating his clinical

> > experiences in a straightforward manner, there's no reason to be

> > modest if he's had success.

> >

> > Of course, if his results can't be verified by others, then his

> > success remains his own. But it sounds like Dahl's study

confirmed

> > his own (prolonged remission in more patients with continuing

> topical

> > after course of oral antibiotics), as have subsequent studies.

> >

> > What am I missing? We usually agree more than this (although

> > disagreeing can also be fun). <g>

> >

> > Marjorie

> >

> > Marjorie Lazoff, MD

[Guest guest]

> My only real point concerning the editorial policy here is that it

is

> somewhat different than other technical literature, where comments

> such as those made by Wilkin about other work would have required

> communication (and possible rebuttal) with the other author prior

> to publication. But I understand and appreciate your comments

> about the medical literature.

That is the policy in medical literature too, Rick, but in reverse:

when someone critiques an already published study (or editorial), it

is published in the Letters or Correspondence section and the

original author is invited to publicly reply.

Rather than do the same with original contributions, the better

medical journals pride themselves on the peer review process --

experts in the field without bias to any agenda read the original

study or article and reveal or eliminate biases before it gets

publication. Original contributions are to contribute objective data

to the medical community, not subjective opinion.

Obviously editorials and other think pieces aren't subjected to peer

review, but traditionally these are reserved for leaders or experts

in various fields and aren't used to bash anyone. Again, I just don't

see where Wilkin is bashing Dahl at all, quite the contrary, but more

on that below.

All that's the ideal, anyway. <g>

> The slightly more substantive comment has to do with his assertion,

> both here and in the 1994 article, that he has a higher rate of

> remission maintenance than other published studies. This has

> nothing to do with his " technique " , since all we're really talking

> about is slapping on Metronidozale (sp?) and seeing if it retains

> remission after a course of systemic antibiotics. Hence,

> statistics becomes an essential part of the analysis. (BTW, I

build predictive

> mathematical models against very noisy data like internet purchase

> behavior and stock-market tick data, so I'm a bit over-sensitive

when

> I see casual statements made in the medical literature about these

> sorts of things ...).

>

> Hence, my major issue is that if (as an extreme) you select a bunch

> of rosaceans whose rosacea subsides (by itself) during the summer,

> subject them to a clinical study, and then conclude that your

> " technique " has retained remission for 3 months, you've simply

> conducted a biased experiment that would should be rejected (IMHO)

> as serious science. The sample has to be drawn randomly, i.e.

> starting

> people on this regiment independent of when their rosacea would be

> expected to improve. This may well be what Dahl etal have done

(I'm

> not sure on this ...), and indeed the Noritate clinical study

> (summarized very nicely in the little foldout you get with

Noritate)

> carries no indication that it followed the Wilkin approach.

I agree with you completely regarding the necessary rigors of

statistics.

Here's where I think our differences lie: I don't interprete Wilkin's

private practice results as a personal achievement over Dahl's study

results (and I don't believe he does either). Instead, I read this as

Wilkin's declaration against evidence-based medicine. Wilkin is

taking the side that individual nuisances in patient presentation and

physician care account for *significant* improvement in results

beyond the results promised by the aggregated data in studies.

Advocates of evidence based-medicine would agree, esp those who

adhere closely to Cochrane, EBM's founder. But the majority in the

late 1990s were paying only lip-service to the private practitioner,

concentrating instead on data collection and dissemination based on

well-controlled studies, and the creation of practice guidelines

based on this data. Wilkin's is right: individualized attention to

the patient by an individual physician is characteristic of patient

care, the hallmark of the healing arts in tangible and intangible

ways that cannot be measured by the group averages and tendencies

characteristic of clinical trials.

Wilkin lists some of the nuisances he has identified for rosacea care

in bullet form, if I recall. One of them is individualizing a

patient's tapering schedule according to their particular

manifestion, for example, what season they are least likely to

exacerbate. Another bullet, I recall, involved attention to ocular

rosacea not just skin features, unlike Dahl's study.

So I hear Wilkin's implicit argument in this editorial as follows:

like Dahl's, even the best designed and conducted studies --the

database of evidence-based medicine -- will underestimate a patient's

likely response when cared for as an individual by a skilled

practitioner -- not just for his patients, but all patients.

> Having, gotten this far, I will also pose the following gedanken

> experiment. Suppose that, left to their own skin-care regimen, 10%

> of rosaceans observe some improvement in their rosacea over the next

> 6 months. Now, select a sample from this group, and treat them

with

> photoderm (or whatever). Now, if 10% get better over the next 6

> months, does this mean the treatment is effective? I mention this,

> because it is my crude estimate from reading this forum for 2 years

> that around 10% of people undegoing photoderm have noticed any

> *significant* improvement. And this could, in principle, be what

> physicists simply call a background effect: it could have happened

in

> the absence of the postulated theory.

This sounds to me like a placebo-controlled research, in which case I

agree with you. Placebo-control is essential in studying conditions

characterized by exacerbations and remissions such as rosacea.

What strikes me about the laser therapy posts I've read here is the

variety of results from what sounds like very reasonable, educated

people. Some clearly believe they have improved because of

phototherapy, others who are as certain that phototherapy has made

their condition worse, and a third group believing that phototherapy

hasn't significantly changed their condition one way or the other.

I don't see any pattern, so it's hard for me to either advocate

photoderm or reject it out of hand. I suspect it needs technological

advancement, and more and better studies conducted by independent

researchers following a placebo-controlled, double-blinded, random

and multi-centered design.

> Thanks as always for your informed comments - I don't read this

> forum that often any more, but always check out your posts ...

Thanks for the kind words. I hope you'll post more often, I very much

enjoy discussions like this.

Marjorie

Marjorie Lazoff, MD

>

> > > Here is another, more recent 1999 editorial by Jonathon

Wilkin.

> It

> > > discusses the use of topicals to maintain remission:

> > >

> > > http://archderm.ama-assn.org/issues/v135n1/fpdf/ded8021.pdf

> > >

> > > Again, the derm literature is a bit weird. Only here can

someone

> > > (Wilkin) totally trash someone else's study (in this case, Mark

> > Dahl,

> > > who, like Wilkin, is a prominent rosacea researcher an member

of

> > the

> > > National cea Society advisory board) in an editorial (as

> > opposed

> > > to letter to the editor), with no opportunity for the

criticized

> > > party to respond.

> >

> > Rick, I had a different take on the article. In 1999 evidence-

based

> > medicine was making significant inroads, and from Wilkin's

comments

> > he doesn't sound like a believer in that approach. Dahl's study,

> > published a year earlier, may well have been suggested as a model

> for

> > evidence-based protocol. (This was exactly the time when all of

> > medicine was going protocol-happy. <g>)

> >

> > Wilkins feels that rosacean care needs to be more individualized

> that

> > treatment protocols allow. That's not dissing Dahl's study. Plus,

> > it's an editorial, so Wilkin is free to voice his opinion. If he

> > cared to, Dahl may respond in a Letter to the Editor to the

> Archives

> > of Dermatology journal, or by writing his own editorial. But I

> don't

> > see why he would, unless Dahl was a strong supporter of evidence-

> > based medicine.

> >

> > To me, this is how physicians and/or researchers always talk to

one

> > another about each other's work. I'm not picking up any ad

hominem

> > comments, esp since Dahl's results support his own clinical

> approach.

> >

> > > Second, note that Wilkin carefully inquires of his patients

which

> > > season is typically " best " for their rosacea (summer seems to

be

> > the

> > > most popular choice), and then deliberately starts the

remission

> > > program to coincide with what would otherwise be the most

benign

> > > period for each patient. Assuming he followed this

statitically

> > > biased approach in his 1994 editorial (where he bragged about

his

> > > superior success rate in weaning patients off of systemic

> > > anitbiotics

> > > to topicals), it certainly raises questions about the conduct

of

> > > his studies (and his rather remarkable ego.)

> >

> > Oh, I didn't read it that way at all! It's good medical care to

> taper

> > medications when remission is most likely to take place, for the

> > longest period of time. As long as he treated all patients the

> same,

> > I don't see the bias.

> >

> > I don't know anything about Wilkin or Dahl, so you may have the

> > advantage there. But in my ignorance, I'm not reading any ego or

> > bragging or dissing. To me Wilkin is communicating his clinical

> > experiences in a straightforward manner, there's no reason to be

> > modest if he's had success.

> >

> > Of course, if his results can't be verified by others, then his

> > success remains his own. But it sounds like Dahl's study

confirmed

> > his own (prolonged remission in more patients with continuing

> topical

> > after course of oral antibiotics), as have subsequent studies.

> >

> > What am I missing? We usually agree more than this (although

> > disagreeing can also be fun). <g>

> >

> > Marjorie

> >

> > Marjorie Lazoff, MD

[Guest guest]

> My only real point concerning the editorial policy here is that it

is

> somewhat different than other technical literature, where comments

> such as those made by Wilkin about other work would have required

> communication (and possible rebuttal) with the other author prior

> to publication. But I understand and appreciate your comments

> about the medical literature.

That is the policy in medical literature too, Rick, but in reverse:

when someone critiques an already published study (or editorial), it

is published in the Letters or Correspondence section and the

original author is invited to publicly reply.

Rather than do the same with original contributions, the better

medical journals pride themselves on the peer review process --

experts in the field without bias to any agenda read the original

study or article and reveal or eliminate biases before it gets

publication. Original contributions are to contribute objective data

to the medical community, not subjective opinion.

Obviously editorials and other think pieces aren't subjected to peer

review, but traditionally these are reserved for leaders or experts

in various fields and aren't used to bash anyone. Again, I just don't

see where Wilkin is bashing Dahl at all, quite the contrary, but more

on that below.

All that's the ideal, anyway. <g>

> The slightly more substantive comment has to do with his assertion,

> both here and in the 1994 article, that he has a higher rate of

> remission maintenance than other published studies. This has

> nothing to do with his " technique " , since all we're really talking

> about is slapping on Metronidozale (sp?) and seeing if it retains

> remission after a course of systemic antibiotics. Hence,

> statistics becomes an essential part of the analysis. (BTW, I

build predictive

> mathematical models against very noisy data like internet purchase

> behavior and stock-market tick data, so I'm a bit over-sensitive

when

> I see casual statements made in the medical literature about these

> sorts of things ...).

>

> Hence, my major issue is that if (as an extreme) you select a bunch

> of rosaceans whose rosacea subsides (by itself) during the summer,

> subject them to a clinical study, and then conclude that your

> " technique " has retained remission for 3 months, you've simply

> conducted a biased experiment that would should be rejected (IMHO)

> as serious science. The sample has to be drawn randomly, i.e.

> starting

> people on this regiment independent of when their rosacea would be

> expected to improve. This may well be what Dahl etal have done

(I'm

> not sure on this ...), and indeed the Noritate clinical study

> (summarized very nicely in the little foldout you get with

Noritate)

> carries no indication that it followed the Wilkin approach.

I agree with you completely regarding the necessary rigors of

statistics.

Here's where I think our differences lie: I don't interprete Wilkin's

private practice results as a personal achievement over Dahl's study

results (and I don't believe he does either). Instead, I read this as

Wilkin's declaration against evidence-based medicine. Wilkin is

taking the side that individual nuisances in patient presentation and

physician care account for *significant* improvement in results

beyond the results promised by the aggregated data in studies.

Advocates of evidence based-medicine would agree, esp those who

adhere closely to Cochrane, EBM's founder. But the majority in the

late 1990s were paying only lip-service to the private practitioner,

concentrating instead on data collection and dissemination based on

well-controlled studies, and the creation of practice guidelines

based on this data. Wilkin's is right: individualized attention to

the patient by an individual physician is characteristic of patient

care, the hallmark of the healing arts in tangible and intangible

ways that cannot be measured by the group averages and tendencies

characteristic of clinical trials.

Wilkin lists some of the nuisances he has identified for rosacea care

in bullet form, if I recall. One of them is individualizing a

patient's tapering schedule according to their particular

manifestion, for example, what season they are least likely to

exacerbate. Another bullet, I recall, involved attention to ocular

rosacea not just skin features, unlike Dahl's study.

So I hear Wilkin's implicit argument in this editorial as follows:

like Dahl's, even the best designed and conducted studies --the

database of evidence-based medicine -- will underestimate a patient's

likely response when cared for as an individual by a skilled

practitioner -- not just for his patients, but all patients.

> Having, gotten this far, I will also pose the following gedanken

> experiment. Suppose that, left to their own skin-care regimen, 10%

> of rosaceans observe some improvement in their rosacea over the next

> 6 months. Now, select a sample from this group, and treat them

with

> photoderm (or whatever). Now, if 10% get better over the next 6

> months, does this mean the treatment is effective? I mention this,

> because it is my crude estimate from reading this forum for 2 years

> that around 10% of people undegoing photoderm have noticed any

> *significant* improvement. And this could, in principle, be what

> physicists simply call a background effect: it could have happened

in

> the absence of the postulated theory.

This sounds to me like a placebo-controlled research, in which case I

agree with you. Placebo-control is essential in studying conditions

characterized by exacerbations and remissions such as rosacea.

What strikes me about the laser therapy posts I've read here is the

variety of results from what sounds like very reasonable, educated

people. Some clearly believe they have improved because of

phototherapy, others who are as certain that phototherapy has made

their condition worse, and a third group believing that phototherapy

hasn't significantly changed their condition one way or the other.

I don't see any pattern, so it's hard for me to either advocate

photoderm or reject it out of hand. I suspect it needs technological

advancement, and more and better studies conducted by independent

researchers following a placebo-controlled, double-blinded, random

and multi-centered design.

> Thanks as always for your informed comments - I don't read this

> forum that often any more, but always check out your posts ...

Thanks for the kind words. I hope you'll post more often, I very much

enjoy discussions like this.

Marjorie

Marjorie Lazoff, MD

>

> > > Here is another, more recent 1999 editorial by Jonathon

Wilkin.

> It

> > > discusses the use of topicals to maintain remission:

> > >

> > > http://archderm.ama-assn.org/issues/v135n1/fpdf/ded8021.pdf

> > >

> > > Again, the derm literature is a bit weird. Only here can

someone

> > > (Wilkin) totally trash someone else's study (in this case, Mark

> > Dahl,

> > > who, like Wilkin, is a prominent rosacea researcher an member

of

> > the

> > > National cea Society advisory board) in an editorial (as

> > opposed

> > > to letter to the editor), with no opportunity for the

criticized

> > > party to respond.

> >

> > Rick, I had a different take on the article. In 1999 evidence-

based

> > medicine was making significant inroads, and from Wilkin's

comments

> > he doesn't sound like a believer in that approach. Dahl's study,

> > published a year earlier, may well have been suggested as a model

> for

> > evidence-based protocol. (This was exactly the time when all of

> > medicine was going protocol-happy. <g>)

> >

> > Wilkins feels that rosacean care needs to be more individualized

> that

> > treatment protocols allow. That's not dissing Dahl's study. Plus,

> > it's an editorial, so Wilkin is free to voice his opinion. If he

> > cared to, Dahl may respond in a Letter to the Editor to the

> Archives

> > of Dermatology journal, or by writing his own editorial. But I

> don't

> > see why he would, unless Dahl was a strong supporter of evidence-

> > based medicine.

> >

> > To me, this is how physicians and/or researchers always talk to

one

> > another about each other's work. I'm not picking up any ad

hominem

> > comments, esp since Dahl's results support his own clinical

> approach.

> >

> > > Second, note that Wilkin carefully inquires of his patients

which

> > > season is typically " best " for their rosacea (summer seems to

be

> > the

> > > most popular choice), and then deliberately starts the

remission

> > > program to coincide with what would otherwise be the most

benign

> > > period for each patient. Assuming he followed this

statitically

> > > biased approach in his 1994 editorial (where he bragged about

his

> > > superior success rate in weaning patients off of systemic

> > > anitbiotics

> > > to topicals), it certainly raises questions about the conduct

of

> > > his studies (and his rather remarkable ego.)

> >

> > Oh, I didn't read it that way at all! It's good medical care to

> taper

> > medications when remission is most likely to take place, for the

> > longest period of time. As long as he treated all patients the

> same,

> > I don't see the bias.

> >

> > I don't know anything about Wilkin or Dahl, so you may have the

> > advantage there. But in my ignorance, I'm not reading any ego or

> > bragging or dissing. To me Wilkin is communicating his clinical

> > experiences in a straightforward manner, there's no reason to be

> > modest if he's had success.

> >

> > Of course, if his results can't be verified by others, then his

> > success remains his own. But it sounds like Dahl's study

confirmed

> > his own (prolonged remission in more patients with continuing

> topical

> > after course of oral antibiotics), as have subsequent studies.

> >

> > What am I missing? We usually agree more than this (although

> > disagreeing can also be fun). <g>

> >

> > Marjorie

> >

> > Marjorie Lazoff, MD