Original Skin

Dermatology has quietly grown into a department that is leading research and comprehensive care for skin diseases in Southern California.

By Katie Sweeney

The changes in the dermatology program at the Keck School of Medicine of USC may not qualify as an extreme makeover, but the before-and-after stories are striking.

In 1999, the program was a small division of the Keck School of Medicine’s Department of Medicine. It had a long clinical history but lacked research laboratories and had no National Institutes of Health (NIH) research grants.

But when David T. Woodley, M.D., arrived that same year to lead the program, he brought with him a passion for research—and a vision of a bigger and broader dermatology presence at USC. He brought two basic scientists with him, created the USC Laboratory for Investigative Dermatology and slowly began recruiting new faculty members. Today, the program is a leader in federal research funding, with eight grants, including seven from the NIH. Meanwhile, the faculty numbers 58, and the full-time clinical faculty has more than doubled in size in just the last three years.

Perhaps most importantly, this past summer the division was elevated to an individual department—the first of its kind at a medical school in Southern California. It may sound like mere semantics, but the new department status will help boost the program’s visibility and reputation, which, in turn, will help to recruit new faculty, says Woodley, professor and chair of the new department.

“Top faculty members usually prefer to come to a department instead of a division,” he explains. “Most of the top-tier medical schools nationally have dermatology departments, so it’s important that we’re able to compete on a level playing field.”

And while the program is already well-known for extensive clinical expertise and the management of rare skin diseases and wound healing, this latest move sets the stage for fulfilling Woodley’s ultimate goal: Making USC/Norris Comprehensive Cancer Center the go-to center for skin cancer care in Southern California.

“We have one of the highest skin cancer rates in the country,” he notes. “And yet there really hasn’t been a comprehensive, integrated skin cancer program in this area. We think we’re in a great position to provide that here at USC.”

Common cancers

Han N. Lee, M.D., has noticed something troubling about her skin cancer patients lately: They are getting younger.

“The average patient is still over 50, but I would say that about a third of my patients now are in their late 20s and early 30s,” says Lee, director of dermatologic surgery and assistant professor of dermatology at the Keck School.

That is a disturbing development, given that skin cancer is already the most common cancer in the United States and the world, affecting more than 1 million Americans every year. The most common form is basal cell carcinoma, followed by squamous cell carcinoma. Both of these cancers arise from cells in the epidermis, the skin’s outer layer, and typically appear on sun-exposed areas of the head and neck.

While basal and squamous cell carcinomas are highly curable and rarely metastasize, they can do plenty of damage. “They are locally destructive,” Lee says. “Left untreated, they slowly eat away at the surrounding tissue.”

The third major type of skin cancer—and the most serious—is melanoma, a cancer of the pigment-producing skin cells found in the dermis, the skin’s inner layer. Melanoma is more likely to metastasize and spread to other areas of the body and thus accounts for the vast majority of skin cancer deaths.

Lee was recruited to USC three years ago because of her expertise in skin cancer surgery. She is a fellowship-trained surgeon in Mohs micrographic surgery, considered the gold standard for removing non-melanomas in the head-and-neck area. It is also sometimes used to remove certain melanoma tumors. The specialized technique uses mapping and careful analysis of the entire tumor to ensure that all of it is removed, including its finger-like roots.

“Mohs surgery has the highest cure rate because we check 100 percent of the margins to make sure we remove all of the tumor,” she says. “And it helps conserve normal tissue because we trace out the exact tumor rather than guessing at a wide margin.”

Although melanoma makes up less than 5 percent of all skin cancer cases, its incidence is rising around the world, in all ethnic groups. The problem is particularly acute in Los Angeles, which has the second-highest rate of melanoma in the world. Only Australia has a higher incidence of the disease.

For that reason, USC/Norris recently established a melanoma program designed to cover the full spectrum of melanoma care, from prevention and education to treatment and follow-up for all stages of the disease. The interdisciplinary program involves dermatology as well as other departments, including oncology, pathology and preventive medicine.

“There hasn’t been a prominent melanoma center in Los Angeles before,” explains David Peng, M.D., M.P.H., Keck School assistant professor of dermatology. “We’re trying to provide one place where patients can go for every aspect of treatment.”

Peng has been working in the melanoma center at USC/Norris with Jeffrey Weber, M.D., Ph.D., the Lucy and Berle Adams Chair in Cancer Research, Keck School associate professor and chief of oncology and one of the foremost melanoma oncologists in the world. The center focuses primarily on treating melanoma patients, but also includes non-melanoma patients.

Advanced therapies

One of the biggest areas of growth in the Department of Dermatology is research, and much of it focuses on skin cancer.

For example, Peng and Manjunath Vadmal, M.D., director of dermatopathology at the Keck School, are trying to identify new markers that would more accurately predict how aggressive a melanoma tumor is and better direct a patient’s treatment.

“Right now, the only thing physicians have to go by is the thickness of the tumor,” explains Vadmal, assistant professor of pathology and medicine. “The deeper it goes, the more aggressive it is deemed to be. But that’s not a foolproof method.”

Researchers also are looking at new ways to prevent skin cancer. Peng is examining whether drugs known as COX-2 inhibitors prevent the onset of skin cancers. The drugs already have been shown to prevent skin cancer in mice. COX-2 drugs received extensive media attention due to concerns about heart problems in humans. The drug Celebrex now carries an FDA-mandated “black box warning” and two other COX-2 drugs, Vioxx and Bextra, were voluntarily withdrawn from the market in 2004.

Another area of study is the use of photodynamic therapy to treat actinic keratoses—thickened and scaly patches on the skin that can turn into squamous cell carcinoma. The therapy involves rubbing a topical medication on the skin, and then shining artificial ultraviolet light on it to stimulate destruction of abnormal cells.

The department is also trying to improve public education campaigns. Jeff Ashley, M.D., a voluntary faculty member, is helping schools to better educate children about sun safety. And Peng is working on how to better reach Spanish-speaking populations with campaigns about sun safety and how to recognize the signs of skin cancer.

“There’s a large rate of skin cancers in the Spanish-speaking population of Los Angeles,” Peng says, “but our education campaigns in this country have targeted English-speaking populations. We’re missing an important community.”

Genetic glitches

Skin cancer is just one area of expertise and research in the department. Faculty members have been known for their clinical excellence and management of rare diseases, thanks in part to a large patient population, with outpatient visits now totaling more than 37,000 each year. Researchers are particularly known for their work in genetic skin disorders, autoimmune blistering diseases, wound healing and psoriasis.

Mei Chen, Ph.D., Keck School professor of research in dermatology, is a leader in gene therapy for genetic diseases of the skin. In the disease epidermolysis bullosa, for one, children develop chronic, incurable blisters throughout their lives and ultimately develop aggressive skin cancers. Chen is working to devise gene or protein therapies to treat this condition.

One possibility is to inject a specific collagen, called type VII, to help the blistering. Patients with this disease are missing type VII, which helps create the essential “staples” that bind the skin’s epidermis to the inner dermis.

Woodley was part of the group of researchers to first clone the human gene for type VII collagen and continues to be involved in wound-healing research. He and Wei Li, Ph.D., Keck School associate professor of research in dermatology, are trying to determine what signaling mechanism prompts skin cells to start rapidly dividing and migrating to fill the gap created by a wound. Rapid cell division and migration, present in wound healing, are also the hallmarks of cancer cells. A better understanding of this process may provide important clues to the causes of some aggressive forms of skin cancer. Also, non-healing wounds are a chronic clinical problem, particularly in the elderly and people with diabetes or spinal cord injuries.

“If we could figure out how to deliver something to a wound that would jump-start this healing process, it could have a tremendous impact,” Woodley suggests.

Beneath the surface

It was Woodley’s determination that advanced dermatology from small division to department. Now he plans to recruit a full-time pediatric dermatologist and establish a fellowship in dermatopathology, a growing specialty field. As an expert in diagnosing skin biopsies under the microscope, a dermatopathologist works closely with pathologists and dermatologists in providing consultative expertise in difficult skin lesions and biopsies, so that clinical findings are correlated with biopsy findings.

“There aren’t many programs that offer a fellowship in this area, particularly in Southern California,” Vadmal says. “And yet there’s a great need because there is a high demand for dermatopathologists.”

Besides recruitment, Woodley also hopes to develop fellowships in Mohs surgery, laser surgery and cosmetic surgery. Meanwhile, David E. Sawcer, M.D., Ph.D., Keck School assistant professor of dermatology and director of clinical research, is leading efforts to build a strong clinical trials program.

“This is a dynamic time for dermatology at USC,” Woodley says. “We’ve accomplished so much in the past few years, but we’re really just beginning.”

Katie Sweeney is a freelance writer based in Los Angeles.

For more information about the Department of Dermatology at the Keck School of Medicine, or to learn more about The Doctors of USC, call 1-800-USC-CARE (1-800-872-2273).

 

PRESS THE FLESH

Skin is the body’s largest organ—and an important one. Its main job is to protect other organs and body parts from the outside world, while regulating body temperature, storing water and converting sunlight into vitamin D.

Given the skin’s importance, it makes sense that the study of skin—dermatology—is one of medicine’s oldest specialties. Modern dermatology has a 200-year history, and books on skin conditions date back to the ancient Greeks.

Dermatology has been part of a medical education at the Keck School of Medicine of USC almost since its inception over a century ago, says John T. Crissey, M.D., emeritus professor of dermatology. Crissey says that there have been significant changes since he began teaching at USC in 1964. First, the specialty is more diversified, encompassing medicine, surgery and pathology. More dermatologists are research-oriented, with one foot in

the clinic and the other foot in the laboratory.

By far, he says, the biggest advances in day-to-day dermatology care are drugs. “Cortisone and penicillin revolutionized the specialty, and there have been a whole host of new drugs to treat skin conditions such as psoriasis,” Crissey says.

The advent of new drugs throughout medicine has had a downside for dermatology, though: More skin problems. “It’s a rule of thumb that the more effective a drug is, the more likely it is to have side effects,” he says. “Many of those side effects are dermatological.”

Cosmetic dermatology also has expanded dramatically, with advances in everything from facial fillers to specialized lasers. Just a little over a decade ago, there were only about three types of lasers used in practice; today there are 33, says David E. Sawcer, M.D., Ph.D., Keck School assistant professor of dermatology and director of clinical research. While the first lasers offered only a couple of static settings, today’s lasers are designed for specific tasks and are dynamic and flexible, giving physicians more control over the intensity of the beam and reducing side effects. Sawcer remembers testing one of the first lasers on his own face, only to be left with huge bruises that took weeks to heal.

“Today you can do the same treatment, and a few hours later no one would ever know you had anything done to your face,” he says.