Pivotal dermatologists elevate the status of specialty
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In each medical specialty and each generation, there are a handful of individuals whose contributions change the field. As the American Academy of Dermatology concludes its 75th anniversary celebration this month (learn more at www.aad.org/75th), Dermatology World chose five giants in the field’s past who helped chart the course of its future: Drs. Louis A. Duhring, Donald M. Pillsbury, Walter F. Lever, Frederic E. Mohs, and A. Bernard Ackerman.

Louis A. Duhring (1845-1913)

Louis A. Duhring, MD, may be known as “Philadelphia’s first skin specialist,” but his legacy extends far beyond Pennsylvania.

After receiving his medical degree from the University of Pennsylvania in 1867, Dr. Duhring interned at Philadelphia (Blockley) Hospital. There, he became interested in skin diseases and went abroad to study dermatology. Dr. Duhring returned to Philadelphia and in 1871 opened the Philadelphia Dispensary for Skin Diseases, a move that raised dermatology’s profile among the other specialties. The same year, he was appointed a lecturer on skin diseases at the university, launching a 40-year career there.

In 1874, the university opened its own hospital, naming Dr. Duhring the first chief of dermatology. He also was appointed visiting dermatologist to the newly established dermatology department at Blockley Hospital. Dr. Duhring was made full professor at the university in 1890, making him one of the first professors of skin disease in America.

“Dr. Duhring is an important historical figure at Penn,” noted George Cotsarelis, MD, professor and chair of the department of dermatology at the University of Pennsylvania. He created the department of dermatology, which is the oldest in the country, he said. [pagebreak]

Dr. Duhring is credited with authoring the first American textbook on skin diseases. He self-published the Atlas of Skin Diseases, which remained the definitive work on the topic for the next 50 years. His next book, A Practical Treatise on Diseases of the Skin, published in 1877, was translated into several languages, establishing him as a top American authority of dermatology. He published Cutaneous Medicine, a two-part encyclopedia; the third part was destroyed in a fire so the work was never completed.

Early in his career, Dr. Duhring described an uncommon inflammatory disease that was hotly debated at the time. That disease is dermatitis herpetiformis, which is now commonly referred to as Duhring’s disease.

Dr. Cotsarelis has had an opportunity to look at some of the textbooks that Dr. Duhring wrote as they are housed in the university’s archives. Dr. Cotsarelis was shocked at how similar the information in A Practical Treatise on Diseases of the Skin is to current textbooks. With regard to alopecia, a personal interest of Dr. Cotsarelis, not only were the descriptions accurate, the explanations of what causes it haven’t changed significantly either, he noted.

Dr. Duhring was also a founding member of the American Dermatological Association and twice served as its president. He was made an honorary member of dermatologic societies in five European countries. [pagebreak]

Dr. Duhring died in 1913. A wise investor who started from a substantial inheritance, “he accumulated a significant fortune,” according to Pantheon of Dermatology, a book that chronicles the lives of more than 200 historic dermatologists. But he had no children of his own to leave it to (though, Pantheon notes, he was “generous with his nephews, nieces, and cousins”). Upon his death, he left more than $1 million to various Philadelphia organizations, with much of it going to the Penn dermatology department, helping to establish its world-renowned reputation. A wing of the university’s Furness Library (now the Fisher Fine Arts Library) was named in his honor, as is a laboratory. Portraits of Dr. Duhring hang on walls in many campus buildings.

“Historically, Penn has had a really great program and reputation and that, in part, goes back to Dr. Duhring,” Dr. Cotsarelis said.

Donald M. Pillsbury (1902-1980)

Donald M. Pillsbury, MD, is credited with helping fund and direct dermatologic research in this country.

After graduating from medical school, Dr. Pillsbury trained in dermatology and syphilology at the University of Pennsylvania, where he participated in some of the earliest studies of the skin. His research was interrupted by World War II, in which he served as a dermatologic consultant first for the National Research Council and then for the U.S. Army in Europe. In 1942, Colonel Pillsbury co-wrote the Manual of Dermatology with Marion Sulzberger, MD, and Clarence Livingood, MD. The manual became the bible for treating venereal disease and managing skin diseases of the troops scattered around the world, noted Robert Goltz, MD, professor emeritus, department of medicine, at the University of California San Diego. [pagebreak]

After the war, Dr. Pillsbury returned to the university where he became a professor and chair of the dermatology department. Dr. Pillsbury established a core research group including such individuals as Walter Shelley, MD, and Albert Kligman, MD. “By recruiting excellent faculty members, he maintained the status of Penn as one of the outstanding training centers in the country,” noted Samuel Moschella, MD, an investigative dermatologist at Lahey Hospital and Medical Center in Burlington, Mass., and clinical professor of dermatology, emeritus, at Harvard Medical School in Boston.

Although Dr. Pillsbury remained department chair at Penn for 20 years and a faculty member for more than 50 years, he always answered the government’s call. Dr. Pillsbury chaired or was a member of at least 20 major national governmental agencies and commissions, including the armed forces’ first commission on dermatologic research, the Public Health Service, and the Veterans Administration.

Because of his connections during the war and at the National Institutes of Health (NIH) after the war, Dr. Pillsbury helped secure financial funding of dermatologic research elevating dermatology in the scientific community, explained Lawrence Charles Parish, MD, clinical professor of dermatology and cutaneous biology, and director of the Jefferson Center for International Dermatology at the Jefferson Medical College of Thomas Jefferson University in Philadelphia.

Dr. Moschella recalled when he worked at the U.S. Naval Hospital in Philadelphia in the late 1940s. Shortly after explaining to Dr. Pillsbury that there was no research budget, he received a $10,000 grant to conduct studies. “If you needed something in the military, you just asked Dr. Pillsbury,” he said. [pagebreak]

A founding member of the Dermatology Foundation, Dr. Pillsbury was the logical choice for its first president. “It’s one of the reasons why the foundation got off to a good start,” said Eugene Van Scott, MD, an investigative researcher who helped establish the Dermatology Branch of the National Cancer Institute and served as its chief for more than 15 years. Dr. Pillsbury also has the distinction of serving as president of all six national dermatologic organizations in this country. In addition to medals given for his military service, he was bestowed the highest awards in his field. Dr. Pillsbury was an honorary member of dermatologic societies around the world. He also wrote five textbooks and published more than 100 scientific articles.

Since 1984, the University of Pennsylvania has hosted the Annual Pillsbury Dinner and Lecture. “His trainees established the lectureship in his honor,” explained Dr. Cotsarelis, who speaks at the dinner. “It’s an indication of how well loved he was.” While Dr. Cotsarelis didn’t know Dr. Pillsbury personally, he worked with Dr. Kligman, who did, and still remembers hearing stories about him. “Albert Kligman held Pillsbury in the highest regard. The word he always used was ‘angelic.’” And Dr. Kligman saw Dr. Pillsbury’s other talents firsthand as well, Dr. Cotsarelis said. “One day, he was amazed to see Pillsbury sit down and play the piano. There was a musical side to him that not many people were aware of.”

Walter F. Lever (1909-1992)

Walter F. Lever, MD, immigrated to the United States in 1936 from Germany where he received his training as a dermatologist. After finishing his residency at Harvard Medical School and Massachusetts General Hospital in Boston, he stayed on to do research in internal medicine. His focus was two-fold: bullous disease and dermatopathology. After receiving a grant from the NIH, Dr. Lever started his own research lab. Next, he was appointed assistant professor of dermatology at Harvard. Eight years later, Dr. Lever was named professor and chair of dermatology at Tufts University Medical School in Boston. “The department grew remarkably under his leadership, in part, because he was able to obtain NIH support for his research and training,” noted Dr. Moschella, who met Dr. Lever in the 1950s. He was also chief of dermatology at the Tufts service at Boston City Hospital and the New England Medical Center and remained a dermatologic consultant at Massachusetts General. [pagebreak]

After World War II, Dr. Lever began giving courses in dermatopathology designed for physicians who were returning to practice after serving in the armed forces. Because there was no textbook to use, Dr. Lever wrote one. Now in its tenth edition, Histopathology of the Skin was the first dermatopathology textbook written in English, Dr. Moschella said. Dr. Lever was involved in writing eight of the 10 editions, which have been translated into several languages. Dr. Lever also authored two other textbooks, one of which he wrote with his wife Gundula Schaumburg-Lever, MD, and nearly 180 scientific articles. Among the latter is the first paper published in the JAAD in 1979.

Dr. Moschella routinely attended Dr. Lever’s pathology lectures at Massachusetts General. “Walter was a very forceful teacher and a good clinician,” he said. Dr. Lever was instrumental in teaching dermatopathology to generations of dermatopathologists, pathologists, and dermatologists.

He also was known as a worldwide authority on blister diseases, Dr. Moschella said. His research on bullous diseases led him to distinguish between pemphigus vulgaris, bullous pemphigoid, and dermatitis herpetiformis. Dr. Lever separated the blister diseases and cleared up a lot of confusion about them, Dr. Moschella said. Dr. Lever promoted the treatment of pemphigus vulgaris and bullous pemphigoid with an initial high dose of corticosteroids.

Dr. Lever was a founding member and past president of the American Society of Dermatopathology. He held an honorary membership in 16 dermatologic societies throughout the world. “Walter had a passion for what he did,” Dr. Moschella said. “He had a twinkle in his eye and a lot of energy. He was a little guy; I don’t know how he had so much energy. He never walked, he ran. When he talked, you couldn’t shut him up.” In addition to his energy, Pantheon notes Dr. Lever’s many hobbies, among them mountain climbing, skiing, travel, classical music, and opera.

Although Dr. Lever retired from the university in 1976, he continued to work in private practice and at his dermatopathology lab with his wife. In 1983, they returned to Dr. Lever’s native Germany, where Gundula took over the dermatopathology department at Tübingen. [pagebreak]

Frederic E. Mohs (1910-2002)

Frederick E. Mohs, a general surgeon, is responsible for transforming dermatology into a surgical as well as medical specialty.

As a medical student and then cancer research fellow at the University of Wisconsin-Madison, Dr. Mohs pioneered the concept of microscopic control of skin cancer. He developed a zinc chloride paste that when applied to tumors as a topical fixative penetrated the tissue without causing systemic toxicity. Next, he used surgical excision to remove the tumor and a microscope to examine the tumor’s margins. These steps were repeated until the entire tumor was removed and the margins cleared. The wound was allowed to heal by secondary intention.

This fixed tissue technique, which became known as chemosurgery, was used for more than a decade. Although initially it was not widely accepted, its ability to allow for maximum tissue sparing, high cure rates, and excellent cosmesis won over the skeptics. Dr. Mohs received a patent for his fixative paste and sold it to the Wisconsin Alumni Research Foundation for one dollar. In 1967, he founded the American College of Chemosurgery, which is now known as the American College of Mohs Surgery.

The critics were silenced when this fixed tissue technique evolved into a fresh tissue technique. In 1969, Dr. Mohs reported a five-year 100 percent cure rate for 66 basal cell and squamous cell carcinomas of the eyelid removed using this technique.

Despite having revolutionized dermatologic surgery, Dr. Mohs was a modest, very unassuming individual, Dr. Goltz noted. Physicians from across the country, including Dr. Goltz, referred the most difficult skin cancer patients to Dr. Mohs. “He operated in a little cubicle on a lawn chair. He charged five dollars a layer,” Dr. Goltz said. [pagebreak]

When treating those patients, Dr. Mohs had a most gentle manner, recalled Stephen Snow, MD, a dermatologist in the Mohs surgery unit at Kaiser Permanente, who had a year-long fellowship with Dr. Mohs starting in 1981. Having heard about Mohs surgery, Dr. Snow contacted Dr. Mohs who promptly told him to “come on over and learn the technique,” Dr. Snow said. “I had no letters of recommendation. I had no contract. It was just his word that I had a job. That’s how he handled his fellowships. He was very unassuming.” In 1982, Dr. Snow joined the faculty at the University of Wisconsin-Madison in the surgery department where he worked with Dr. Mohs until the latter retired in 1986. Dr. Mohs continued to come into UW Health Dermatologic/Mohs Surgery Clinic until the early 1990s.

He had a very gentle manner when it came to managing patients, Dr. Snow said. “He treated them like human beings, not just patients.” And his clinic was his baby. “It was important to him that we continue the clinic the way he set it up. He never told us that. You just knew it. He was very paternal.” In addition to his stewardship of his clinic, Dr. Mohs helped shepherd into being the First Unitarian Society Meetinghouse in Madison, working with Frank Lloyd Wright. The building is on the National Register of Historic Places and has been designated a National Historic Landmark.

In addition to making surgery a component of dermatology, which was previously considered a medical specialty, Dr. Mohs helped dermatologists claim skin cancer as their area of expertise, said David M. Pariser, professor in the department of dermatology at Eastern Virginia Medical School in Norfolk. Dr. Mohs trained a generation of fellows from across the country and around the world, said Dr. Pariser, who is also a member of the AAD’s History Committee. Today, all dermatology residency training programs in the United States must provide exposure to the Mohs technique; many second- and third-year residents receive hands-on experience.

“Without Dr. Mohs, dermatologists would still be doing only biopsies,” Dr. Snow concluded. [pagebreak]

A. Bernard Ackerman (1936-2008)

A. Bernard Ackerman, MD, was to dermatopathology what Dr. Mohs was to dermatologic surgery, Dr. Pariser noted. “He was an icon of dermatopathology who helped define the field.”

A graduate of Princeton University majoring in religion and literature and of Columbia University’s College of Physicians and Surgeons, Dr. Ackerman did dermatology residencies at Columbia Presbyterian Medical Center, Hospital of the University of Pennsylvania, and Harvard-Massachusetts General Hospital. He capped those off with a dermatopathology fellowship at Harvard. Dr. Ackerman served as director of dermatopathology at New York University for 20 years. During that time, he founded the International Society of Dermatopathology. In 1999, Dr. Ackerman founded the Ackerman Academy of Dermatopathology in New York City, in conjunction with AmeriPath, Inc. He served for five years as the director of the center devoted to the diagnosis, teaching, and advancing knowledge of skin diseases.

His overarching contribution to the field is the algorithms that Dr. Ackerman developed for interpreting and classifying inflammatory diseases, Dr. Moschella said. These were published in the book entitled Histological Diagnosis of Inflammatory Skin Diseases in 1978. Dr. Ackerman’s emphasis on pattern analysis had a profound influence not only in dermatology, but in pathology, as well. He went on to write approximately 60 books in which he covered every aspect of dermatopathology. Among his groundbreaking publications were Differential Diagnosis in Dermatopthology, The Lives of Lesions, Pitfalls in Histopathologic Diagnosis of Malignant Melanoma, and Clues to Diagnosis. “Bernie applied what he called Sherlockian dermatopathology in which he looked for clues to arrive at a diagnosis,” Dr. Moschella said. He also contributed criteria for recognition of mycosis fungoides, Kaposi’s sarcoma, and melanoma in situ. [pagebreak]

Dr. Ackerman published more than 700 scientific papers and even started two journals: The American Journal of Dermatopathology and Dermatopathology: Practical and Conceptual. He was also involved in creating the website www.derm101.com.

Dr. Ackerman may be best known for his 27-headed microscope. Students from around the world came to sit around it as he reviewed hundreds of cases, noted Dr. Moschella, who never missed an opportunity to visit with Dr. Ackerman when in New York. “His mastery of art and science in lecturing made him a legend,” he said. “Bernie mesmerized the audience with his interludes of musicians and artists.” Dr. Ackerman is credited with training more than 400 dermatopathologists.

He was an intellectual and combatant at times, Dr. Moschella said. “He didn’t tolerate or defend ignorance and critiqued everybody, including himself.” But he also was generous and created numerous educational grants for medical students. Among them is the A. Bernard Ackerman Endowment for the Culture of Medicine at Harvard Medical School, designed to encourage collaboration among the arts and sciences, medical school, and other departments. Additionally, he donated a dermatopathology reading room at Massachusetts General Hospital.