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Research rebound

Steady funding fuels dermatologic research after pandemic paralysis.


By Jan Bowers, Contributing Writer, December 1, 2022

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With the exception of the lifesaving mRNA vaccines developed at remarkable speed, many non-COVID-related research projects ground to a halt as the pandemic seized the nation. “Our laboratories shut down for several months in 2020. Patient clinical studies were severely impacted because we couldn’t bring in subjects,” said George Cotsarelis, MD, FAAD, professor of dermatology at the University of Pennsylvania’s Perelman School of Medicine and chair of the department of dermatology at the University of Pennsylvania Health System. “In addition, the ability to hire clinical coordinators, technicians, and other front-line workers for research became really challenging. One silver lining was that some of our physician scientists pivoted to COVID research; for example, what’s the best way to introduce the COVID vaccine? What cells take it up?”

Researchers applying for grants, and the public and private organizations reviewing the applications, also felt the impact of COVID, but those activities continued with some adjustments. The Dermatology Foundation, for example, conducted its reviews of grant applications remotely throughout 2020, said Dr. Cotsarelis, who oversees the foundation’s Research Award Program. “We also allowed flexibility for when funding would start, with multiple instances of months-long delays and extensions. At the same time, we saw an increase in the number of applications because people were stuck at home and had more time to write them.”

At the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) — one of 27 institutes and centers that comprise the National Institutes of Health (NIH) and a major source of funding for skin research — a new director assumed her responsibilities in early 2021, as the pandemic was raging. Lindsey A. Criswell, MD, former vice chancellor of research and professor of rheumatology and orofacial sciences at the University of California, San Francisco, said that NIAMS staff and research scientists showed “incredible resilience and responsiveness” in coping with severe disruption, revising their procedures to accommodate remote work, without knowing how long it would last. Now, even with effective vaccines and treatments, “there could be another surge, so we have to continue to be nimble and able to adjust quickly to changing circumstances.”

As the nation and the scientific community emerge from the worst of the pandemic, four prominent researchers discussed with DermWorld their views about the state of funding and current trends in dermatologic research.

Skin funding holds its own

The NIH has seen substantial funding increases over the past few years, not just for COVID research, but also targeted funding “to specific institutes for specific problems, whether that be Alzheimer’s research or the cancer moonshot,” said Dr. Criswell. However, “NIAMS has not received new funding targeted to an important problem. That means that the annual increases, on the order of 3% per year, don’t allow us to keep up with the rising costs of research, which are driven by new technologies and resources, salaries, etc.” From FY2012 to FY2022, NIH funding increased 46%, from $30.9 billion to $45.2 billion, while NIAMS funding grew only 22%, from $536 million to $656 million. Funding for skin research in the extramural portfolio has increased by 60% from $67 million in FY2012 to $108 million in FY2021.

“NIAMS has not received new funding targeted to an important problem. That means that the annual increases, on the order of 3% per year, don’t allow us to keep up with the rising costs of research, which are driven by new technologies and resources, salaries, etc.”

The success rates of reviewed research project grant (RPG) applications (i.e., the percentage of applications that receive funding) has also held steady over the past decade, rising slightly from 14.9% in FY2011 to 17.6% in FY2021). In this competitive environment, “the dermatology research community is absolutely outstanding,” said Dr. Criswell. “They are training top-notch physician scientists who are well supported by the dermatology nonprofit organizations. As a result, they’re competing well for some of the most competitive funding mechanisms, such as our centers of research translation, our so-called P50 grants. We have centers of research translation funding efforts in alopecia areata, psoriasis, scleroderma, and acne. We are also funding clinical trials focusing on eczema and allergic skin conditions, acne, a novel form of therapy for some of the dermatologic manifestations of Down syndrome, and some of the skin problems in amputees.” Dr. Criswell also noted that “there are at least 10 or 12 institutional research training grants that focus on dermatology, so that’s a testament to the promise that this field holds for continuing to train a strong pipeline of investigators.”

NIAMS is the primary source of government funding for skin biology and disease research, but by no means the only one. The National Cancer Institute, the National Institute of Allergy and Infectious Diseases, the National Institute of General Medical Sciences, and the Department of Defense also support skin research. Additional funding sources include medical associations, disease-focused foundations, and private industry (see sidebar).

Research focus on skin of color

When Paul Nghiem, MD, PhD, FAAD, launched his dermatology career in the 1990s, “the giant problems were melanoma, psoriasis, and atopic dermatitis. Those were chronic disorders affecting a lot of people that we didn’t have satisfactory therapies for; they were big problems that needed research. Since then, the progress in those areas has been exciting and significant, and they’re still getting lots of research and attention. That’s because progress begets progress, and excitement begets excitement.” Dr. Nghiem is professor and chair of dermatology at the University of Washington School of Medicine, where he heads a research lab dedicated to the study of Merkel cell carcinoma.

Now many researchers are turning to the study of diseases with an outsized impact on skin of color, such as hidradenitis suppurativa (HS) and vitiligo. “Hidradenitis suppurativa is a uniquely horrible skin disease that I think we’re on the cusp of learning more about,” said Dr. Nghiem. “It’s a huge area that I think we all recognize needs, and is finally getting, more attention. Another exciting area is itch; our biological understanding of itch is so much more sophisticated, and it’s garnering a lot more research as well.” At the University of Massachusetts Chan Medical School, John E. Harris, MD, PhD, FAAD, professor and chair of the department of dermatology, recently recruited a clinician, Dr. Jessica St. John, and a physician scientist, Dr. Sarah Whitley, to focus on HS. “Dr. St. John started an HS clinic that has grown significantly over the past few years,” he noted. “Dr. Whitley has a lab devoted to the study of HS, and she is supported by a K08 [NIH career development] award. The two of them are working together to diagnose, treat, and investigate HS — I see that as a huge opportunity to address unmet need in our patient community.”

Dr. Harris recently received an NIH P50 grant of $5.7 million over five years to study vitiligo. He said that in his grant applications, “we communicate that vitiligo disproportionately affects particularly vulnerable populations, those with darker skin who have been historically underserved. At some point, [funding organizations] must make sure they’re supporting research in a diverse cadre of diseases, including those that impact historically underserved populations. I think they’re starting to do this, including both HS and vitiligo, which are quite common and traditionally have had very little research.”

“There have been a lot of efforts, particularly in the last five years, to increase the share of underrepresented minorities in the pipeline.”

In addition to HS and vitiligo, Dr. Harris cited atopic dermatitis, psoriasis, and alopecia areata as diseases that are maintaining or increasing their level of funding. One that is somewhat overlooked, in his opinion, is lupus. “I think we need to redouble our efforts there because it’s such a devastating disease that affects so many people, and there are so many different forms. Studying skin lupus could give you insights into systemic lupus, which is deadly.” Systemic lupus and psoriasis are two of the disorders that will be studied as part of a public-private partnership launched in 2021, Dr. Criswell said. The Accelerating Medicines Partnership® Autoimmune and Immune-Mediated Diseases (AMP® AIM) Program is managed by the Foundation for the NIH and combines resources from the NIH, pharmaceutical companies, and nonprofit organizations. NIAMS participates in two other AMP programs, including one focused on gene therapies for rare diseases.

The American Academy of Dermatology Association (AADA) addresses the need to study disorders in skin of color through its advocacy at the national level. “Our role is really on the front end of advocating for funding from Congress,” said Jennifer Mangone, JD, the AADA’s manager of congressional policy. “This past year, we approached some of our champions in the House of Representatives about ways we could advance our DEI initiatives. Was there anything we could potentially do around skin cancer in underserved communities?”

The upshot of those discussions was a major win for the AADA. In March, Congress approved the Consolidated Appropriations Act, 2022 (HR 2471), which included AADA-approved language “directing the CDC to conduct a study specifically on skin cancer in underserved and minority communities to understand why the rates are often higher in those communities and whether they’re getting the resources they need,” Mangone said. “It’s not a line item, it doesn’t cost any money to include. It just requires the agency to move forward with finding a way to do the study.”

Derm societies support research efforts

In addition to robust funding from the federal government, dermatology researchers receive support through medical societies, disease-focused nonprofit groups such as the National Alopecia Areata Foundation and the National Psoriasis Foundation, and pharmaceutical firms. The AAD provides a list of funding organizations on its website to help members find support for their research efforts.

The Dermatology Foundation core mission is to help fund the most promising junior investigators, said George Cotsarelis, MD, FAAD. With about $3 million per year in funding, “past studies have shown that 80-90% of the investigators we fund end up getting NIH funding and establishing an independent research program.” In 2022 the Dermatology Foundation made awards to 49 researchers for projects ranging from basic science to population studies. Career development awards were given in a variety of categories, including dermatologic surgery, diversity, equity, and inclusion, public health, the science of human appearance, and women’s health. The Diversity Research Supplement Award is available to recent recipients of DF awards to support the in-depth participation of a medical student belonging to one or more groups considered to be underrepresented in biomedical research. Learn more.

The Society for Investigative Dermatology, through its Freinkel Diversity Fellowship program, awards two-year fellowships to women and underrepresented minorities. Using funds provided by Sanofi and Regeneron Pharmaceuticals, the SID also offers the SID Type 2 Inflammation Innovation Awards, intended to support cutting-edge, innovative research projects being conducted in the U.S. by junior investigators. The SID also helps members connect with funding opportunities related to its annual meeting and other partner society meetings. Learn more.

The AAD offers more than two dozen awards, grants, and scholarships to recognize the contributions of individuals to the specialty and support research in the field of dermatology. For 25 years, the Academy has recognized outstanding basic, translational, and clinical research by young dermatology investigators in the United States and Canada through the AAD Young Investigator Awards (YIA). Currently, one basic/translational researcher and one clinical are selected each year to receive a $6,000 prize based on their body of research. During the past few years, the YIA recipients’ areas of study have included management of acne, prurigo nodularis pathogenesis, epidemiology of pediatric atopic dermatitis, and inflammatory diseases and skin.

In 2021, the Academy established the AAD Hair Loss and Alopecia Initiative in Research (HAIR) Grant Program to fund projects that address gaps in hair disorders research. Read more about the research that received HAIR Grants in the May and October 2022 issues of DermWorld.

Support for young, diverse investigators

Initiatives at NIAMS and at many academic research centers are focused on the goal of increasing the number of underrepresented minorities who conduct research and receive funding. “Unfortunately, dermatology is one of the least diverse specialties. I’m not really sure why that is, but it’s definitely the case,” said Dr. Cotsarelis. “So there have been a lot of efforts, particularly in the last five years, to increase the share of underrepresented minorities in the pipeline.” At Penn, that effort starts early, through a program that recruits Philadelphia-area high school students to come to the dermatology department for four Saturdays to learn about skin and research, Dr. Cotsarelis said. “Those types of programs are really important, and we do have to work on the pipeline because right now there is a very limited number of candidates for faculty positions, and everybody wants them.” Dr. Nghiem noted that in addition to efforts by the AAD, the Society for Investigative Dermatology, the Dermatology Foundation, and other dermatologic societies, “every university is realizing this is important, and there are many fellowships and funded rotation opportunities for students who are underrepresented in dermatology.”

Are DEI initiatives translating to more funding for researchers of color? UNITE, the NIH’s broad program designed to address “structural racism within the NIH-supported and the greater scientific community,” includes elements to increase diversity among funding recipients. But according to NIH data from 1995 to 2019, the share of PhD applicants receiving funding is still overwhelmingly white, although Asian, Hispanic, and African American applicants have made incremental gains. NIH funded investigators may be eligible to apply for a Diversity Supplement Award to support research training for individuals with diverse backgrounds. “The diversity supplements program has been around for quite a long time,” said Dr. Criswell. “What NIAMS is doing that’s new is to bring together the diversity supplement awardees as a cohort for mentoring and networking. These efforts started just prior to the pandemic and have continued virtually. We are really excited with how well this is working.”

Several dermatology societies focus on helping young investigators launch their research careers and advance to the point where they can compete successfully for NIH funding. “I think that’s an important role for the foundations,” said Dr. Harris. “I received awards from the Dermatology Foundation, the American Skin Association, and the Skin of Color Society early in my career. They all played a really important role in getting me started so that I could survive long enough to successfully compete for NIH and other funding.” NIAMS gives a boost to early-stage investigators through a differential payline (a percentile ranking derived from the score awarded a grant application): in the FY2022 funding plan, competing applications for R01 grants are paid through the 12th percentile, while R01 applications from early-stage investigators are paid through the 17th percentile.

Another group seeing greater success in the hunt for research support is the MD/PhD, said Dr. Harris. “When I was training, I was told that it’s much harder for a physician scientist to get funding, because we’re ‘distracted’ — the time we spend doing clinics is time we’re not spending reading papers or writing grants. But now, being a physician scientist gives you access to patients and patient tissues that you can’t get otherwise. And now that we have translational research, new tools like single-cell sequencing, and so much research is being done using translational methods, we’re not disadvantaged anymore and maybe we even have a leg up. I know that at least at my institution, many of the MD/PhD students want to be dermatologists because of this new opportunity.”

The competition for research funding is intense and can be discouraging. “I’m kind of famous in the dermatology community because I received seven rejections on R01 applications before I got one,” said Dr. Harris. “That was hard for me, and I almost gave up. But my program officer at the NIH, Ricardo Cibotti, and my wife made me write at least one more application, and that was the one that was funded.” Dr. Nghiem maintained that “it remains difficult to get funding, but it’s pretty feasible if you show you’re really going to lend support and biological understanding, and it has relevance to a disease. I think COVID made everybody realize — everybody who’s awake at all — that biomedical science is really important, and I view it as having actually increased the size of the funding pie.”