In conversation with Dr. Vincent Piguet: Academic dermatology is more than treating ‘bumps on the skin’

Dr. Vincent Piguet is a full professor and the Departmental Division Director for Dermatology, in the Department of Medicine at the University of Toronto and Division Head of Dermatology at Women’s College Hospital.

Dr. Piguet spoke with Department of Medicine Communications Officer, Jocelyn Lagerquist, about academic dermatology in Canada; how academic clinicians in the Division of Dermatology are improving health care outcomes for patients; and what the future holds for academic dermatology and the Division of Dermatology.

Dermatology, particularly academic dermatology, seems to be a misunderstood field of medicine. Can you tell me a little bit more about academic dermatology in Canada and how you might address some common misconceptions?

In Canada, skin diseases account for 10% of all primary care visits, which is a significant statistic, but the field of academic dermatology is actually quite small. Currently, we have 15 full-time dermatologists sited at three of the teaching hospitals — Women’s College, Sunnybrook, and UHN — serving a GTA population of more than 5.9 million people.

I think there is oftentimes a misconception with the general public as well as some of our medical colleagues that we are treating easy conditions and “bumps on the skin,” — acne, wrinkles, etc. But the reality is that academic dermatologists, for the most part, are treating severe skin diseases including aggressive skin cancers and diseases of the immune system —such as eczema or psoriasis — using complex and targeted therapies.

As the body’s largest organ, the role of the skin is to protect us against mechanical, thermal and chemical injuries, liquid loss, pathogens and UV light. In a clinical hospital setting, we are evaluating how these processes and injuries can lead to severe skin diseases. For instance, we are treating aggressive skin cancers such as melanoma and squamous cell carcinomas with specialized micrographic surgeries called MOHS. We manage autoimmune disorders and inflammatory skin diseases, such as severe eczema or psoriasis, with biologics and immunosuppressive medications. Finally, there are a great variety of conditions that we deal with medically and/or surgically such as chronic wounds, skin infections, genetic diseases affecting the skin, and catastrophic adverse drug reactions leading to skin detachment such as Stevens–Johnson syndrome/toxic epidermal necrolysis.

Historically, health care systems focused on addressing hard outcomes: treating immediate and life-threatening issues to save lives. As dermatologists, we, of course, are treating life threatening skin diseases, but we are also managing and improving our patients’ long-term quality of life.

Would you say the division’s ‘bench-to-bedside’ research also sets academic dermatology apart from community dermatology?

Yes. Our clinician-scientists are conducting incredible research to improve the health and health outcomes of patients suffering from skin diseases.

Dr. An-Wen Chan was recently awarded two research grants for ‘bench-to-beside’ projects. To monitor the incidence and impact of skin cancer in Canada and inform public health initiatives, An-Wen — in collaboration with Cancer Care Ontario — will use artificial intelligence to develop an automated algorithm that will identify skin cancers from pathology reports in Ontario. Dr. Chan also recently received the inaugural UHN Transplant Strategic Clinical Projects Fund Award to expand on a randomized controlled trial — currently in pilot stage — which is investigating the use of an oral vitamin (nicotinamide) for preventing skin cancer in the high-risk transplant recipients.

Dr. Aaron Drucker and I just received a grant from the Canadian Dermatology Foundation to establish the Canadian Atopic Dermatitis Cohort for Translation Immunology and Imaging (CACTI) project. The CACTI project is meant to advance biomarker development and precision medicine for atopic dermatitis, using a controlled trial that compares the two most common forms of UVB phototherapy.

I conduct research that analyzes how viruses, such as HIV, can cross the skin and manipulate the cutaneous immune system. More specifically, we study cutaneous immune cells called Dendritic cells (DCs), which are one of the earliest targets of HIV-1 infection and other viruses. We are also studying how to leverage the skin immune system to improve vaccines. The skin immune system is very efficient. Thus, delivering a vaccine via the skin is more potent than the usual intramuscular route. This research is more important than ever due to COVID-19.

Members of the division are also conducting research in inflammatory skin diseases, such as Hidradenitis Suppurativa (HS). HS presents as painful nodules, cysts and severe scarring. HS affects about 1% of the population, predominantly young women, but is not as well understood as other skin diseases. Many factors play a role in making this disease very complex and interesting — including inflammation, hormones, smoking, stress, obesity — and associated rheumatological, gastroenterological, and endocrine diseases as co-morbidities. Because there are high incidence rates of anxiety, depression amongst HS patients this research ensures that we are better equipped to improve our patients’ quality of life and provide holistic, person-centred care.

You’ve mentioned a few times now how dermatological diseases and disorders can impact a patient’s overall quality of life. What are your thoughts regarding what seems like a strong correlation between mental and physical health in dermatology?

Conditions such as HS, eczema and psoriasis are not “hidden diseases.” Patients with these disorders can often feel rejected or stigmatized, which can lead to severe mental health issues. Addressing the psychological co-morbidities associated with skin diseases is very important.

A growing number of studies, including one I recently published with our colleague Dr. Andre Carvalho from CAMH, show there are disproportionate rates of clinical depression and anxiety amongst patients suffering from HS. The research found that the overall prevalence of depression and anxiety amongst patients with HS was 16.9% and 4.9% respectively, which is roughly twice that of the general population. These results suggest that there is a need to develop and implement strategies to better integrate mental health into the management of these patients. The impact of these skin diseases and disorders on person’s sense of wellbeing cannot be underestimated.

How has care delivery in the Division of Dermatology been shaped by the COVID-19 pandemic?

COVID-19 has fueled a rapid acceleration of virtual care in dermatology. Dr. Trevor Champagne is leading several new programs to assist with patient assessment. In Toronto, and across Ontario, more than 3,000 patients have already benefited from this initiative. Trevor is currently piloting a Women’s College Hospital program that offers rapid virtual assessments for in-patients at Unity Health/St. Michael’s and Sinai Health System/Mount Sinai Hospitals.

But, virtual care had been integrated into our dermatology care prior to the pandemic. We had completed more than 2,300 consultations in underserviced communities across Ontario — identifying and forming a plan to treat potentially deadly skin cancers within hours instead of months. Virtual care also enabled us to provide 473 family practice consultations, which prevented up to 400 in-person visits and improved response times to under 24 hours, on average.

What’s your vision for the Department of Medicine’s Division of Dermatology and academic Dermatology in Canada?

I’d like the Division of Dermatology to be recognized as a leader in educating and training academic dermatologists — those clinicians who want to address the complications and challenges of severe skin diseases. We are currently training 35 residents: one third of Canada’s dermatology trainees.

I would like to recruit more full-time academic dermatologists so that we can be more easily accessible to our colleagues in other subspecialities who may be dealing with patients with autoimmune diseases, complicated wounds and adverse dermatological responses to drug therapies in the ICU or transplant wards, for example.

The vision I have for academic dermatology in Canada is starting to take shape. We were recently awarded $1.2M in research funding through the Canadian Institutes of Health Research Network Catalyst Grant to establish SkIN Canada – the first national skin research network, led by Dr. An-Wen Chan.

Bringing together multidisciplinary teams, including patients, clinicians and scientists, the SkIN Canada network is positioned to conduct research designed to elucidate barriers and facilitate optimal care that will be translated into improved care for Canadians with skin conditions. Additionally, the network’s annual training boot camps, trainee exchanges and leadership positions for early-career investigators will help develop the next generation of research leaders in dermatology.