CCE Dermatology: Wake Forest University Baptist Medical Center

January 23, 2009

A small-town atmosphere that fosters collaboration and a research center with many achievements make Wake Forest's Department of Dermatology a Clinical Center of Excellence.

WakeForest University Baptist Medical Center
Winston-Salem, North Carolina

A “small town” community atmosphere that fosters collaborative research is the hallmark of the Wake Forest University Baptist Medical Center Department of Dermatology, a Clinical Center of Excellence.

Wake Forest’s program, in spite of its small size, is well represented at education and advisory meetings, making a large contribution to dermatology, says Steven R. Feldman, MD, Director, Center for Dermatology Research. The depth of its research team is exemplified by its participation in the research and development of many of the latest drugs for the treatment of psoriasis, atopic dermatitis, and acne.

“Our publication and presentation numbers compare very favorably with many of the larger programs, in spite of our smaller faculty. We have seven faculty with enormous innovative research productivity, national and international presence in speaking and clinical care,” says Alan B. Fleischer, Jr., MD, Chairman of the Department of Dermatology. 

In this “small-town” community, dermatologists collaborate with clinicians and researchers in other disciplines at Wake Forest University Medical School (WFUSM).  For example, with the use of imaging technology, dermatologists and neuroscientists are working together to determine what happens in the brain when patients scratch, why it feels so good – and why it can be difficult to stop.   

Strong collaboration with other specialties bolsters the dermatology program at Wake Forest.  “Joint appointments are a testament to the interdisciplinary work we do,” says Feldman. Most of dermatology’s clinical collaborations are with plastic surgery and otolaryngology while researchers work with their colleagues in family medicine, neurosciences, physiology/pharmacology, and public health sciences, Fleischer says. 

Many of these efforts focus on underserved patients. “We have a tremendously productive collaboration with the rural health researchers in our Department of Family and Community Medicine. We are also working together to address skin disease issues in migrant Latino farm workers and other underserved populations,” says Feldman.

International Presence Forms and Referrals
Boosted by a vibrant foreign fellowship program, Wake Forest’s dermatology program extends far beyond the borders of North Carolina, drawing trainees from Malaysia, Saudi Arabia, Jordan, Pakistan, China, and Romania. This foreign presence strengthens the center’s training program. The residency program draws more than 450 applicants for three annual resident positions. As one of the smaller residency programs in the country, it is analogous to a first-tier liberal arts college, with a faculty/resident ratio of about 1:1.   

The Wake Forest dermatology department is a destination for patients with common and complex conditions. A balance between patient care, research, and education makes it a referral center for western North Carolina and surrounding states. “As a referral center, it gives us a strong base for educating dermatology residents and other trainees,” says Feldman. “Our research focuses on clinically relevant, common problems facing dermatologists and our patients that supports our education programs and strengthens the patient care we provide.”

Center for Dermatology Research
Founded in 1998, the Center for Dermatology Research has participated in groundbreaking treatments and notable discoveries. 

Feldman’s research on the relationship between patient compliance with treatment and outcome is one example. “Perhaps our most recent groundbreaking discovery is our finding that patients with skin disease are poorly adherent to their topical treatment regimens,” he says. “That work has profoundly changed how dermatologists view some of our most basic concepts of topical drug effects and is changing how many dermatologists approach treatment planning.”

He cites as an example the case of 16-year-old girl with severe psoriasis of the scalp. She’d tried traditional treatments, which failed, and was referred to the department by a dermatologist in South Carolina as a candidate for a new expensive biological treatment.

“We saw her and managed to control her scalp psoriasis with an inexpensive topical medication in just one week,” says Feldman. Based on his research on patients’ adherence to topical therapy he managed her disease simply by monitoring how she used the medications. “We were able to get much better control of the disease with a treatment she had previously used, by simply changing how she used the medication,” he explains. 

In collaboration with the university’s Public Health Sciences Division, Wake Forest’s research efforts extend beyond the clinical.  Feldman’s research on the economic impact of gatekeeping measures that were restricting patients’ access to dermatologists in the early 1990s helped remove barriers to care.

“In the 1990s, gatekeeping managed care systems were threatening to eliminate dermatology as a specialty.  We provided much of the research demonstrating the quality and cost effectiveness of dermatologists in the management of skin diseases,” says Feldman. “Today we continue to have a vibrant specialty.”

WFSUM also developed cost-effective treatment algorithms for psoriasis.  In a collaborative research effort, and with the assistance of a researcher in the WFUSM psychiatry department, researchers studied the impact of chronic diseases like psoriasis on a patient’s mental health and quality of life.

Treatment of patents with autoimmune skin diseases is another area of concentration. “This was possible only because of the strength of our clinical program and its ability to attract patients with rare autoimmune skin diseases from hundreds of miles away,” says Feldman. “They drive right by Duke and UNC to get here!”  

The center also studied the addictive properties of indoor tanning. “This [research] has critical implications for efforts to reduce excessive UV exposure and was only possible because of the ability at WFUSM to collaborate with an outstanding addiction researcher in our Department of Physiology & Pharmacology,” Feldman says.

New Promising Research
Patients with chronic pruritus may soon find relief, based on research by Wake Forest dermatologist Gil Yosipovitch, MD, a pruritus specialist.  Patients occasionally report that intense scratching – to the point of drawing blood – is the only thing that  relieves the chronic pruritus. Yosipovitch has found that certain areas of the brain are activated when a patient scratches; by understanding the brain relationship to scratching, new treatments can be developed for 30 million patients with eczema and kidney dialysis patients bothered by pruritus.

The department also is studying lymphoma. “Right now we are developing gene rearrangement studies for T-cell lymphomas of the skin,” says Fleischer. “It allows earlier and more definite diagnosis.  It’s a molecular fingerprint of cancer.”

Award and Recognitions
The number of published works by members of the dermatology department are too numerous to list, notes Feldman. The founding chair of the department, Joseph Jorizzo, MD, is one of the lead authors of the textbook, Dermatology, considered to be a standard reference book in the field.  “Our faculty publish in the top clinical dermatology journals on a regular basis,” says Feldman. “The editor of one of these journals quipped that he has a separate inbox just for papers from our department.”

Feldman has received numerous awards. He is the recipient of the 2006 Clarence Livingood Lectureship, one of the most prestigious awards given by the American Academy of Dermatology.  He received in 2005 a presidential citation from the AAD for his work in psoriasis education. This year, Feldman also received an Astellas Award honoring research that has improved public health in the field of dermatology.

Feldman recalls a compliment from a basic science researcher who told him, “I have been toiling away for 20 years in basic skin immunology and finally my work is about to make a difference in the clinic. I’m so jealous of the research you do, because every one of your papers is making an immediate impact on how patients with skin disease are being treated.”