Dermatologists have a rich history of thinking outside the box. We are especially adventurous as
compared to our medical peers when it comes to trying novel or off-label therapies for various skin
diseases. This willingness to try new treatments, and experiment with old remedies but for new
indications, has become especially apparent in the last decade with regards to acne and rosacea.
This issue of the JDD serves to highlight a few examples of such unconventional and creative
thinking in the treatment of these two ubiquitous disorders.
One category of novel ingredients that has received abundant attention from the scientific, cosmetic, and consumer community as of late is "natural" or botanical ingredients. Natural ingredients found to be effective for acne and rosacea include green tea, niacinamide, and feverfew, to name a
few. In this issue, Moy et al investigate the use of sandalwood oil, a botanical ingredient with anti-inflammatory and antimicrobial properties, in the treatment of acne. As consumers and patients
continue to seek out natural remedies for their chronic skin diseases, the dermatological community will continue to feel pressure to explore these compounds and become experts regarding
which ones actually work.
Freeman, Moon, and Spencer think outside the box in their application of an FDA-approved acne
medication containing a retinoid in the treatment of rosacea. The late Dr. Albert Kligman was the
first to explore the role of topical retinoids in rosacea. He postulated that photodamage may play a
role in certain forms of this condition, and was well aware of tretinoin's ability to help repair photodamage. However, this concept never caught on as topical retinoids were classically considered
too irritating for the sensitive rosacea patient. Freeman et al's study suggest that retinoids might
be effective and well tolerated in the papulopustular rosacea patient, thus challenging our long-standing reluctance to use this class of medications in this patient population.
Thinking outside the box can also pertain to looking at old diseases in new ways. Classic outcome
measures for acne trials have included lesion counts and global severity scales. Most dermatologists also appreciate that adolescent skin might be more tolerant of drying or irritating ingredients
than more mature skin. Although hormonal treatments for acne have always been restricted to
the female gender by necessity, only recently has gender emerged as an outcome variable in nonhormonal acne studies. Gender differences in the skin might not only influence acne pathogenesis,
but might also help predict response to treatment. This issue of the JDD contains two independent
investigations focusing on how gender might influence a subject's response to a particular acne
medication. Could studies such as these lead to gender-specific treatment regimens in the future?
Only time will tell.
The inventor Trevor Baylis once said, "The key to success is to risk thinking unconventional
thoughts. Convention is the enemy of progress." This issue is dedicated to those brave souls who
dare to think outside the box. We hope you enjoy it.
Alan R. Shalita MD and Whitney P. Bowe MD