CCE Dermatology: University of California, San Francisco Medical Center

January 23, 2009

The Department of Dermatology at the University of California, San Francisco Medical Center is often found near the top of numerous rating lists, and an inquiry into the department's activities reveals why.

Universityof California, San Francisco Medical Centers
San Francisco, California

An in-depth look into the many endeavors of the dermatology departments of the University of California, San Francisco Medical Centers reveals that clinical care is anchored by an underlying foundation of research and education. “We are basically the last resort for complex dermatology problems in the region,” says Bruce Wintroub, MD, professor and chair, dermatology departments. “The clinical program is of high quality in every area that we operate in.”

The UCSF Medical Centers, include the affiliated San Francisco General Hospital and VA Medical Center, and are strong in general dermatology, dermatologic surgery, including the 1,500 skin cancer procedures performed annually, cutaneous oncology, and dermatopathology.

The dermatology hospitalist program typifies how successful integration of education and research can emerge through quality clinical care. The first of its kind in the country, UCSF employs two dedicated dermatology hospitalists. A typical patient may be the 65-year-old man with chronic obstructive pulmonary disease referred by his primary care physician for admission due to a severe psoriasis flare upon systemic steroid withdrawal.

There are more dramatic cases, says Lindy P. Fox, director, hospital consultation service, and assistant professor of clinical dermatology. She describes a patient with 40 percent of his upper thigh and leg eaten away by what was misdiagnosed as cellulitis with thrombocytosis after elective surgery. Fox was consulted just before the patient was to have interventional surgery in an attempt to debride the wound. “It was classic pyoderma gangrenosum that feeds on trauma,” she says. Additional surgery would have worsened the condition.

While UCSF dermatology hospitalists treat many challenging conditions, they also specialize in treating graft vs. host disease, soft tissue infections, fungal infections, and fever with rash.

UCSF is developing a program to expand the dermatology hospitalist service outside the UCSF Medical Centers, says Timothy G. Berger, MD, director of clinics and executive vice chair, department of dermatology, and associate director of the dermatology residency program.

Pediatric dermatology 
“Our pediatric dermatology program is a resource for the entire San Francisco Bay area and the West Coast, especially for vascular malformations in children, and has pioneered the understanding of therapy in that area,” says Wintroub.

The Birthmarks and Vascular Anomalies Center was founded in 1991 and its seven-member staff is led by pediatric dermatologist and Director Ilona Frieden, MD. While patients are referred for more common capillary malformations such as port wine stains and salmon patches, the majority of referrals are for more debilitating and potentially life-threatening vascular tumors and malformations.

In addition to hemangiomas, the staff treats a variety of venous, lymphatic, arteriovenous, and mixed malformations including lymphangioma, cavernous hemangioma, glomangioma, Klippel-Trenaunay-Weber syndrome,and Proteus syndrome. Because many of these are chronic malformative diseases rather than curable vascular anomalies, treatment focuses on alleviating the most debilitating aspects of the disease.

Through the pediatric fellowship program, UCSF has seeded and propagated other vascular anomaly treatment programs that are now available in many dermatology centers, Berger says.

UCSF operates several outpatient skin care centers and according to Wintroub, has the largest phototherapy center on the West Coast. “We take patients with very serious skin disease who would have been hospitalized 20 years ago as outpatients.” The skin care centers and phototherapy center treat 10 to 12 patients daily with aggressive topical treatment, systemic care, and phototherapy for their sometimes intractable psoriasis and eczema. The most difficult psoriasis cases are often incorporated into UCSF research protocols.

Conjunctive Programs
The UCSF dermatology community outreach efforts and its dermatopathology department are notable complements to the institution’s clinical care programs.

The three full-time and two part-time dermatopathologists review about 80,000 tissue specimens each year and, of these, about 10,000 are previously prepared slides making diagnosis more challenging. “This is a very high-powered service,” notes Wintroub. The department’s special research interests include the molecular cytogenetics of melanoma, cutaneous lymphoma, vascular neoplasms, and inflammatory skin disease.

While 90 percent of the tissue specimens examined are referred from California and throughout the United States, the department does receive international requests. The department accepts glass slides, immunofluorescence samples, wet tissue specimens, and frozen tissue specimens. 

Members of the UCSF dermatology department have long been active in community melanoma education and outreach. In 2007 the department built a playground shade structure and offered free skin cancer screenings, but in 2008 developed a more pointed approach. “We decided to have a community-based skin cancer screening in each of the ethnic neighborhoods to specifically tailor screening to the issues that address that community,” explains Berger.

In 2008 the community-based screening program began with the gay community and focused on risk factors specific to the community such as increased sun exposure. In 2009 the UCSF skin cancer screening will target the Chinese-American community. “It will address their issues -- thinking they can’t get skin cancer when, in fact, they can,” Berger says. The screening programs are conducted in association with the American Academy of Dermatology and the local health department.

Research and Education
Successful research programs ultimately lead to better patient care and the UCSF dermatology department has consistently ranked among the top five in terms of National Institutes of Health research funding for the past decade, says Wintroub. In 2007 the department received 20 research grants totaling $2.6 million and in 2004 it received $3.5 million.

Areas of research encompass basic, clinical, and translational science as well as clinical investigation and UCSF research protocols are often carried out in conjunction with the affiliated VA Medical Center and San Francisco General Hospital. Current research focuses on the following:

Cutaneous oncology

Skin disease genetics

Virology pathogenesis

Translational epidemiology

Biology of permeability and skin barrier function

Photosensitivity

Carcinogenesis

Melanoma

Drug resistance

Immunology

Environmental and occupational contact dermatitis

Health policy science

HIV/AIDS-associated dermatologic disease

Hair and nail disorders

In addition, research within the dermatopathology department includes clinicopathologic studies and immunoperoxidase, ultrastructural, and molecular biologic investigation of the aspects of skin disease.

“Our educational program is marked by being among the most competitive dermatology residency programs in the country,” Wintroub says. Post-residency fellowships are offered in pediatric dermatology, Moh’s surgery, and diagnostic dermatopathology including ancillary diagnostic training in immunoperoxidase techniques and molecular biology.

Several research fellowships are offered annually and current areas of focus are clinical hair research, HIV dermatology, psoriasis, melanoma, and cutaneous oncology.