CCE Dermatology: Mayo Clinic

January 23, 2009

Hospitals around the country have given up their inpatient dermatology practices, but the one at the Mayo Clinic continues to thrive.

Mayo Clinic
Rochester, Minnesota

A dedicated inpatient service, an outpatient service seeing 60,000 patients per year, the 13,000 procedures performed annually, and the more than 430,000 laboratory and dermatopathology tests addressed each year provides ample support for the clinical and population-based research the Mayo Clinic dermatology department is known for.

While most of the patients entering dermatology inpatient treatment are referred for serious or recalcitrant skin diseases, the overwhelming number of  referrals are to the Mayo Clinic’s dermatopathology laboratory, says Randall K. Roenigk, MD, chair, department of dermatology.

Of the more than 430,000 blood and tissue samples processed in 2008, 70 to 80 percent of those requiring immunohistologic processing were sent in from outside the Mayo Clinic area. “I would estimate that for routine pathology 70 to 80 percent of specimens are from the Rochester area and only 30 percent come from other institutions. But for immunopathology, the ratio is reversed,” Roenigk says.

In fact, the immunopathology department has grown substantially during the past few years to accommodate the referrals. “We have a large volume of specimens that are sent in relating to gastrointestinal disease because we developed some of the tests for GI disorders that have skin implications,” Roenigk explains. For example, the antigliadin antibody test for celiac disease, which has both GI and dermatologic manifestations, is commonly ordered by dermatologists and GI specialists.

Enhancing Primary Care
The large volume of dermatology outpatient visits combined with the 3,000 Moh’s procedures and 10,000 non-biopsy procedures for other skin cancer treatments, wide-excisions, grafts, flaps, and wound repairs has prompted Mayo Clinic dermatologists to actively engage and educate primary care practices. This helps primary care physicians diagnose and treat the more common dermatologic conditions that account for 70 percent of cases such as warts, dermatitis, psoriasis, eczema, and skin cancer. “If we took care of all of these people in our department it would make it difficult for more complicated patients to access care,” Roenigk says.

The dermatology department has therefore initiated a program for wart treatment where primary care patients have warts evaluated and treated by a dermatologic nurse. Follow-up care is through their primary care physicians.

Mayo Clinic dermatologists also help primary care practices with skin cancer diagnoses. “Primary care physicians are pretty good at identifying skin cancer,” says Roenigk. “We can train them how to do a biopsy and when there is a biopsy there is a pathology specimen. If you have a basal cell and have seen your family practitioner there is no reason for a separate dermatology consult before surgery.”

The dermatology department is currently planning other ways to help primary care physicians bring more dermatology care into their practices, Roenigk says.

Clinical Care
In addition to a dedicated dermatology inpatient treatment program and the diverse dermatologic surgery program, the Mayo Clinic offers an intensive 3-week inpatient psoriasis treatment program and maintains a phototherapy treatment center.

The psoriasis programs emphasize patient education about the disease as well as the importance of follow-up care, says Marian T. McEvoy, vice chair of the dermatology department. “Within that 3-week period there are stress management classes and when released patients will have an ongoing plan for how they will manage their disease,” she says. Since many of these patients are referrals, some will follow up with outside community dermatologists.

Clinical care is also provided by dermatologists specializing in research and treatment of atopic dermatitis, cutaneous lymphoma, connective tissue disease, transplant, bullous disease, and contact/occupational dermatitis. Some of the more difficult conditions treated include lupus erythematosus, nephrogenic fibrosing dermopathy, pyoderma gangrenosum, scleroderma, calciphylaxis, dermatomyositis, erythema multiforme, porphyrias, and vascular abnormalities.

Academics and Research
Dermatology academics and research are structured to be intertwined with patient care at the Mayo Clinic. “We have a comprehensive academic program that has been highly successful over a long period of time,” says Roenigk, who is also chair of the dermatology residency program. Established in 1916, the Mayo Clinic Rochester has 25 residents and seven fellowship slots annually. “We are probably the largest academic clinical practice in the country at a single site center,” says Roenigk “This brings a large educational aspect to our practice.”

We also engage our residents and fellows in research because our education program requires a research or scholarly component,” he adds. “Our residents are not only learning from the clinical practice, our faculty is full-time in the department, they are not just sitting as faculty part-time. Faculty are with the residents all the time.”

While electronic health records are a recent development, the dermatology department has long been able to use the Mayo Clinic’s meticulously-kept records to foster retrospective disease state and population-based studies. “If a research idea develops in our practice we are able to go back and look at patient records,” explains Roenigk. A large research staff also helps to put prospective study protocols in place that use data gathered from the ongoing high-volume procedural and office dermatology practice.

As a result of these efforts, Mayo Clinic dermatologists consistently publish 52 to 65 unique research papers annually in peer-reviewed journals.

The Mayo Clinic also has an active Melanoma Study Group that is currently engaged in nine basic science and clinical trials. The research includes a blood and tissue repository for evaluating potential inheritable factors in families with melanoma and pancreatic cancer and a study to evaluate outcomes of radiation therapy following surgery for desmoplastic melanoma. Metastatic melanoma clinical trials include a phase 1 study of a poly (ADR-ribose) polymerase inhibitor, a phase 2 trial of an intravenous acylsulfonamide, and a phase 3 trial of intralesional allovectin-7.

Researchers are also evaluating a heat-shock vaccine and peptide vaccines combined with other agents for melanoma treatment as well as an investigational antibody plasma therapy.