Pearls for Using Drugs for Common Conditions, With Ilona Frieden, MD

Beyond newer biologics, some of the most useful tools in pediatric dermatology are drugs already sitting on the shelf. At Maui Derm NP+PA Summer 2026, Ilona Frieden, MD, professor of dermatology and pediatrics at the University of California, San Francisco, shared practical pearls on repurposing topical timolol and sirolimus.¹ Her examples spanned common conditions like spider angiomas to keratosis pilaris rubra.

In the following Q&A, Frieden discusses where the evidence stands for these off-label approaches. She also touches on why they may be worth considering for difficult-to-treat patients and what research is still underway. In the first part of the interview, Frieden discussed expanded, off-label uses of dupilumab in conditions including epidermolysis bullosa pruriginosa, epidermal differentiation disorder, Netherton syndrome, and solid facial edema.²

HCPLive: What pearls do you have for using existing drugs to treat more common conditions?

Frieden: I had a couple of examples. One is using topical timolol, which we now use quite commonly as an off-label treatment for infantile hemangiomas. There's a very large body of literature [showing] more than 1000 patients [were] treated with topical timolol very safely in infancy.

Now there are reports of that medication—which is a topical beta blocker… basically a repurposed glaucoma eye drop—being used for spider angiomas and pyogenic granulomas. These are 2 vascular conditions where the blood vessels are dilated or proliferating, and in both there's evidence that [they] can be effective.

HCPLive: What does that look like in practice for a condition like spider angiomas?

Spider angiomas [are] something we see commonly: dilated little blood vessels often on the hands or face of young children. Pulsed dye laser is a great treatment for that, but it's not a great treatment for a 4-year-old, because you have to hold them completely still and cover their eyes, and that's hard to do. So topical timolol could be tried in those kinds of patients just to see if it's effective.

There's one small case series where [in] 2 out of… 6 or 7 patients, it was completely effective, and in some of the others, it was partially effective. It sort of falls into the "worth a try" category for a pretty common condition, and it's been used very safely. If you use just 1 or 2 drops a day, it's very safe on the skin, and we know that from our experience with hemangiomas.

HCPLive: Are there other conditions where this kind of off-label repurposing applies?

Another condition I'm going to talk about is keratosis pilaris rubra. These are people who have…very rough, red cheeks. Prince Harry is the leading example of a famous person with keratosis pilaris rubra on the face. It can be a really disturbing condition to people because their face is either partly red all the time or turns red very easily [with] heat.

There's a very small number of cases that have now been treated with topical sirolimus as an off-label treatment. Sirolimus is an mTOR inhibitor. We use it orally [for] treating [severe] vascular birthmarks… often being treated at major tertiary care centers. Topical sirolimus is [FDA] approved in children [ages] 6 and up for treatment of angiofibromas, which is a complication of tuberous sclerosis.

HCPLive: How early are we in understanding sirolimus's potential for KP rubra?

This medication topically may be repurposed… for treating KP rubra, and it's very early. But there are some open-label, investigator-initiated trials ongoing to look at this further, so it's just something to think about that might be useful in the future.

References

1. Frieden I. Pediatric Dermatology Update 2026. Session presented at the Maui Derm Summer 2026 meeting in Colorado Springs on June 26.

2. Frieden I. Expanding Use of Dupilumab in Pediatric Patients, With Ilona Frieden, MD. HCPLive. Published on June 27, 2026. Accessed June 30, 2026. https://www.hcplive.com/view/expanding-use-dupilumab-pediatric-patients-ilona-frieden-md