The skin: meeting-place of medical specialties
Lars French heads up the dermatology department at the University Hospital Zurich (CH). Martin Röcken is his counterpart at the University of Tübingen (DE). Both are simultaneously clinicians and researchers. Two viewpoints on European research in dermatology(1).
A new association, the European Skin Research Foundation (ESRF), was set up at the end of 2007. Both of you had a hand in this. Why?
Lars French Despite dermatology's deep European roots, skin research is better funded in the United States. Even if bodies like the European Society for Dermatological Research (ESDR) establish links between laboratories, European dermatologists are much less involved than their American colleagues in collecting research funds from private donors. The success in the United States is based on structures like the Dermatology Foundation (DF), which has been a major force in developing American dermatological research and bridging the gulf between clinicians and laboratory researchers. ESRF is therefore setting out to create the equivalent of the DF in Europe.
Martin Röcken The speed at which dermatology research is advancing makes it vital for clinicians to update their knowledge of biology and skin physiology. One of ESRF's objectives is to improve European clinicians' understanding of how the skin works, with grants for short-term research projects in well- known laboratories. In this way young physicians will benefit from the experience of major laboratories and use the skills gained there to set up their own independent research groups.
This will enable us to build an innovation culture in European dermatology. What have been the main advances in dermatological research over the past 20 years?
M.R. Dermatology has made considerable progress in each of its four main research directions: inflammation, genetic disorders, the understanding of cancer and its treatment . Better understanding of the mechanisms of skin inflammation have allowed us to develop new care strategies. This includes, for example, psoriasis, which affects almost 2% of Europeans, and where no effective care previously existed for the most severely affected patients. Similarly, phototherapy now exists to relieve sclerodermia, a pathology which provokes cutaneous lesions. In the 1980s, dermatologists were unable to treat AIDS-engendered skin disorders like Kaposi's sarcoma. Today, patients with these pathologies can live almost normal lives. Nor, 20 years ago, was there any strategy for treating melanoma. Today we know that these tumours can be reversed by stimulating the immune system. And even if this treatment is not yet fully developed, we already better understand the different mechanisms of tumour formation at cell level.
L.F. Dermatology has benefited enormously from the technological developments of the past two decades. Today biotechnology allows us to generate, from cells or bacteria, antibodies or fusion proteins which can accurately target and block the inflammatory reaction which is responsible for psoriasis. Similarly, progress in genomics has made it possible to identify the genes responsible for certain genodermatoses (hereditary skin diseases). From these it will be possible to develop new treatment methods, in particular using gene and protein therapies. Stem cell research has also provided new advances. At the last World Dermatology Congress in Kyoto, researchers presented very promising results for patients suffering from dystrophic epidermolysis bullosa, a serious genetic disorder which causes the skin to come away. The results of bone marrow transplants on mice have shown that a total remission of the sickness may perhaps be possible if scientists succeed in transposing the technology to humans.
What are the most deadly skin diseases?
M.R. Cancers, of course, among them melanoma, which is set to become one of the five most lethal cancers in white populations in 10 or 20 years' time. In the poorest countries inflammatory and infectious skin diseases are some of the biggest killers. Certain sicknesses which have been totally eradicated in other parts of the world, like leprosy or noma (see box), still claim large numbers of victims in developing countries. Indirectly, diseases like lupus or AIDS also engender skin diseases, for which treatments need to be developed in consultation with other disciplines. The secondary skin effects of certain treatments also illustrate the importance of inter-disciplinary approaches in dermatology. Patients being treated for colon cancer sometimes suffer generalised acne of a severity that necessitates a total interruption of treatment.
L.F. Severe allergies to medication are extremely dangerous and sometimes lead to toxic epidermal necrolysis, which can kill up to 30% of patients. These require very fast treatment, as within just a few hours large surfaces of the patients' skin becomes detached and they find themselves in a situation similar to severe burn victims. Over the past few years we have also seen a recrudescence of sexually transmitted diseases (STDs) like syphilis and gonorrhoea, which had totally disappeared. In Western Europe, this recrudescence has been observed in particular among homosexuals, but the considerably higher incidence of syphilis in Eastern Europe constitutes an increased risk of the transfer of new cases westwards.
This requires us physicians to relearn to detect these disorders. These examples - and, more generally, increased personal mobility - show just how important it is to collaborate beyond national frontiers. There are more than 2000 skin diseases, many of them rare. It is vital to combine forces at European level, both for prevention and for the research and development of new treatments.
Interviews by Julie Van Rossom
- Lars French and Martin Röcken were interviewed separately