By Abby S. Van Voorhees, MD, July 02, 2012Paradigm changes are rare; this month I have two for you.
One comes to us from Washington, and the other from science. For those of you who remember the game we played as children where the question was how big a step is possible, these are big steps. I know that you will want to read our analysis of the events as a result of the Supreme Court decision about health care reform and, at press time, we were anxious to write it, awaiting the decision. Whatever it ended up being — and we hope, by the time you’re holding this, the answer has been revealed — we promise to do our best to provide you with as thorough an analysis as feasible. We promise to keep our focus on dermatology, and try to help you digest the possible ramifications, both the opportunities that may open up to us as well as the concerns for practice as it stands now. I hope that you will find our analysis useful whether you think that the decision is a good one or not. Head to www.aad.org for the latest and look forward to more coverage of the ruling’s impact in DW in the months to come.
The second paradigm change this month is in our Acta Eruditorum column. Tom Kupper, MD, and his colleagues have moved us forward in our understanding of immunology. Not too often that our knowledge of science takes a big step forward, but I think that you’ll agree that his article in Nature does just that. Using smallpox infection as a model, they were able to identify CD8-positive skin cells that reside locally, which turn out to be of utmost importance in our development of immunity to this infection. Previously it was believed that most of our immunity to infections like this resided in the lymph nodes or blood, and that these cells came rushing in response to infection, sort of like the fire engine paradigm. It turns out that our immune systems function more like turtles hanging out in the skin for long periods, rarely getting attention but ready for action if re-exposure occurs. These skin-resident immune cells have previously been overlooked, and so understanding their important role in protecting the host against skin infections such as vaccinia is a critical new understanding; ground changing. This also explains the mechanism for contact dermatitis, and maybe even why my psoriasis patients always tell me that their lesions recur in the same locations. This may even change the way we vaccinate people over the next few years. I, for one, never understood why vaccines were all uniformly given in the arm, and maybe this new understanding tells us that this is not the best strategy after all. Maybe we’ll start to vaccinate ourselves in different ways taking advantage of these local immune cells for each type of infection before too long. As Tom says, “Imagine, for HIV, if you could generate populations of tissue-resident T cells that went to and remained in reproductive and anogenital mucosa — that’s really what you need for a vaccine. You don’t need T cells circulating in the blood.” You won’t want to miss reading this one.
Don’t limit yourself to those two pieces. Be sure to check out our others. I know that you’ll enjoy reading about what is going on with some of the drug shortages that are impacting dermatology, the importance of having a compliance plan, our piece on quality measures, and even an update on the less-often-utilized modifiers. Vicky Werth, MD, also shares with us how she uses a beloved hobby to share some special time with her family … seems like she’s figured out how to continue her love of music while at the same time hanging out with her kids. Pretty clever if you ask me.
Hope that you find each of these pieces of value and of interest. Enjoy your reading.