Medical dermatology: a view to the future.

Developing a rigorous basic science foundation was the primary focus of Irwin Freedberg’s vision for dermatology. When I was a student working in Irwin’s lab at Johns Hopkins University, his dedication to the scientific underpinnings of dermatology expanded my own view of the field. The explosion in our scientific understanding of the skin during Irwin’s career as a basic scientist and as an advocate for basic science has been a remarkable achievement. But dermatology underwent several other major transformations during the span of Irwin’s career. There has also been an expansion in the surgical and cosmetic aspects of the field. We have lost venereology to infectious diseases, a subspecialty of internal medicine. As I describe below in more detail, we may be losing cutaneous autoimmune diseases to rheumatology, another subspecialty of internal medicine. Recently, we have gained a significant epidemiologic effort. The urgent issue in Irwin’s day was how to make dermatology a solid, respectable field capable of intellectual growth, and his answer was basic scientific rigor. The urgent issue today, in my opinion, is how to translate scientific advances from dermatology and other fields into improved care for patients with skin disease. The recent epidemiologic efforts have worked well for common dermatologic diseases, such as psoriasis and skin cancers, but there are many complex dermatologic diseases that are not represented in sufficient numbers in available epidemiologic databases. These diseases include cutaneous lupus erythematosus, dermatomyositis, and autoimmune blistering diseases, among others — diseases in which there are significant systemic manifestations and/or the need to use powerful medicines with significant systemic side effects. These conditions fall within medical dermatology, a branch of dermatology that requires of its practitioners a substantial familiarity with internal medicine. In an effort to advocate for medical dermatologists and their patients, we formed the Medical Dermatology Society ten years ago (Sontheimer et al., 1996). The overarching goal of the group is to keep medical dermatology within dermatology, to stop its piecemeal removal into other subspecialties of internal medicine where cutaneous expertise is slight (Sontheimer et al., 1996). Our advocacy has included testifying to a subcommittee of the Department of Health and Human Services about the impact of federal policies on medical dermatology in academic medical centers (Sontheimer and Werth, 1998). Throughout all of medicine, not just dermatology, the cognitive specialties and subspecialties have suffered for many years (Werth et al., 1998). Medical dermatology suffered a heavy blow when the government stopped paying for a second residency for an individual; this, in many situations, forces us to select applicants who complete no more than one year of internal medicine training. Another blow was the tightening of clinical reimbursements, which pushed faculty away from patients with complex medical dermatologic problems. It’s hard to cover your salary when each patient takes so much time. Many academic dermatologists who had a primary focus on complex medical dermatology dropped out of full-time academic medicine. Irwin made passionate contributions as a coauthor of a “case report” that documented the difficulties experienced by one medical dermatologist (Werth et al., 2001). Irwin built an in-patient dermatology service, even making a site visit to the University of Miami to see its very successful service, but experienced firsthand at his own institution the difficulties of sustaining individuals committed to in-patient and complex medical dermatology. Other fields facing similar problems have built foundations to fund different types of research, including translational and patient-oriented research. In rheumatology, the Alliance for Lupus Research and the Lupus Research Institute have funded millions of dollars’ worth of research and have tried to focus funding in areas traditionally not funded by the National Institutes of Health. They have evolved new private sources of funding that have provided the seed money to develop and sustain people in academic careers, as well as to fund trial infrastructure at 30 lupus centers so they would be well positioned when trials became available. Those centers can now also perform more mechanistic work related to those trials to further evaluate therapies. Without a diversity of individuals to see patients with complex diseases, teach, and do patient-oriented and translational research, it is hard to develop and mentor the next generation in those areas. We are now confronted with that reality. Developments have occurred over the past five years that will have exciting implications for the future of medical dermatology. There are mentoring awards through the Medical Dermatology Society and the Women’s Dermatologic Society to fund electives focused on medical dermatology for dermatology residents. There is now a thriving combined internal medicine–dermatology program at several institutions in the United States. These are attracting new residents who might otherwise have chosen other fields in internal medicine. The Dermatology Foundation now has a Medical Dermatology Career Development Award to protect people’s time as they start their academic careers. This award will allow individuals to become competitive for National Institutes of Health funding mechanisms for patient-orient1Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA; and 2Veterans Affairs Hospital, Philadelphia, Pennsylvania, USA