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The rise and rise of a specialty

The Irish Association of Dermatologists (IAD) is celebrating its 50th anniversary with a bang. As well as an array of national and international speakers, the Minister for Health Leo Varadkar opened the Association’s recent Spring Meeting, a coup by any standards. The event also provided a chance to reflect on the past.

Speaking in advance of the meeting, IAD President Dr Rosemarie Watson tells the Medical Independent (MI) that much has changed for dermatologists in Ireland over the past half century.

“In the 1960s, dermatology was a fledgling specialty, with only a handful of specialists in the area. Dermatologists both North and South of the island recognised the advantages of forming a society whose mission would be to advance education and research into skin disease, and so the Association was born. Today, it continues to deliver the mission of the founding members and has grown to 135 members, which includes consultants and trainees.”

Sixty per cent of members practice in the South and 40 per cent in the North of Ireland, Dr Watson adds.

“Since its establishment, IAD members had to manage and treat a range of conditions, as well as incorporate new medications. In the 1960s, chronic skin infections were far more common than today, and we are fortunate now to have the tools for early diagnosis and more effective treatment,” Dr Watson explains.

“These infections included cutaneous TB (lupus vulgaris) and late manifestations of syphilis. Some chronic inflammatory skin conditions have decreased significantly in incidence for unclear reasons,” she says. “Treatments available for dermatology patients in this decade included predominantly topical therapies, often given on a prolonged inpatient basis, sunlight and radiation therapy.”

However, five decades of change and innovation have almost made the practice of dermatology in Ireland today “unrecognisable to that of our founding members,” Dr Watson adds.

Extraordinary pace

“We are living in a remarkable era where science and technology are moving at an extraordinary pace. The IAD holds two meetings yearly to update our members on recent advances by inviting world-renowned speakers and to present our research. The evolution of the IAD would not have been possible without the support of the pharmaceutical industry over the years. Funding has allowed us to invite international speakers who are experts in their fields and to award travel scholarships to our younger members to further their education.”

When asked about the speakers lined-up for the IAD Spring Meeting, Dr Watson describes them as “internationally-renowned leaders in their fields of expertise”.

“We are particularly looking forward to Prof Desmond Burrows, who was the Association’s inaugural Secretary, who will talk on the history of the IAD. We have much to learn from history, and the passion, enthusiasm and leadership of our founding members is inspiring to all. It has been said that leaders should not be judged on the number of men they lead, but on the number of leaders they create. Our founding members have created many leaders of whom Irish dermatology can be very proud.

“I am particularly excited by the talks which incorporate bench-to-bedside research. Prof Alan Irvine, Our Lady’s Children’s Hospital, Crumlin, St James’s Hospital and Trinity College Dublin, will present his ground-breaking research in epidermal barrier function in atopic dermatitis, which will give us insight into how malfunctions in our skin barrier may be the initiating factor in the development of allergic diseases. He will also address what potential therapies are/will be available to repair the defect, which theoretically if introduced early enough could prevent disease development in a condition affecting up to 20 per cent of children.”

Another speaker, Prof Michelle Petri, Consultant Rheumatologist at the Johns Hopkins University School of Medicine Baltimore, USA, shared her experience of treating patients with systemic lupus and which treatments produce best outcomes for this multi-system disease.

“Prof Gary Sibbald is a Dermatologist and Internist at the University of Toronto and is a world leader in wound care management and research,” Dr Watson adds. “This is a very important area to keep abreast of, as chronic wounds have a huge impact on quality of life and are a significant financial burden to every government. A recent publication in International Wound Journal 2015 found the annual cost of treatment of chronic wounds in Wales was £328 million (5.5 per cent of their total annual health expenditure).”

Another world leader, Prof Angela Christiano, Professor of Dermatology and Genetics and Development at the University of Columbia, New York, discussed a potential cure for alopecia areata through her studies on its pathogenesis and the use of JAK inhibition of inflammation in mice and subsequent preliminary human experiences.

“This is a major breakthrough for those suffering from this condition, which has a profound effect on quality of life, and was published in Nature Medicine in September 2014.”

Job satisfaction

As well as these exciting developments, part of the appeal of a life in dermatology is job satisfaction. A recent poll of US doctors carried out by the CDC found that dermatology ranked number one, followed closely by ophthalmology. This popularity is reflected on this side of the Atlantic too.

“In Ireland, we have no difficulty in recruitment of trainees and places on the Specialist Register remain very competitive. Our consultant numbers have increased over the years but not at the pace we would like, considering the increased demand by our expanding paediatric and elderly population,” explains Dr Watson. “In 1992, there were 11 dermatologists in the Republic and now we have 46, 13 of whom are in full-time private practice. Compare that to the number of dermatologists in the city of Vienna, which is about 300 for a population of 1.7 million.”

The appointment of new consultants and retention of consultants has been a recent challenge, she adds. This is due to difficulties in service delivery because of resource deficits and recent changes in remuneration, the latter point affecting all specialties. However, Dr Watson says that Minister Varadkar is very aware of the challenges for dermatology, which are predominantly related to delivery of service.

“He has a challenging job, considering current financial constraints. He is being invited to celebrate the success of the IAD and as such, I will not be raising any specific issues. We will be happy to be available in an advisory capacity to his Department for future initiatives. We are confident of his support of our specialty.”

The Spring Meeting also saw the unveiling of the IAD’s new website. The new site is designed to improve communication among members and trainees, and to alert patients and primary care physicians and other specialists about delivery of the dermatology service. It will also provide ‘signposts’ on skin disease.

Endless possibilities

“The possibilities for the website are endless and we will be expanding the website in the future under the guidance of our Website Committee,” Dr Watson explains.

When asked about the general use of telemedicine, Dr Watson says that while the Association has no formal policy on telemedicine, many of its members are using it on an informal basis. “Telemedicine relies on visual cues and thus is ideally suited to dermatology. I personally find it useful in communications with dermatology and non-dermatology colleagues who are at a distance.”

However, Dr Watson does not think this technology will reduce the need for dermatologists. She believes that challenges to expanding teledermatology include an underdeveloped infrastructure, fragmented electronic medical health records, and legal, ethical and reimbursement issues.

After 50 years of achievement and innovation, IAD members can feel justifiably proud of their contribution to medicine in Ireland, and can look forward to the promise of the next 50 with hope and expectation.

Changing times — innovation in dermatology

Every decade has brought significant change to the specialty of dermatology, as Prof Rosemarie Watson explains to the Medical Independent (MI).

During the ’70s, day-care units became more popular, with the use of light therapy offering effective treatment for psoriasis and other inflammatory skin diseases. Photochemotherapy (PUVA) was also introduced as an even more effective form of phototherapy.

The ’80s witnessed the introduction of vitamin A synthetic analogues, ie, isotretinoin and other retinoid drugs offered a cure or dramatic improvement for severe acne and other inflammatory skin diseases, Dr Watson adds.

“Laser was also introduced, initially for port wine stains, but the indications for treatment have since expanded exponentially. In terms of clinical practice, a major advance was subspecialisation. The recognition of the critical role dermatopathologists play in dermatologic diagnosis was recognised, with subsequent appointments over the next decade.”

Other subspecialties which were evolving at the time include photobiology, paediatric dermatology, surgical dermatology and occupational dermatology.

“The first patient support group for children and adults with severe inherited blistering disease was formed and has been an invaluable advocate for such patients since then,” she adds.

In the next decade, “advances in molecular genetics heralded a new era, which greatly improved our understanding of the pathogenesis of many skin disorders, improved diagnosis for many inherited skin conditions and offered new potential treatments for many skin conditions,” Dr Watson continues.

“Skin cancer was becoming an increasingly important part of the dermatologist’s workload. Microscopically-controlled Mohs surgery was introduced to Ireland to offer the highest cure rate for skin cancers with high risk of recurrence. Multidisciplinary team meetings, which are now a regular part of skin cancer patient management, were evolving.”

Dermatologists also developed close links with the Irish Cancer Society to promote the message of early detection and prevention of skin cancer, including melanoma and non-melanoma skin cancers.

Since 2000, the introduction of biologic therapies have revolutionised the management of severe psoriasis and made a marked improvement in quality of life for patients.

“Biologic treatments for severe eczema have been slower to evolve but are currently in phase II trials. New, more improved and patient-friendly biologic agents continue to be developed,” Dr Watson says.

“The drug propranolol was serendipitously discovered in 2008 to dramatically affect the course of infantile haemangiomas, reducing or eliminating disfigurement and subsequent suffering for children in their first decade of life. Exome screening, where we can view the human genome, has become mainstream and can offer a diagnosis and shed light towards treatment in previously undiagnosed patients.”

Other developments in the area of clinical practice have included further consultant appointments throughout the country. While this increase recognises the rising demands for the service, significantly more are required, says Dr Watson.

“In addition, special multidisciplinary clinics for patients with rare or debilitating skin diseases such as epidermolysis bullosa, lupus erythematosus, vascular tumours and malformations, came on-stream. Cosmetic dermatology is a rapidly-evolving area where the challenge is regulation of the industry in the interest of patient safety. The Irish Dermatology Nurses Association was founded in 2002 and is closely linked and supported by the IAD in recognition that they are a valuable and integral part of the dermatology service and their influence is pivotal in patient compliance with skin therapy.”

There have also been other significant developments in patient awareness and in building research infrastructure.

“Following the sale of Hume St Hospital, which served the people of Dublin and indeed the whole country for over 100 years, in 2006, three major projects were initiated,” says Dr Watson.

“The Irish Skin Foundation was founded in 2011 to assist patients with all forms of skin disease in Ireland. This Foundation gives a voice to our patients and promotes education on prevention and management of skin disorders and where necessary, will lobby for introduction/improved availability of new treatments.

“The second project was the development of the Charles Institute of Dermatology, which opened in 2011 at the University College Dublin campus.”

The Institute was named after the Charles family, one of whom was a founding member of Hume St Hospital and another, Dr Havelock Charles (1905-1980), served as Dermatologist at Hume St Hospital. The Board of the Charles Institute appointed its Director of Research, Prof Martin Steinhoff, a researcher of international renown, in 2014. The Institute now employs 27 scientists and is Ireland’s only dedicated dermatology research unit.

The third project saw funding directed to develop the Charles Centre for the treatment of patients with skin disease at St Vincent’s University Hospital, Dublin. This opened in January 2012.

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