Spirit and Soul of Swiss Dermatology and Venereology 1913–2013

Home , Monika Harms, Robert Willan, Sahachiro Hata

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Spirit and Soul of Swiss Dermatology and Venereology 1913-2013

Schweizerische Gesellschaft für Dermatologie und Venerologie Société Suisse de Dermatologie et Vénéréologie

Spirit and Soul of Swiss Dermatology and Venereology 1913-2013

Éditions Alphil © Éditions Alphil, 2013 Case postale 4 2002 Neuchâtel 2 Suisse www.alphil.ch

Alphil Distribution [email protected]

ISBN 978-2-940489-46-6

We would like to thank: – This book could be realized through the generous support of the SSDV. It is the birthday present from the SSDV to its faithful members and friends.

– Translations: • English: Susan Travis, [email protected] • Français: Pierre Prince, [email protected] • Italiano: Davide Donghi, [email protected] • Rumantsch: Gion Tscharner, [email protected]

– English Proof Reading: The SSDV would like to acknlowledge the outstanding cooperation with Mrs Susan Travis, [email protected]

Responsable d’édition : Inês Marques Couverture : Andreas Spörri, [email protected] Photographies du dos de couverture: Première page de l’invitation pour la 12e Réunion annuelle de la SSDV et commémoration du 25e anniversaire de sa fondation, Genève 25 et 26 juin 1938. Archives de la SSDV. Photo de 2013: source Jürg Hafner, Zürich

Table of contents

Happy Birthday SSDV!...... 11

1 – Introduction 100 Jahre Schweizerische Gesellschaft für Dermatologie und Venerologie: Vergangenheit – Gegenwart – Zukunft...... 15 Les 100 ans de la Société Suisse de Dermatologie et Vénéréologie : passé – présent – futur...... 25 100 Anni di Società Svizzera di Dermatologia e Venereologia: Passato – Presente – Futuro...... 35 100 ons Società Svizra da Dermatologia e Venereologia: passà – preschaint – avegnir...... 45 Centennial of the Swiss Society of Dermatology and Venereology: Past – Present – Future...... 55

2 – Dermatology in Switzerland – the outside perspective of the Doyens The Perspective of the German Doyens...... 67 The Perspective of the Austrian Doyens...... 71 The Perspective of the French Doyens...... 75 The Perspective of the Italian Doyens...... 77 The Perspective of the US Doyens...... 83

3 – The Five University Dermatology Departments of Switzerland University Hospital of Basel...... 93 University Hospital of Berne...... 101

7 Spirit and Soul of Swiss Dermatology and Venereology

University Hospital of Geneva...... 135 University Hospital of Lausanne...... 147 University Hospital of Zurich...... 161

4 – The Six Public Outpatient Clinics Aarau...... 183 Bellinzona...... 195 Frauenfeld...... 201 Lucerne...... 205 St. Gall...... 209 Zurich Triemli...... 221

5 – The Presidents of the SSDV 1975-1978...... 235 1981-1984...... 239 1987-1990...... 241 1993-1996...... 251 1996-1999...... 255 1999-2002...... 261 2002-2005...... 265 2005-2007...... 273 2007-2009...... 277 2009-2011...... 283 2011-...... 295 Secretary...... 305

6 – Dermatological research in Switzerland one hundred years ago The first scientific congresses of the Swiss Society of Dermatology and Venereology (SSDV)...... 315

7 – Subspecialities and Working Groups Acne...... 343 Allergology...... 345

Andrology...... 369 Angiology, Phlebology, Leg Ulcers...... 373 Aesthetic Dermatology...... 379 Genetic Diseases in Dermatology...... 389 Dermatological Immunology...... 393 Dermatology in immunosuppressed patients...... 401 Infectious Diseases of the skin (except STI)...... 411 Dermatologic Mycology...... 443 Lasers in Dermatology...... 453 Cutaneous Lymphomas...... 459 Dermatologic Oncology...... 469 Radiotherapy...... 479 Dermatopathology...... 485 Pediatric Dermatology...... 493 Dermatologic Surgery...... 501 Trichology...... 511 Tropical Dermatology...... 519 Venereal Diseases (Sexually Transmitted Infections)...... 537 Wound Healing...... 545

8 – Educating Physicians Undergraduate...... 553 The Residents’ View...... 561 The Research Fellow’s View...... 567 Hospital Careers for Women...... 571 Postgraduate, and the UEMS...... 575 Swiss Institute for Medical Education (SIME)...... 583

9 – Health Politics in Switzerland Health Politics in Switzerland...... 591 List of autors...... 605 Editors...... 609

Happy Birthday SSDV!

100 years ago, on the 24th of April 1913, the Swiss Society of Dermatology and Syphilology (from 1917 the Swiss Society of Dermatology and Venereology) was founded by a group of then pioneers of the specialty (picture see verso/back). A year earlier, the Seventh International Congress of Dermatology and Syphilology had been held in Rome with the modern idea of founding an international association of dermato-venereological societies of all nations. This gave the Swiss dermatologists the impetus to establish their own society. The years 1914-1945 were characterised by two world wars and the Great Depression, the years 1945-1989 by the post-war economic boom and the Cold War, and the years since 1989 by globalisation. In the 1940s it was antibiotics, in the post-war years engineering sciences and fundamental scientific research, and in the last 25 years molecular biology and the global spread of information technology and the Internet, which have led to breath-takingly rapid advances in medicine. In particular molecular diagnosis and the so-called “targeted therapies” have most definitely dragged dermatology out of the corner of the “dirty diseases” and made it one of the most modern medical specialties. He who knows history can better understand the present. Past – present – future is the motto of this year’s annual general meeting of the SSDV in Montreux and of this book. We wanted to write a living book, which reflects the spirit and soul of Swiss dermatology. With its broad diversity of culture, languages and landscapes, Switzerland is extremely well-connected globally. The introductory chapter is therefore written in all four Swiss

11 Spirit and Soul of Swiss Dermatology and Venereology languages, and all other chapters in English, in order to reach our friends and interested readers all over the world. The three editors, the board of the SSDV and the SSDV members would like to thank the authors for their lively and authentic contributions and to wish all readers inspiration and pleasure. We wish the SSDV itself, however – and we are the SSDV! – a wonderful birthday party and continued success in the future.

Jürg Hafner, Michael Geiges, Michel Gilliet (Editors)

12 1

Introduction

100 Jahre Schweizerische Gesellschaft für Dermatologie und Venerologie: Vergangenheit – Gegenwart – Zukunft

Jürg Hafner*, Peter Bloch*, Lars French*°°, Jean-Pierre Grillet*, Daniel Hohl*, Carlo Mainetti*, Gionata Marazza*, Monica Pongratz*, Enrica Bianchi°, Konstantine Buxtorf Friedli°, Stephan Lautenschlager°, Christian Schuster°, Andreas Skaria°, Elisabeth Toszeghi°, Gion Tscharner°, Wolf-Henning Boehncke°°, Luca Borradori°°, Michel Gilliet°°, Peter Itin°°

*Ausschuss, °Vorstand, °°Universitätsklinikdirektor und Vorstand

Am 24. April 2013 begeht die SGDV ihren 100. Geburtstag. In diesem Moment denkt man an Respekt, Dankbarkeit und Entschlossenheit: Respekt vor der Pioniergeneration, welche Ende des 19. Jahrhunderts die Schweizer Dermatologie und Venerologie aus der Taufe hob und neu etablierte, sowie vor den nachfolgenden Generationen, welche diese Erfolgsgeschichte fortschrieben; Dankbarkeit für das Privileg, den Arztberuf ausüben zu dürfen, wahrscheinlich einen der am meisten sinngebenden Berufe

15 Spirit and Soul of Swiss Dermatology and Venereology

überhaupt, und dies auf dem unglaublich abwechslungsreichen Gebiet der Dermatologie und Venerologie; Entschlossenheit, die Aufgaben der Zukunft in einer rasch sich ändernden Zeit intelligent und erfolgreich zu meistern. Zu einer Zeit, als in den fünf Universitätsstädten der Schweiz die Dermatologischen Kliniken in kurzer Abfolge neu gegründet wurden (Tabelle 1), fand am 24. April 1913 in Genf die erste Jahresversammlung der damaligen Schweizerischen Gesellschaft für Dermatologie und Syphilidologie unter der Leitung von Herrn Prof. Hugues Oltramare statt. Der damalige Vorstand umfasste alle Verantwortungsträger der Pionierzeit der Schweizer Dermatologie: Bloch, Dind, J. Jadassohn, Oltramare, Tièche sowie Antonietti, Du Bois, Dösseker, Guth, Lennhof, Helg, Lassueur, Merian, Narbel und Winkler (Figure 1). Aus ihren Reihen wählte das damalige provisorische Komitee Prof. Dr. Oltramare zum ersten Präsidenten der heutigen SGDV. Epidemiologisch war die Dermatologie – wie die gesamte Medizin − stark von den Infektionskrankheiten geprägt: Syphilis und Gonorrhoe, Tuberkulose, Pilzerkrankungen, Scabies, Lepra. Sie machten mehr als die Hälfte der stationären Patienten aus. Natürlich existierten auch schon damals die „grossen Dermatosen“, für welche es aufwändige Lokaltherapien gab. Die Medizin war ganz und gar eine moderne Naturwissenschaft geworden und die pathophysiologische und biochemische Forschung machte grosse Fortschritte. Geschichtlich wurde die erste Hälfte des 20. Jahrhunderts bekanntlich durch die grossen Katastrophen des Ersten Weltkrieges, der Weltwirtschaftskrise und des Zweiten Weltkrieges geprägt. Die Schweiz blieb von den Kriegskatastrophen weitgehend verschont, aber konnte sich dem Einfluss der Weltgeschichte selbstverständlich nicht entziehen. Nachdem die ersten Jahrestagungen einerseits dem stetigen Wissenszuwachs der Pathologie und Biochemie der Haut- und Geschlechtskrankheiten und andererseits der Arsen-Therapie der Syphilis (Ehrlich 606, wenig später Neosalvarsan) gewidmet waren, brachte die Einführung der klassischen Antibiotika in den 1940er Jahren eine revolutionäre Wende in den Therapiemöglichkeiten der Infektionskrankheiten, was die Medizin ganz allgemein und

16 Introduction die Dermatologie und Venerologie im Besonderen grundlegend veränderte. Schwerste und zuvor nur bedingt behandelbare Infektionskrankheiten mit chronischem Verlauf wurden innert weniger Jahre wirksam behandelbar und wechselten von den grossen Spitalabteilungen in die ambulante Medizin. Ein zweite Erfindung, welche das Gesicht des Faches grundlegend veränderte, war die Einführung der systemischen und kurz darauf der topischen Glucokortikosteroide anfangs der 1950er Jahre, welche es erstmals möglich machte, entzündliche Hautkrankheiten wirksam und rasch zu behandeln. Die vier Jahrzehnte nach dem Zweiten Weltkrieg waren von einem beispiellosen weltweiten Wirtschaftsboom geprägt, der in allen gesellschaftlichen Bereichen und auch in der Wissenschaft von einem rasanten Aufbau und Ausbau der technischen Möglichkeiten und des Wohlstandes begleitet wurde. Politisch war die Zeit vom Kalten Krieg und der Zweiteilung der Welt geprägt, in welcher sich die freie westliche Welt viel rascher entwickeln konnte. Die Möglichkeiten des Wachstums schienen praktisch unbegrenzt. Krankheiten, die mit Mangelernährung und niedrigen Hygienestandards gepaart aufkommen, traten in den Hintergrund und die Zivilisationskrankheiten gewannen an Bedeutung. Insgesamt stiegen die Lebensqualität und die Lebenserwartung der westlichen Völker von Jahrzehnt zu Jahrzehnt eindrücklich an. Die dermatologische Forschung gewann mit den Möglichkeiten der Immunhistochemie, der aufkommenden Immunologie und der Ultrastrukturforschung am Elektronenmikroskop an Schwung. Der Vorstoss zur Weltspitze der Forschung sollte jedoch erst in den letzten zwei Jahrzehnten mit dem rasanten Zuwachs in der immunologischen Forschung und der Etablierung der molekularen Medizin erfolgen. Heute hat die moderne Dermatologie ihre frühere „Schmuddelecke“ und das dazugehörige Image längst verlassen und ist in vielerlei Hinsicht ein Vorzeigefach geworden. Sie muss sich hingegen wehren, nicht in die „Schönheitsecke“ gedrängt zu werden. Die Wende von 1989 mit der Aufhebung des Kalten Krieges brachte für die gesamte Erde einen erneuten Paradigmenwechsel. Im Rahmen der sich rasch abspielenden Globalisierung müssen die politisch und wissenschaftlich zuvor prägenden westlichen Nationen ihren Führungsanspruch zunehmend mit Ländern aus anderen Weltgegenden teilen. Die Revolution der

17 Spirit and Soul of Swiss Dermatology and Venereology

Informationstechnologie und das Internet tragen zum rasanten Wandel leise, doch hochrelevant bei. Die Verfügbarkeit und der Austausch von Informationen jeglicher Art haben sich heute gegenüber vor 20 bis 40 Jahren in ungeahntem Mass beschleunigt. Die vergangenen 20 Jahre waren durch eine exponentielle Entwicklung der immunologischen Forschung und der molekularen Methoden geprägt. Diese Forschungsinstrumente erlaubten es in den vergangenen Jahren, bisher schlecht verstandene Pathomechanismen dermatologischer Erkrankungen weitgehend zu entschlüsseln, und damit das „Organfach“ Dermatologie an die Spitze der biologisch-medizinischen Forschung zu katapultieren. Die Haut ist einfach und sozusagen nicht-invasiv biopsierbar, und so lassen sich heute modellhaft viele Krankheiten aus der gesamten Medizin an der Haut beispielhaft studieren. Im Bereich der entzündlichen Hautkrankheiten führt diese Entwicklung aktuell zur Einführung von immer mehr gezielt wirksamen Biologika und im Bereich der dermatologischen Onkologie (wie in der übrigen Onkologie) zur Entwicklung der gezielten molekularen Therapien mit völlig neuen Molekülen, welche die entgleiste Zellteilung an ihren Wurzeln angreifen. Man braucht kein Prophet zu sein, um vorauszusagen, dass diese Entwicklung unser Fach auch in den kommenden 10 bis 20 Jahren weiter revolutionieren wird. Dass wir mit diesem theoretisch unendlich fortsetzbaren Wachstum der Medizin an ökonomische Grenzen stossen, lässt sich heute kaum noch übersehen und eine Priorisierung wird unumgänglich werden. Es ist nicht einfach zu berechnen, bis zu welchem Punkt der boomende Gesundheitsmarkt der Volkswirtschaft als tragende Säule zudient und ab wann er der übrigen Wirtschaft Ressourcen entzieht, die besser anderswo eingesetzt würden. Die Kluft zwischen dem Wünschbaren und dem Machbaren wird in den kommenden Jahren sicher zunehmen und die Ärzteschaft ist gut beraten, wenn sie sich mit Verstand und Herz für eine intelligente und ethisch verträgliche Verteilung der Mittel persönlich an vorderster Front einsetzt. Eine glaubwürdige und starke Ärzteschaft dient auch am besten dem eigenen Berufsstand.

Wo steht die Schweizer Dermatologie als medizinisches Fach? Der Vorstand der SGDV und die Verantwortlichen für die Weiter- und Fortbildung sind sich einig, dass die Dermatologie und Venerologie sich auch in Zukunft als integrales „Organfach“

18 Introduction verstanden wissen will. Dies bedingt, dass die Kerngebiete sowie die zahlreichen Subspezialitäten und Grenzgebiete allesamt auf hohem klinischem und wissenschaftlichem Niveau betrieben und gelehrt werden. Ohne diese Anstrengungen verliert das Fach seine Ausstrahlung und seine Glaubwürdigkeit. Spezielle Herausforderungen bringen die rasanten Erkenntnisse und Therapie- Innovationen auf dem Gebiet der entzündlichen Dermatosen, die Wiederzunahme der sexuell übertragbaren Krankheiten sowie die Hautkrebs-Epidemie. Mit ihr einhergehen wird eine rasche Weiterentwicklung und-verbreitung der Dermatochirurgie inklusive der mikrographischen Hautkrebschirurgie. Unabdingbar ist der Verbleib der Dermatopathologie innerhalb des Fachs. Die molekulare Diagnostik und die damit verbundenen Targeted Therapies werden das Fach in all seinen Aspekten vorwärts bringen.

Wo steht die Schweizer Dermatologie in der Gesundheitspolitik? Politisch ist die SGDV innerhalb der Schweiz und Europa gut aufgestellt. Wir sind in der Ärztekammer und über den Dachverband fmCh in der Delegiertenversammlung der FMH gut vertreten. In praktisch allen kantonalen Ärztegesellschaften sind Vertreter der SGDV aktiv, oft sogar im Vorstand. Akademische Kaderärzte unserer Kliniken vertreten die SGDV in den Vorständen der SGAI und der USGG. International ist die SGDV in der EADV, der ESDR, der ILDS und der SID stark vertreten. Die Weiter- und Fortbildung ist ein Schlüsselelement für die Entwicklung eines medizinischen Fachgebiets. Auch diesbezüglich ist die SGDV sehr aktiv und an allen relevanten Stellen gut integriert. Das studentische Lernen wird durch das interaktive Trainingsprogramm „DOIT“ unterstützt, das sich auch international grosser Beliebtheit erfreut. Das beim SIWF hinterlegte und vom EDI überprüfte Weiterbildungsprogramm deckt das Fach Dermatologie und Venerologie in seiner gesamten Breite ab. Die SGDV hat Einsitz im Vorstand des SIWF, wo die 44 Facharzttitel und die ungefähr 100 Fähigkeitsausweise und Schwerpunktdiplome der Schweiz gepflegt und überwacht werden. Seit 2012 können die SGDV-Mitglieder von drei überregionalen Schwerpunktfortbildungen im ersten Halbjahr (Swiss Derma Day, Rencontres Romandes de Dermatologie et Venerologie, Zürcher Dermatologische Fortbildungstage) und von der traditionellen Jahresversammlung im Herbst profitieren. Alle vier Fortbildungsveranstaltungen bieten konzentrierte und dennoch

19 Spirit and Soul of Swiss Dermatology and Venereology umfassende Fortbildung innert ein bis drei Tagen und müssen mit ihrem beachtlichen Niveau den internationalen Vergleich nicht scheuen. Auch in der Weiter- und Fortbildung spielt e-Learning eine zunehmend grosse Rolle. Das elektronische Dermatologie- Lehrbuch DERMOKRATES ist nach dem Wikipedia-Prinzip ständig aktualisierbar. Über die elektronische Plattform DERMARENA werden pro Jahr ungefähr 15 grössere Fortbildungsveranstaltungen aus den Unikliniken in die teilweise geographisch weit verteilten Schweizer Praxen übertragen.

Wie gedenkt die SGDV die Herausforderungen der Zukunft anzupacken? Die SGDV ist in ihrem Vorstand gut organisiert. In sämtlichen relevanten Ressorts finden sich kompetente Vorstandsmitglieder, welche auf die neuen Herausforderungen und Probleme der Gesundheitspolitik rasch und kompetent reagieren können. Die Vernetzung innerhalb der fachlichen Dachverbände sowie der politischen Organisationen ist ausgesprochen stark und der Informationsfluss läuft gut. In den vergangenen vier Jahren haben die Standesorganisationen FMH und fmCh einen Politradar aufgebaut, welcher es erlaubt, Veränderungen im Gesundheitswesen mit der nötigen Vorlaufzeit rechtzeitig zu erkennen, um darauf wirksam reagieren zu können. In letzter Konsequenz das wirksamste Instrument zur Schadensbegrenzung bei Fehlentscheidungen der Gesundheitspolitiker ist das Eidgenössische Referendum. Zuletzt wurde dieses anfangs 2012 zur Bekämpfung der sogenannten Manage-Care-Vorlage angewandt. Statt der verlangten 50’000 konnten innert weniger als drei Monaten über 130’000 beglaubigte Unterschriften gesammelt werden und die Managed-Care- Vorlage wurde mit 76% Nein-Stimmen überdeutlich abgelehnt. Solche Erfolge zeigen uns, dass wir in der Gesundheitspolitik grosse Wirkung entfalten können und grundsätzlich das nötige Gewicht haben, die Zukunft der Schweizer Medizin aktiv sinnvoll mitzugestalten. Dies wird eine unserer wichtigsten Aufgaben für die nächsten Jahre werden. Es gilt aber auch, dass der Ärztestand sich nicht ausschliesslich aufs Neinsagen beschränken kann. Es ist an uns, zu den brennenden Themen der Gesundheitspolitik eigene ausgereifte und ethisch vertretbare Lösungsvorschläge aufzuzeigen und dafür einzustehen.

20 Introduction

In der SGDV vereint in sich ein ungewöhnlich dichtes Wissen um die spezifischen beruflichen Problemfelder und eine beachtliche Vernetzung innerhalb der Instanzen der Schweizer Gesundheitspolitik. Wenn wir dieses Potenzial geschickt nutzen, werden wir die wichtigen Herausforderungen der Zukunft weiterhin meistern können. Dies wünschen wir unserer Generation und den kommenden Generationen von Dermatologinnen und Dermatologen in unserem Land. Seien wir dankbar dafür, dass wir in einem derart interessanten Beruf arbeiten dürfen, tragen wir ihm weiterhin Sorge und setzen wir uns dafür ein, dass sich die gesamte Medizin und die Dermatologie im Speziellen zum Wohl der Menschen, die sie versorgt, weiterhin gut entwickeln können wird. In diesem Sinne und an dieser Stelle gratulieren wir daher der SGDV – wir sind die SGDV! − ganz herzlich zu ihrem 100. Geburtstag! Jürg Hafner und Vorstand SGDV

Figure 1. Meeting in Geneva, 24. April 1913 In the forefront: Tièche, Narbel, Dind, Oltramare, Jadassohn, Helg Behind: Du Bois, Dösseker, Lassueur, Winkler, Antonietti, Guth, Bloch, Lennhof, Merian

21 Spirit and Soul of Swiss Dermatology and Venereology

HIV Osler kopie PTCA (1846) (1886) (1890) (1895) Aether Insulin Kocher Duplex Human Aspirin Sterilis. Naegeli Cibazol Billroth Heparin -Tx Tbc Allergie Genome Röntgen CT/MRI Prontosil Penicillin Biologics Salvarsan Helio-/UV Pacemaker Ultraschall Antikörper Borrelia B. Microarray TargetedTx Ciclosporin Nierentrspl. Fiberendos- /Hepatitis C Helicobacter Anaphylaxie Streptomycin Antibabypille Treponema p. Treponema Herzchirurgie Haemodialyse Osteosynthese BCG-Impfung Meilenst. Med. WHO-Gründung Koch/Tbc (1882) Antisepsis (1867) s ’ NS Radio Korea „9/11“ Laptop Telefon Ruanda Vietnam Tsunami Zeppelin Flugzeug Einstein Mauerfall Fernsehen Srebrenica Überschall Automobil Fukushima Tienanmen 1 Weltkrieg 2 Weltkrieg Geschichte Rote Khmer Atombombe Kalter Krieg Camp David Grammophon Mondlandung Mobiltelefonie Globalisierung Arab. Frühling Gotthard tunnel Klein-Computer Relativitätstheorie Weltwirtsch. Krise Weltwirtsch. Allergie Immunol DER Insel KSB//USZ Allergologie Allergologie: Aarau Zürich Luzern Thurgau StädtPoli St.Gallen Nicht-Uni Bellinzona Burg Bloch Storck French Zürich Miescher Schnyder Dind Frenk Jaeger Gilliet Ramel Pautrier Panizzon Lausanne Delacrétaz Genf Saurat Laugier Du Bois Boehncke Oltramare Jadassohn W Bern Krebs Kuske Lesser Robert Braathen Nägeli O Borradori Jadassohn J Itin Lutz Rufli Basel Bloch Schuppli Lewandowsky Itin Lutz Lutz Lutz Dind Rufli Rufli Favre Favre Hofer Krebs Bloch Fuchs Mazzi Mazzi Kuske Ramel Grillet Gabud Robert SGDV Hafner Paillard Gabbud Stauffer Stauffer Tenchio Ramelet Ramelet Bigliardi Schuppli Schuppli Lassueur Gueissaz Panizzon Panizzon Perrooud Miescher Miescher Oltramare Oltramare Antonietti Delacrétaz Delacrétaz Burckhardt Jadassohn J Ramel/Lutz Jadassohn W Jadassohn W Lewandowski Winkler/Nägeli du Bois/Chable 1880 1890 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010

22 Introduction

Les 100 ans de la Société Suisse de Dermatologie et Vénéréologie : passé – présent – futur

Traduction : Pierre Prince

*Bureau du Comité ; °Comité ; °°Directeur de clinique universitaire et membre du Comité

Le 24 avril 2013, la SSDV fêtera son 100e anniversaire. Ce moment inspire respect, reconnaissance et détermination. Respect envers la génération de pionniers qui, à la fin du xixe siècle, ont créé la Société Suisse de Dermatologie et de Vénéréologie et l’ont établie, et respect envers les générations suivantes qui ont poursuivi cette histoire à succès. Reconnaissance pour le privilège de pouvoir exercer la profession médicale, probablement l’une des professions donnant vraiment le

25 Spirit and Soul of Swiss Dermatology and Venereology plus de sens à sa vie, et ce dans le domaine incroyablement varié de la dermatologie et de la vénéréologie. Détermination à maîtriser intelligemment et avec succès les tâches de l’avenir en des temps qui changent rapidement. À l’époque où, dans les cinq universités de Suisse, les cliniques de dermatologie ont été fondées en un cours laps de temps (illustration 1), la première assemblée annuelle de la Société suisse de dermatologie et de syphilidologie de l’époque avait lieu à Genève le 24 avril 1913, sous la direction du Professeur Hughes Oltramare. Le Comité se composait alors de tous les responsables de cette période de pionniers de la dermatologie suisse. Bloch, Dind, J. Jadassohn, Oltramare, Tièche, ainsi qu’Antonietti, Du Bois, Dösseker, Guth, Lennhof, Helg, Lassueur, Merian, Narbel et Winkler (illustration 1). Le Comité provisoire a choisi à ce moment-là dans ses rangs le Prof. Dr. Oltramare en qualité de premier président de l’actuelle SSDV. Au plan épidémiologique, la dermatologie – comme d’ailleurs l’ensemble de la médecine – était fortement marquée par les maladies infectieuses : syphilis et blennorragie, tuberculose, mycoses, gale, lèpre. Elles représentaient la moitié des patients en milieu stationnaire. Évidemment, il existait déjà à cette période les « grandes dermatoses », pour lesquelles il y avait de coûteuses thérapies locales. La médecine était devenue indubitablement une science naturelle moderne, et la recherche pathophysiologique et biochimique faisait de grands progrès.

Au plan historique, la première moitié du xxe siècle a été le théâtre, comme chacun le sait, des grandes catastrophes de la première guerre mondiale, de la crise économique mondiale et de la deuxième guerre mondiale. La Suisse a été largement épargnée par les catastrophes de la guerre, mais elle n’a pas pu se soustraire, et c’est bien compréhensible, à l’influence de l’histoire mondiale. Après les premières assemblées annuelles qui furent consacrées tant à la constante augmentation des connaissances en pathologie et biochimie des affections cutanées et des maladies sexuelles qu’au traitement de la syphilis au moyen de l’arsenic (Ehrlich 606, puis Neosalvarsan), l’introduction des antibiotiques classiques dans les années quarante a constitué un tournant révolutionnaire dans les

26 Introduction thérapies des maladies infectieuses et a fondamentalement changé la médecine de façon générale, la dermatologie et la vénéréologie en particulier. Certaines maladies infectieuses les plus graves sous évolution chronique, qui ne pouvaient être traitées auparavant que sous certaines conditions, devinrent curables efficacement en quelques années et passèrent des grands départements hospitaliers à la médecine ambulatoire. Une deuxième découverte, qui a changé fondamentalement le visage de la discipline, a été l’introduction des glucocorticoïdes systémiques et, peu après, topiques, au début des années cinquante, qui ont permis pour la première fois de soigner efficacement et rapidement des affections cutanées inflammatoires. Les quatre décennies suivant la deuxième guerre mondiale ont connu un boom économique mondial sans pareil, accompagné dans tous les domaines de la société comme de la science d’une énorme création et extension des moyens techniques et de la prospérité. Politiquement, c’était la guerre froide et la scission du monde en deux pôles, dans lequel l’Ouest a pu se développer bien plus rapidement. Les possibilités de croissance apparaissaient pratiquement illimitées. Les maladies imputables à une alimentation déficiente et au bas standard d’hygiène sont passées à l’arrière-plan, et celles dites de la civilisation ont gagné en importance. Dans l’ensemble, la qualité et l’espérance de vie des peuples occidentaux ont augmenté de manière impressionnante d’une décennie à l’autre. La recherche dans le domaine dermatologique a gagné en dynamisme avec les moyens de l’immunohistochimie, de l’immunologie naissante et de l’étude de l’ultrastructure au microscope électronique. La poussée de la recherche au niveau de pointe à l’échelle mondiale ne devait cependant se manifester que dans les deux dernières décennies du siècle, avec la croissance fulgurante de la recherche en immunologie et l’établissement de la médecine moléculaire. À l’heure actuelle, la dermatologie moderne a abandonné depuis longtemps ses « quartiers misérables » d’antan ainsi que l’image qui en découlait pour elle ; elle est devenue une discipline exemplaire sous de nombreux aspects, mais elle doit veiller à ne pas se laisser acculer dans le « rayon beauté ». Le tournant de 1989, avec la fin de la guerre froide, a opéré dans le monde entier un nouveau changement de paradigme. Dans le cadre de la globalisation menée rapidement, les nations occidentales – autrefois marquantes au niveau politique et scientifique – doivent

27 Spirit and Soul of Swiss Dermatology and Venereology désormais partager de plus en plus leur rôle de leader avec des pays d’autres régions de la planète. La révolution de la technologie de l’information et le réseau Internet contribuent à pas feutrés à un changement fulgurant et décisif. La disponibilité et l’échange des informations de toute nature se sont énormément accélérés aujourd’hui, par rapport à ce qui se passait il y a 20 ou 40 ans. Les vingt dernières années ont été placées sous le signe d’un développement exponentiel de la recherche en immunologie et des méthodes moléculaires. Ces instruments de recherche ont permis au cours des années passées de décrypter largement les mécanismes pathologiques, jusqu’alors mal compris, des maladies dermatologiques et, par conséquent, de catapulter la « spécialité d’organes » – la Dermatologie – à la pointe de la recherche biologico- médicale. La peau peut aisément faire l’objet d’une biopsie, pour ainsi dire de façon non invasive, et ainsi nombre de maladies intéressant toute la médecine peuvent aujourd’hui être étudiées de manière exemplaire sur la peau. Dans le domaine des affections cutanées inflammatoires, cette évolution conduit actuellement à l’introduction de produits biologiques d’une efficacité toujours plus ciblée et, dans le domaine de l’oncologie dermatologique (comme dans le reste de l’oncologie d’ailleurs), au développement de thérapies moléculaires ciblées comportant des molécules entièrement nouvelles qui attaquent la division désordonnée des cellules à ses racines. Nul besoin d’être prophète pour prédire que cette évolution continuera à révolutionner notre discipline dans les 10 à 20 prochaines années encore. Que sous l’effet de cette croissance théoriquement illimitée de la médecine nous nous heurtions à des limites économiques ne saurait guère être ignoré actuellement et il sera inévitable de fixer des priorités. Il n’est pas simple de prévoir jusqu’à quel point le boom du marché de la santé sert l’économie nationale en tant que pilier et à partir de quel moment il soustrait des ressources au reste de l’économie, qui seraient mieux investies ailleurs. Le fossé entre ce qui est souhaitable et faisable augmentera certainement au cours des années à venir, et le corps médical serait bien inspiré de s’engager personnellement au premier plan, avec compréhension et ardeur, pour une répartition intelligente et éthiquement défendable des moyens à disposition. Un corps médical crédible et fort est également le meilleur moyen de servir notre propre branche.

28 Introduction

Où en est la dermatologie suisse en tant que spécialité médicale ? Le comité de la SSDV et les responsables de la formation postgrade et continue s’accordent unanimement pour dire que la dermatologie et la vénéréologie entendent être perçues absolument, à l’avenir encore, comme une « spécialité d’organes ». Ceci suppose que les domaines traditionnels ainsi que les nombreuses sous-spécialités et les domaines limitrophes soient tous pratiqués et enseignés à un haut niveau clinique et scientifique. Sans ces efforts, la discipline perd son rayonnement et sa crédibilité. Des exigences spéciales naissent des découvertes et innovations thérapeutiques qui se succèdent à un rythme extrêmement rapide dans le domaine des dermatoses inflammatoires, de la recrudescence des maladies sexuellement transmissibles ainsi que de l’épidémie du cancer de la peau. Cette dernière entraînera un développement et un élargissement rapides de la dermatochirurgie, chirurgie micrographique du cancer de la peau incluse. Le maintien de la dermatopathologie dans la discipline est incontournable. Le diagnostic moléculaire et les « targeted therapies » qui lui sont liées feront avancer la discipline sous tous ses aspects.

Où en est la dermatologie suisse face à la politique de la santé ? Politiquement, la SSDV est bien placée en Suisse et en Europe. Nous sommes bien représentés au sein de la Chambre médicale et, via l’association faîtière fmCh, dans l’assemblée des délégués de la FMH. Il y a des représentants actifs de la SSDV dans presque toutes les sociétés cantonales de médecine, souvent même au Comité. Des médecins faisant partie des cadres académiques de nos cliniques représentent la SSDV dans les comités de la SSAI, de l’USSMV et d’autres associations scientifiques faîtières. Au plan international, la SSDV est fortement représentée dans l’EADV, l’ESDR, l’ILDS, la SID, l’UEMS, l’ESPD et d’autres sociétés de spécialistes internationales. La formation postgrade et continue est un élément crucial du développement d’une discipline médicale. À ce sujet aussi, la SSDV est très active et bien intégrée dans tous les lieux déterminants. L’enseignement aux étudiants est soutenu par le programme d’entraînement interactif « DOIT », qui jouit d’une grande estime au niveau international. Le programme de formation postgrade déposé à l’ISFM et accrédité par le DFI couvre la branche de la dermatologie et de la vénéréologie dans toute son

29 Spirit and Soul of Swiss Dermatology and Venereology amplitude. La SSDV siège au comité de la SIWF, où les 44 titres de médecin-spécialiste, les quelques 100 certificats de capacité et les diplômes complémentaires de Suisse sont suivis et surveillés. Depuis 2012, les membres de la SSDV peuvent bénéficier de trois formations continues transrégionales au premier semestre (Swiss Derma Day, Rencontres romandes de Dermatologie et Vénéréologie, Zürcher Dermatologische Fortbildungstage) ainsi que de la traditionnelle Réunion annuelle en automne. Ces quatre sessions de formation proposent une formation continue concentrée et pourtant globale, en l’espace de un à trois jours, et elles n’ont pas à rougir de la comparaison internationale vu leur niveau remarquable. L’e-learning joue un rôle de plus en plus important dans la formation postgrade et continue. Le manuel électronique de dermatologie DERMOKRATES peut être constamment mis à jour selon le principe de Wikipedia. Via la plateforme électronique DERMARENA, ce sont environ 15 sessions de formation continue relativement importantes qui sont retransmises à partir des cliniques universitaires dans les cabinets suisses, largement disséminés au plan géographique.

Comment la SSDV envisage-t-elle de s’attaquer aux défis de l’avenir ? Le comité de la SSDV est bien établi. Dans tous les ressorts déterminants se trouvent des membres compétents du Comité, qui peuvent réagir rapidement et avec compétence aux nouveaux défis et problèmes présentés par la politique de la santé. La connexion au sein des associations faîtières des disciplines médicales et des organisations politiques est extraordinairement forte et les flux d’information sont fluides. Durant les quatre dernières années, les organisations professionnelles que sont la FMH et fmCh ont mis sur pied un radar politique permettant de reconnaître à temps, avec l’anticipation nécessaire, les changements dans le système de la santé pour être à même de réagir efficacement à ces mutations. En dernière extrémité, l’instrument le plus efficace pour éliminer les dommages résultant de mauvaises décisions des politiciens de la santé réside dans le référendum au plan fédéral. Il a été utilisé la dernière fois au début 2012 pour lutter contre le dénommé projet Managed Care. Au lieu des 50’000 signatures exigées, il a été possible de récolter en moins de trois mois plus de 130’000 signatures authentifiées, et le projet

30 Introduction en question a été très nettement rejeté par 76 % de non. De tels succès nous montrent que nous pouvons avoir un grand effet sur la politique de la santé et, en principe, le poids nécessaire pour participer activement et pertinemment au modelage de l’avenir de la médecine suisse. Ceci sera l’une de nos principales tâches pour les prochaines années. Mais il s’agit également pour le corps médical de ne pas se limiter exclusivement à dire non. Il nous appartient de présenter nos propres propositions de solutions mûrement réfléchies et éthiquement défendables sur des sujets brûlants de la politique de la santé, et de tout mettre en œuvre pour les faire triompher. Un savoir extraordinairement dense se concentre dans la SSDV elle-même, dans les champs professionnels spécifiques posant problème et il existe un réseau remarquable nous reliant aux instances de la politique de la santé en Suisse. Si nous sommes capables de mettre habilement à profit ce potentiel, nous pourrons encore maîtriser les importants défis de l’avenir. Nous le souhaitons à notre génération – comme à celles qui viennent – de dermatologues femmes et hommes dans notre pays. Soyons reconnaissants de pouvoir exercer une profession aussi intéressante, continuons à lui porter soin et défendons-nous pour que l’ensemble de la médecine, et la dermatologie en particulier, puissent continuer à bien se développer, pour le bien de l’homme dont elles s’occupent. Dans cet esprit, nous félicitons donc très cordialement ici la SSDV – et nous sommes la SSDV! – pour son 100e anniversaire!

Traduction française par Pierre Prince

31 Spirit and Soul of Swiss Dermatology and Venereology

DNA Osler PTCA (1867) (1882) Kocher Naegeli Cibazol Billroth Insuline Allergie Aspirine Ultrason CT/MRI Prontosil Héparine Biologics Salvarsan Koch/Tbc Antisepsie Pénicilline Pacemaker Borrelia B. Duplex US Microarray importante Targeted Tx Targeted Etape méd. Vaccin BCG Vaccin Ether (1846) Helicobacter Anaphylaxie Ciclosporine Hémodialyse Antibabypille Treponema p. Treponema Ostéosynthèse Streptomycine Stérilis. (1886) HIV/hépatite C Fondation OMS Génome humain Fibroendoscopie Anticorps (1890) Radiologie (1895) Hélio-/UV-Tx Tbc Hélio-/UV-Tx Chirurgie cardiaque Chirurgie Transplantation du rein Transplantation Corée Radio Avion „9/11“ Laptop Ruanda Vietnam Histoire Tsunami Ultrason Zeppelin mondiale Téléphone Télévision Srebrenica Alunissage Fukushima Tienanmen la relativité Automobile Camp David Gramophone Globalisation Guerre froide guerre mondiale guerre mondiale Khmers rouges Mini-ordinateur Printemps arabe e Bombe atomique ère Crise économique Téléphonie mobile 2 Tunnel du Gotthard Tunnel 1 National-socialisme Théorie d’Einstein sur Chute du mur de Berlin Allergie l’Île, BE Immunol. Allergologie Allergologie: DER Hôp. de Hôp. univ. ZU Hôp. univ. Hôp. cant. Bâle// Aarau Zurich St-Gall ville de Lucerne Non univ. Thurgovie Bellinzone Polycl. de la Burg Bloch Storck French Zurich Miescher Schnyder Dind Frenk Jaeger Gilliet Ramel Pautrier Panizzon Lausanne Delacrétaz Saurat Laugier Genève Du Bois Boehncke Oltramare Jadassohn W Krebs Berne Kuske Lesser Robert Braathen Nägeli O Borradori Jadassohn J Itin Lutz Bâle Rufli Bloch Schuppli Lewandowsky Itin Lutz Lutz Lutz Dind Rufli Rufli Favre Favre Hofer Krebs Bloch Fuchs Mazzi Mazzi SSDV Kuske Ramel Grillet Gabud Robert Hafner Paillard Gabbud Stauffer Stauffer Tenchio Ramelet Ramelet Bigliardi Schuppli Schuppli Lassueur Gueissaz Panizzon Panizzon Perrooud Miescher Miescher Oltramare Oltramare Antonietti Delacrétaz Delacrétaz Burckhardt Jadassohn J Ramel/Lutz Jadassohn W Jadassohn W Lewandowski Winkler/Nägeli du Bois/Chable 1880 1890 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010

32 Introduction

100 Anni di Società Svizzera di Dermatologia e Venereologia: Passato – Presente – Futuro

*Ufficio, ° Comitato, °°Capo Servizio e Comitato

Il 24 aprile 2013, la SSDV ha festeggiato il proprio 100o anniversario. Questa occasione ci ispira rispetto, riconoscenza e determinazione. Rispetto verso la generazione di pionieri che alla fine del xix secolo crearono e portarono all’affermazione la Società Svizzera di Dermatologia e Venereologia, e rispetto verso le generazioni seguenti che hanno proseguito questa storia di successo. Riconoscenza per il privilegio di poter esercitare la professione medica, probabilmente una delle professioni che danno maggiore senso alla vita, e in più nel mondo incredibilmente variegato della dermatologia e della venereologia.

35 Spirit and Soul of Swiss Dermatology and Venereology

Determinazione a gestire intelligentemente le sfide del futuro in tempi che cambiano rapidamente. All’epoca in cui nelle cinque università svizzere le cliniche di dermatologia vennero fondate in breve sequenza (Tabella 1), la prima assemblea annuale della Società svizzera di dermatologia e sifilologia ebbe luogo a Ginevra il 24 aprile 1913 sotto la direzione del prof. Hughes Oltramare. Il Comitato di allora era composto da tutti i protagonisti del periodo dei pionieri della dermatologia svizzera. Bloch, Dind, J. Jadassohn, Oltramare, Tièche, oltre a Antonietti, Du Bois, Dösseker, Guth, Lennhof, Helg, Lassueur, Merian, Narbel e Winkler (Immagine 1). Il Comitato provvisorio dell’epoca elesse tra i propri ranghi il prof. dott. Oltramare come primo presidente dell’odierna SSDV. Sul piano epidemiologico, la dermatologia – come d’altronde tutto l’insieme della medicina – era fortemente caratterizzata dalle malattie infettive: sifilide e gonorrea, tubercolosi, micosi, scabbia, lebbra. Queste rappresentavano la metà dei casi in ambito degente. Naturalmente esistevano già a quei tempi le “grandi dermatosi”, per le quali erano a disposizione costose terapie locali. La medicina era diventata indubbiamente una scienza naturale moderna e la ricerca patofisiologica e biochimica faceva grandi progressi.

Sul piano storico la prima metà del xx secolo fu il teatro, come ben sappiamo, delle grandi catastrofi legate alla Grande Guerra, della crisi economica e della Seconda Guerra mondiale. La Svizzera fu ampiamente risparmiata dai disastri della guerra ma, come ben comprensibile, non poté sottrarsi all’influenza della storia globale. Dopo le prime assemblee annuali, che furono consacrate alla costante crescita delle conoscenze nella patologia e biochimica delle affezioni cutanee e a trasmissione sessuale oltre che al trattamento della sifilide con l’arsenico (Ehrlich 606, poi Neosalvarsan), l’introduzione degli antibiotici classici negli anni quaranta costituì una svolta rivoluzionaria nella terapia delle malattie infettive. Questo avvenimento cambiò profondamente la medicina in senso generale, e la dermatologia e la venereologia in particolare. Alcune tra le malattie infettive più gravi a decorso cronico, che prima non potevano essere trattate se non in determinate condizioni, divennero curabili efficacemente in pochi anni e passarono dai grandi reparti ospedalieri alla medicina ambulatoriale. Una seconda

36 Introduction scoperta che cambiò radicalmente il volto della disciplina fu l’introduzione dei glucocorticoidi sistemici e, poco più tardi, dei loro corrispettivi topici all’inizio degli anni cinquanta, che permisero per la prima volta di curare rapidamente e con successo le affezioni cutanee infiammatorie. I quattro decenni che seguirono la Seconda Guerra mondiale conobbero un boom economico senza precedenti, accompagnato in tutti gli ambiti della società e della scienza da un’enorme vena creativa e dall’ampliamento dei mezzi tecnici, portando alla prosperità. Sul piano politico, il periodo fu caratterizzato dalla guerra fredda e dalla scissione del mondo in due poli, dove l’Occidente poté svilupparsi molto più rapidamente. Le possibilità di crescita apparivano praticamente illimitate. Le malattie imputabili ad un’alimentazione insufficiente e ai cattivi standard igienici passarono in secondo piano, mentre quelle definite come “della civiltà” aumentarono in importanza. Nell’insieme, la qualità e la speranza di vita dei popoli occidentali aumentarono in maniera impressionante nel giro di un decennio. La ricerca nell’ambito dermatologico acquisì dinamismo attraverso l’immunoistochimica, la nascente immunologia e lo studio dell’ultrastruttura al microscopio elettronico. La scalata della ricerca verso i vertici mondiali non si manifestò che durante gli ultimi due decenni, con lo sviluppo folgorante della ricerca in immunologia e l’affermazione della medicina molecolare. Al momento attuale, la dermatologia moderna ha abbandonato da tempo gli “angoli bui” degli esordi come anche l’immagine che ne risultava; è infatti divenuta una disciplina esemplare sotto molti aspetti, ma deve rifiutarsi di essere confinata nell’ “angolo dell’estetica”. Gli avvenimenti del 1989 con la fine della guerra fredda portarono in tutto il mondo un nuovo cambiamento di paradigmi. Nel quadro della rapida globalizzazione, le nazioni occidentali – prima all’avanguardia sul piano scientifico e politico – devono ormai condividere sempre più il loro ruolo di leader con paesi di altre regioni del pianeta. La rivoluzione tecnologica e dell’informazione e la rete internet hanno contribuito a questo cambiamento folgorante e decisivo. Oggigiorno la disponibilità e lo scambio di informazioni di qualsiasi natura risultano enormemente accelerati rispetto a quando accadeva venti o quarant’anni fa. Gli ultimi vent’anni sono stati caratterizzati da uno sviluppo esponenziale della ricerca in immunologia e dei metodi molecolari. Questi strumenti hanno permesso di decrittare ampiamente

37 Spirit and Soul of Swiss Dermatology and Venereology i meccanismi patologici, prima mal compresi, di diverse malattie dermatologiche, e di conseguenza di catapultare la disciplina “organospecifica” – la Dermatologia – verso i più alti livelli della ricerca medico-biologica. La pelle è facilmente raggiungibile e analizzabile in maniera quasi non-invasiva attraverso una piccola biopsia. Per questo molte malattie di varie branche mediche possono essere studiate in maniera esemplare sulla cute. Nell’ambito delle affezioni cutanee infiammatorie, questa evoluzione ha portato di recente all’introduzione di prodotti biologici ad azione sempre più mirata e nella dermatooncologia (come d’altronde nel resto dell’oncologia) allo sviluppo di terapie molecolari altrettanto mirate che utilizzano nuove molecole capaci di intervenire alla radice della divisione cellulare patologica. Non bisogna essere dei profeti per predire che questa evoluzione continuerà a rivoluzionare la nostra disciplina nei prossimi dieci o vent’anni. Non può essere comunque ignorato che con questa crescita pressoché illimitata della medicina presto raggiungeremo dei limiti sul piano economico, e sarà dunque importante stabilire delle priorità. Non è facile prevedere fino a che punto il boom del mercato della sanità serva da sostegno all’economia nazionale e a partire da quando invece sottragga risorse che potrebbero essere meglio investite altrimenti. Il gap tra l’auspicabile e il fattibile aumenterà sicuramente nel corso degli anni a venire, e il corpo medico sarà chiamato a impegnarsi personalmente in prima linea, con comprensione e ardore, per una ripartizione intelligente ed eticamente difendibile dei mezzi a disposizione. Una classe medica credibile e forte è inoltre il miglior mezzo per servire la nostra branca.

Dove si situa la dermatologia svizzera come specialità medica? Il comitato della SSDV e i responsabili della formazione postgraduata e continua sono unanimi nel dire che la dermatologia e venereologia intende assolutamente continuare ad essere concepita come specialità “organospecifica”. Questo implica che sia gli ambiti principali tradizionali della dermatologia, sia le sue sottospecialità e le aree di sovrapposizione con altre branche vengano praticati e insegnati ad alto livello clinico e scientifico. Senza questi sforzi, la specialità perderà la sua attrattività e credibilità. Delle esigenze particolari nascono dalle scoperte e dalle innovazioni terapeutiche che si succedono a un ritmo estremamente rapido nel campo delle dermatosi infiammatorie, e dalla recrudescenza delle malattie

38 Introduction sessualmente trasmissibili come anche dall’epidemia dei tumori cutanei. Quest’ultima porterà ad uno sviluppo e ad un ampliamento rapidi della dermatochirurgia, compresa la chirurgia micrografica dei tumori della pelle. Il mantenimento della dermatopatologia all’interno della specialità è irrinunciabile. La diagnostica molecolare come anche le relative terapie mirate porteranno ad un avanzamento della disciplina in tutti i suoi aspetti.

Dove si situa la dermatologia svizzera nella politica sanitaria? Dal lato politico, la SSDV è ben piazzata in Svizzera e in Europa. Siamo rappresentati in seno alla Camera medica e, attraverso l’associazione mantello fmCh, nell’assemblea dei delegati FMH. In quasi tutti gli Ordini dei medici dei vari cantoni sono presenti membri attivi della SSDV, spesso addirittura a livello dei comitati. Dei medici appartenenti ai quadri accademici delle nostre cliniche rappresentano la SSDV presso i comitati della SSAI e dell’USSMV. Sul piano internazionale, la SSDV è fortemente rappresentata nell’EADV, l’ESDER, l’ILDS e l’ISD, l’UEMS, l’ESPD. La formazione postgraduata e continua è un elemento cruciale dello sviluppo di una disciplina medica. Anche a questo proposito, l’SSDV è molto attiva e ben integrata in tutte le sedi rilevanti. L’insegnamento agli studenti è sostenuto dal programma di istruzione “DOIT”, che gode di grande stima pure a livello internazionale. Il programma di formazione postgraduata depositato presso la SIWF e verificato da parte del DFI copre la branca della dermatologia e della venereologia in tutto il suo spettro. La SSDV ha un seggio presso il comitato della SIWF, dove i quarantaquattro titoli di medico specialista e i circa cento attestati di capacità e diplomi di formazione approfondita vengono seguiti e sorvegliati. Dal 2012 i membri SSDV possono beneficiare di tre formazioni continue prioritarie transregionali durante il primo semestre dell’anno (Swiss Derma Day, Rencontres romandes de Dermatologie et Vénéréologie, Zürcher Dermatologische Fortbildungstage), oltre che della tradizionale Assemblea annuale in autunno. Queste quattro manifestazioni propongono una formazione concentrata e comunque di ampia gamma nello spazio di uno a tre giorni, e non hanno nulla da invidiare a confronto con altri eventi internazionali, visto il loro livello molto alto. L’e-learning gioca un ruolo sempre maggiore anche nella formazione postgraduata e continua. Il manuale elettronico di dermatologia DERMOKRATES

39 Spirit and Soul of Swiss Dermatology and Venereology viene aggiornato costantemente secondo il principio di Wikipedia. Attraverso la piattaforma elettronica DERMARENA sono circa quindici le sessioni di formazione continua di varia importanza che vengono trasmesse annualmente a partire dalle cliniche universitarie verso gli studi medici disseminati per le diverse regioni geografiche.

Come verranno affrontate le sfide del futuro dalla SSDV? Il Comitato SSDV è ben assortito. In tutte le strutture determinanti si trovano dei membri del Comitato che possono reagire prontamente e in modo competente alle nuove sfide e ai problemi presentati dalla politica sanitaria. I rapporti con le associazioni mantello delle discipline mediche e delle organizzazioni politiche sono straordinariamente forti e i flussi di informazioni fluidi. Durante gli ultimi quattro anni, le organizzazioni professionali FMH e fmCh hanno dato vita ad un radar politico che permette di riconoscere per tempo, con necessario anticipo, i cambiamenti nel sistema sanitario, in modo da reagire efficacemente a questi mutamenti. In ultima istanza, lo strumento più efficace per rimediare ai danni causati dalle decisioni sbagliate dei politici sulla sanità consiste nel referendum federale. È stato utilizzato per l’ultima volta all’inizio del 2012 per combattere il progetto denominato Managed Care. Al posto delle 50’000 firme necessarie, è stato possibile raccogliere in meno di tre mesi più di 130’000 firme autenticate, e il progetto in questione è stato nettamente rifiutato con il 76% di voti contrari. Tali successi ci mostrano come possiamo esercitare un forte influsso sulla politica sanitaria e avere il peso specifico necessario a contribuire attivamente e in modo pertinente a plasmare il futuro della medicina svizzera. Questo sarà uno dei nostri compiti principali nei prossimi anni. È anche vero che la classe medica non deve limitarsi unicamente a dire di no. È nostro compito presentare le nostre proposte per soluzioni mature e ponderate e eticamente difendibili su temi scottanti della politica sanitaria, e di impegnarci a tutto campo per far sì che vengano accolte. All’interno della SSDV si concentra un sapere straordinariamente denso in merito ai campi professionali specifici che pongono dei problemi, nonché una rete impressionante di rapporti che ci legano alle istituzioni politiche della sanità svizzera. Se saremo capaci di sfruttare abilmente questo potenziale, potremo ancora superare

40 Introduction le sfide del futuro. Noi lo auguriamo alla nostra generazione – come a quelle che seguiranno – di dermatologhe e dermatologi del nostro paese. Dobbiamo essere riconoscenti di poter esercitare una professione così interessante, e dobbiamo continuare a portarle rispetto e ad impegnarci perché la medicina in generale e la dermatologia in particolare possano continuare a svilupparsi correttamente per il bene dell’essere umano del quale si prendono cura. Con questo spirito ci congratuliamo di tutto cuore con la SSDV – e la SSDV siamo noi! – per il suo 100o anniversario!

Traduzione italiana per Davide Donghi

41 Spirit and Soul of Swiss Dermatology and Venereology

US Etere DNA Osler OMS Fibro- PTCA Pillola (1846) (1867) (1882) (1886) (1890) (1895) Kocher Duplex Nascita Cardio - Naegeli Eparina Cibazol Billroth Insulina -Tx Tbc Allergia Raggi X Aspirina Sterilizz. chirurgia Prontosil anticonc. Elio-/UV Biologici Antisepsi Anticorpi Salvarsan Koch/Tbc TAC/MRI Sonografo Penicillina Emodialisi Pacemaker Borrelia B. Anafilassia Microarray endoscopia Vacc. BCG Vacc. Trap. renale Trap. Osteosintesi Helicobacter Ciclosporina Treponema p. Treponema Terapie mirate Terapie HIV/Epatite C Streptomycina Storia medica Genoma umano

NS Corea Radio Aereo Caduta Laptop zazione Ruanda Vietnam Tsunami Telefono Zeppelin Cellulare del Muro mondiale Globaliz- Computer Televisore Srebrenica Ultrasuono Fukushima Tienanmen Di Einstein Automobile Camp David Khmer Rossi Grammofono Cenni storici Guerra fredda „11 settembre“ „11 Bomba atomica 1. guerra mond. 2. guerra mond. Teoria relatività Teoria Primavera araba Crisi economica Tunnel Gottardo Tunnel Sbarco sulla luna Allergie DER Insel KSB//USZ Allergologia Allergologia: Immunologia Aarau Zurigo Lucerna Turgovia Städt Poli San Gallo Non univ. Bellinzona Burg Bloch Storck French Zurigo Miescher Schnyder Dind Frenk Jaeger Gilliet Ramel Pautrier Panizzon Losanna Delacrétaz Saurat Laugier Du Bois Ginevra Boehncke Oltramare Jadassohn W Krebs Kuske Lesser Berna Robert Braathen Nägeli O Borradori Jadassohn J Itin Lutz Rufli Bloch Basilea Schuppli Lewandowsky Itin Lutz Lutz Lutz Dind Rufli Rufli Favre Favre Hofer Krebs Bloch Fuchs Mazzi Mazzi SSDV Kuske Ramel Grillet Gabud Robert Hafner Paillard Gabbud Stauffer Stauffer Tenchio Ramelet Ramelet Bigliardi Schuppli Schuppli Lassueur Gueissaz Panizzon Panizzon Perrooud Miescher Miescher Oltramare Oltramare Antonietti Delacrétaz Delacrétaz Burckhardt Jadassohn J Ramel/Lutz Jadassohn W Jadassohn W Lewandowski Winkler/Nägeli du Bois/Chable 1880 1890 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010

42 Introduction

100 ons Società Svizra da Dermatologia e Venereologia: passà – preschaint – avegnir

*Uffzi, °Comitè, °°Schef da servezzan e Comitè

Ils 14 avrigl 2013 festagiarà la SSDV sei 100avel anniversari. In quist mumaint as pensa a respet, recugnuschentscha e resolutezza: Respet vers la generaziun dals pioniers chi han fundà e stabili a la fin dal 19avel tschientiner la Società Svizra da Dermatologia e da Veneralogia, e respet vers las generaziuns seguaintas chi han persisti a quista istorgia da success. Recugnuschentscha per il privilegi da pudair üsar la professiun da meidi, probabelmaing üna da las professiuns cun il meglder sen per la vita, e quai sül chomp zuond varià da la dermatologia e da la venereologia. Resolutezza per dominar da möd intelligiaint e cun success las lezchas da l’avegnir in ün temp chi’s müda talmaing svelt.

45 Spirit and Soul of Swiss Dermatology and Venereology

In ün temp, ingio cha pro las tschinch univerisitats svizras sun gnüdas fundadadas las clinicas dermatologicas üna davo tschella (tabella 1), ha gnü lö la prüma assemblea annuala da la Società svizra da dermatologia e da sifilidologia a Genevra ils 24 avrigl 1913, suot la direcziun da professer Hughes Oltramare. A la suprastanza da quella jada d’eira da la partida tuot ils respunsabels da quel temp dals pioniers da la dermatologia svizra: Bloch, Dind, J. Jadassohn, Oltramare, Tièche, Antonietti, Du Bois, Dösseker, Guth, Lennhof, Helg, Lassueur, Merian, Narbel e Winkler (illustraziun 1). La suprastanza provisorica da quella jada ha lura tschernü a prof. dr. Oltramare sco prüm president da la SSDV odierna. Epidemiolgicamaing dominaivan pro la dermatologia – sco da rest tuot la medicina – las malatias infectusas: sifilis e gonorrea, tuberculosa, micosas e lepra. Ellas importaivan plü co la mità dals paziaints staziunaris. S’inclegia existivan fingià quella jada las „grondas dermatosas”, per las qualas chi daiva charas terapias localas. La medicina d’eira sainza dubi dvantada üna scienza natürala moderna, e las retscherchas patologicas e biochemicas faivan gronds progress. Istoricamaing d’eira la prüma mità dal 20avel tschientiner dominà, sco cha tuot sa, da las grondas catastrofas da la prüma guerra mundiala, da la crisa economica mundiala e da la seguonda guerra mundiala. La Svizra es plü o main statta schaniada da las duos guerras, mo ella ha s’inclegia na pudü sguinchir da l’influenza da l’istorgia mundiala. Davo las prümas assembleas annualas chi d’eiran dedichadas dad üna vart al constant cresch da las cugnuschentschas da la patologia e da la biochemia da las malatias da la pel e da quellas sexualas e da l’otra vart a la terapia ersenica da la sifilis (Ehrich 606, pü tard Neosalvarsan), ha portà l’introducziun da l’antibiotica classica ils ons quaranta ün müdamaint revoluziunari illas terapias da malatias infectusas. Quai ha müdà fundamentalmaing la medicina in general e la dermatologia e venereologia in special. Fich greivas malatias infectusas cun ün andamaint cronic, infin là tratablas be limitadamaing, s’ha infra pacs ons pudü trattar e quai tras la medicina ambulanta e na plü in grondas partiziuns dals ospidals. Üna seguonda invenziun, chi ha müdà da fuond sü la fatscha da quista disciplina, es statta l’introducziun da la glucocorticoseroida locala al cumanzamaint dals ons tschinquanta, quai chi per la prüma

46 Introduction jada ha pussibilà da trattar efficaziamaing e svelt malatias da la pel tras inflammaziuns. Ils quatter decennis davo la seguonda guerra mundiala han gnü ün boom economic mundial sainza congual, accumpagnà in tuot las domenas da la società ed eir da la scienza tras üna enorma creatività ed grond schlargiamaint dals mezs tecnics e da la benestanza. Politicamaing d’eira quel temp caracterisà da l’uscheditta guerra fraida e da la spartiziun dal muond in duos parts, ingio cha’l Vest s’ha pudü sviluppar bler plü svelt. Las pussibiltats da creschentscha paraivan praticamaing illimitadas. Malatias in connex cun ün’alimentaziun manglusa sun dvantadas main importantas e quellas da la civilisaziun plü importantas. Tuot in tuot s’ha augmantada fermamaing la qualità da viver e l’aspettativa da vita d’ün decenni a tschel pro la populaziun dal Vest. La perscrutaziun dermatologica es dvantada plü dinamica culs nouvs mezs da l’immunistochemia, da l’immunologia e cun la perscrutaziun da l’ultrastructura cul microsop electronic. Sül s-chalin mundial da la perscrutaziun s’esa pero pür rivà ils ultims duos decennis cul cresch rasant da la perscrutaziun immunologica e cun la stabilisaziun da la medicina moleculara. Actualmaing ha la dermatologia moderna bandunà daspö lönch seis „stadi d’infanzia“ e seis nom in quist connex per dvantar ün rom da model in divers reguards. Mo ella sto as dostar da nu gnir chatschada aint il „chantun da bellezza“. La müdada da 1989, cun la fin da la guerra fraida, ha darcheu causà per tuot il muond ün nouv müdamaint paradigmatic. In connex cun la globalisaziun rasanta, ston las naziuns politicas e scientificas dal Vest partir adüna daplü lur posiziun da leader culs pajais d’otras regiuns dals muond. La revoluziun da la tecnolologia d’infuormaziun e l’internet han contribui sainza blera canera mo da möd decisiv a quist müdamaint rasant. La disponibilità ed il barat d’infuormaziuns da qualunque gener s’han accelerats enormamaing in congual cul temp avant 20 fin 40 ons. Ils ultims 20 ons sun stats caracteristics tras il svilup da la perscrutaziun immunologica e tras las metodas molecularas. Quists instrumaints da perscrutaziun han pussibiltà ils ultims ons da decifrar dret bain ils patomecanissems da malatias dermatologicas infin là na bain inclettas, per uschè catapultar il „rom“ dermatologia a la testa da la perscrutaziun biologic-medicinica. La pel nu’s po biopsar da möd simpel e na-invasiv; ed uschè as po stübgiar vi da la pel hozindi quasi sco model bleras malatias da tuot la medicina.

47 Spirit and Soul of Swiss Dermatology and Venereology

Sül chomp da las malatias inflammatoricas maina quist svilup actualmaing a l’introducziun dad adüna daplü prodots biologics punctualmaing efficazis, e sül chomp da la dermatologia oncologica (sco pro l’oncologia insomma) al svilup da las terapias molecularas punctualas cun cumplettamaing nouvs molecüls, chi attachan la divisiun dischordinada da cellas a sia ragisch. I’s nu sto esser ün profet per predir, cha quista evoluziun gnarà a revoluziunar eir nos rom ils prossems 10 fin 20 ons. Cha suot l’effet da quist cresch teoreticamaing illimità da la medicina nus rivaran a limits economics, quai nu’s po hozindi plü ignorar, ed is stuvarà sainza dubi fixar prioritats. I nun es simpel da preverer infin ingio cha il boom dal marchà da la sandà serva sco crap da chantun a l’economia, e da cura davent cha quist boom piglia davent resursas a l’economia generala, resursas chi füssan meglder d’investir inglur oter. Il foss tanter il giavüschabel ed il realisabel gnarà tschertamaing ils prossems ons plü grond; ed ils meidis faran bain da s’ingaschar persunalmaing in prüma lingia cun incletta ed inchant per ün scumpart intelligiaint ed eticamaing güstifichabel dals mezs dispuonibels. Meidis credibels e ferms, quai es il meglder mezs per servir a l’aigna professiun. Ingio es la dermatologia svizra sco rom medicinic? Politicamaing es la SSDV bain plazzada in Svizra ed in Europa. Nus eschan bain rapreschantats illa Chombra medicinala e, sur la Federaziun fmCh, illa radunanza da delegats da la FMH. IN quasi tuot las societats chantunalas sun rapreschantants da la SSDV activs, suvent dafatta illa suprastanza. Meidis da cader academics da nossas clinicas rapreschaintan la SSDV illas suprastanzas da la SSAI e da l’USSMV. Sül plan internaziunal es la SSDV fich bain rapreschantada in l’EADV, l’ESDR, l’ILDS, ed in l’ILDS e l’ISD, l’UEMS, l’ESPD. Il perfecziunamaint es ün elemaint central per il svilup d’ün chomp medicinic. Eir sün in quist sectur es la SSDV fich activa e fich bain integrada in tuots lös relevants. L’instrucziun pels students vain sustgnü dal program da trenamaint interactiv „DOIT”, chi gioda eir internaziunalmaing gronda stima. Il program da perfecziunamaint deposità pro la SIWF e verifichà dal DFI cuverna ils roms dermatologia e venereologia in tuot sia totalità. La SSDV fa part da la suprastanza da la SIWF, ingio cha’ls 44 titels da meidis specialists ed ils ca. 100 certificats ed ils diploms prioritaris da la Svizra vegnan chürats e survagliats. Daspö l’on 2012 pon

48 Introduction profitar ils commembers da la SSDV da trais perfecziunamaints prioritaris surregiunals il prüm mez on (Swiss Derma Day, Rencontres Romandes de Dermatologie et Venerologie, Zürcher Dermatologische Fortbildungstage) e da la trdiziunala radunanza generala l’utuon. Tuot las quatter occurenzas da perfecziunamaint spordschan ün perfecziunamaint concentrà e tantüna cumplessiv dürant ün fin trais dis, occurenzas chi stan a pêr ed a pass a quellas internaziunalas. Eir pro’l perfecziunamaint dvainta l’e-Learning adüna plü important. Il manual electronic da dermatologia DERMOKRATES po adüna gnir actualisà seguond il princip da Wikipedia. Sur la plattafuorma DERMARENA electronica vegnan transmissas our da las clinicas universitaras minch’on var 15 occurenzas da perfecziunamaint plü grondas illas pratchas svizras, per part geograficamaing fich sparpagliadas. Co voul la SSDV tour per mans las sfidas da l’avegnir? La SSDV es bain etablida in sia suprastanza. In tuot ils ressorts relevants sun commembers cumpetents da la supratanza, chi pon reagir svelt e da möd cumpetent a las sfidas ed als problems da la politica da sandà. La colliaziun infra las associaziuns professiunalas e da las organisaziuns politicas es zuond ferma, e la circulaziun d’infuormaziuns funcziuna. Dürant ils ultims quatter ons ha las organisaziuns professiunalas, la FMH e la fmCh miss ad ir üna radar public chi permetta da verer ad ura ils müdamaints i’l sistem da la sandà per pudair reagir efficaziamaing lasura. E schi fa propa dabsögn es il referendum sül plan federal l’instrumaint il plü effectiv per limitar dons pro decisiuns falladas dals politikers da sandà. L’ultima jada esa gnü fat adöver da quai al cumanzamaint dal 2012 per cumbatter l’uschedit proget Managed Care. Impè da las 50’000 suottascripziuns necessarias sun gnüdas ramassadas infra main da trais mais 150’000 suottasscripziuns tschertifichadas, ed il proget Managed Care es gnü sbüttà cleramaing cun 76 % cuntravuschs. Tals success ans muossan cha nus pudain avair ün grond effet sün la politica da sandà ed in princip il pais nessessari per as participar activmaing per l’avegnir da la medicina svizra e per il bön da quella. Quai sarà üna da las lezchas las plü importants per ils prossems ons. Ma is sto eir dir, cha’ls meidis nu das-chan as restrendscher al dir da na. Nus stuvain preschantar aignas soluziuns per temas

49 Spirit and Soul of Swiss Dermatology and Venereology ardaints da la politica da sandà, soluziuns pussiblas, madüradas ed eticamaing güstifichablas e s’ingaschar per quellas. Ün savair extraordinariamaing concentrà es uni illa SSDV in reguard a chomps professiunals specifics ed üna colliaziun remarchabla infra las instanzas da la politica svizra da sandà. Scha nus fain bain adöver quist potenzial, gnaran nus da mustriar eir da quindervia las sfidas da l’avegnir. Quai giavüschain nus a nossa generaziun ed a quellas futuras da dermatologas e dermatologs in nos pajais. Sajan grats, cha nus pudain lavurar in üna professiun uschè interessanta, continuain ad avair chüra da quella ed ans defendain per cha tuot la medicina, e la dermatologia in special, possa cuntinuar a’s sviluppar bain a bön da l’uman, dal qual la medicina s’occupa. In quist sen ed in quist lö gratulain nus dimena cordiamaing a la SSDV – e nus eschan la SSDV – per seis 100avel anniversari!

Translaziun rumantsch Gion Tscharner

Spirit and Soul of Swiss Dermatology and Venereology

DNA Osler PTCA (1867) (1882) (1890) (1895) aspirin insulin cibazol Tx Tbc Kocher allergia heparin Naegeli Billroth ultrasun Röntgen antibaby CT/MRI prontosil Koch/tbc anticorps biologics salvarsan penicillin anafilaxia antiseptica borrelia B. helio-/UV- targetedTx pacemaker microarray ciclosporin Duplex US hemodialisa osteosintesa helicobacter streptomicin treponema p. vaccin.-BCG Decisiv-med. Aether (1846) genomsumans sterilis. (1886) HIV/hepatitis C cardio-chirurgia transpl. ranuogls feivr-endoscopia fundaziun-WHO NS radio aviun Corea laptop „9/11“ telefon Ruanda Istorgia Vietnam Tsunami Zeppelin mundiala televisiun automobil Srebrenica supersonic Fukushima Tienanmen grammofon ilmürcrouda Camp David guerra fraida globalisaziun mini-computer arrivsüllaglüna bomba atomica Khmercotschen crisa economica vitàdad Einstein telefonia mobila tunnel d.Gotthard teoria da la relati- guerra 1914-1918 guerra 1939-1945 prümavaira arabica allergia dal’Insel Immunol KSB//USZ allergologia: Allergologia Aarau Na-uni Lucerna Turgovia da Turich San Galla Bellinzona Poli da cità Burg Bloch Storck French Turich Miescher Schnyder Dind Frenk Jaeger Gilliet Ramel Pautrier Panizzon Losanna Delacrétaz Saurat Laugier Du Bois Genevra Boehncke Oltramare Jadassohn W Krebs Kuske Lesser Berna Robert Braathen Nägeli O Borradori Jadassohn J Itin Lutz Rufli Bloch Basilea Schuppli Lewandowsky Itin Lutz Lutz Lutz Dind Rufli Rufli Favre Favre Hofer Krebs Bloch Fuchs Mazzi Mazzi SSDV Kuske Ramel Grillet Gabud Robert Hafner Paillard Gabbud Stauffer Stauffer Tenchio Ramelet Ramelet Bigliardi Schuppli Schuppli Lassueur Gueissaz Panizzon Panizzon Perrooud Miescher Miescher Oltramare Oltramare Antonietti Delacrétaz Delacrétaz Burckhardt Jadassohn J Ramel/Lutz Jadassohn W Jadassohn W Lewandowski Winkler/Nägeli du Bois/Chable 1880 1890 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010

52 Introduction

Centennial of the Swiss Society of Dermatology and Venereology: Past – Present – Future

Jürg Hafner*, Peter Bloch*, Lars French*°°, Jean-Pierre Grillet*, Daniel Hohl*, Carlo Mainetti*, Gionata Marazza*, Monica Pongratz*, Enrica Bianchi°, Konstantine Buxtorf Friedli, Stephan Lautenschlager°, Christian Schuster°, Andreas Skaria°, Elisabeth Toszeghi°, Gion Tscharner°, Wolf-Henning Boehncke°°, Luca Borradori°°, Michel Gilliet°°, Peter Itin°°

Translation: Susan Travis

*Office, ° Board, °°Head of Department and Board

The SSDV turns 100 on the 24th of April, 2013. Respect, gratitude and determination are brought to mind at this moment: Respect for the pioneer generation, who christened Swiss dermatology and venereology at the end of the 19th century, and established it for the following generations who continued this success story. Gratitude for the privilege of being able to practise the profession of physician, probably one of the most meaningful professions, and to do so in the incredibly varied field of dermatology and venereology.

55 Spirit and Soul of Swiss Dermatology and Venereology

Determination to master the challenges of the future intelligently and successfully in these rapidly changing times. The first annual meeting of the then Swiss Society of Dermatology and Syphilology took place on the 24th of April 1913, at a time when dermatology clinics in the five university cities in Switzerland were being newly founded in rapid succession (Tab. 1), led by Professor Hughes Oltramare. The board at that time included all those responsible for pioneering Swiss dermatology: Bloch, Dind, J. Jadassohn, Oltramare, Tièche, as well as Antonietti, Du Bois, Dösseker, Guth, Lennhof, Helg, Lassueur, Merian, Narbel and Winkler (Figure 1). The provisional committee elected Prof. Dr. Oltramare from their ranks to become the first President of what is now known as the SSDV (Swiss Society of Dermatology and Venereology). Epidemiologically, dermatology – as is true for medicine in general – was greatly influenced by infectious diseases: syphilis and gonorrhoea, tuberculosis, fungal diseases, scabies, leprosy. They constituted more than half of the hospitalised patients. The “great dermatoses” of course also already existed, for which complex local therapies were available. Medicine had become a completely modern natural science, and research into pathophysiology and biochemistry was making great advances. Historically, the first half of the 20th Century was shaped by the First World War, the global economic crisis and the Second World War. Switzerland was largely spared the war catastrophes, but naturally could not escape the influence of world history. Initially, the first annual meetings were dedicated to the constant advancement of knowledge about the pathology and biochemistry of skin and venereal diseases on the one hand, and to arsenic therapy for syphilis (Ehrlich 606, followed by Neosalvarsan) on the other. The introduction of classical antibiotics in the 1940s revolutionised treatment options for infectious diseases, which fundamentally changed medicine in general and dermatology and venereology in particular. Within a few years the most serious, and previously only to a limited extent treatable, chronic infectious diseases could be effectively treated and transferred from large hospital departments to outpatient clinics. A second

56 Introduction discovery which fundamentally changed the face of the field was the introduction in the early 1950s of systemic corticosteroids, quickly followed by topical corticosteroids, which made the effective and rapid treatment of inflammatory skin diseases possible for the first time. The four decades following the Second World War were characterised by an international economic boom, the likes of which had never been seen before, accompanied in all areas of society, including the sciences, by the rapid development and expansion of technical possibilities and prosperity. The possibilities for growth appeared practically unlimited. Diseases resulting from malnutrition and poor hygiene standards receded and lifestyle diseases became more relevant. On the whole, quality of life and life expectancy increased impressively from decade to decade for western people. Dermatological research gained momentum with the possibilities of immunohistochemistry, emerging immunology and ultrastructure research with the electron microscope. However, it has only reached the peak of world research in the last two decades with the rapid expansion in immunological research and the establishment of molecular medicine. Today, modern dermatology has well and truly lost its earlier “dirty” image and is now a showcase field in many aspects. On the contrary, it has to defend itself against being forced into the “beauty corner.” The fall of the Iron Curtain in 1989 brought a new paradigm shift for the whole world. As a result of the rapid development of globalisation, the Western countries, which previously exerted the strongest political and economic influence, are increasingly required to share their claim to leadership with countries from other areas of the world. The information technology revolution and the Internet are quietly but very relevantly contributing to this rapid change. The availability and exchange of information of all types has today accelerated to an extent unforeseeable 20-40 years ago. The last 20 years have been characterised by the exponential development of immunological research and molecular methods. These research tools have made it possible to unravel the poorly understood pathomechanisms of dermatological diseases to a

57 Spirit and Soul of Swiss Dermatology and Venereology large extent, and with that have catapulted the “organ specialty” of dermatology to the peak of biological-medical research in recent years. It is simple and effectively non-invasively possible to perform skin biopsies, which means that a number of diseases from all medical areas can be studied model-like on the skin. In the area of inflammatory skin diseases, this development is currently responsible for the introduction of an increasing number of biologicals with targeted effectiveness, and in the area of dermatological oncology (and oncology in general), for the development of targeted molecular therapy with completely new molecules, which combat deranged cell division at its roots. One doesn’t need to be a prophet to predict that this development will continue to revolutionise our specialty in the coming 10-20 years. It is hardly possible to overlook the fact that this theoretically infinite growth of medicine will reach economic limitations, and prioritisation will be unavoidable. It is not easy to calculate up to which point the booming health market supports the economy and at which point it takes resources from the rest of the economy which would be better deployed elsewhere. The gap between the desirable and the possible will definitely decrease in the coming years, and the medical profession would be well-advised to take to the frontlines personally to campaign with intelligence and heart for an intelligent and ethical distribution of resources. A credible and strong medical profession also serves its own profession best.

Where does Swiss dermatology stand as a medical specialty? The board of the SSDV and those responsible for continuing education are in agreement that dermatology and venereology are also to be considered an integral organ specialty in the future. This requires that the core areas, along with the innumerable subspecialties and margin areas are all practised and taught at a highly clinical and scientific level. If this effort is not made the field will lose its image and credibility. The rapid discoveries and treatment innovations in the field of inflammatory dermatoses, the renewed rise in sexually transmitted diseases and the skin cancer epidemic provide special challenges. This will be accompanied by the rapid development and spread of dermatosurgery, including

58 Introduction micrographic skin cancer surgery. It is absolutely vital that dermatopathology remains part of the specialty area. Molecular diagnosis and the related targeted therapies will advance the field in all respects.

Where does Swiss dermatology stand in healthcare politics? The SSDV is politically well-positioned within Switzerland and Europe. We are well-represented in the Swiss Medical Association FMH General Assembly through the Medical Association and the governing body fmCh. Representatives of the SSDV are active in almost all cantonal medical societies, often even on the boards. Academic consultants from our clinics represent the SSDV in the boards of the Swiss Society of Allergology and Immunology (SGAI) and the Swiss Union of Vascular Societies (USGG). The SSDV is well-represented internationally in the European Academy of Dermatology and Venereology (EADV), the European Society of Dermatologic Research (ESDR), the International League of Dermatologic Societies (ILDS) and the International Society of Dermatology (ISD). Continued professional development (CPD) is a key element in the advancement of a specialist medical field. The SSDV is also very active and well-integrated in all the relevant areas in this respect. Student learning is supported by the interactive training program “DOIT,” which is also extremely popular internationally. The CPD program registered with the SIWF and assessed by the EDI covers the whole spectrum of dermatology and venereology. The SSDV sits on the board of the SIWF, which maintains and oversees the 44 medical specialist qualifications and the around 100 competency certificates and special focus diplomas in Switzerland. Since 2012 SSDV members can benefit from 3 cross-regional CPD specialist workshops (Swiss Derma Day, Rencontres Romandes de Dermatologie et Vénéréologie, Zürcher Dermatologische Fortbildungstage), and from the traditional annual general meeting in autumn. All 4 CPD events provide concentrated and comprehensive training in 1 to 3 days, and their impressive standard compares well to international standards. E-learning plays an increasingly important role in CPD. The electronic dermatology textbook DERMOKRATES can be continuously updated, similar to the Wikipedia principle. Around

59 Spirit and Soul of Swiss Dermatology and Venereology

15 larger CPD events are presented by the university clinics each year to the geographically widespread Swiss practices on the electronic platform DERMARENA.

How does the SSDV plan to tackle the challenges of the future? The board of the SSDV is well-established. Expert board members are to be found in all relevant departments and are able to react to the challenges and problems of health care politics rapidly and competently as they arise. Networking within the specialist governing bodies and the political organisation is extremely strong and there are good lines of communication. In the last four years the professional associations FMH and fmCh have built up a political “radar,” which enables the timely recognition of changes in the health care system and enough preparation time to react effectively. As a last resort, the most effective damage limitation instrument in cases of misguided healthcare policies is the federal referendum. This was last implemented in early 2012, in the campaign against the so-called Managed Care Model. Instead of the required 50,000, over 130,000 certified signatures were collected in less than 3 months, and the Managed Care Model was very clearly rejected with over 76 per cent voting against it. Successes such as this demonstrate that we can have a strong impact on healthcare politics, and that we have the necessary weight to sensibly and actively shape the future of medicine in Switzerland. It is also a fact, however, that the medical profession must not limit itself to nay-saying. It is up to us to propose and advocate our own well-considered and ethical solutions to the hot topics in health care politics. The SSDV combines an unusual concentration of knowledge regarding the specific professional problem areas and a substantial network within the authorities of Swiss health care politics. If we utilise this potential cleverly, we will continue to be able to overcome the important challenges of the future. This is what we hope for, for this and the future generations of dermatologists in our country. Let us be grateful that we are able to work in such an interesting profession, let us continue to care for it, and to fight for the right of

60 Introduction all medicine, and especially dermatology, to continue to improve for the benefit of the people it cares for. On this note, let us now give the SSDV – we are the SSDV! – our heartfelt congratulations on its 100th birthday!

English translation by Susan Travis, Berlin

61 Spirit and Soul of Swiss Dermatology and Venereology

BCG DNA Osler PTCA (1890) Insulin Kocher Kidney Aspirin Allergy Naegeli Cibazol Billroth The pill Heparin CT/MRI of WHO Prontosil Penicillin Biologics Salvarsan transplant endoscopy Pacemaker Antibodies Fibre-optic Borrelia B. Ultrasound Duplex US Microarray Foundation vaccination Targeted Tx Targeted Cyclosporin Ether (1846) Helicobacter Anaphylaxia X-ray (1895) Streptomycin Heart surgery Treponema p. Treponema Haemodialysis Osteosynthesis Human Genome HIV/Hepatitis C Koch/Tbc (1882) Antisepsis (1867) Light-/UV-Tx Tbc Light-/UV-Tx Sterilisation (1886) Medical Milestones Radio Korea „9/11“ Laptop Ruanda History Vietnam Tsunami World War World Zeppelin relativity World War World Cold War Telephone Television Aeroplane Srebrenica Fukushima st nd Automobile Atom bomb Supersonics Rote Khmer Arab. spring Camp David Gramophone Globalisation 1 Moon landing 2 Gotthard tunnel Small computer Mobile telephone Tienanmen square Tienanmen Fall of Berlin wall National Socialism Einstein’s Theory of Einstein’s The Great Depression Allergy Immunol DER Insel KSB//USZ Allergology Allergology: Aarau Zürich Lucerne Thurgau Non-Uni Städt Poli St. Gallen Bellinzona Burg Bloch Storck French Zürich Miescher Schnyder Dind Frenk Jaeger Gilliet Ramel Pautrier Panizzon Lausanne Delacrétaz Genf Saurat Laugier Du Bois Boehncke Oltramare Jadassohn W Bern Krebs Kuske Lesser Robert Braathen Nägeli O Borradori Jadassohn J Itin Lutz Rufli Basel Bloch Schuppli Lewandowsky Itin Lutz Lutz Lutz Dind Rufli Rufli Favre Favre Hofer Krebs Bloch Fuchs Mazzi Mazzi SSDV Kuske Ramel Grillet Gabud Robert Hafner Paillard Gabbud Stauffer Stauffer Tenchio Ramelet Ramelet Bigliardi Schuppli Schuppli Lassueur Gueissaz Panizzon Panizzon Perrooud Miescher Miescher Oltramare Oltramare Antonietti Delacrétaz Delacrétaz Burckhardt Jadassohn J Ramel/Lutz Jadassohn W Jadassohn W Lewandowski Winkler/Nägeli du Bois/Chable 1880 1890 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010

62 Introduction

Dermatology in Switzerland – the outside perspective of the Doyens

The Perspective of the German Doyens

For most people, Switzerland is known as a country of mountains, lakes, watches, banks, cheese and chocolate, but also for its political neutrality, and its different cultures and languages. Swiss punctuality and reliability are oft-cited virtues, and the referendums and outstanding direct democracy impress foreigners. However, laymen may not know of the exemplary Swiss dermatology that has already existed for longer than 100 years. One hundred years of the Swiss Society for Dermatology and Venereology, the SSDV: we, the neighbours in Germany, would like to congratulate our colleagues and their Society very warmly on this impressive anniversary! When others celebrate their birthdays, one is reminded of one’s own age. The German Dermatology Society (DDG) has a history of almost 130 years and could be envious of the comparably young age of its southern neighbour. Anniversaries also raise memories of successful births. In this context, numerous parallels exist between the early years of dermatology in Switzerland and in Germany. Similarly, the development and growth of the Societies have been characterised by continuous communication and fruitful exchange between many generations of dermatologists and dermatology schools in the two countries. In the founding years of the dermatological Societies, well- known pioneers and respected professors at Swiss universities were also active in Germany, at least temporarily. Likewise, German professors were offered positions in Switzerland. For example, Josef Jadassohn, originally a German from Silesia, became Extraordinary Professor and Head of Dermatology in Bern. He then

67 Spirit and Soul of Swiss Dermatology and Venereology succeeded Albert Neisser as Dermatology Professor in Breslau, but returned to Switzerland for political reasons at an advanced age. Edmund Lesser was another Silesian who became Professor of Dermatology in Bern in 1889. He too moved later from Bern to Germany to take the Chair of Dermatology and Venereology at the Charité in Berlin. Bruno Bloch, the first Ordinary Professor of Dermatology in Zürich, studied medicine in Basel and specialised in dermatology in Vienna, Berlin, Paris and Bern. Later, already professor in Zürich, he received offers from the University of Frankfurt a. M. and the Charité in Berlin, but declined both of them. Felix Lewandowsky, a native of Hamburg, also specialised in dermatology in Bern, was then active in Hamburg in St. Georg Hospital, and later returned to Switzerland to become the Chief of Dermatology in Basel. The trend of mutual exchange continued with Urs Walter Schnyder, a Swiss physician who spent important years as Professor and Chair of Dermatology in Heidelberg in the 1960s and 70s, before returning to Zürich to chair the Dermatology Department there. His collaborator of many years, Ernst Jung, also Swiss, became Professor and the Director of Dermatology in Mannheim. In the 1990s, Günter Burg moved from Würzburg to become Schnyder´s successor in Zürich and, very recently, Henning Boehncke from Frankfurt became Chair of Dermatology in Geneva. Both recruited other German dermatologists who became active players in Swiss dermatology. Several well-known dermatologists in Germany and Switzerland are associated with the names of skin diseases. Two Swiss eponyms come to mind: Alfred Guido Miescher, who held an honorary degree (Dr. h.c) from the medical faculty of the Ludwig-Maximilian-University in Munich and who received the Karl-Herxheimer-Medal, the highest distinction of the German Dermatological Society, first described cheilitis granulomatosa and granulomatosis disciformis progressiva and became the namesake for both diseases. The dermatologist Max Winkler from Lucerne is the eponym for chondrodermatitis nodularis helicis Winkler. More recently, thanks to advancing European collaboration and more permissive workforce mobility regulations, Switzerland is becoming an increasingly attractive country for German medical practitioners. Better income and less hectic clinics, combined with a high quality of life and more stable perspectives, motivate German dermatologists to emigrate. Currently, there are practitioners from

68 The Perspective of the German Doyens

Germany in most parts of German-speaking Switzerland. They seem happy in their new country, at least the authors have not heard of anyone who has returned to Germany after having established their own practice. One distinguishing feature of Swiss dermatology, as compared to the same discipline in Austria or Germany, is the influence of the French and Italian schools of dermatology. Like the country itself and its culture, dermatology in Switzerland also reflects European diversity more than is the case in the neighbouring countries. Substantial influence came from the French dermatology schools via their representatives as department chairs in Geneva and Lausanne. Jean Delacrétaz, Lausanne, and Jean-Hilaire Saurat, Geneva, were both trained in the famous Paris School of Dermatology. The French School of Dermatology continues to reach out from Western Switzerland to German-speaking Switzerland in a fruitful way. Genevan dermatology currently influences Swiss-German dermatology through the appointments of Lars French and Luca Borradori as professors and Department Chairs in Zürich and Bern, respectively. Other important personalities in dermatology in Lausanne and Geneva include professors Edgar Frenk, Renato Panizzon in Lausanne and the allergologist Conrad Hauser in Geneva, all internationally renowned dermatologists with close contacts to German dermatology. The above influences are also noticeable within the SSDV, in the communication among colleagues. For dermatologists from Austria and Germany, it is both astounding and attractive to observe Swiss dermatological meetings, where communication takes place in at least three different languages. Since the discussions at Austrian and German Societies are usually only in German, we experience the exchange in Swiss meetings as particularly varied and stimulating, when each representative speaks in the language of her/his place of work. In addition to the above special and fascinating features of Swiss dermatology, which are discernible from the German perspective, we are united in facing the current challenges of securing the future of dermatology as an independent medical specialty. In concrete terms this means on one hand the preservation of the broad spectrum of our discipline with all its exciting facets and singular features in both in- and outpatient sectors under the current framework of strongly economically-oriented health policies and, on the other

69 Spirit and Soul of Swiss Dermatology and Venereology hand, training of young academics in dermatology to the highest level and with the goal of European harmonisation, and, last but not least, sustaining the stimulation of intellectual curiosity and interest in dermatological research. We wish our colleagues in Switzerland continued success in pursuit of all of this – Swiss dermatology should remain an exemplary European dermatology!

Roland Kaufmann, Leena Bruckner-Tuderman, Otto Braun-Falco

70 The Perspective of the Austrian Doyens

Swiss Society of Dermatology and Venereology – Tradition and Innovation

2013 marks a significant and treasured moment in the history of the Swiss Society of Dermatology and Venereology with the celebration of its 100th anniversary. Scientific, cultural and cordial relations between Swiss and Austrian dermatology have a long mutual tradition. It is for that reason a distinct honour for me to dedicate a few words to the Society from an Austrian perspective and to express my heartfelt congratulations on the occasion of this milestone gala. This short memoir seeks to capture a few personal aspects of three Swiss dermatologists with whom I have had notable connections during the more than 40 years that I have studied dermatology. They are Schnyder, Saurat and Burg.1 I would like to begin with Urs Walter Schnyder, who came from Heidelberg to Zurich in 1978. In 1979 he invited me to co- write, with Hans Kresbach, a long chapter of over 150 pages on cutaneous lymphoproliferative and histiocytic diseases for his book entitled ‘Histopathologie der Haut’ (Spezielle pathologische Anatomie, Doerr-Seifert-Uehlinger). This was the first modern text on cutaneous lymphomas in the literature displaying Lennert’s new Kiel classification with immunological findings.

1 It is impossible to relate to all of those individuals or events with a significant impact on the interrelations of Switzerland and Austria in the area of dermatology.

71 Spirit and Soul of Swiss Dermatology and Venereology

Schnyder’s particular research interest was genetic diseases and he became a world-renowned leader on ichthyoses and epidermolysis bullosa. He was also one of the most important protagonists in German language dermatopathology. But probably more importantly, the essence of his long academic life was guided by setting high-class standards and being a model for all of us by demonstrating the principal characteristics which are needed in medicine and dermatology. Jean-Hilaire Saurat, coming from Paris, became chairman of the Department of Dermatology in Geneva in 1982. My daughter Katrin Kerl-French had her residency training in dermatology in Geneva. At that time (1999) I was privileged to be invited by Saurat to a Guest Professorship. I came to Geneva several times, visiting the clinic and presenting lectures. Among Saurat’s best known contributions to investigative and clinical dermatology are lichen planus-like eruption in graft vs. host disease, toxic epidermal necrolysis and the effects of retinoids on human skin. One of the things I admired most about him was his masterly ability to examine incompletely understood clinical phenomena in the laboratory. This functional-dynamic feedback expanded our understanding of both the clinical and scientific domains. Saurat was also President of the International League of Dermatological Societies (2007-2011). Another example of Swiss-Austrian dermatological relations which I would like to mention is typified by Monika Harms, a native of Vienna. She was ‘Erste Oberärztin’ in the Geneva clinic and described, with Saurat in 1990, ‘papular purpuric gloves-and- socks syndrome’. My association with Günter Burg, whom I want to acknowledge particularly in this essay, extends back to 1972/1973 when I first met him in the Department of Dermatology at the University of Munich (Chairman: O. Braun-Falco), where I was a Visiting Fellow. From this moment our friendship flourished, especially because of our shared interest in the field of cutaneous lymphomas. We initiated many projects and founded the German-Austrian Lymphoma Cooperative Study Group (1973). In 1991, Burg left Würzburg and became Schnyder’s successor in Zurich. I visited him many times and enjoyed his hospitality. On one occasion (2001) I had the honour of presenting the Bloch Lecture.

72 The Perspective of the Austrian Doyens

Burg has made outstanding contributions, pre-eminently to our understanding in the field of cutaneous lymphomas. Until the early 1970s there was no clarity regarding the nature of the disease process. The reticulum cell was considered to be the progenitor of lymphoid cells and most diseases were designated as reticuloses (also mycosis fungoides). With the discovery of two functionally different lymphocyte systems it became evident that it was necessary to rethink the concepts of skin lymphomas. Together, we launched the EORTC-Cutaneous Lymphoma Study Group in 1980, which had a tremendous impact on the accumulation of knowledge of cutaneous lymphomas and the maturation of this field in Europe. Foremost, a new EORTC-classification was formulated respecting the unique features of primary skin lymphomas, and later in 2008 incorporated into the WHO-classification (Figure 1).

Figure 1. Meeting of the Cutaneous Lymphoma Working Group in Zurich 2004: Acceptance by haematopathologists (involving E. S. Jaffe, N. L. Harris and S. H. Swerdlow) of the concept of organ-specific lymphomas by the inclusion of cutaneous lymphomas in the WHO-classification.

Dermatology in Switzerland and Austria has finally made the transition from a mostly morphologically-oriented discipline to an impressive dynamic specialty of experimental research. The necessity for this surfaced gradually during the last quarter of the twentieth century. Today dermatology is in an extraordinary period. The practice of dermatology has only recently evolved towards a new phase of treatment paradigms in ways that appeared unbelievable a few years ago.

73 Spirit and Soul of Swiss Dermatology and Venereology

The Swiss Society of Dermatology and Venereology can look back with pride on its history. The Society has flourished at the same time as it has matured during its 100 years of existence. I wish our Swiss colleagues the very best on their path to a distinguished future fulfilling an important role in medicine.

Helmut Kerl

74 The Perspective of the French Doyens

100 years are beyond any doubt the end of youth and the age of a remarkable maturity for Swiss dermatology. Nevertheless, the intimate interaction of Swiss and French dermatology has an even longer history: As early as 1801, the young Swiss Dr. Laurent Biett came to the Clinic Saint-Louis in Paris to be taught by his master Alibert, where he later directed the out-patient clinics. Many Swiss dermatologists, among them UW Schnyder and Luca Borradori, followed his path in the last two centuries to obtain their practical skills in Paris. In return, Lucien-Marie Pautrier from Paris and Strasbourg directed briefly the Dermatology Clinic in Lausanne during the 2nd World War. His pupil Paul Laugier from Besancon, and subsequently Jean-Hilaire Saurat from Paris, directed the Clinic in Geneva after the War. In this sense, Swiss dermatology should be and become one day European dermatology! Your traditional sense of living together, speaking three different languages and creating one common culture is certainly a great achievement. Five university departments in competition, but capable of joining their forces on specific subjects; an exemplary harmony between academic dermatology and private practice; an organisation of thematic working groups, which is the only possible way to achieve excellence in a specialty grouping 1200 different diseases; academic research of the highest quality reaching from basic fundamental science to bedside research; a multi-lingual teaching program, DOIT, made available to all European medicine students: this all gives an idyllic picture of how European dermatology should look like to defend our fragile specialty, which is not well known, often misunderstood and not

75 Spirit and Soul of Swiss Dermatology and Venereology recognised by politicians, but remains the only medical specialty which treats both a complex organ and its self image. What can we hope for the future? Possibly, that each thematic working group finds its international sensitivity to collaborate more efficiently with similar working groups in other countries. This should allow the establishment of true European networks. One could also hope that patient-based medicine will take its place in Swiss dermatology, rendering our specialty all its legitimacy to exist. 100 years of development and success is a remarkable accomplishment, but also a responsibility! Most valuable human progress is made possible by crystallisation. Small steps are needed to grow progressively. Switzerland is a small country, fortunately nearly, but not completely, European. Let’s hope that its talent will nourish always International dermatology. Bravo and keep going!

Louis Dubertret

76 The Perspective of the Italian Doyens

100 years of the Swiss Dermatology Society: the Italian perspective

We wish to congratulate our colleagues in Switzerland on the occasion of the 100th anniversary of the Swiss Society of Dermatology and Venereology. We have had significant professional contacts with Swiss dermatology and dermatologists, whose scientific insights have constituted a considerable experience for Italian dermatology. Wishing the Swiss Society of Dermatology and Venereology success for the years to come, here we reflect on old and current interactions between Swiss and Italian Dermatology.

Italian pupils of Josef Jadassohn’s school of Dermatology in Bern Josef Jadassohn (1863-1936), pupil and successor of Neisser in Breslau, was one of the founders and main experts in modern dermatology from the late nineteenth century to the early twentieth century. Jadassohn was Professor of Dermatology at Bern University from 1896 to 1917. Among Jadassohn’s pupils in Bern, Cosimo Lombardo, Leonardo Martinotti and Enzo Bizzozero ought to be mentioned. Cosimo Lombardo (1875-1945 (Professor of Dermatology at the University of Sassari (1919-1923) and Pisa (1923-1945), pupil and successor of Giuseppe Mazza. Lombardo trained at the Dermatological Clinic in Bern in 1905. Leonardo Martinotti (1881-1963) was Professor of Dermatology at the

77 Spirit and Soul of Swiss Dermatology and Venereology

University of Sassari (1922), Siena (1922-1924) and Bologna (1924-1951). He was Domenico Majocchi’s pupil and successor. Enzo Bizzozero (1882-1975), Professor of Dermatology at the University of Perugia in 1925 and the University of Turin from 1926 to 1952. He was the son of Giulio Bizzozero, the great histologist and pathologist. Enzo Bizzozero trained at the Bern Dermatological Clinic in 1908, with the qualification of “Zweiter Assistent”.

Two famous Swiss-Italian dermatologists born under Mount Vesuvius Naples is the protagonist of a historical curiosity: in the fascinating metropolis of Southern Italy two eminent figures of international dermatology were born during the second half of the 19th century: Augusto Ducrey and Guido Miescher. They were both born under Mount Vesuvius of Swiss parents, yet their lives followed different paths: Ducrey studied and graduated in Naples and spent his academic career in Italy, while Miescher graduated in Basel and was Professor of Dermatology in Zurich. Augusto Ducrey was born in Naples in 1860, son of Giuseppe Ducrey (Swiss) and Amalia Mazzoni (Neapolitan). He graduated in Medicine and Surgery in Naples at the age of 22. He committed to dermatology, pupil of Professor Tommaso De Amicis. Ducrey is famous for the discovery of the bacterium responsible for soft chancre (chancroid), which, in fact, is named after him (Haemophilus ducreyi). A methodical and enthusiastic researcher, Ducrey investigated this bacterium in the early years of his academic career and presented the results at the International Congress of Dermatology and Syphilography in Paris in 1889, at the age of 29. Ducrey was Professor of Dermatology at the University of Pisa (1849-1911), Genoa (1911-1919) and Rome (1919-1923). He died in Rome in 1940. Guido Miescher was born in Naples in 1887, son of Max Eduard Miescher, businessman, and Marietta Berner, both Swiss. His uncle was Friedrich Miescher, Professor of Physiology at the University of Basel and discoverer of nucleic acids, and his grandfather was Professor of Anatomy at the University of Basel. Due to the premature death of her husband, Guido Miescher’s mother decided to leave Naples in 1896 and moved to Basel, Switzerland. Guido Miescher thus completed his education there and graduated in Medicine

78 The Perspective of the Italian Doyens and Surgery in 1913. After graduation he committed to the study of dermatology, pupil of Bruno Bloch, Professor of Dermatology at the Basel University. In 1916 Bruno Bloch became Professor of Dermatology at the University of Zurich and took Miescher with him. In 1927 Miescher was given the direction of the Radiology Unit (Strahlenabteiliung) of the Dermatological Clinic in Zurich. In 1933, when Bruno Bloch prematurely died, Guido Miescher was appointed Professor of Dermatology at the University of Zurich, where he remained until he retired in 1958. He died in Zurich in 1961. Miescher was a pioneer in radiotherapy in dermatology and gave his name to cheilitis granulomatosa, to granulomatosis disciformis chronica et progressiva and, with Wilhelm Lutz, to elastosis perforans serpiginosa. Guido Miescher was President of the International Committee of Dermatology from 1952 to 1957.

Publications of Italian dermatologists in the Swiss Journal of Dermatology (Dermatologica) After World War II, the Swiss Journal of Dermatology and Venereology, by then called Dermatologica, published several articles by Italian authors, and most of them were written in Italian, which indicated that ours was considered one of the journal’s official languages. In particular, many publications were from the Turin dermatological school of Bizzozero and his successor Midana. In 1957 Gianotti and Crosti published their article on papular acrodermatitis of childhood in Dermatologica (in French).

Current interactions between Swiss and Italian Dermatology In spite of the geographical proximity of the two countries, the collaboration between Swiss and Italian Dermatology has not been very strong in the recent past. Most of the occasions for Italian Dermatologists to visit Switzerland for professional purposes have been for the annual meetings of the European Dermatology Forum, which are typically held in Switzerland, usually in Interlaken and more recently in Lucerne. However, over the last decade collaborative links between Italian and Swiss Dermatology have been strengthened, in particular in the

79 Spirit and Soul of Swiss Dermatology and Venereology research field, also thanks to participation in European networks on rare skin diseases. Several current Heads of Dermatology first met during their post-doctoral fellowships in foreign countries (USA, France), where strong friendships and collaborative relationships were established and have since been maintained. Giovanna Zambruno (Istituto Dermopatico dell’Immacolata, IDI-IRCCS, Rome) coordinated a European network on genodermatoses supported by the European Commission (EC) during the sixth Framework Programme (project title “Rare genetic skin diseases: advancing diagnosis, management and awareness through a European network”, acronym “Geneskin”). Daniel Hohl (CHUV, Lausanne) was a partner in this project and collaborations between the Rome and Lausanne centres were developed, in particular on autosomal recessive congenital ichthyoses. The funding during the fifth Framework Programme of a European project entitled “The pemphigoids, autoimmune blistering diseases of the skin and mucosae: immunopathogenetic mechanisms, prognostic and diagnostic markers” has fostered the implementation of different studies on the humoral immune response in bullous pemphigoid. The collaboration between Giovanna Zambruno, Luca Borradori (Department of Dermatology, University Hospital, Geneva) and Michael Hertl (Department of Dermatology, Marburg, Germany), all project participants, has been central to the realisation of these studies, as attested by several joint publications. The cooperation has continued beyond the end of the project and led to the funding during the seventh Framework Programme of another research project entitled “Pemphigus – from autoimmunity to disease”. The continuing partnership between the laboratory directed by Giovanna Zambruno at IDI and the clinics and laboratory of Luca Borradori, who in the meantime became Chair of the Dermatology Department in Bern, has contributed to the successful project development.

Corrado Del Forno1, Giovanna Zambruno2, Giampiero Girolomoni3

1 Department of Dermatology, University of Pavia. 2 Istituto Dermopatico dell’Immacolata, IDI-IRCCS, Roma. 3 Department of Dermatology, University of Verona, Italy.

80 The Perspective of the Italian Doyens

Guido Miescher Augusto Ducray

The Perspective of the US Doyens

100th anniversary of the Swiss Society of Dermatology and Venereology. A perspective on Swiss-United States interactions

On the occasion of the 100th anniversary of the Swiss Society of Dermatology and Venereology, it is a great pleasure for us to congratulate our Swiss colleagues and wish them all future success for the years to come. Both of us have had considerable professional and personal interactions with Swiss dermatology and dermatologists that have provided us with many important scientific insights and pleasurable experiences. Here we reflect on the interactions between Swiss and United States dermatology. We asked many people what they would write about before we started this essay. Almost without exception, “Sulzberger” was the first topic recommended. Marion Baldur Sulzberger, born in the United States, was widely recognised, along with Stephan Rothman, as the founder of American investigative dermatology and both dominated the landscape of our specialty in the US for many decades. Sulzberger got his start in dermatology and science in Switzerland. The son of a wealthy Chicago meat-packing house family, Sulzberger had an adventurous early life including service as a shepherd in Australia and as a naval aviator in the First World War. He then joined his mother in Geneva and started medical school. Through his sister’s fiancé, he met Bruno Bloch, the Chairman of Dermatology in Zürich, and continued his medical studies in Zürich. After graduation in 1926, he worked as a dermatology resident for two years under Bloch and became good friends with

83 Spirit and Soul of Swiss Dermatology and Venereology

Werner Jadassohn, a more senior department member. His interest in dermatology derived from the fact that his sister suffered from severe acne. He then spent a year in Breslau, the world Mecca for dermatology, before returning to the US in 1929. Under Bloch, Sulzberger was exposed to substantive experimental dermatology. Bloch had developed the dopamine reaction, still one of the most definitive methods of identifying melanocytes. Sulzberger first worked on fungal id reactions and then on contact sensitisation. Bloch had purified primin from primrose plants and it proved to be a most potent sensitiser, ideal for experimental work. In addition, Bloch in 1926 and Sulzberger in 1927 described the congenital disorder we now know as incontinentia pigmenti. While they were not the first to identify such patients, the eponym Bloch- Sulzberger syndrome is often applied. In New York, Sulzberger joined the practice of Fred Wise and the staff at the Skin and Cancer Hospital. He continued his investigations in allergic contact dermatitis and other areas of what today might be called clinical immunology. He was a founder of the Society for Investigative Dermatology and the first editor of the Journal of Investigative Dermatology. During the 1930s, Sulzberger was instrumental in helping many Jewish escapees from Nazi Germany get established in New York City. In 1949 he became Chairman of Dermatology at the NYU School of Medicine and helped make that department pre-eminent in American dermatology. He frequently credited his great success to the excellent training he had received from Bloch. Sulzberger’s successor at NYU, Rudolf Baer, also owed a great debt to Switzerland. Baer was born in Strasbourg in 1909 but his family returned to their ancestral home of Frankfurt after Alsace was placed under French rule in 1918. He attended medical school in Frankfurt, Berlin, Heidelberg and Vienna, but just as he was finishing his doctoral thesis on tracheal metaplasia in 1933, German universities refused to accept theses from Jews. Basle was the last bastion of fairness among German-speaking universities. In a fly-by-night action in early 1934, he took the train to Basle on a Saturday, met with Wilhelm Lutz, Chairman of Dermatology and a former student of Bloch, who contacted Ernst Oppikofer, Chairman of Otorhinolaryngology. They read the thesis on Sunday, gave Baer his oral examination on Monday, and approved his doctoral degree. He then emigrated to New York where he contacted Sulzberger,

84 The Perspective of the US Doyens who had trained in Breslau with his cousin, Heinrich Baer. Baer was always grateful to Basle for giving him this opportunity and left the university a generous sum in his will. The mechanisms of contact dermatitis continued to fascinate Swiss investigators, especially Werner Jadassohn in Bern. Johann R. Frey did basic research at Hoffmann-LaRoche in Basle, concentrating on chemical structures of allergens and experimental disease in animals. One of his most able and long-term associates at Hoffmann-LaRoche laboratories was Ladislav Polak, who also worked with John Turk in London. Polak focused on delayed hypersensitivity in guinea pigs, demonstrating the pathophysiology of the recall phenomenon using a potassium dichromate sensitivity model. In our professional careers, the main interactions between Swiss and US dermatology have been the many Swiss dermatologists who have received training in the US, including a number at the NIH. For example, all five of the current Swiss chairmen spent time in the US:

Chairman University US institution Dates Mentor Wolf- Ronald Henning Geneva NIH 1989-1990 Germain Boehncke Luca Kim Bern NIH 1993-1995 Borradoni Yancey University Alain Lars French Zürich 1999-2000 of Pennsylvania Rook DNAX Research Yong-Jun 1999-2001 Michel Institute Liu Lausanne Gilliett M.D. Anderson Ronald 2004-2010 Cancer Center Rapini Mark Peter Itin Basle Mayo Clinic 1989-1990 Pittelkow

Perhaps the first Swiss dermatologist to train in the US was Edgar Frenk, who worked with Thomas Fitzpatrick and Madhu Pathak at Harvard in 1965-66, producing papers on PABA (which included a trial on Glacier des Diablerets) and depigmenting agents.

85 Spirit and Soul of Swiss Dermatology and Venereology

Later there were successful Swiss investigators at the NIH in the 1980s and 1990s. Conrad Hauser in Steve Katz’s laboratory developed methods to generate T helper cells by primary intro sensitisation. Daniel Hohl, working with Peter Steinert and later Dennis Roop, identified loricrin, a major component of the keratinocyte envelope. Finally, some of Steve Katz’s early training was with Theo Inderbitzin, a Swiss immunologist who had worked with Walter Lever and Peter Grob in Boston on pemphigus autoimmunity, and became an adjunct professor at the University of Miami during Steve’s training. A number of Swiss physicians and scientists who were not dermatologists made great contributions to our field. Dear to the heart of one of us (WB) is his Namensvetter Willy Burgdorfer, a Basle-trained entomologist and parasitologist, who, while working at the Rocky Mountain Laboratory in Hamilton, Montana, discovered the causative spirochete for Lyme disease, now known as Borrelia burgdorferi. Most Americans are relatively uninformed about Swiss medicine, but all have some vague awareness of the many accomplishments of the Swiss pharmaceutical industry. Many drugs without which we could almost not practice our specialty were developed in Switzerland. The two major firms – Hoffmann-LaRoche and Novartis (a fusion of Sandoz and CIBA-Geigy) – are both located in Basle and started as offshoots of the booming chemical industry there. Both developed substantial research programs in the US, Novartis in Cambridge, Massachusetts, and Hoffmann-LaRoche in Nutley, New Jersey. The latter program will cease at the end of 2013. The retinoids were developed by Werner Bollag at Hoffmann- LaRoche. He developed a mouse papilloma model in which an anthracene derivative and croton oil are used to induce hyperkeratotic lesions which serve as a crude model for efficacy in psoriasis and keratinizing disorders. Then over a thousand variations on vitamin A were synthesised and tested to identify those with a favourable therapeutic index. Out of this work came both 13-cis-retinoic acid, which revolutionised the treatment of severe acne, and etretinate, which was one of the first available agents for disorders of keratinization. The initial clinical testing of 13-cis retinoic acid and etretinate was done at the NIH by a team led by Gary Peck. In addition, although all-trans-retinoic acid

86 The Perspective of the US Doyens was not initially felt suitable for systemic use, it became one of the mainstays of topical acne treatment. It was tested by Albert Kligman in Philadelphia and then introduced as Retin-A. Jean- Hilaire Saurat, the long-time Chairman of Dermatology in Geneva, and his team also contributed substantially to the introduction of retinoids into clinical practice. Another example of Swiss pharmaceutical innovation is cyclosporine. Sandoz in Basle set up a program in 1958 to screen antibiotics. In 1966 a group under Hartmann Stähelin was formed to search for non-cytotoxic antibiotics with immunosuppressive properties. Cyclosporine was isolated from the fungus Tolypocladium inflatum found in a Norwegian soil sample by Hans Peter Frey. The final development, including purification and synthesis of the agent, was led by Jean-Francois Borel. The drug was tested in renal transplant patients in the UK and liver transplant patients in the US, and then widely introduced. It also turned out to be very effective for psoriasis and atopic dermatitis, providing clues as to the crucial role of T cells in both these diseases, although always being reserved for refractory cases. Terbinafine, the first of the allylamine antifungals, and topical calcineurin inhibitors were developed by Anton Steutz at Novartis’ research facility in Vienna, Austria. For these major contributions Dr. Stutz was awarded the Eugene Van Scott-Phillip Frost Award at the 2011 American Academy of Dermatology Annual Meeting. The Swiss have also been active in the field of medical publishing. S. Karger Verlag was started in Berlin by the Jewish publisher Samuel Karger in 1890. In 1937, the firm transferred operations to Basle to escape Nazi Germany. Its most famous dermatology journal was Dermatologische Zeitschrift (renamed Dermatologica in 1939 and Dermatology in 1992). Dermatologica featured articles in four languages – German, French, Italian and English – while Dermatology is only in English, making it a useful source for American readers. Karger also publishes Current Problems in Dermatology; the first volume in 1959 was in German but the subsequent 42 volumes have been in English. Volume 2 was on Antibiotic Treatment of Venereal Diseases by Anton Luger, while Volume 43 is titled Transplantation Dermatology. One of us (WB) recalls using a Swiss textbook when taking dermatology as a medical student at the University of Wisconsin in the late 1960s. Walter Burckhardt, chief of the Ambulatorium

87 Spirit and Soul of Swiss Dermatology and Venereology in Zürich, wrote a practical dermatology textbook and atlas which was published in English by Williams & Wilkins as Burckhardt’s Atlas and Manual of Dermatology and Venereology. It went through three editions between 1959 and 1977; the first two were translated by Stephan Epstein and the third by Peter Lynch. Taken together, the interactions between Swiss and US dermatology and dermatologists have been considerable and have contributed greatly to our knowledge base of skin biology and skin disease and to our therapeutic armamentarium in dermatology. Dermatology in both countries is richer because of these interactions, which we hope will continue. We send our many friends and colleagues in the Swiss dermatology community our best wishes for continued success as their society moves into its second century.

Walter Burgdorf, Stephan I. Katz Bethesda

88 Geographic distribution of public dermatology departments and divisions in Switzerland

1 – Genève 7 – Bellinzona 2 – Lausanne 8 – St. Gallen 3 – Basel 9 – Aarau 4 – Bern 10 – Frauenfeld 5 – Zürich 11 – Sion 6 – Luzern 12 – Winterthur

The Five University Dermatology Departments of Switzerland

University Hospital of Basel

The History of Dermatology in Basel can be classified in different time periods. The period of time encompasses the time frame from the foundation of the University in Basel in 1460 until the designation of its own Dermatology Department at the University Hospital of Basel. This aspect is reported with the help of historical documents from the medical faculty of Basel and the annual reports of the Bürgerspital Basel, which were extensively reviewed by Professor Theo Rufli and reported in his well-known book called “Die Geschichte der Dermatologen und der Dermatologie an der Universität Basel 1460-1930” (ISBN 978-3-7965-2420-2). In 1527 Theophrastus Bombastus von Hohenheim, also known as Paracelsus, came to Basel. He was brought to work by the magistrate of Basel, and the University was not informed about this step. Paracelsus assumed that he was not only “Stadtarzt” but also “Ordinarius” of the medical faculty of the University of Basel. However, the faculty of Basel did not accept him. He had to leave town in 1528. In the field of dermatology and venereology Paracelsus established erroneous theories. He assumed gonorrhea to be the first phase of syphilis. This idea was kept for more than 200 years. At this time patients were mainly treated in asylums or hospitals of monasteries, and the ones who were suspected to have a contagious condition, which was often the case in skin diseases, were assigned to sick asylums (Siechenhäuser), usually outside of the city walls. In 1842 a new building of the Bürgerspital Basel was opened in the Markgräflerhof and in its north and south wing, a division for the treatment of patients with skin and venereal diseases was

93 Spirit and Soul of Swiss Dermatology and Venereology opened. The northern wing was dedicated for women, the southern part for men. This separation of gender was kept in the outpatient clinic and inpatient clinic until 1978, and in the waiting rooms even until the eighties of the 20th century. Skin diseases have been treated in a separate division within the Department of Internal Medicine of the Bürgerspital Basel since 1897. In those days the head of this sub-discipline in internal medicine was Professor Jaquet. In the year 1898, 256 inpatients were treated on the dermatology ward. From 1905 Dr. Bruno Bloch was responsible for dermatology. In the annual report of 1906 there is an interesting anecdote cited: “… an unexpected additional work load has been observed in the ward of the skin diseases especially from the outpatient clinic, caused by increasing cases of fungus of the hair (Trichophytia) in young people.” In this report it was stated that a special room was established to perform radiotherapy on this hair disease. This x-ray machine became a central part of therapy in dermatology in those days. In 1908 an independent and separate Department for skin diseases was founded within the Bürgerspital, and Dr. Bruno Bloch was assigned to be head of this Department. On 01.10.1908, after the habilitation of Bruno Bloch (30.07.1908), he became Professor. Bloch had several topics of research interest including mycology, pigmentation, eczematous diseases and allergic reactions. In 1916 Bruno Bloch was appointed at the Department of Dermatology of the university of Zürich. The period of Lewandowsky (1918-1922) is remembered for the first description of epidermodysplasia verruciformis in 1922. The original patient numbers 2 and 3 were treated by Lutz, Schuppli and Rufli, and actually the third patient is still undergoing treatment by Itin in the Department of Dermatology in Basel. Our research lab is working deeply into the genetic background of epidermodysplasia verruciformis and the role of HPV for the development of squamous cell cancer. Professor Lewandowsky had worked before his engagement in Basel on tuberculosis of the skin, lepra and Staphylococcus aureus as the cause of impetigo contagiosa. The Department of Dermatology under Lewandowsky had 57 beds. In 1920 a laboratory for light therapy was founded with a new x-ray machine, two Finsen-Reyn lamps, two Kromayer quartz lamps and a Hanau mercury vapor lamp. Lewandowsky died in 1922 from colon cancer.

94 University Hospital of Basel

After the early death of Felix Lewandowsky, Arndt, Jadassohn and Miescher, together with Lutz, were evaluated as new Directors of Dermatology. Kyrle, who had refused to come to Basel in 1918, was not included anymore on the list of candidates. Finally the University of Basel decided to put Professor Wilhelm Lutz in first place of the short list, and Miescher was put in second position. The time with Professor Wilhelm Lutz (1922-1956) was described by anecdotes and reports from his daughters to Professor Rufli and also to his scholars Professor Rudolf Schuppli and Dr. Ferdinand Wortmann, which are very nicely covered in the book by Professor Theo Rufli. The parents of Wilhelm Lutz were running the famous Hotel Krafft in Basel. At the age of 10 Lutz lost his father, and at the age of 19 years also his mother; therefore he had to run the hotel in addition to his work in the clinic until his younger brother was able to take over. The scientific work by Lutz was rather broad and included a contribution to the biologic effects of radiation, and especially on pigmentation. In addition, he worked on infections of the skin including tuberculosis, cutaneous adverse drug reactions and eczematous skin reactions. His most important publication was the description of epidermodysplasia verruciformis together with Lewandowsky. From 1937 he was Editor of Dermatologica. In 1951 his famous book entitled “Lehrbuch der Haut- und Geschlechtskrankheiten,” edited by S.Karger from Basel, was printed. “Lutz described the blister-spread sign in pemphigus vulagris chronicus in his textbook.” After a myocardial infarction Lutz retired in 1956 and died in 1958. Professor Rudolf Schuppli was elected as Head and Ordinarius of Dermatology in 1956. He was born in Moscow into a family of Swiss expats and his family came to Switzerland in 1918 as refugees. At the age of 18 Schuppli had already started his study of medicine. In 1939 he finished his study and in 1947 he habilitated in Basel. He worked for several years in private practice until he was asked to take over the Department of Dermatology in Basel in 1956. The scientific work of Schuppli was very broad and clinically oriented. He had a main focus on allergology concerning antigen-antibody reactions and the effect of mast cells. Schuppli was very active in the field of syphilis therapy and prevention and he included especially the group of men who had sex with men in his prevention campaign. He offered the possibility for anonymous testing, which was used quite frequently. He also observed an increasing resistance against penicillin in patients with gonorrhea.

95 Spirit and Soul of Swiss Dermatology and Venereology

In addition, Schuppli published on protection ointments for patients with hand eczema. The ointment contained ion exchangers, which should help patients with chromate eczema. An additional topic Schuppli was interested in was leprosy and he published several papers on this topic. At a later stage he investigated the question of whether continuous immunologic stimulation leads to T-cell malignancy, for which he coined the term “immunoma.” Schuppli was an excellent clinician, and contributed to the work after the dioxin disaster in Seveso, as he had described keratosis follicularis epidemica in 1947 in Dermatologica after an accident in a pharmaceutical company in Basel, which was thought to have been caused by a dioxin. He was also a pioneer in the introduction of systemic retinoids for psoriasis and acne. The era of Professor Rudolf Schuppli (1956-1985) was personally experienced by Professor Theo Rufli from 1969, and due to this the report in Rufli’s book is therefore very authentic. The period from 1985-2005 was covered by Professor Theo Rufli as Head of the Department. His primary interests were sexually transmitted infections, and he later developed a growing interest in entymology. On these topics he was the main expert in Switzerland and was also well known throughout Europe. With the beginning of the AIDS epidemic he also worked on the cutaneous manifestations in HIV infected patients. He was an extremely successful and sought-after lecturer. In addition, he was much- esteemed by the students for his excellent lecturing. He retired in 2005 and sadly passed away in 2007. In 2005 the Interregnum started under the lead of Professor S. Büchner and Professor A. Bircher. In the second half of the year Professor Bircher was directing the clinic alone, because Professor S. Büchner had moved to a private practice in Basel. The evolution of the clinic from a purely morphologic-oriented institution to a modern scientific and also molecular-oriented institution was encouraged by Professor Rufli and maintained by Professor Peter Itin, who took over the Department in June 2006. In 2007 a research laboratory was founded which focuses on genodermatoses, and is located within the Department of Biomedicine in Basel. Currently two associate physicians, PD Dr. Peter Häusermann responsible for dermatology and particularly dermatohistopathology, and Professor Dr. Andreas J. Bircher, whose main responsibilities are for the Allergology

96 University Hospital of Basel

Division, for members of staff and for helping to manage the clinic. The founding and evolution of this Policlinic is described in detail elsewhere in Rufli’s book. In 2013 the registrars Dr. Susanna Bohn (general dermatology, autoimmune disorders), Dr. Andreas Arnold (psoriasis, melanoma), Dr. Andreas Volz (surgery, lasers), PD. Dr. Marcel Müller (wound healing, informatics), and PD Dr. Kathrin Scherer Hofmeier (Allergology, Contact Dermatitis) specialize in the various clinical sub-fields of dermatology. 10 residents are currently at different stages of their formation in dermatology and venereology, and 2 in allergology and clinical immunology. Since Peter Itin’s start in 2006 the clinic has maintained and extended its excellence in all clinical disciplines of dermatology; it has established a small but successful research team with its main focuses on genodermatology and the development of in vitro allergological test procedures; and last but not least it puts a lot of effort into the formation of the next generations of medical doctors by giving more than 200 lectures and courses every academic year. Changes within the last few years: The clinic has maintained its high standards for teaching students. The level reached by Professor Theo Rufli was brilliant and his team aimed to continue this success story. Professor A. Bircher reformed and consolidated the content of dermatologic lessons together with the group responsible within the Bologna reform, and as a matter of fact the lecturers of dermatology and allergology have received every year since 2006 the award “teacher of the year” from the medical students. A second important aspect of dermatology and allergology in Basel is the formation of practical, well-skilled dermatologists with a broad clinical knowledge. This tradition also continues, and we are still putting much effort into this task. The curriculum was adapted so that every resident trainee goes through all sub-specialities for 6 months, which is very difficult to maintain from an organizational point of view. A board-certified dermatopathology was established, which is headed by PD. Dr. Häusermann, and a surgical unit was founded with the responsible dermatologic surgeon Dr. Andreas Volz, who is teaching our residents in dermatosurgery. The laser park has been extended and a new device for radiotherapy has been installed. In addition, light therapy has grown, with UVA1 equipment.

97 Spirit and Soul of Swiss Dermatology and Venereology

A further step was the founding of a research lab within the Department of Biomedicine in Basel. Together with Dr. Bettina Burger, a biologist, a lab for genetic investigations in dermatology was established. Dr. Andreas Arnold is participating in this lab on the topic of genodermatoses and he has just submitted his thesis to obtain the title “Privatdozent.” In addition, Professor A. Bircher has continued, together with PD Dr. Kathrin Scherer Hofmeier, his research into adverse drug reactions and with its important results he has put Basel on the map. Also the number of clinical trials is maintained, although it is becoming more and more complicated and the resources are scarce. The next major milestone will be the strategy of how the Department will be organized in the future, as Professor A. Bircher will retire in 2016 and Professor P. Itin in 2018.

Table 1: The medical staff in 2013 Professor Peter Itin Professor Andreas Bircher PD Dr. Peter Häusermann Dr. Andreas Arnold Dr. Andreas Volz Dr. Susanna Fistarol PD Dr. Kathrin Scherer Hofmeier Dr. Simon Müller Katja Ivanova etc

Peter Itin

98 University Hospital of Basel

The medical staff of the Dermatology Clinic in Basel in 1993. Front row left to right: Andreas Bircher, Stan Büchner, Theo Rufli, Sabine Langauer, Peter Itin Middle row left to right: Dominik Müller, Luzi Gilli, Stephan Lautenschlager, Ian Izakovic Upper row left to right: Francis Levy (Allergology), Peter Schiller, Christoph Waldmann (Internist), Marianne Koch (GP)

The medical staff of the Dermatology Clinic in Basel in December 2012. Front row left to right: Maritha Wieland, Aline Büchner, Sabine Fiechter, Celine Manrique, Philipp Cesana, Katja Ivanova, Isabella Terrani, Simon Müller Upper row left to right: Maja Wüest, Bettina Burger, Kathrin Scherer, Andreas Volz, Peter Itin, Susanna Fistarol-Bohn, Peter Häusermann, Andreas Arnold, Mike Recher

University Hospital of Berne

The Department of Dermatology of the University Hospital of Bern: the achievements and the challenges on its 125th birthday

Looking back The Department of Dermatology in Switzerland was created in 1892 on the premises of the Inselspital’s thermal spa. The Inselspital (Isle Hospital), one of the leading university hospitals in Switzerland, was originally a charitable foundation dedicated to supporting and treating poor, sick and bed-ridden people. The hospital, established in 1354 according to the will of Anna Seiler, a wealthy Bernese, began life with thirteen beds and three nurses. It acquired its current name in 1531 after moving into the buildings of a convent named “St. Michaels Insel.” Since 1841 the Inselspital has participated in the training of medical students. The hospital moved to its present location in 1885 and by 2025, a completely new hospital comprising four main buildings is expected to be erected on the current location (Figure 1).

1892-1896: Edmund Lesser, one of the most charismatic representatives of modern German dermatology, acted as the first Medical Director (Figure 2). In his era, he was a renowned syphilis specialist. His textbook on skin and venereological diseases published in 1885 provided a significant and comprehensive contribution to the understanding of skin diseases, and was thus

101 Spirit and Soul of Swiss Dermatology and Venereology

1 2

3 4 Figure 1. The Inselspital and the Department of Dermatology in the past and present. The hospital in 1896 (1) and in 2010 (2). The building of the Department of Dermatology in 1930 (3) and today (4). of invaluable help for the training of students and physicians. Professor Lesser left Bern in 1896 following his appointment as Chairman of the Department of Dermatology at the Charité Hospital in Berlin.

1896-1917: Josef Jadassohn started his career as Head of the Dermatology Department in Breslau. In 1892, he was appointed as Professor Extraordinarius at Bern, where he succeeded Edmund Lesser. Under his leadership, Bern achieved a worldwide reputation in the field of dermatology. Novel and innovative therapies were introduced. For example in 1898, x-rays were first applied for the treatment of Favus and Lupus erythematosus. In 1902, the first Finsen Institute for the treatment of Lupus vulgaris was founded and an effective therapy for syphilis was developed. Jadassohn became one of the founding members of the Swiss Society of Dermatology and Venereology. In 1906, he hosted the 9th Congress of the German Society of Dermatology and Venereology. His remarkable legacy and extraordinary contributions to dermatology and venereology are exemplified by his comprehensive textbook on dermatology and venereology. These 23 volumes with 41 sections on skin and sexual diseases represented the main source of reference during the first half of the 20th century. Jadassohn chaired the Department

102 University Hospital of Berne of Dermatology in Bern for 21 years. He continuously dealt with a lack of financial support and insufficient reimbursement for clinical activities by the hospital. He finally returned to Breslau in 1917, where he continued his remarkable activities until 1937.

1917-1941: Oskar Naegeli, a former associate of Jadassohn, became the Director of the Dermatology Department in 1917. During his directorship the Inpatient Department was extended to up to 116 beds, while he also developed an x-ray unit. During his time, the first effective treatments with sulfonamides for gonorrhea and ulcus molle became available. In 1941, Oskar Naegeli retired due to health reasons.

1942-1953: Paul-Ernst Robert, who started as Professor Extraordinarius, became Full Professor in 1945. He unfortunately died from a heart attack in 1953 at the age of 47. During the 2nd World War, the Inselspital and the Department of Dermatology experienced a significant reduction in staff, but it was during this time that many soldiers were treated for venereal diseases. With the discovery of penicillin and sulfonamides, the treatment of venereal diseases underwent radical change. Paul-Ernst Robert’s interests were focused on the investigation of vitiligo and other pigmentary diseases. Furthermore, he was involved in research on the copper and iron content in healthy skin.

1954-1970: Hans Kuske showed a broad scientific interest in dermatology, although cutaneous mycoses represented his favoured area. Together with his successor Alfred Krebs, he assessed the value of various treatments of psoriasis, including with Locacorten-Tar. He also started interfacing and collaborating with other departments in the hospital, such as internal medicine and rheumatology. Under his auspices, an outpatient clinic for allergy was created in October 1967 with the green light of the local government in Bern. The designated Chief of the Allergy Unit was Alain de Weck (1920-2013). Professor de Weck later became one of the most important European leaders in immunology with studies focusing on penicillin allergies and toxic drug reactions. Alain de Weck started working in the Department of Dermatology under Kuske in 1961, and set up the first real research laboratory in the department’s cellar. Ostensibly his experimental work raised almost no interest from Kuske, who, it is said, almost never set foot

103 Spirit and Soul of Swiss Dermatology and Venereology in de Weck’s lab. The work of Alain de Weck, who was appointed Associate Professor in 1969, was entirely funded by the Swiss National Fund. When in 1970 Hans Kuske died of heart disease, Alain de Weck was not interested in succeeding him despite his now international profile. De Weck went on to subsequently create the Institute of Clinical Immunololgy and Allergy, which he headed until 1993 with international recognition.

1970-1989: After his 8 years as Kuske’s associate, Alfred Krebs, a specialist in internal medicine and dermatology, became Chairman of the Department. During his directorship, the clinic was considerably extended with consultations in phlebology and andrology, as well for light therapy and cosmetic dermatology. Moreover, students’ education was reformed. As for research studies, Professor Krebs was involved in investigations on the pathogenesis of psoriasis and pigmentary disorders. Together with K. Zuercher, he edited the textbook “Hautnebenwirkungen interner Arzneimittel,” which had significant success. From 1985 to 1987, Alfred Krebs served as President of the Swiss Society of Dermatology.

From 1989 to 2008, Lasse R. Braathen was Head of the Dermatology Department in Bern. After graduation from the University of Freiburg in Breisgau, Lasse R. Braathen, a Norwegian citizen, worked in research, psychiatry, internal medicine, surgery and as a naval physician before specialising in dermatology. In 1988, he acquired a Master of Health Administration. From 1998 to 2000, he was the Chairman of NATO Medical Officers. Furthermore, he founded and chaired as president several dermatological societies such as the European Immunodermatology Society and the European Dermatology Forum. Under the Chairmanship of Professor Braathen a number of collaborators contributed to the development of the department. Research was specifically focused on immunological mechanisms in skin diseases, as well as in photodynamic therapy. Christoph Brand introduced a unique method of lymph cannulation to investigate cell migration from the skin to the draining lymph nodes in contact allergy. Thomas Hunziker, who became Full Professor in 1995, investigated skin repair mechanisms. His method of growing in vitro skin from outer root sheet cells was an outstanding achievement, which finally allowed the treatment of chronic wounds. Both Lorenz Zala and Helga Nievergelt contributed to the

104 University Hospital of Berne development of a highly acclaimed dermatopathology unit, which served as a reference centre for generations of dermatologists. Together they facilitated the publication of numerous case reports, and supported clinical trials and other scientific studies. Nikhil Yawalkar, Robert Hunger and Dagmar Simon started their research activities in the mid-nineties. The main interest of Nikhil Yawalkar has been cutaneous immunology: after completing two postdoctoral research fellowships in San Francisco and Boston, he became Associate Professor in 2005. Robert Hunger was involved in studies on the role of the cutaneous immune system and in vaccination protocols for patients with cutaneous melanoma. For two years he worked as a postdoctoral fellow in Los Angeles. Dagmar Simon, who attended a fellowship in dermatopathology in Toronto, has been primarily investigating pathogenic mechanisms of atopic dermatitis, in particular the inflammatory cell and cytokine milieu in order to define new therapeutic targets. Finally, the medical activities of the department greatly benefited from the presence of an internationally well-known specialist of nail diseases and nail surgery, Professor Eckart Haneke, who had an encyclopedic knowledge of dermatology. Professor Haneke had been working part-time in Bern for many years and made Bern a national referral centre for nail diseases and a nail training centre of international acclaim.

In 2008, Luca Borradori became Chairman in Bern. Lugano born and bred, Luca Borradori subsequently studied in Bern and first embarked upon his dermatological training in Lausanne (Chair: Professor Edgar Frenk), then in Paris in the Hospital Saint-Louis (Chair: Professor Antoine Puissant), and finally in Geneva (Chair: Professor Jean-Hilaire Saurat). Between 1993 and 1997 Luca Borradori spent two research fellowships with the Dermatology Branch (Chair: Professor Steve Katz) of the National Cancer Institute in Bethesda, USA, and with the Netherlands Cancer Institute in Amsterdam working on the molecular organisation of hemidesmosomes and dermoepidermal adhesion. In 1997 he returned to Geneva for ten years, where under the Chairmanship of Professor Saurat, he became Head of the Outpatient Unit and Associate Professor in 2005. While his research interests have been mainly concentrated around the role of hemidesmosomal components in cellular cytoarchitecture, his specific clinical interests were applied to autoimmune bullous

105 Spirit and Soul of Swiss Dermatology and Venereology

Figure 2. Portraits of the Chairmen of the Department of Dermatology of Bern since 1892. 1. Edmund Lesser, 1892-1896; 2. Josef Jadassohn, 1896-1917; 3. Oskar Nägeli, 1917-1940; 4. Paul Robert, 1941-1953; 5. Hans Kuske, 1954-1970; 6. Alfred Krebs, 1970-1987; 7. Lasse R. Braathen, 1987-2008; 8. Luca Borradori, 2008. diseases and connective tissue diseases. Associate editor of numerous scientific journals, including the Journal of Investigative Dermatology, Professor Borradori served as Swiss representative within the board of the European Academy of Dermatology and Venereology and chaired its Scientific Committee between 2009 and 2013. He also acted as representative of medical medicine in Bern within the Swiss Academy of Medical Sciences. In Bern, Luca Borradori initiated a reorganisation of the department attracting several outstanding consultants in surgery, phlebology, trichology and lasers. Thomas Hunziker was appointed as Vice Chairman of the department, while Robert Hunger and Dagmar Simon became Associate Professors under his Chairmanship in 2011 and 2010 respectively. Finally, Dr. Ivan Hegyi spent a short but intensive period as dermatopathologist in Bern, where he obtained his Privat- Dozent title in 2010 with molecular studies focused on squamous cell carcinomas and prognostic markers (Figure 2). Emphasising still further his commitment to Bern and the positioning of dermatology

106 University Hospital of Berne within the hospital, Professor Borradori went on to decline the Chairmanship of Geneva, which he had been offered in 2010. After the retirement of Professor Hunziker, Professor Yawalkar became Vice-Chairman of the Department in 2011.

Present status and current challenges Background, structural organisation, medical staff and nursing team The Department of Dermatology is part of the University Hospital Inselspital in Bern, one of the major tertiary healthcare centres in Switzerland. The Inselspital belongs to a private foundation, the Insel Stiftung, which has an agreement with the State of Bern to provide a tertiary healthcare centre and university teaching hospital for the population of the Canton of Bern (Figures 2 and 3).

Figure 3. Facilities of the Department of Dermatology. Clinical ward (1). Example of a patient’s room (2). ISO-certified laboratory of dermatopathology (3). Research laboratory (4).

The Department of Dermatology serves as a tertiary referral centre and university hospital for skin and sexually-transmitted diseases. Patients come not only from the Canton of Bern, but also from all neighbouring states, as well as from the rest of Switzerland.

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More than 20% of patients treated come from outside the Canton of Bern. The Department of Dermatology encompasses an inpatient sector with up to 22 beds available, an outpatient sector with several specialised clinics, a day hospital for complex cases, a phototherapy unit, a surgical unit, a laser platform, and, finally, a dermatopathology sector. In 2012, the medical staff comprised 11 senior physicians, 9 junior physicians, 3 research associates and 4 PhD students. There are 4 professors, 2 senior lecturers and 8 part-time board- certified consultants. There is a close collaboration between the specialised outpatient and inpatient nursing teams. The latter take particular care in ensuring the best education and practice quality in nursing. The nursing activity for the inpatient ward has regularly passed official quality control tests attesting to the quality of the overall standard of nursing practice.

Mission and objectives The department aims at a reflective and well-balanced positioning of the specialty between, on the one hand the actual dilemma of steadily increasing the options for dermatological diagnostics and treatments, and on the other the at best stagnating resources, thus providing the highest level of medical care and service in an ethically responsible and cognisant manner. Major efforts have been made to provide specialised ambulatory consultations, as well as the appropriate evaluation and management of those patients requiring hospitalisation. Although our specialty does not belong to the main strategic focus of the Inselspital (which includes cardiology/cardiosurgery and neurology/neurosurgery), our wish is to act as a fully dynamic medical specialty by carrying out translational clinical and basic research to achieve a better understanding of disease mechanisms and to ensure better patient care and state of the art therapy. Last but not least, respect for both patient dignity and ethical issues remains a constant priority within the treatment spectrum.

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Teaching Activities include pregraduate and postgraduate teaching for medical students, physicians and specialists in dermatology and venereology. In the context of the national reorganisation of medical studies (the introduction of Bachelor and Masters programmes, as well as a 6th compulsory year of study with clinical options), pregraduate teaching in dermatology involves large class lectures, small group seminars with new-problem-based methods, bedside teaching, as well as the use of electronic media. The University Department, recognised by the Swiss Medical Association (FMH) as an academic teaching centre, also ensures postgraduate training for future dermatologists and prepares them for the board examination. It is also actively involved in CME- CPD by organising half-day educational sessions with varied and contemporary programmes with guest speakers from Switzerland and all over Europe. Finally, in recent years, in close collaboration with the Departments of Dermatology of the University Hospital of Basel (Chair: Professor Peter Itin), as well as of the hospitals of Lucerne (Professor Christoph Brand), Aarau (Dr. Markus Streit), Bellinzona (Dr. Carlo Mainetti), and of the Stadtspital Triemli in Zurich (Professor Stephan Lautenschlager), an annual one-day postgraduate teaching meeting “the Swiss Derma Day” has been held with increasing success. Finally, the department is also a teaching centre for specialised nursing.

Clinically-oriented research activities and developments Interest is currently focused on melanoma and non-melanoma skin cancers, Mohs’ micrographic surgery for selected indications, the development of tissue-engineered skin equivalents and novel wound dressings for chronic wounds, pigmentation disorders, the management of psoriasis, and atopic dermatitis with investigator driven studies. Autoimmune skin blistering disorders represent another area of interest, with inclusion in prospective clinical observational and therapeutic trials and the use of novel biological treatments. Finally, novel laser modalities are employed in the management of skin vascular lesions and malformations in adults and in children.

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The Department of Dermatology in Bern at the beginning of the third millenium: current activities, organisation and state of the art

Healthcare statistics and trends The activity of the department relies on three main pillars: outpatients, inpatients and dermatopathology. In 2012, the outpatient sector had 35,000 walk-in visits, including 3,600 visits to the chronic wound healing clinic, 5,500 phototherapy treatments and 2,300 surgical procedures. Over the past decade, there has been an annual increase of approximately 5% (Figure 4).

Outpatient units Number of consultations 2009 2010 2011 2012 Outpatient unit 16'340 17’320 19’126 21’791 (including private consultations) Day care clinic 3’166 3’407 3’332 3’609 Surgery sector 1’799 2’154 2’281 2’299 Phototherapy sector 4’410 4’068 4’836 5’298 Corrective cosmetic procedures 689 821 1’050 695 Activity of the dermato-allergology laboratory: 6’579 7’537 1’234 1’818 Patch tests Activity of the dermatopathology sector 10’806 11’477 11’739 12’079

Figure 4. Evolution of the activities of the outpatient clinics in recent years.

The number of patients hospitalised in 2012 was 540, with more than 20% of those cases coming from outside the Canton of Bern. In the past few years the length of a hospital stay has been significantly reduced from an average of 20 days in 2000 to an average of 10 days in 2010, and finally to 5.5 days in 2012 (Figure 5). This shortening of the admission period has been made possible by improved patient flow and management; by carrying out more diagnostic procedures and treatments on either an outpatient basis or in the day hospital, respectively. Accordingly, the number of beds used for dermatological patients has consistently decreased: from 35 beds in 1989, to 22 beds in 2005, and finally to 14 beds with a flexible reserve in 2012.

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Durchschnittliche Aufenthaltsdauer 25.0 20.2 18.4 20.0 14.4 13.8 13.1 13.7 15.0 11.4 10.3 9.8 9.0 8.6 8.9 8.8 9.1 8.9 8.5 8.4 9.2 10.0 7.7 7.6 7.2 7.1 7.7 7.6 8.2

5.0

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Jun-08 Jul-08 Jul-09 Nov-07 Dec-08 Jan-08Feb-08 Mar-08Apr-08 May-08 Aug-08 Sep-08 Oct-08 Nov-08Dec-08 Jan-09 Feb-09Mar-09 Apr-09May-09 Jun-09 Aug-09 Sep-09 Oct-09Nov-09

Aufenthaltsdauer (exkl. TK) Linéaire (Aufenthaltsdauer (exkl. TK)

Figure 5. Evolution of the hospital stay length during the years before the officlal introduction of the Swiss DRGs (Swiss Diagnosis Related Groups). In 2012 during the first year after the introduction of the SwissDRGs the hospital stay length was 5.5 days.

The dermatopathology sector has processed 12,000 skin biopsy specimens per year for a total of more than 20,000 sections. It provides the entire range of specialised immunohistochemistry studies and is currently one of the few specialised dermatopathology units in Switzerland which is still fully technically and physically integrated with a department of dermatology. The dermatology sector, which obtained an ISO/IEC 17025 certification in 2012, can look back on its remarkable success during the 1980s and 90s as a reference laboratory for many specialists. Nevertheless, the increasing number of private dermatopathology institutes offering similar services, and the difficulties facing the laboratory itself of undergoing a significant reorganisation of the processes, including the speeding up of medical reporting, have resulted in a significant drop of biopsies received for analysis from outside. Only in recent years under the supervision of Dr. H. Beltraminelli and his team, has it been possible to acquire new clients and to again become competitive.

The challenging future of dermatology and venereology: more opportunities or threats?

We are at the beginning of the 21st century: we are experiencing an unprecedented time of rapid change in all areas; economics, politics, lifestyle, global travel and communication. The IT revolution with

111 Spirit and Soul of Swiss Dermatology and Venereology its new communication and media tools profoundly affect daily life and how we interact at local, regional and global levels. In research, and specifically in medicine, there have been impressive advances with new knowledge, new powerful research tools, such as for high-throughout put genomic analyses, bioinformatics, pharmacogenomics, animal models, and stem cell research. The latter have allowed not only a better understanding of diseases and entire regulatory pathways, but are now starting to impact therapeutic decisions allowing personalised medicine versus the “one size fits all” approach. All of these developments have also raised a serious cost issue. In fact, there is a worldwide difficulty for governments and insurers to pay the costof healthcare and to provide the newest drugs. Cost-effectiveness and comparative effectiveness are slowly emerging as important paradigms and criteria to justify the outcome and usefulness in the practical sense of certain new and highly-priced drugs. Finally the political and economical pressure to stop rising health costs has resulted in a far-reaching reorganisation of both the health system and of reimbursement policies with the introduction to Switzerland (Swiss-DRGs) of the diagnosis-related group system.

What about the future of our specialty in Switzerland?

We anticipate that the above changes with an urgent need to cut health costs will have a profound impact on our practice. Furthermore, it is likely that dermatologists will face increased competition from other specialties in what concerns the evaluation and management of distinct groups of diseases (such as from infectiologists, paediatricians, rheumatologists, plastic surgeons, angiolologists… just to mention but a few…). In addition to a committed transformational attitude, some of the following issues need to be addressed to ensure the further development and long-term success and/or survival of our specialty. – Further growth and consolidation of the SGDV/SSDV as a united advocacy body for all issues related to dermatology and venereology (D/V). In this context, it is imperative: – To have full-time specialists and consultants dealing with issues related to coverage and payment policies in both the

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outpatient and inpatient sectors to properly defend the interests of the specialty and affiliated members within all important groups of political, regulatory and paying partners. – To position D/V within the various medical specialties by advertising and making the strengths, specificities and added value of D/V more public. – To actively promote issues such as public health, prevention of skin diseases and skin ageing, as well as maintenance of skin health (skin wellness) within the public arena. – To ensure that the reimbursement for activities of both outpatient and inpatient clinics is adequate to cover costs. The threat is that by neglecting the hospital-based activities, the specialty would not only lose its wards within the hospitals but would also lose one of the “raison d’être” of our patients, namely the assurance of optimal cost-efficient patient care. – To make sure that all specialist members perform their work to high standards and professionalism, thereby providing excellent patient care of the highest but still affordable level. Adherence to ethics by all members at all times would unequivocally place patient care as the first goal. – To make efforts to optimally integrate dermatology among the various medical specialties (from general practitioners and paediatricians, to internists and geriatric doctors). By providing a good service to our population in collaboration with other specialties, we seek to actively contribute to an efficient and more cost-effective medical service to an ageing, as well as to the elderly part of the Swiss population. Dealing with new challenges, such as the management of significantly increasing malignant skin tumour rates would be just one advantage of wider collaborative efforts. – Promotion of postgraduate education in D/V, as well as basic, clinical and translational research in our field are an essential premise for the perception and acknowledgement of our specialty as a highly dynamic and competent medical branch. – Promotion of the training and mentoring of the new generation of dermatologists and researchers, with the support of younger colleagues interested in academic careers.

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– Ensuring that our specialty is flexible by constantly adapting to new or changing environments and needs. Our specialty should be able to anticipate trends within health politics to avoid being dictated to by politicians (volens or nolens). New communication tools (teledermatology, online-based medical services) and better integration of the role of nurses inpatient care should be implemented.

Specific activities in Bern at the beginning of the 21st century: the search for high quality evaluation, diagnosis and care as a tertiary referral centre

Under the Chairmanship of Professor Borradori, the department has made a major effort to provide a wide range of specialised clinics to ensure excellent patient evaluation and care. The goal is to serve as a tertiary referral centre for high quality medical care and as a respected teaching centre for the future generation of dermatologists. Clinics for melanocytic and non-melanoma skin cancers, dermatosurgery, psoriasis, allergic and atopic dermatitis, acne together with hidradenitis suppurativa, autoimmune skin and connective tissue diseases, represent the core of the department’s activities. The latter are complemented by clinics for paediatric dermatology, chronic wounds, phlebology, cutaneous lymphomas, trichology, nail disorders, as well as interventional aesthetic dermatology and laser treatments. Some of these clinics are supervised by external part-time consultants, who are national or international experts in their field.

Pigment lesion and melanoma clinic (Professor Robert Hunger) The incidence of malignant melanoma is growing rapidly. The current incidence rate in Switzerland is one of the highest in the world. A melanoma and pigmented skin lesions clinic provides follow-up for patients with melanoma, and enhances the early recognition of tumours; patients with atypical moles and melanoma also receive clinical follow-up. Subjects at risk are regularly evaluated using a digital dermatoscopic system (Fotofinder) and confocal laser microscopy.

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The names of all melanoma patients since 1996 have been put into an inter-departmental database (dermatology, plastic surgery, pathology, nuclear medicine, oncology) which currently comprises over 1400 patients and which is used to identify prognostic factors and impact management and therapeutic intervention (sentinel lymph node dissection) on disease-free survival and prognosis.

The non-melanoma skin cancer (NMSC) clinic (Dr. Patrick Oberholzer, Professor Robert Hunger) The importance of NMSC such as basal cell carcinoma and squamous cell carcinoma, and thus of dermatosurgery is steadily increasing. This is related firstly to an increase of skin cancers (4-8% in Europe per year) due to life style (sun exposure) and population ageing. Since the Inselspital is one of the Swiss reference sites for organ transplantation, we are involved in managing skin tumours in this high-risk organ-recipient population. The NMSC provides multidisciplinary skin tumour consultations, dermatologic surgery, with particular focus on Mohs micrographic surgery (see below), as well as alternate therapeutic approaches, such as radiotherapy (in collaboration with the Department of Radiotherapy), photodynamic therapy (PDT), cryosurgery, and non-invasive topical immunomodulatory therapies.

Micrographic surgery clinic (Dr. Rocco della Torre, Dr. André M. Skaria) Mohs micrographic surgery is a technique which combines a surgical act with an immediate intraoperative histopathological examination of the excised tumour. The major part of treated tumours is mostly of an epidermal nature, but a modified technique called slow Mohs surgery also allows the treatment of certain forms of skin sarcomas and melanomas. Our department has been one of the first centres in Switzerland to provide Mohs surgery and was introduced in Bern by Dr. A.M. Skaria, who has been Director of the Dermatosurgery Committee of the SSGV for many years. Dr. Skaria, one of the most talented and gifted surgeons in our discipline, has trained several colleagues working now throughout the country.

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Psoriasis clinic (Professor Nikhil Yawalkar) Psoriasis is a common inflammatory skin disease of variable severity with profound psychosocial implications and morbidity. Recent insights into the immunopathogenesis of psoriasis have provided exciting new therapeutic opportunities, e.g. with biologic treatments. In our specialised clinic we provide topical and systemic treatments including phototherapy, traditional systemic agents, and tumour necrosis factor inhibitors (etanercepts, infliximab, adalimumab) are routinely used. We provide interdisciplinary courses of medical education for affected patients (dermatologists, psychologist, nutritionists). Clinical activities are complemented by clinical research studies with the testing of novel biologic treatments, and participation in phase 3 trials, as well as by basic investigative studies.

Drug reaction clinic (Professor Nikhil Yawalkar) The skin is commonly affected by adverse drug reactions, the severity of which can be mild to life-threatening. In close collaboration with the Allergology Unit of the Inselspital under the leadership of Professor Werner Pichler we have a specific clinical and research expertise in cutaneous drug reactions. Patient evaluation and assessment include skin testing (prick, intradermal and patch tests), lymphocyte transformation tests and basophil activation tests. We have performed basic investigative studies aimed at the characterisation of the pathomechanisms of cutaneous drug reactions (see research below).

Autoimmune skin disease clinic (Professor Luca Borradori) We have a specific interest in the management of patients with autoimmune blistering diseases, such as bullous pemphigoid, cicatricial pemphigoid, epidermolysis bullosa, and pemphigus. Our clinic is involved as a referral centre for patients from all over the country. Bullous pemphigoid represents one of the most frequent disease groups, which requires hospital admission and makes up to 10% of our inpatient diagnoses. In addition to clinical management, we have been involved in clinical multi-centre European studies aimed at characterising the clinical course and prognostic markers

116 University Hospital of Berne in affected patients, as well as in investigator-driven therapeutic trials (e.g. intravenous immunoglobulins, rituximab, anti-IL-5 antibodies).

Dermatopaediatric clinic (Dr. Kristin Kernland) Our department is in close collaboration with the University Children’s Hospital in Bern for the evaluation of children with genetic, infectious, metabolic and endocrine diseases, and skin manifestations. There are two major areas of interest and expertise: 1) vascular malformations evaluated in the context of an interdisciplinary hemangioma board; 2) the evaluation and management of patients with inherited skin blistering disorders such as epidermolysis bullosa (EB) within the so called EB-Insel centre. We offer a specialised interdisciplinary evaluation of affected EB patients involving paediatricians, gastroenterologists, dentists, plastic surgeons, and dietitians/nutritionists, as well as a diagnostic genetic workup in collaboration with various leading European molecular-genetic laboratories. We have a specialised team ensuring appropriate wound dressing care and physiotherapy of affected patients. Finally, we provide information to people living with these disorders, as well as their family members and friends.

Laser clinic (Dr. Nathalie Irla, Dr. Klaus Fritz, Dr. Maurice Adatto) Our laser centre led by Dr. N. Dietrich in close collaboration with Dr. Nathalie Irla is equipped with most of the state of the art laser devices (e.g. Cynergy lasers). Cooperation with specialists from other departments (angiology, paediatrics, paediatric surgery) allows interdisciplinary clinical management. Efforts are made to improve therapy algorithms by the use of lasers for a number of skin disorders, such vascular malformations, pigmentary disorders, tattoos, psoriasis, and sun damage. The laser clinic treats both in- and outpatients, and closely cooperates with two experienced consultants to provide high standard clinical care taking advantage of their extensive database with more than 95,000 patients. The activities in this area have taken great advantage from the teaching and support of Dr. Maurice Adatto, (Geneva), and Dr. Klaus Fritz (Lindau, Germany), two international experts and well recognized

117 Spirit and Soul of Swiss Dermatology and Venereology leaders in this area who have both been Presidents of European Society of Laser Dermatology (ESLD).

Atopic eczema clinic (Professor Dagmar Simon) Eczematous skin diseases concern over 20% of dermatologic patients. Atopic dermatitis affects approximately 10% of children at the age of 6-7 years. Irritant and allergic contact dermatitis are common in adults, often as occupational eczema. We provide all diagnostic and therapy facilities for patients with eczematous skin diseases. Diagnostic tests comprise blood and skin tests (patch tests, skin prick tests, atopy patch tests, provocation tests) to identify exogenous and endogenous pathogenic factors. The treatment includes an adequate anti-inflammatory therapy including systemic therapy, skin care, skin protection, psychological advice, and pathogenic trigger avoidance strategies, including changes in occupational life. Furthermore, we offer medical education courses for atopic dermatitis patients.

Trichology clinic (Dr. Pierre de Viragh) We provide a specialised evaluation and care of patients with complex diseases of the scalp and hair. Expert evaluation and individualised therapy are mandatory when hair loss, hair structure alteration or scalp inflammation are treatment-resistant or when scarring occurs. To analyse in detail the features of the disease, a number of exams are carried out; trichogramscanning electron microscopy stereotactic photography, computer-assisted digital imaging (trichoscan), and dermoscopic scalp evaluation. Scalp biopsies are for examination by light microscopy and immunohistochemistry. Dr. P. de Viragh, who acts as a consultant, has an outstanding clinical expertise in hair disorders with a solid background in basic investigative studies (carried out under the mentorship of prof. Dennis Roop in Houston) and dermatopathology (coauthor of a reference book with Dr. Bernard Ackerman, New York) in this complex field.

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Nail disease clinic (Professor Eckart Haneke) In a dermatological practice, 10 to 15% of the patients present because of nail disorders. Little is known about the management of nail patients since until recently little could be done for many nail diseases. The diagnosis of nail diseases is further hampered by the fact that very few dermatopathologists and pathologists are experienced with nail biopsies, since most physicians are afraid to biopsy a nail organ. Finally, some nail diseases require a specific surgical approach for treatment evaluation with both conservative and surgical management, which is offered for inflammatory, infectious, tumoral and congenital nail diseases. Bern is proud to have been able to provide an almost unique consultation in Europe led by an international expert, Professor E. Haneke, who combines clinical expertise with surgical skills in this complex area.

Phlebology (Dr. Albert-Adrien Ramelet, Dr. Urs Büttiker) Our department is able to provide clinical evaluation, clinical investigation (plethysmography, cw-Doppler and colour duplex), as well as in both the conservative (compression, venoactive drugs, physiotherapy) and surgical (sclerotherapy, echo-guided sclerotherapy, surgery) treatment of CVD. The management of chronic wounds is another speciality in our department with several specialised nurses for wound care. Our phlebology clinic benefits from the expertise of an internationally known phleblologist, Dr. dr h.c. A.A. Ramelet. The latter past Vice-President of the International Union of Phlebology, is an author of several standard textbooks in this field.

Chronic wounds clinic (Professor Thomas Hunziker, Dr. Nedzmidin Pelivani) Our department has a large outpatient clinic dealing with the evaluation and management of recalcitrant skin wounds with specialised nurses, providing the entire range of conservative (with all kind of the novel wound dressings) and surgical treatments (such as conventional skin grafting, complex grafting). The clinic is at the leading edge in the development of biotechnologically developed treatments, including tissue-engineered skin equivalents

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(with the development of an autologous epidermal skin equivalent derived from hair taken from affected patients).

Dermatopathology unit (Dr. Helmut Beltraminelli) The dermatopathology unit is involved in the histopathological examination and evaluation of 15,000 to 20,000 tissue samples per year (with 50,000 slides). Biopsy specimens are obtained from our and other departments within the University Hospital, and from dermatologists from all over the country. This sector provides the entire diagnostic spectrum for inflammatory, autoimmune and neoplastic skin diseases using conventional histological investigation, immunohistochemistry and molecular technologies (in collaboration with the Institute of Pathology). One of our interests is the diagnosis of malignant melanoma (approximately 400 new cases per year), dysplastic melanocytic naevi, as well as cutaneous lymphomas. The dermatopathology sector is actively implicated in the pre- and post-graduate teaching courses. In addition to Dr. Beltraminelli, the sector relies on the excellent work of Dr. Helga Nievergelt and Dr. Robert Blum.

African dermatology and dermatopathology Since 2009 we have started collaboration with the Regional Dermatology Training Centre (RDTC) in Moshi, Tanzania. This initiative under the driving force of Dr. Beltraminelli is aimed at promoting expertise in dermatopathology in Moshi and to support young African dermatopathologists to acquire the expertise necessary and required to ensure a good histopathological diagnostic level in Africa. (H. Beltraminelli. Focus on dermatopathology in developing countries in capacity to benefit: A CD of the story of community dermatology – International Society of Dermatology – task force skin care for all: community dermatology – 2011 (www.intsocderm.org).

Research and development projects The department follows different lines of translational as well basic investigative research. All physicians, including senior staff and young residents together with research associates and PhD

120 University Hospital of Berne students, are either promoted or directly involved in developing their own areas of interest. The department makes efforts in providing the time frame, the appropriate technical platform, and the human resources required for the elaboration of grant proposals, the performance of different research projects (studying nursing, laboratory facilities, bench place), as well as the environment to facilitate interactions and partnerships with research groups inside and outside Switzerland. Some of the themes which have been specifically addressed in the past two decades are listed here. The research projects have been supported over the years by grants from the Swiss Foundation for Scientific Research (SNF), European Framework Programs, University of Bern and a variety of private foundations and industry-supported grants.

Atopic eczema and contact dermatitis Pathogenic mechanisms of chronic inflammatory skin diseases including eczema represent an important research area in our department. By analysing skin infiltrating cells and cytokines, as well as their regulation, we aim to better understand the underlying pathophysiologic mechanisms of eczema. Within this research frame, the function of eosinophilic granulocytes is of particular interest. Investigating their pathogenic role in eosinophilic skin diseases will help to develop new therapeutic strategies. – Simon D, Simon HU, “Eosinophilic disorders », J Allergy Clin Immunol, n°119, 2007, p. 1291-1300. – Simon D, Hoesli S, Roth N, Städler S, Yousefi S, Simon HU, “Eosinophil extracellular DNA traps in skin diseases”, J Allergy Clin Immunol, n° 127, 2011, p. 194-199. – Roth N, Städler S, Lemann M, Hösli S, Simon HU, Simon D, “Distinct eosinophil cytokine expression patterns in skin diseases – the possible existence of functionally different eosinophil subpopulations”, Allergy, n° 66, 2011, p. 1477-1486. – Morshed M, Yousefi S, Stöckle C, Simon HU, Simon D, “Thymic stromal lymphopoietin stimulates the formation of eosinophil extracellular traps required for efficient killing of Staphylococcus epidermidis”, Allergy, n° 67, 2012, p. 1127-1137.

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Psoriasis Our studies are aimed at investigating immunological mechanisms, e.g. cytokines, chemokines, cytotoxic and apoptosis mediators and their regulation through therapeutic interventions such biologicals in psoriasis. These investigations may help identify new targets for future therapeutic intervention. – Yawalkar N, Karlen S, Brand CU, Hunger RE, Braathen LR, “Expression of IL-12 in normal and psoriatic skin”, J Invest Dermatol, n° 111, 1998, p. 1053-1057. – Yawalkar N, Hunger RE, Buri C, Egli F, Brand CU, Mueller C, Pichler WJ, Braathen LR, “A comparative study of the expression of cytotoxic proteins in allergic contact dermatitis and psoriasis: Spongiotic skin lesions in allergic contact dermatitis are highly infiltrated by T cells expressing perforin and granzyme B”, Am J Pathol, n° 158, 2001, p. 803-808. – Yawalkar N, Tscharner GG, Hunger RE, Hassan AS, “Increased expression of IL-12p70 and IL-23 by multiple dendritic cell and macrophage subsets in plaque psoriasis”, J Dermatol Sci5, n° 4, 2009, p. 99-105.

Cutaneous drug reactions The clinical documentation of cutaneous drug reactions started by Professor Alfred Krebs was pursued by Professor Thomas Hunziker in collaboration with Professor Rolf Hoigné of the Zieglerspital in Bern, who for 20 years performed comprehensive hospital drug monitoring. Professor Nikhil Yawalkar subsequently focused his interest on pathogenesis of cutaneous drug eruptions. Many studies were performed in close collaboration with Professor Werner Pichler and his research group from the Allergology Unit of the Inselspital. The ultimate goal of these studies was the development of tools for the diagnosis of drug-induced adverse reactions and a better assessment of the risk of subsequent relapse. – Hunziker TH, Kuenzi UP, Braunschweig S, Zehnder D, Hoigné R, “Comprehensive hospital drug monitoring (CHDM): Adverse skin reactions, a 20-year survey”, Allergy, n° 52, 1997, p. 388-393.

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– Yawalkar N, Egli F, Hari Y, Nievergelt H, Braathen LR, Pichler WJ, “Infiltration of cytotoxic T cells in drug-induced cutaneous eruptions”, Clin Exp Allergy, n° 30, 2000, p. 847-855. – Yawalkar N, Shrikhande M, Hari Y, Nievergelt H, Braathen LR, J. Pichler W, “Evidence for a role for IL-5 and eotaxin in activating and recruiting eosinophils in drug-induced cutaneous eruptions”, J Allergy Clin Immunol, n° 106, 2000, p. 1171-1176. – Britschgi M, Steiner U, Schmid S, Bircher A, Burkhart C, Yawalkar N, Pichler J, “Immunological characterization of four patients with drug-induced acute generalized exanthematous pustulosis”, J Clin Invest, n° 107, 2001, p. 1433-1441. – Schlapbach C, Zawodniak A, Irla N, Adam J, Hunger RE, Yerly D, Pichler WJ, Yawalkar N, “NKp46(+) cells express granulysin in multiple cutaneous adverse drug reactions”, Allergy, n° 66, 2011, p. 1469-1476.

Translational medicine: cell therapies for chronic wounds, skin rejuvenation and pigmentation disorders In the 1990s, Professor Thomas Hunziker, together with Dr. A. Limat, ran a cell culture laboratory, focusing on the development of skin equivalents obtained from the outer root sheath (ORS) cells of plucked anagen hair follicles. In collaborative studies with start-up companies, Professor T. Hunziker and Dr. A. Limat developed, clinically tested and introduced to the market two tissue engineering products, EpiDex (autologous ORS-derived organotypic keratinocyte cultures for recalcitrant skin wounds) and Allox, presently HP802-247 (an allogeneic, two-cell-type [fibroblasts and keratinocytes] wound stimulation product). Based on the presence of melanocyte precursor cells, autologous ORS- cells are currently being tested for the treatment of depigmentation disorders such as vitiligo or depigmented scars. Furthermore, the same technology applying freshly isolated ORS-cell solutions onto the skin is now being introduced for skin rejuvenation. EpiDex was the first autologous tissue engineering product reimbursed by Swiss Health Insurances. – Limat A, Mauri D, Hunziker TH, “Successful treatment of chronic leg ulcers with epidermal equivalence generated from

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cultured autologous outer root sheath cells”, J Invest Dermatol, n° 107, 1996, p. 128-135. – Tausche AK, Skaria M, Böhlen L, Liebold C, Hafner J, Friedlein H, Meurer M, Goedkoop RJ, Wollina U, Salomon D, Hunziker TH, “An autologous epidermal equivalent tissue engineered from follicular outer root sheath keratinocytes is as effective as split-thickness skin autograft in recalcitrant vascular leg ulcers”, Wound Rep Reg., n° 11, 2003, p. 248-252. – Goedkoop R, Juliet R, Hou Kang You P. Daroczy J, de Roos KP, Lijnen R, Rolland E, Hunziker TH, “Wound stimulation by growth-arrested human keratinocytes and fibroblasts: HP802- 247, a new generation allogeneic tissue engineering product”, Dermatology, n° 220, 2010, p. 114-120. – Ortega-Zilic N, Hunziker Th, Läuchli S, Mayer DO, Huber C, Baumann Conzett K, Sippel K, Borradori L, French LE, Hafner J, “EpiDex Swiss field trial 2004-2008”,Dermatology, n° 221, 2010, p. 365-372. – Vanscheidt W, Hunziker TH, “Repigmentation by outer-root- sheath-derived melanocytes: proof of concept in vitiligo and leucoderma”, Dermatology, n° 218, 2009, p. 342-343.

Acne inversa (hidradenits suppurativa) At present, the pathophysiology of acne inversa, a chronic inflammatory disorder of the apocrine gland-bearing, is still poorly understood. To better understand its mechanisms we are performing the following studies: 1) analysis of the expression of Toll-like receptor 2 (TLR2) in lesional tissue, which seems to play an important role in maintaining chronic inflammation; 2) characterisation of the role of different subsets of macrophages (M1 and M2 subsets) and T cells (Th1 and Th2 cells) in immune response. – Hunger RE, Surovy A, Hassan AS, Braathen LR, Yawalkar N, “Toll-like receptor 2 is highly expressed in lesions of acne inversa and colocalizes with C-type lectin receptor”, Brit J Dermatol, n° 158, 2008, p. 691-697.

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– Schlapbach C, Yawalkar N, Hunger RE, “Human beta- defensin-2 and psoriasin are overexpressed in lesions of acne inversa”, J Am Acad Dermatol, n° 61, 2009, p. 58-65. – Schlapbach C, Yawalkar N, Hunger RE, “Human beta- defensin-2 and psoriasin are overexpressed in lesions of acne inversa”, J Am Acad Dermatol, n° 61, 2009, p. 58-65.

Melanoma One big challenge in melanoma research is to find adjuvant therapeutic options, able to also remove clinically and radiologically undetectable metastases. A possible approach to reach this goal is to mount an effective immune response against the malignant melanoma cells. In our department we have performed two vaccintion studies aiming to induce immunological responses against the malingnant cells using synthetically produced peptides (mutated ras peptides and telomerase specific peptides) and GM- CSF as an adjuvant. In both studies we were able to generate tumour specific immune responses against the vaccinated peptide. Further studies will be needed to assess if these immunological T cell responses may improve the survival of patients. – Hunger RE, Brand CU, Streit M, Eriksen JA, Gjertsen MK, Saeterdal I, Braathen LR, and Gaudernack G, “Successful induction of immune responses against mutant ras in melanoma patients using intradermal injection of peptides and GM-CSF as adjuvant”, Exp Dermatol, n° 10, 2001, p. 161-167. – Hunger RE, Kernland Lang K, Markowski CJ, Trachsel S, Møller M, Eriksen JA, Rasmussen AM, Braathen LR, Gaudernack G, “Vaccination of patients with cutaneous melanoma with telomerase-specific peptides”, Cancer Immunol Immunother, n° 60, 2011, p. 1553-64.

Non-melanoma skin cancers The research is focused on skin and oral squamous cell carcinomas. Our study aims to identify clinically suitable molecular markers with regards to metastatic properties, tumour development and tumour recurrence potential by combining proteomic (tissue microarray, immunohistochemistry, in situ Hybridisation, FISH) and genomic (cDNA array, RT-PCR) investigation methods. This approach

125 Spirit and Soul of Swiss Dermatology and Venereology should: 1) help to select high-risk patients who may benefit from more aggressive treatment and follow-up protocols and 2) might identify target genes for novel pharmacological intervention. We are currently establishing cohorts of patients with NMSC in the local population to evaluate the demographic and epidemiological data of the high-risk sub-population. – Keller B, Braathen LR, Marti HP, Hunger RE, “Skin cancers in renal transplant recipients: A description of the renal transplant cohort in Bern”, Swiss Med Wkly, n° 15, 2010, p. 140. – Stucker F, Marti HP, Hunger RE, “Immunosuppressive drugs in organ transplant recipients-rationale for critical selection”, Curr Probl Dermatol, n° 43, 2012, p. 36-48. – Oberholzer PA, Kee D, Dziunycz P, Sucker A, Kamsukom N, Jones R, Roden C, Chalk C, Ardlie K, Palescandolo E, Piris A, MacConaill LE, Robert C, Hofbauer GFL, McArthur GA, Schadendorf D, Garraway LA, “RAS Mutations are associated with the development of cutaneous squamous cell tumours in patients treated with RAF inhibitors”, J Clin Oncol, n° 30, 2012, p. 316-321. – Shafaeddin Schreve B, Anliker M, Arnold AW, Laffitte E, Lapointe AK, Mainetti C, Pelloni F, Oberholzer P, Serra AL, Streit M, Hofbauer GFL, “Pre- and posttransplant management of solid organ transplant recipients – risk-adjusted follow-up”, Curr Probl. Dermatol, n° 43, 2012, p. 57-70.

Cutaneous T cell lymphomas Primary cutaneous T-cell lymphoma (CTCL) represents a heterogeneous group of extranodal non-Hodgkin lymphomas of which mycosis fungoides (MF) and their closely related leukemic variant, Sézary syndrome (SS), are the most common types. We have previously analysed the frequency and distribution of dendritic cells (DC) in lesions of CTCL. We have been involved in vaccination studies of CTCL patients with a human telomerase specific peptide (hTERT). Our specialists are well-connected internationally, especially with the Groupe Français pour l’Étude des Lymphomes Cutanés (GFELC) and with the Dermatology Clinic in Graz, where we studied the characteristics of rare cutaneous CD4+ pleomorphic skin lymphomas and related diseases.

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– Beltraminelli H, Leinweber B, Kerl H, Cerroni L, “Primary cutaneous CD4+ small-/medium-sized pleomorphic T-cell lymphoma: a cutaneous nodular proliferation of pleomorphic T lymphocytes of undetermined significance? A study of 136 cases”, Am J Dermatopathol, n° 31, 2009, p. 317-322. – Leinweber B, Beltraminelli H, Kerl H, Cerroni L. “Solitary small- to medium-sized pleomorphic T cell nodules of undetermined significance: clinical, histopathological, immunohistochemical and molecular analysis of 26 cases”, Arch Dermatol, n° 219, 2009, p. 42-47. – Beltraminelli H, Mülegger R, Cerroni L, “Indolent CD8+ lymphoid proliferation of the ear: A phenotypic variant of the small-medium pleomorphic cutaneous lymphoma?”, J Cut Pathol, n° 37, 2010, p. 81-84. – Schlapbach C, Ochsenbein A, Kaelin U, Hassan AS, Hunger RE, Yawalkar N, “High numbers of DC-SIGN+ dendritic cells in lesional skin of cutaneous T cell lymphoma”, J Am Acad Dermatol, n° 62, 2010, p. 995-1004. – Schlapbach C, Yerly D, Daubner B, Yawalkar N, Hunger RE, “Telomerase-specific GV1001 peptide vaccination fails to induce objective tumour response in patients with cutaneous T cell lymphoma”, J Dermatol Sci, n° 62, 2011, p. 75-83.

Investigation on human skin lymph The skin acts as a mechanical, physicochemical and immunological control and defense system, and its lymphatic vessels play a role in the regulation of cell hydration and osmosis, as well as in immunologic responses. Skin derived signals, produced in response to various agents acting on the skin, are transported with the afferent lymph to the regional lymph nodes. These signals reflect the immunological processes in the skin and may also determine the reactions in the lymph node. By analysing afferent lymph derived from specific skin lesions it is therefore possible to gain insight into local pathomechanisms as well as signal transmission in skin disorders. – Brand CU, Hunziker T, Braathen LR, “Isolation of human skin-derived lymph: flow and output of cells following sodium

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lauryl sulphate-induced contact dermatitis”, Arch Dermatol Res, n° 284, 1992, p. 123-126. – Brand CU, Hunziker T, Limat A, Braathen LR, “Large increase of Langerhans cells in human skin lymph derived from irritant contact dermatitis”, Br J Dermatol, n° 128, 2003, p. 184-188. – Brand CU, Hunziker T, Schaffner T, Limat A, Gerber HA, Braathen LR, “Activated immunocompetent cells in human skin lymph derived from irritant contact dermatitis: an immunomorphological study”, Br J Dermatol, n° 132, 1995, p. 39-45. – Brand CU, Yawalkar N, Hunziker T, Braathen LR, “Human skin lymph derived from irritant and allergic contact dermatitis: interleukin 10 is increased selectively in elicitation reactions”, Dermatology, n° 194, 1997, p. 221-228. – Brand CU, Hunger R, Yawalkar N, Gerber HA, Schaffner T, Braathen LR, “Characterisation of human skin-derived CD1a- positive lymph cells”, Arch Dermatol Res, n° 291, 1999, p. 65-72. – Hunger R, Yawalkar N, Braathen LR, Brand CU, “The HECA- 452 epitope is highly expressed on human skin derived lymph cells”, Br J Dermatol, n° 141, 1998, p. 565-569. – Hunger RE, Yawalkar N, Braathen LR, Brand CU, “CD1a- positive dendritic cells transport the antigen DNCB intracellularly from the skin to the regional lymph nodes in the induction phase of allergic contact dermatitis”, Arch Dermatol Res, n° 293, 2001, p. 420-426.

Dermo-epidermal junction, hemidesmosomes and autoimmune bullous diseases between Geneva and Bern

Starting from 1997 to 2007 in Geneva under the chairmanship of Professor JH Saurat, and thereafter in Bern, Luca Borradori and his collaborators were implicated in three major areas of research in independent and collaborative studies: a) The molecular organisation and assembly of hemidesmosomes, junctional adhesion complexes in skin. The mechanisms by which distinct components of hemidesmosomes and

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desmosomes belonging to the spectraplakin family of proteins associate with intermediate filament (IF) proteins. b) The pathophysiologic mechanisms of bullous pemphigoid and the other diseases of the pemphigoid group associated with an immune response to the spectraplakin family member, BP230/BPAG1-e and BP180/BPAG2. c) Finally, we have also perfomed epidemiological studies to characterise the frequency and features of bullous pemphigoid in Switzerland.

Among the various post-docs working with Borradori either in Geneva or in Bern, Dr. B. Favre, Dr. L. Fontao, Dr. K. Lapouge, Dr. I. Schepens and Dr. Steiner-Champliaud have been the most successful and otherwise outstanding collaborators.

Characterisation of the molecular organisation of hemidesmosomes We have investigated the molecular organisation of hemidesmosomes; adhesion complexes that promote epithelial stromal attachment in stratified and complex epithelia. We have mapped the binding sites on the hemidesmosomal proteins BP180, the β4 integrin subunit, BP230, and plectin (PL) involved in their associations. The results have disclosed a hierarchy of interactions among these proteins that are crucial for the assembly and stabilisation of HDs. We have finally identified ERBIN as a novel binding partner for both BP230 and the α6β4 integrin and studied its expression in normal skin and cutaneous cancers (9, 10). – Borradori L, Sonnenberg A, “Structure and function of hemidesmosomes: more than simple adhesion complexes”, J Invest Dermatol, n° 112, 1999, p. 411-418. – Borradori L, Koch PJ, Niessen CM, Erkeland S, van Leusden M, Sonnenberg A, “The localization of bullous pemphigoid antigen 180 (BP180) in hemidesmosomes is mediated by its cytoplasmic domain and seems to be regulated by the β4 integrin subunit”, J Cell Biol, n° 136, 1997, p. 1333-1347. – Borradori L, Chavanas S, Shaapveld RQJ, Gagnoux-Palacios L, Calafat J, Meneguzzi G, Sonnenberg A, “Role of the bullous pemphigoid 180 (BP180) in the assembly of hemidesmosomes

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and cell adhesion. Re-expression of BP180 in generalised atrophic benign epidermolysis bullosa keratinocytes”, Exp Cell Res, n° 239, 1998, p. 463-476. – Borradori L, Schaapveld RQJ, Geerts D, van Leusden M, Kuikman I, Nievers M, Niessen CM, Steenbergen RDM, Snjijders PJF, Sonnenberg A, “Hemidesmosomes formation is initiated by the β4 integrin subunit, requires complex formation of β4 and HD1/plectin, and involves a direct interaction between β4 and the bullous pemphigoid antigen 180”, J Cell Biol, n° 142, 1998, p. 271-284. – Favre B, Fontao L, Koster J, Shafaatian R, Jaunin F, Saurat JH, Sonnenberg A, Borradori L, “The hemidesmosomal protein bullous pemphigoid antigen 1 and the integrin beta 4 subunit bind to ERBIN. Molecular cloning of multiple alternative splice variants of ERBIN and analysis of their tissue expression”, J Biol Chem, n° 276, 2001, p. 32427-32436.

Characterisation of the mode of interaction of BP230/BPAG1-e, plectin and desmoplakin, members of the plakin family of cytolinkers, with intermediate filament (IFs) proteins We have dissected the mechanism of interaction of the hemidesmosomal proteins BP230 and plectin as well as desmoplakin, a desmosomal protein, with various IFs. By cell transfection, biochemical and molecular studies, we have found that 1) specific sequences contained in the linker region and the C-terminal extremity of BP230, plectin and desmoplakin account for their binding selectivity for different IF proteins; 2) cytokeratins and type III IF proteins bind to BP230, desmoplakin, plectin by using distinct set of sequences within their rod and/or tail domain. Overall, the interaction of different IFs with plakins occurs in specific ways. Finally, we have studied the dynamic regulation of the association between desmoplakin and plectin with IFs and found that phosphorylation involving the MAPK pathways and MNK2 of the plectin COOH extremity regulates IF binding. – Fontao L, Favre B, Riou S, Geerts D, Jaunin F, Saurat JH, Green K, Sonnenberg A, Borradori L, “The interaction of the bullous pemphigoid antigen 1, desmoplakin, and plectin with intermediate filaments is mediated by distinct and specific

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sequences within their COOH-terminus”, Mol Biol Cell, n° 14, 2003, p. 1978-1992 – Gontier Y, Taivainen A, Fontao L, Sonnenberg A, van der Flier A, Carpen O, Faulkner G, Borradori L, “The Z-disc proteins myotilin and FATZ-1 interact with each other and are connected to the sarcolemma via muscle-specific filamins”, J Cell Sci, n° 118, 2005, p. 3739-3749. – Lapouge K, Fontao L, Champliaud MF, Jaunin F, Frias MA, Favre B, Paulin D, Green KJ, Borradori L, “New insights into the molecular basis of desmoplakin-and desmin-related cardiomyopathies”, J Cell Sci, n° 119, 2006, p. 4974-4985. – Favre B, Schneider Y, Lingasamy P, Bouameur JE, Begré N, Gontier Y, Steiner-Champliaud MF, Frias MA, Borradori L, Fontao L, “Plectin interacts with the rod domain of type III intermediate filament proteins desmin and vimentin”, Eur J Cell Biol, n° 90, 2011, p. 390-400.

BP180/BPAG2 and BPAG1-e/BP230 as disease targets of the pemphigoids For the past 15 years we have carried out clinical investigative studies into bullous pemphigoid (BP), the most frequent autoimmune subepidermal disease of the skin and mucosae, as well as in the pemphigus. The studies were supported by two European framework programmes. We have been able in independent and collaborative studies to 1) identify new immunodominant epitopes on BP180 and BP230 recognised by patients’ autoantibodies by various approaches, including the testing of a BP180 random epitope library; 2) characterise the evolution of the immune response to BP180 and BP230 (epitope spreading) during the evolution of the disease in a prospective multi-centre study; 3) develop highly sensitive and specific ELISAs for the detection of anti-BP180 and anti-BP230 antibodies; 4) characterise autoreactive T cells, that regulate autoantibody production; 5) characterise the expression of matrix metalloproteinase-9 and neutrophil elastase in skin samples obtained from BP patients; Finally we have been to 6) identify the p180 autoantigen in paraneoplastic pemphigus as the alpha 2-macroglobulin-like 1 protein.

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– Büdinger L, Borradori L, Yee C, Eming R, Ferencik S, Grosse- Wilde H, Merk HF, Yancey KB, Hertl M, “Identification and characterisation of autoreactive T cell responses to bullous pemphigoid (BP) antigen 2 in patients with BP and HLA- DQB1*0301 positive normals”, J Clin Invest, n° 102, 1998, p. 2082-2089. – Skaria M, Jaunin F, Hunziker T, Riou S, Schumann H, Bruckner-Tuderman L, Hertl M, Bernard P, Saurat JH, Favre B, Borradori L, “IgG autoantibodies from bullous pemphigoid patients recognise multiple antigenic reactive sites located predominantly within the B and C subdomain of the COOH- terminus of BP230”, J Invest Dermatol, n° 114, 2000, p. 998-1004. – Di Zenzo G, Grosso F, Terracina M, Mariotti F, De Pita O, Owaribe K, Mastrogiacomo A, Sera F, Borradori L, Zambruno G, “Characterization of the anti-BP180 autoantibody reactivity profile and epitope mapping in bullous pemphigoid patients”, J Invest Dermatol, n° 122, 2004, p. 103-110. – Thoma-Uszynski S, Uter W, Schwietzke S, Hofmann SC, Hunziker T, Bernard P, Treudler R, Zouboulis CC, Schuler G, Borradori L, Hertl M. BP230- and BP180-specific autoantibodies in bullous pemphigoid”, J Invest Dermatol, n° 122, 2004, p. 1413-1422. – Thoma-Uszynski S, Uter W, Schwietzke S, Schuler G, Borradori L, Hertl M, “Auto-reactive T and B cells from bullous pemphigoid (BP) patients recognise similar antigenic regions of BP180 and BP230”, J Immunol, n° 176, 2006, p. 2015-2023. – Di Zenzo G, Thoma-Uszynski S, Fontao L, Calabresi V, Hofmann SC, Hellmark T, Sebbag N, Pedicelli C, Sera F, Lacour JP, Wieslander J, Bruckner-Tuderman L, Borradori L, Zambruno G, Hertl M. Clin Immunol, n° 128, 2008, p. 415-426. – Schepens, I., Jaunin F, Begré N, LäderachU, Marcus K, Hashimoto T, Favre B, Borradori L, “The protease inhibitor alpha-2-macroglobulin-like-1 is the p170 antigen recognised by paraneoplastic pemphigus autoantibodies in human”, PloS one, n° 5, 2010, p. 12250.

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– Di Zenzo G, Thoma-Uszynski S, Calabresi V, Fontao L, Hofmann SC, Lacour JP, Sera F, Bruckner-Tuderman L, Zambruno G, Borradori L, Hertl M, “ Demonstration of epitope-spreading phenomena in bullous pemphigoid: results of a prospective multicenter study.”, J Invest Dermatol, n° 131, 2011, p. 2271-2280.

Epidemiology of autoimmune bullous diseases in Switzerland and the characteristics of bullous pemphigoid patients

In studies involving all dermatology departments and dermatologists in Switzerland, we have carried out nationwide prospective epidemiological studies. By including all new cases of autoimmune blistering diseases diagnosed over a two-year period, we have found that: 1) BP showed a mean incidence of 12.1 cases per million people per year. Its incidence significantly increases after the age of 70. In contrast, pemphigus has an average annual incidence was 0.6 cases per million people per year; 2) the one- year, two-year and three-year probability of death were 20.9%, 28% and 38.8% respectively. The mortality of our cohort of patients with BP was three times higher than the mortality of age and sex-matched general Swiss population. Finally, 3) 20% of the patients with bullous pemphigoid present with non-specific lesions at the time of diagnosis. – Marazza G, Pham HC, Scharer L, Pedrazzetti PP, Hunziker T, Trueb RM, Hohl D, Itin P, Lautenschlager S, Naldi L, Borradori L, “Incidence of bullous pemphigoid and pemphigus in Switzerland: a 2-year prospective study”, Br J Dermatol, n° 161, 2008, p. 861-868. – Cortés B, Marazza G, Naldi L, Combescure C, Borradori L, “Mortality of bullous pemphigoid in Switzerland: a prospective study”, Br J Dermatol, n° 165, 2011, p. 368-374. – della Torre R, Combescure C, Cortés B, Marazza G, Beltraminelli H, Naldi L, Borradori L, “Clinical presentation and diagnostic delay in bullous pemphigoid: a prospective nationwide cohort”, Br J Dermatol, n° 167, 2011, p. 1111-1117.

Luca Borradori, Thomas Hunziker

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University Hospital of Geneva

Department of Dermatology of the University Hospital of Geneva

The Geneva medical faculty was founded in 1876, and its Department of Dermatology 13 years later in 1889. Hugues Oltramare was the first Head of the newly created Dermatological Clinic. It was also Professor Oltramare, who invited his Swiss colleagues to Geneva to found – relatively late compared to other European societies – the then Swiss Society of Dermatology and Syphilology: on April the 24th 1913 a special session was held in Geneva. The “grey booklet” edited by Edgar Frenk (2004) presents all this in more detail; it also contains a historical photo taken on this occasion – though it is difficult to recognise specific personalities in the crowd of black-clad, smoking gentlemen with moustaches. The Department of Dermatology in Geneva has had five professors since 1889. Personally, having arrived in the city of Calvin in the nineteen-sixties, I have known four of them. I cannot say that I really knew Werner Jadassohn; however, I was once invited to meet him at his villa located just behind the hospital. He was certainly an impressive personality, even if you only met him once. The clinic library allows the contemplation of the portraits of three former heads of the department. Hugues Oltramare, nominated 1889, no photo available.

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Figure 1. Figure 2. Charles Du Bois, Werner Jadassohn, nominated 1946 – nominated 1926. for once without his pipe.

Figure 3. Figure 4. Paul Laugier, 1968, Jean Hilaire Saurat, with a formal lace cravat. nominated 1982.

As opposed to the very severe looks of Professor Charles Du Bois, I cannot resist illustrating a complementary side of his personality with his “Ex libris” – bookplate, which I found in one of his dermatology books. Is this hilarious young female pointing to the library above her head or is she treading on the books and

136 University Hospital of Geneva on the microscope; does she illustrate some hard to diagnose dermatological case? When I started work in the clinic during the period directed by Paul Laugier, I encountered a very France- oriented environment, though this period had followed upon Joseph Jadassohn’s son Werner Jadassohn’s reign of nearly twenty years.

For me, this was an occasion to discover the French dermatology bible – the “Traité” of dermatology by Robert Degos – which, I admit, I had never seen in Vienna. This important oeuvre, exclusively written by its single author, is also physically remarkable: very heavy – two volumes – and arranged in a clever metallic Figure 5. structure which allowed the Ex-libris of Charles Dubois. incorporation of updates (provided by the author up until 1981). Initially, I was struck by the fact that an encyclopaedia of this importance was organised into chapters corresponding to lesions – such as papules, vesicles, ulcers etc. – a concept introduced by Robert Willan (1757-1812); when I started to read, everything seemed to be mixed up. But with time I became a very fervent admirer of this book. It contains many unique clinical descriptions, which are only found in “the Degos” and one does not even miss colour illustrations. Whilst working with JH Saurat, I realised that he had memorised every single black-and-white photo in this book. Just as the iron framework of the Degos was a remarkable means of organising knowledge, Saurat introduced me to his sophisticated reference archive system, which he had brought with him from

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Paris in the days before computer support had really been put to work. It rapidly became a tool which enabled all of us to find important references within moments. During his period in Geneva, Saurat created a new and modern French language “dermatology bible” – again an exceedingly heavy book (first edition 1986). It involved the collaboration of innumerable co-workers and has seen 5 editions in 22 years! This anniversary coincides with the beginning of a new period at the Geneva clinic: a new Head of the Department – WH Boehncke – has just been nominated.

Monika Harms

E. Frenk. : la société Suisse de dermatologie et de vénéréologie, telle qu’elle se présente dans ses archives : 1913-1993. Dermatologica Helvetica 1993, 7, 6-14 E. Frenk. : Dermatolgie und Venerologie in der Schweiz. Ein historischer Rückblick. Edition Alphil 2004

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Department of Dermatology at the University Hospital of Geneva under the directorship of Prof. Jean-Hilaire Saurat (1982-2009)

JH Saurat began his career at Hôpital St. Louis in Paris. Before taking over the professorship in Geneva he led the paediatric dermatology department of the Hôpital Necker-Enfants Malades in Paris, which he had created himself. It is reported that thanks to his competence, no child left the clinic without having had a dermatological consult. JH Saurat had become familiar with the clinic in Geneva as a young scientist at a lecture he was invited him to by P. Laugier – perhaps this was the basis for his later application as Laugier’s successor.

Saurat began his role as clinic head with an intensive inventory and clinic restructuring. At the same time, he undertook a marathon of lectures in many hospital departments, emphasising the importance of dermatology in other medical specialties. The modern concept of a dermatology that was not only descriptive was so popular that it resulted in a steep increase in requests for dermatological consults. His efforts paid off!

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The improvements introduced in the first phase affected a number of areas: rounds, special consultations, research activities involving the laboratory, postgraduate training, cooperation with other institutions. Rounds with the head of the clinic took place once a week; the “bedside” round was followed by a “seated” round, where each patient was discussed and the patient notes were consulted and commented upon! The secretary had usually prepared for this by providing important references from the clever reference filing system (which Saurat had brought with him from Paris). From 1996 on, Saurat had great support from Christa Prins. She joined dermatology from internal medicine and was able to take charge of the ward extremely competently, and continues to do so.

Ms. Liliane Didierjean, who Saurat brought with him from Paris, took over the research department and the laboratory. She was a biologist and had an incredible and prudent working style which simply made everything function. She died prematurely in 2006.

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The most important fields of research were the retinoids, pharmacological biology and immunology. Yves Merot, Georges Siegenthaler, Coni Hauser, Martin Röcken, Lars French, Luca Borradori, Philippe Bernard, Olivier Sorg and Gürkan Kaya worked in these areas.

Group photo, 2000

A series of special consultations was introduced. One of the first was atopic dermatitis, an area in which Saurat specialised. Jann Lübbe took over this consultation from 2002. I was assigned the acne consultation. This common skin disorder was very popular with patients, who I continued to monitor despite the frequent turnover of residents. The strictly monitored management of patients on oral Isotretinoin led to high acceptance of this medication and very few severe side effects. Anne-Marie Calza was responsible for the special paediatric consultation. She continues to run it with great involvement and is often requested to speak on the subject. She also initiated the interdisciplinary consultation for angiomas with angiologists, paediatricians and radiologists In cooperation with the gynaecologists a weekly consultation on the vulvar region was introduced; this related field is frequently neglected.

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The introduction of the dermatoscope led to the development of the field of dermatoscopy and melanoma, which Ralph Braun took over. He soon also became renowned as a specialist abroad. Surgery also received a boost, although Saurat, as the son of a surgeon, had certain reservations about this specialty. The rigorous education of residents in this field became obligatory and, thanks to colleagues such as Andre Skaria with his surgical training and Denis Salomon, the department soon became a specialty of the clinic in Geneva and was able to defend itself against plastic surgery. The Mohs procedure and subsequent reconstruction became routine practices. Colloquia took place on a daily basis – almost leading to “colloquitis“: Monday the usual weekend discussion, then the senior consultant meeting; Tuesday patient rounds and seated round; Wednesday the senior consultant colloquia in the individual departments; Thursday the colloquium for dermatologists in private practice; and finally Friday – yes, there was a special colloquium at 8am sharp, called „colloque des fessées“ (best translated as „Watschenkolloquium“, or beating colloquium); discharge letters and written answers to consultations were commented on and criticised – Saurat is very articulate and critical – need I say more? Here are some original Saurat quotes from my collection: • Lettre de sorti : quand un message n’est pas claire savez vous ce qu’il faut faire ? Il faut le clarifier • Vous vous intéressez ? Oui, vous avez fait le Medline ? Oui, aujourd’hui – non hier ! • On a déjà discuté de cela pendant que vous étiez en vacances • Publications – ? Tiroir des éternels regrets • Il faut désigner un assistant sain The colloquium on Thursday (for dermatologists in private practice) began with the presentation of cases by residents. A presentation from an invited speaker or someone from the hospital followed. After a break a recent publication would be discussed – usually only the first or last author needed naming for Saurat to know the subject and present the research background. These colloquia were filled to the last non-existent armchair. Even

142 University Hospital of Geneva colleagues from as far afield as France and Annecy did not want to miss out on this “event” and Saurat’s comments. Close cooperation existed with the department of dermatology from the Hôpital St.Lous in Paris for many years. A forum had been founded in addition to the clinics which very unconventionally organised case presentations about four times a year. These took place in a cinema and lasted until well into the night and the Genevans were actively involved. Saurat had the microphone permanently in his hand! It is thanks to Saurat’s foresightedness that he was able to set the course early in respect to the tendency to reduce bed numbers. Despite resistance from the hospital administration, a 20-bed ward became the CSA (Centre des soins ambulatoires). Complex outpatient treatments are carried out here. A particularly important event during Saurat’s era was the examination and treatment of the Ukrainian President Yushchenko. The dioxin poisoning had caused a very specific major skin change which affected the whole integumentary system. For the most part it consisted of cysts of all sizes which were so numerous that they made a normal life practically impossible. Treatment was aimed at reducing the accompanying inflammation and elimination of the contents of the cysts and thus the poison. The President had given Saurat written consent to use any material for research purposes. Saurat took advantage of this and he and his colleagues were able to make important discoveries regarding the pathogenesis of dioxin poisoning. In addition, based on these discoveries Saurat was able to postulate a new concept on the pathogenesis of acne. If I am not mistaken, 9 lecturers have become professors (Habilitation) during Saurat’s era (in chronological order: Harms, Hauser, French, Borradori Salomon, Piguet, Kaja, Lübbe, Braun), two of whom now hold professorships in Zurich and Bern. Saurat has been editor in chief of Dermatologica since 1986, which he changed to Dermatology with Karger in 1990. His publication list contains almost 1000 publications.

Monika Harms

143 Spirit and Soul of Swiss Dermatology and Venereology

Translational research in Geneva

Appointed only last year as the new Chair of the University of Geneva’s Dermatology Unit, I personally oversee merely 1% of what has happened here since the Swiss Society of Dermatology and Venereology’s foundation (which actually took place right here in Geneva!). But it takes little more than a few minutes to understand where I have arrived. All you have to do is to step into the library, where not even the questionable aesthetics of the Geneva University Hospital‘s architecture can block a telling look into the past. It is here you will find the portraits of 4 out of the 5 chairs this Unit has had so far (Professor Saurat´s portrait is not there yet, for reasons I will explain later), along with a copy of “Dermatologie et Vénéréologie en Suisse” from 2004, edited by Edgar Frank. Those who do not know will learn that the early years, as so often in our specialty, were dominated by the study of syphilis and its potential therapies (Professor Hughes Oltramare, 1889-1926). His successor, however, Professor Charles Du Bois (1926-1046) published on a much wider spectrum of topics. It was Professor Werner Jadassohn (1946-1968) who then systematically applied animal models to the study of human dermatoses, namely the guinea pig model for allergic contact dermatitis. Professor Paul Laugier led the unit from 1968-1982. His inaugural lecture was entitled “The role of dermatology in current medicine” – what a timeless subject, looking at dermatology in Geneva in 2013, where dermatology is part of the Department of Specialties in Medicine (DSM), using more and more systemic therapies to treat seemingly organ-specific diseases! Then came Professor Jean-Hilaire Saurat, not even 40 years old. I heard of him long before I first met him, although I had never touched a French textbook (until recently – and guess who it was edited by?), nor had I attended any French (or Swiss) meetings until recently, nor was I particularly interested in diseases of the sebaceous gland until recently. After all, I am a T-cell guy! Et voilà: In 1992, Martin Roecken, now Chair of the Department of Dermatology in Tuebingen, published a wonderful paper with Professor Saurat and Conrad Hauser, documenting that Types 1

144 University Hospital of Geneva

and 2 helper T cells can be physically derived from a common precursor . So, even as a T-cell guy you could not but acknowledge what went on in Geneva. I guess what Professor Saurat is best known for is his work on retinoids. And indeed, this is groundbreaking work. It spans the whole range from molecular biology to clinical research, and to me represents one of the most Figure 6. comprehensive examples Wolf-Henning Boehncke. of translational research in dermatology: You unravel molecular signalling, and build a therapy for the most common skin disease. And then come the ramifications of this, such as the use of retinoids to treat cutaneous lymphoma. Good stories become great stories once there are unexpected twists to them. And so it came, as Professor Saurat would not stop studying what seemed to be one of the more trivial lesions in dermatology, the comedone. The extraordinary case of the poisoning of a renowned personality prompted Professor Saurat to re-visit what was once considered “simple” chloracne. To this end, that observation sparked a series of studies explaining the effects of the ubiquitously present dioxins on the development, no, the involution of the sebaceous glands, the role of the transcription factor aryl hydrocarbon receptor in this process, and even the effect of dioxins on the polarization of T-cell development (here it is again: the T-cell guy’s bias…). To achieve all of this, Professor Saurat, in his conceptual manner founded the Swiss Centre for Applied Human Toxicology, which is why his picture cannot yet become part of the ancestral portrait gallery; he is simply too busy to retire yet… So much for past and present. What will the future bring? Well, there is “vision 2015” with a lot of ideas around the academic aspects of practising medicine in Geneva. I am optimistic that

145 Spirit and Soul of Swiss Dermatology and Venereology dermatology will continue to be highly active scientifically, with a focus on translational research, namely in the field of chronic inflammation. I am already surrounded by a group of young and eager dermatologists (Professor Saurat’s academic grandchildren if you will). And yes: At some point in time, you may find 5 portraits in the library…

Wolf-Henning Boehncke

146 University Hospital of Lausanne

The University Department of Dermatology and Venereology in Lausanne

Introduction The Medical Faculty of Lausanne was founded in 1890 during the transformation of the Ancient Academy of Lausanne of 1537 into a modern university. As stipulated in its first by-law of 1891, a teaching unit for venereal and cutaneous diseases was created in 1892. A moving testimony of the life of this unit between 1915 and 1950 was given in a manuscript by Sister Henriette; its main parts were published in 1998 in Dermatologica Helvetica (number 4, pages 8-9). The history of the Department of Dermatology of Lausanne from 1892 to 2004 was summarized in a booklet published by the Swiss Society for dermatology and venereology.4

From 1959 to 1996 : Professor Edgar Frenk Arriving in Lausanne in 1959 from my native German-speaking part of Switzerland, I had planned to stay there for a one-year residency in dermatology. The Department of Dermatology and Venereology of that time was located in the basement of the old

4 Frenk E, Le service de dermatologie et de vénéréologie du centre hospitalier universitaire vaudois Lausanne, in Frenk E, (éd.), Dermatologie und Venerologie in der Schweiz – Dermatologie et vénéréologie en Suisse, Neuchâtel: Alphil, 2004.

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“Hôpital cantonal,” opened in 1853 and situated on a vast estate above the city centre, at a place named “En Calvaire.” My residency having nothing in common with the name of the place, I finally stayed there – except for prolonged training and research periods in London and Boston – until 1996 as a resident, chief resident, then as associate physician, and finally head of the department. When I started my residency, Professor Jean Delacrétaz – Head of the Department since 1958 – was preparing to close his private practice in town and to transfer all his activities to the hospital. His chief resident was leaving the hospital to open a private practice. We were five residents in training. The two senior ones were in charge of the outpatients, and the others were taking care of the hospitalized patients. Our working conditions were unconstrained and relaxed and for my medical reports I greatly appreciated the friendly linguistic help of my colleagues. But I also remember the glacial look of the boss, when he found us unduly prolonging our morning coffee break, which was enriched by the hospital with some excellent snacks prepared for our colleagues on duty the night before. The formal teaching program was as limited as my knowledge of the French language. So I rapidly realised that “Learning by doing” was the rule. The laboratory’s activities included, beside routine blood, serum and urine tests, the identification of dermatologically relevant fungi and, as the Swiss reference lab, the Treponema pallidium imobilisation test, at that time the only specific serological test for the diagnosis of syphilis. Dermatohistopathology was the exclusive domain of the professor, and self-taught methods were necessary to grasp its mysteries. All these laboratories were below the basement level of the hospital wards, but from there you could enjoy a beautful view onto the lake, the mountains and the cathedral. Next to the labs was an ancient empty coal cellar, much appreciated by some of the staff for tasting one or several glasses of the excellent local white wine. A particular feature of the Dermatology Department of Lausanne was its Burn Centre, a rather difficult charge for a small hospital unit, especially with regard to the management of the nursing staff because of the significant fluctuations in the number and gravity of patients. For me, as resident for 4 ½ years, this meant being permanently on duty, and this was prior to the advent of mobile telephones. To our satisfaction, the results obtained were comparable

148 University Hospital of Lausanne to those reported by burn centres in other countries. In 1980, when our department moved into the new hospital building, the care of the Burn Centre was taken over by the Department of Plastic Surgery; since the late nineteen-eighties, we have collaborated in burn care by providing the cultured epidermal grafts needed for treating extensive burns. Modern medicine becoming more and more complex, the board of directors of the hospital created in the early nineteen- sixties some new positions of senior staff physicians; the full or part-time associate physicians. In the hierarchy they were situated between the department head and the chief residents. These new jobs permitted the introduction of specialised consultations and an increase in the teaching program for trainee physicians and for dermatologists in private practice. Returning home from a fellowship at the Department of Dermatology at the Massachusetts General Hospital in Boston, devoted to research on melanin pigmentation and skin protection against light, I obtained in 1966 a 80% position as an associate physician. In 1967 I was elected lecturer and in 1973 associate professor. In these positions I could continue my clinical and research activities at the hospital and participate in the management of the department and its different teaching programs. But I was also obliged to be involved in several rather painful sessions aimed at reducing our budget and had thereby to confront teams of full-time experts for budget reduction, but with a rather limited knowledge of the complexities of a university hospital. In addition, I had a 20% part-time private practice in Montreux. In 1986 I succeded Professor Delacrétaz as head of the department with the explicit mission, formulated by the nominating commitee, to introduce new lines of research, but without any mention of its financing. Unexpectedly, I was also confronted with other problems. Dr. D. Grigoriu, in charge of mycology and its laboratory, suddenly died a few months prior to my appointment and an additional associate physician and lecturer resigned. I therefore had to begin in my new position with a considerably reduced senior medical staff. My most urgent task was to find a qualified dermatologist for the position which had become vacant following my promotion. To my great satisfaction I found for this job Dr. Yves Mérot, previously

149 Spirit and Soul of Swiss Dermatology and Venereology scientific chief resident in the Department of Dermatology in Geneva. He joined us on the 1st of October 1987 and was soon recognised as an excellent clinician and histopathologist with research programs on Merkel cells and malignent melanoma. Sadly he was affected a few months later by a serious disease, but continued to work with competence and enthousiasm despite several painful, nearly intolerable treatments. At the beginning of 1989 he was appointed lecturer, but already in November of the same year he informed me, that he could no longer continue his activities and presented me a list of work to be finished, including the organisation of the annual meeting of the French Society for Dermatological Research in 1991. On the 16th of January 1990 he died, much regretted by all of us. The vacant position was taken over on the 1st of October 1990 by Dr. Daniel Hohl, who was appointed lecturer in 1992. In all the years up to my retirement, I greatly appreciated his loyal help in managing the department and his clinical and histopathological competence. I followed with interest the development of his research program on epidermal keratinisation, performed in collaboration with Dr. Marcel Huber, a molecular biologist. One of the highlights of their research was the first publication in 1995 on the demonstration of mutations of keratin-transglutaminase in lamellar ichthyosis in patients from 3 different families. In 1987, the retirement of the biologist in mycology was a good departure point for a reorganisation of this subspecialty. My plan was to increase the biological research activities in dermatomycology, a domain rarely investigated by general microbiologists. The project was to better characterise the virulence and pathogenicity of dermatologically relevant fungi, and also to improve the available diagnostic methods. This was realised with excellence by Dr. Michel Monod, an experienced microbiologist, who has been directing this laboratory since 1988. The clinical aspects of dermatomycology were assumed by Dr. Florence Baudraz. A new research unit on the photobiology of the skin was created in 1991 and was directed by Dr. Lee Ann Laurent-Applegate. She successfully conducted work on the basic defense mechanisms of the skin against UV-A and UVB. All these research activities were mainly financed by the Swiss National Science Foundation, the Swiss Research Foundation

150 University Hospital of Lausanne against cancer and the European research program Biomed II, and to a minor degree by private sources. Furthermore, the Emile Dind Fund, a donation by the first professor of dermatology in Lausanne, was very helpful to cover unexpected urgent expenditures without tedious administrative formalities. During my time as head of the department, our clinical, research and teaching activities also derived much benefit from the regular contributions of associate physicians predominantly in private practice. The principal collaborators have been Dr. Brigitte Vion (histopathology), Dr. Barukh Mevorah (genodermatoses) and Dr. Marie-José Piquerez (phlebology).

***

Figure 1. Visit on the day the direction of the department was transferred from Professor Jean Delacrétaz to Edgar Frenk on the 31st of August 1986, accompanied by Dr. Catherine Ruffieux-Magnin.

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From 1996 to 2010 : Professor Renato G. Panizzon

When I had my first interview with the hospital and university authorities they clearly told me that no supplementary position would be given to me, but guaranteed just laser equipment. In 1996 the department was composed of the following (in 2010) staff positions: 0 (1) Assoc. Prof. MD, 2 (1) MD staff, 2 (6) attending MD staff, 3 (4) chief residents, 6 (8) residents, 0 (1) Assist. Prof. PhD, 4 (7) PhD’s, 2 (8) thesis positions. The inpatient ward section disposed of 20 (18) beds for 298 (508) inpatients per year, with a mean duration of hospitalisation of 16.9 (12.9) days. The outpatient section treated 7030 (13540) new patients. I had the chance to take over a perfectly organised department from my predecessor.

DHURDV: The Dermato-venereologic University Hospital Department of the “Suisse-romande” (the French part of Switzerland). It was the idea of the authorities of the two university hospitals in Lausanne and Geneva that the two departments should collaborate. As the first coordinator, Professor J.H. Saurat from Geneva was named for 4 years before the coordinator would change. Besides an inpatient and outpatient section, each department offered 3 subspecialties on their sites; in Lausanne: Dermato-phototherapy, Dermato-phlebology, and Dermato-mycology, and in Geneva: Dermato-allergology, Dermato-pathology, and Dermato-surgery. Clinical meetings took place twice a month, alternatively in Lausanne and Geneva. A research meeting was held once a month in Rolle (half-way between the two cities). This joint department worked well for a couple of years, then the financial support stopped. Also, a people’s vote on the general collaboration of the two university hospitals was not accepted by Geneva’s population. From then on the DHURDV’s activity diminished, and after 2008 the clinical and research meetings stopped; each department organised their meetings separately once a month, and maintained a joint meeting once a year.

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On the other hand, the departments in the German part of Switzerland (Basel, Bern, Zurich) have only now started joint meetings. As mentioned before, besides two internal and two attending staff personnel, 6 dermatology residents worked in the department. We realised that we could only increase the resident’s positions by considering residents training in general medicine and their willingness to practise dermatology for 6 months. This was possible due to the support of the Department of General Medicine, which offered a special curriculum to candidates in general medicine. By this we were able to increase the pool of residents to seven in 1997, and finally an th8 resident (dermatologist) joined in 2009. In 2002 a new law regulating the working hours of residents and chief residents was introduced in order to limit their maximum weekly workload to 50 hours. This represented supplementary work for the staff including the chairman, and including weekends. We therefore were obliged to engage residents, even part-time, with “soft money.” Concerning patient care the nursing staff were divided between those working in the wards and those working in the outpatient section. We tried to coordinate the two sections and stimulate the polyvalence of the nurses, but we also tried to train specialised nurses in the treatment of chronic wounds for the day-care unit. The administrative staff were unified under a responsible staff person newly created. She unified all the secretaries of the ward, outpatient section and laboratories. Daniel Hohl was appointed assoc. professor and Marcel Huber assist. professor in 2000. Michel Monod was named assoc. professor in 2004. Florence Baudraz, another staff member, left our department in 2005 and was replaced by Paul L. Bigliardi, assistant professor. In the beginning we occupied 20 beds. These were soon reduced to 18 beds, since 2 beds were part of the newly created day-care clinic. This unit was very much appreciated and proved to be successful. The 18 beds were used more and more as readaptation beds or even for patients with internal medical problems only. Of course the mean duration of hospitalisation increased. This situation is in our opinion not the task of a dermatology ward of a university hospital!

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The day-care unit was very much in demand. In the beginning this unit was located in the ward section, but was later installed in the outpatient clinic. A great number of patients were treated for chronic wounds, especially leg ulcers, which helped diminish the mean duration of hospitalisation and in this way the costs.

Similar to the development of the day-care unit the number of the outpatients increased. Besides more medical staff this made a new front desk and waiting room necessary. As a general phenomenon more and more practising dermatologists are doing laser and cosmetic dermatology, and as a consequence patients with general dermatological problems have difficulty getting a consultation in a dermatology practice. Finally we created staff members responsible for the medical, nursing and administrative tasks in the outpatient clinic. We also were chosen by the hospital administration as a pilot clinic for the introduction of new information technology, registration, and electronic charts.

A special consultation for venous problems was already installed and very efficient (Drs. M.J. Piquerez and Dr. B. Noël), as was melanoma consultation (Drs. D. Guggisberg and J.P. Cerottini), which was unfortunately transferred to the general ambulatory oncology section in 2006. We started creating specialised consultations with pediatric surgery (especially for hemangiomas), radio-oncology and plastic surgery (non-melanoma tumor problems), and for laser patients. Later we successfully added consultations for hair problems (Dr. P. de Viragh), genetic counselling (Professor D. Hohl), and in the Pediatrics Department, 20% in the beginning, and 50% later on (Professor Panizzon, Professor Hohl, Dr. St. Christen).

Three main areas of research were well established, i.e. cutaneous biology (Professor D. Hohl, P.D.M. Huber), dermato-mycology (Professor M. Monod), photobiology until 2002 (Dr. L. Applegate), and the tissue culture laboratory (Dr. M. Benathan). In 2002 Dr. M. Benathan and Professor R.G. Panizzon received the “Tissières Prize” for their work and contribution for the burn patients in two of the burn clinics in Switzerland, in Lausanne and

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Zurich. Since the tissue culture lab was situated next to a laboratory with virus particles, it was planned to place it elsewhere. After 2005 a new area of research, neurodermatology, started with the arrival of PD P. and Dr. M. Bigliardi-Qi. Unfortunately the technical parts of the serology laboratory had be transferred to microbiology in 1998, and the one of dermatopathology to general pathology in 2006.

Until 2006 the student’s tutorials in the 4th and 6th year were given by the Department Chairman as a plenary session. After 2003 the lessons received additional support from a new program called DOIT (Dermatology Online with Interactive Technology) created by Professor G. Burg of the Department of Dermatology in Zurich, and translated into French by our department. Later the Geneva students also joined this program. In 2008 the curriculum “Bologna” had to be introduced for medical and other students throughout the whole country. Plenary lessons were abandoned, and teaching in groups was introduced. For a small department such as dermatology with few staff, the teaching of these groups of 8 students 2 days a week nearly all year round is a real challenge. Do these students really learn the basics in dermatology, if it is not the most experienced person (the chairman) who teaches them? Our department organised the Annual Meeting of the SSDV three times; in 1998 with the topic “Dermato-Mycology”, in 2003 “Dermato-Oncology”, and in 2008 “The Clinico-Pathological Correlation in Dermatology” (Figure 2). We hosted the Spring Meeting 2001, the topic being “Pediatric Dermatology,” organised by Professor D. Hohl, who also organised the Congress of the European Society of Pediatric Dermatology together with Dr. St. Christen in 2010. For over 20 years meetings were organised between our department and the one in Besançon, France. These were initiated by Professors E. Frenk from Lausanne and P. Agache, Besançon. These meetings take place every year alternately in Lausanne and Besançon, and are very much appreciated. I do hope that this tradition will continue.

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Figure 2. Miss Switzerland Amanda Ammann, invited to the 2008 SSDV Gala Dinner in Lausanne, with PD P. Bigliardi, Mrs. N. Panizzon, Mrs. G. Maradan, and Professor R.G. Panizzon (from left to right).

Another important and traditional meeting takes place every two years in Lausanne. This is the reunion of the “American Medical Club of Lausanne,” an alumni group of American medical students, who studied medicine in Lausanne from the 1940s to the 1960s. Its President is the dermatologist Dr. Charles Fixler from Cincinnati, Ohio. When this group is in Lausanne our department is the only one which gives a clinical presentation. Since the participants are not getting any younger, the group is becoming smaller and smaller… On the 7th of November 2009 the German Society of Dermatology (DDG), also called the Society of German speaking countries, celebrated its 120th Anniversary at its place of foundation, Charles University in Prague (the Czech Republic). To represent the SSDV I was invited to give a welcome talk. In recognition of my work and efforts for the prevention campaigns in Switzerland over many years, I received the Medal of the Swiss Cancer League on the 16th of September 2010 (Figure 3).

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Figure 3. Professor R.G. Panizzon as recipient of the Medal of the Swiss Cancer League in 2010.

On the occasion of my last working day on the 1st of December 2010, I handed over the keys of the department to my successor Professor M. Gilliet, wishing him success and satisfaction (Figure 4).

Figure 4. Symbolic transfer of the department’s key from Professor Renato G. Panizzon to Professor Michel Gilliet on the 1st of December 2010

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From 2010 to Present : Professor Michel Gilliet

After 7 years in the United States, I arrived in Lausanne in December 2010. The service was directly handed over to me by Professor Renato Panizzon (Figure 4). I was immediately confronted with big challenges. In fact, the hospital directors had decided to reduce the numbers of hospital beds in order to give space to a new palliative care unit. This meant that we needed to operate a major part of our activity towards the outpatient clinic, a clinic that was already full, with waiting times for patient appointments of about 2 months. The hospital directors supported our intention to develop the outpatient activity by allowing the creation of a new day-hospital for outpatient-based therapies, the construction of additional consultation rooms, and the creation of an emergency-care unit for outpatients. Furthermore, I was given an additional chief resident position, for which I recruited Dr. Curdin Conrad from Zürich. Upon his arrival, CC managed to be rapidly promoted to “Privatdocent” and was subsequently appointed “médecin adjoint” and head of our outpatient unit. In addition to operating a major shift towards outpatient activity, we envisioned strengthening the areas of clinical expertise and to create new specialty consultations and centres of excellence. We established the “interventional dermatology unit” and introduced Mohs surgery into the service at the beginning of 2012. We also received a new laser platform and created aesthetic dermatology consultation in collaboration with the Department of Plastic Surgery. Another important focus of the new division was the establishment of the Centre of Excellence for Psoriasis, which included a specialised consultation with a focus on severe psoriasis and biological treatments, as well as clinical trials for new therapies. This clinical activity was complemented by the establishment of a research platform on psoriasis, including mouse models and in- vitro basic scientific studies using patient samples. The Pediatric Dermatology Unit continues its expansion within the division. This unit is now headed by Dr. Stephanie Christen, who was promoted to médecin associé, with clinical activities at two sites; the Division of Dermatology and the Department of Pediatrics. Professor Daniel Hohl, a longstanding collaborator of the Division (from the Frenk and Panizzon period) was appointed head

158 University Hospital of Lausanne of the Dermatopathology Unit. New collaborators were recruited to the division, including PD Dr. Olivier Gaide, trained in Geneva and responsible for the Dermato-oncology Unit, and Dr. Laurence Feldmeyer, trained in Zurich and responsible for autoimmune skin disease consultation. Dr. Philippe Spring, trained in Lausanne, took over dermato-allergology consultation and patch test supervision after the departure of Dr. Paul Bigliardi, who had accepted a new position as associate professor in Singapore. I am very grateful for the continuous support of our “Médecin agrees,” including Dr. Florence Baudraz (mycology), Drs Jean-Philippe Cerottini and David Guggisberg (melanoma), Professor Renato Panizzon (radiotherapy), Dr. Maxime Vernez (dermatopathology), Dr. Anne-Carine Lapointe (autoimmune diseases) and PD Dr. Jan Luebbe (atopic dermatitis consultation) and Dr. Patrick Perrier (Mohs Surgery). Besides providing excellence in clinical care and teaching, a major focus of the present division is the development of strong basic and translational research in dermatology. Over the years, Professor Daniel Hohl and PD Dr. Marcel Huber have acquired an international reputation on their work on keratinocyte biology and genetic skin diseases. Furthermore, Professor Michel Monod, who heads the Laboratory of Mycology, which remains a strong reference laboratory in Switzerland. With my arrival in Lausanne, we developed a new immunodermatology research unit, which now comprises 8 PhDs, MD-PhDs, and PhD students and is focusing on skin immunology and inflammatory skin diseases. We have recruited several enthusiastic clinical and research personnel who are devoted to their careers and are establishing their own laboratories and research activities with the common goal to promote the progress of dermatology in the 21st century.

Edgar Frenk, Renato Panizzon, Michel Gilliet

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University Hospital of Zurich

Department of Dermatology, University Hospital of Zurich The Dermatological Clinic of the University Hospital Zurich (DER USZ) holds a prominent position among the dermatological university clinics of Europe. Based on the academic papers (Citation Index) of the past years it has ranked continuously in the top three. At the centre of this work are the patients, who entrust us with the fate of their health. They are our motivation for this high achievement in clinical work and research towards continuous improvements in diagnosis and therapy in dermatology. Also at our side, at the side of the service provider, are people who are responsibly practising this profession out of a sense of vocation and conviction. Last but not least, one of the most important jobs is the passing on of professional knowledge and skills to young doctors and nursing staff. The beginnings of the clinic go back to its founding by Bruno Bloch (1878-1933), who founded the clinic as a pioneer and shaped it as a charismatic clinician and researcher. Professor Bloch was appointed to Zurich from his position of head of department in Basel in 1916, and a provisional dermatological clinic was created at number 10 Pestalozzistrasse. The building was several storeys high and initially had 48 beds, which increased to 60 within a brief period. On April 2nd, 1922, the voters of Zurich approved the building of a new dermatological clinic at number 31 Gloriastrasse for a loan of 2.4 million Swiss Francs. The clinic, with 100 general, 4 semi- private, 6 private and 16 paediatric beds, integrated histopathology, microbiology, biochemical and animal experimenting department

161 Spirit and Soul of Swiss Dermatology and Venereology

Figure 1. Figure 2. Bruno Bloch, Guido Miescher, Director from 1916 to 1933. Director from 1933 to 1958. was considered extremely modern and attracted many academic visitors from all over the world. Professor Bloch enjoyed a consistently excellent reputation among the Zurich population and the medical faculty until his unexpected death at age 55. His major academic achievements included research on allergic contact dermatitis on the model disease of primula dermatitis, investigation into fungi, pigment research demonstrating melanin biosynthesis with the dopa reaction, in oncology the proof that skin cancer can be caused by tar and x-ray, and finally in the first description of the clinical picture of incontinentia pigmenti after Bloch (which he presented for the first time at the AGM of the SSDV in 1925) and Sulzberger (published in 1927 under the double-barrelled name of Bloch-Sulzberger). Bloch’s successor was his by then internationally renowned student Guido Miescher. Miescher was a pioneer of radiation therapy of skin diseases, which at the time included radiation of skin tuberculosis, tuberculides, and capillitium mycoses. He described the connection between erythema nodosum and the taking of one of the first sulfonamide antibiotics, cibazol, and with tuberculosis. He was also responsible for the histological presentation of the radial granulomas of erythema nodosum. Furthermore, cheilitis granulomatosa, granulomatosis disciformis et progressiva

162 University Hospital of Zurich

Figure 3. Figure 4. Hans Storck, Urs Walter Schnyder, Director from1958 to 1978. Director from 1978 to 1991.

(a variation of necrobiosis lipoidica) and the familial congenital acanthosis nigricans are also named after him. He contributed significantly to the description of occupational eczemas andin general to the pathophysiology of the development of eczema with his students Walter Burckhardt, Ernst Robert, Hans Storck and Theodor Inderbitzin. The introduction of antibiotic therapy to medicine after the Second World War profoundly changed treatment of the most important infectious diseases. Before this, approximately 50% of the patients of the dermatological clinic were treated with physical methods and side-effect-riddled chemotherapeutics for infectious venereal diseases, tuberculosis or chronic mycoses. The decrease in infectious skin diseases was succeeded by an increase of patients with inflammatory dermatoses, and later dermato-oncology. The introduction of systemic and topical corticosteroids for the treatment of inflammatory disorders also occurred during Miescher’s era. Marion Sulzberger, who had also been a student of Bloch’s and was a good friend of Miescher, now practising as

163 Spirit and Soul of Swiss Dermatology and Venereology senior consultant in New York, contributed to the corticosteroid therapy breakthrough. Hans Storck took over as department head from Miescher in 1958 and continued to increase the number of patients treated at the clinic. He and his distinguished senior consultants covered the complete spectrum of clinical dermatology, including all of its modern sub-specialties recognised today. His personal research focus was allergology. He opened one of the first allergy units in Zurich as early as 1948, at the same time as Basel. He and Professor Urs W. Schnyder were the first to describe the atopic syndrome completely. Further areas of interest were venereology and dermatological oncology. Urs W. Schnyder had already been a successful Professor of Dermatology for 12 years when he succeeded Hans Storck in 1978.

Jürg Hafner, Michael Geiges, Günter Burg, Lars French

Activities of the Department of Dermatology at the University of Zurich between 1978-19911, 2, 3, 4

General Organisation & Structure

The points of focus in Zurich under the chairmanship of Urs Walter Schnyder were hereditary diseases of the skin, histopathology and venereology. Alfred R. Eichmann took over the dermatological ambulatorium of the City Hospital Triemli. Renato Panizzon, director of the dermatological clinic in Lausanne since 1996, upheld tradition by focusing on radiation therapy and photochemotherapy. René Rüdlinger specialized in virology.

1 History of German Language Dermatology (Eds.: A. Scholz, K. Holubar, W. Burgdorf, H. Gollnick) Wiley-Blackwell 2009, Ch. 3.1.3. 2 Zürcher Spitalgeschichte, Ed.: Regierungsrat des Kantons Zürich, Kap. 6.4.3, Seite 477-486, G. Burg, M. Geiges: Dermatologie. 3 Die Universität Zürich., Ed.: Rektorat der Universität Zürich, Kap. 5.1.5, Seite 413-414; Dermatologie und Venerologie. 4 Moulagensammlungen des Universitätsspitals Zürich, Ed.: U. Boschung, E. Stoiber, U.W. Schnyder 1993.

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Leena Bruckner-Tudermann worked very successfully on bullous auto-immune diseases and diseases of the connective tissue in the skin. By 1968, the outpatient department for allergology and clinical immunology within the Dermatology Department had been taken over from the senior consultant Fritz Ott by Brunello Wüthrich. Under B. Wüthrich the department continued to develop into a major Allergology and Clinical Immunology Centre, not only in Switzerland but in the whole of Europe. It was accepted as a “Centre of Excellence” by the EAACI and the EU in the network GA²LEN (Global Allergy and Asthma European Network). Between 1985 and 1989 U.W. Schnyder completely renovated the neoclassical clinic built under Bloch. The renovated building contained outpatient treatment rooms including areas for surgery and oncology, light-, x-ray- and laser department, patch test laboratory, the “allergy ward”, an operating wing, a seminar room and a library. There were 61 inpatient beds, physiotherapy, a bathing area and facilities for photopheresis and for clinical research. The basic research laboratories covered the whole length of the upper floor of the building.

Research URS W. Schnyder wrote over 240 scientific publications and several books during his academic career of 44 years. His research focused on light- and electron microscopy and biochemical and molecular analysis of hereditary diseases – especially the epidermolyses and keratinisation disorders. Some newly described disease variants, including the seborrhoic pemphigoid and the epidermolysis bullosa junctionalis, non-Herlitz type, are linked to his name. A major concern was also AIDS during the beginning of the epidemic in the 1980s.

Mentoring The following colleagues (major research focus) passed their habilitation between 1978 and 1991 (alphabetical order, incomplete): L. Bruckner-Tudermann (genodermatoses), A. Eichmann (venereology), R. Panizzon (light and x-rays), R. Rüdlinger (viral diseases).

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Moulage-Collection4 The collection of dermatological and surgical moulages in Zurich is unique. U. W. Schnyder provided continuous support for E. Stoiber, who looked after this distinguished adjunct to the Department of Dermatology in Zürich.

Track records of some former staff members Urs Schnyder was not only a great researcher; he was also an excellent clinical dermatologist. He created the basis for a modern, innovative and scientifically-based dermatology in Zurich, in Switzerland and abroad. The following heads of dermatology came from his school: E. Jung (Mannheim), R. Panizzon (Lausanne), L. Bruckner Tudermann (Freiburg im Breisgau), M. Gloor (Karlsruhe) and A. Eichmann (Zurich, Triemli).

Congresses and other activities On a regional level, Continuing Medical Education (CME) activities for the colleagues practising in the region were organized 6-8 times a year, lasting 3 hours each. On a national level, the SGDV/SSDV annual meeting was hosted in 1980, 1985 and 1989. In 1985 Zurich hosted the International Congress of the German Dermatological Societies. The 3rd conference of the “Vereinigung Operative Dermatologie” took place in Zurich in 1980 and was organised by U.W. Schnyder and A. Eichmann. There is not enough room to list all of the national and international activities which were organised in this period by the Department of Dermatology.

International partnerships Intense cooperation existed with research groups interested in genodermatoses in South Korea and in Japan (K. Hashimoto). In summary, over his 13 years as Head of the Department of Dermatology in Zurich and thanks to his extensive international contacts, Prof. Schnyder was extremely important for the advancement of dermatology in Zurich, in Switzerland and abroad. Günter Burg

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Personal report on the activities of the Department of Dermatology at the University of Zurich between 1991-20061, 2, 3, 4, 5, 6 by Prof G Burg

Preface In May 1991 Günter Burg took over a perfectly functioning clinic, renovated under Urs Walter Schnyder for over 20 million Swiss Francs between 1983 and 1987. The clinic was excellently equipped for clinical and experimental research.

Figure 5. Günter Burg, Director from 1991 to 2006.

1 The development of the clinic and its research activities between 1991 and 2001 is also reflected in a Chronicle, which appeared in 2001 (Eds.: F. Nestle, R. Dummer; Steinkopff Publisher, Darmstadt) on the occasion of the 85th anniversary of the Department of Dermatology in Zurich. 2 Evaluation Report of the University for the period 1998-2002. 3 History of German Language Dermatology (Eds.: A. Scholz, K. Holubar, W. Burgdorf, H. Gollnick) Wiley-Blackwell 2009, Ch. 3.1.3. 4 Zürcher Spitalgeschichte, Ed.: Regierungsrat des Kantons Zürich, Kap. 6.4.3, Seite 477-486, G. Burg, M. Geiges: Dermatologie. 5 Die Universität Zürich., Ed.: Rektorat der Universität Zürich, Kap. 5.1.5, Seite 413-414; Dermatologie und Venerologie. 6 Moulagensammlungen des Universitätsspitals Zürich, Ed.: U. Boschung, E. Stoiber, U.W. Schnyder 1993.

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General Organisation & Structure With 38 inpatient and six semi-inpatient beds (“day-clinic”) and 90,000 outpatient visits per year, the dermatological clinic in Zurich was the largest in Switzerland and one of the largest in Europe. 4 additional beds were implemented for clinical trials in 2000; there were two physicians for clinical trials (B. Heidecker and G. Senti). An appointment-system for outpatients was introduced in order to reduce patients’ waiting time. The Dermatological Outpost of the clinic in Davos-Clavadel, initiated by U.W. Schnyder in 1987, was closed in 2001. Routine laboratories providing services for bacteriology, mycology and dermatopathology were run by J. Meyer and R. Dummer respectively. Thanks to successful negotiations with those responsible at that time: the CEO of the hospital (P. Siefel), P. Wiederkehr in the Ministry of Health and A. Gilgen in the Ministry of Education, over time it was possible to fill 10 additional positions (two nurses, a molecular biologist, two physicians, two senior physicians, a secretary, two information technology specialists). Moreover, a setup credit of 2 million Swiss francs was provided to create a clinical information system in the Department of Dermatology as a prototype for the University Hospital. In addition to newly introduced immunological and molecular diagnostic procedures, some new therapeutic methods were begun: Photopheresis (first unit in Europe; Th. Rehle, trained by R. Edelson); salt-water bath; implementation of Mohs Microscopically Controlled Surgery for the first time in Switzerland. The first Mohs-Unit in Europe had been established in Munich by G. Burg in 1970. Specialized Clinics: Allergy (B. Wüthrich, P. Schmid- Grendelmeier, B. Ballmer), Surgery (A. Blank, E. Küng, J. Hafner, S. Läuchli), Phlebology (J. Hafner), Occupational Dermatology (P. Elsner), Light, Laser, and X-Ray Units (R. Dummer), Trichology (R. Trüeb). Oncology (R. Dummer: melanoma, lymphoma), Photopheresis (F. Nestle), Autoimmune Dermatoses (R. Trüeb), Akne, Hyperhidrosis (R. Böni, O. Kreyden), Psoriasis, Paediatric Dermatology, Andrology (moved to Obstetrics later on), Proctology, Balneotherapy. In contrast to other dermatological clinics in Switzerland, in which dermatopathology was taken over by pathology institutes,

168 University Hospital of Zurich the histological laboratory in the clinic in Zurich was retained and technically improved with one of the world’s first scanning machines for histological preparations (Aperio Scansope; 2003). The gazette “DermaZH” reported on internal issues of the clinic (new collaborators, clinical trials, events, awards, etc.) twice a year. Fifteen editions were distributed to physicians in private practice in Zurich till spring 2005. Guidelines for internal conduct on clinical strategies were discussed once a year and reflected in a Vademecum (blueprint), internal edition 1997 and 2005. In 2002 the Department of Dermatology was evaluated by the Evaluation Office of the University (Prof. Daniel) for the period 1998-2002. The Research Laboratories were perfectly equipped, enabling performance of modern immunohistochemical and molecular investigations (R. Dummer, W. Kempf, J. Meyer, U. Döbbeling) The library of the Department contained more than 700 books and 56 periodical journals, which were stored for at least 10 years. Many journal subscriptions were cancelled when the journals became available online from the central library of the university hospital. To relieve administrative pressure on the physicians, the clinic was able to make a novel appointment in 2000 of a“Clinical Manageress” (Catherine Frey-Blanc), who is also responsible for Congress organisation. Within the framework of Zurich’s cultural project “Land ahoy, off to Zurich”, the dermatological clinic obtained a cow sculpture in 1998. It was painted with a design on the subject of skin cancer and protection against the sun, and still sits defiant and weatherproof in its hat, maintaining its existence in front of the main entrance of the outpatient clinic as a mascot.

Patient Care and Nursing Staff The implementation of new therapeutic procedures (photopheresis, cytokine therapy, vaccination therapies and others) in the context of the new focus on dermato-oncology was a big challenge for the nursing staff. A new appointment system was implemented and Zurich became a member of the “European Skincare Nursing Network”. When W. Keller retired in 2002 as head of the nursing staff, he was succeeded by T. Plötz.

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Research The major research focus switched from hereditary disorders to dermato-oncology, with emphasis on new diagnostic procedures such as immunohistology (W. Kempf) and molecular biology (R. Dummer) in cutaneous lymphomas and malignant melanoma. Gene and cytokine therapy (R. Dummer), vaccination therapy (F. Nestle) and clinical pilot trials for intranodal desensitisation in allergic patients with pollen allergy or bee venom allergy (G. Senti, T. Kündig) were major new therapeutic approaches. In addition to many publications in peer-reviewed journals (1,720 between 1991 and 2002), more than 20 monographs were edited between 1991 and 2006, on such subjects as skin cancer, cutaneous lymphomas, malignant melanoma, skin physiology, trichology, hyperhidrosis, teledermatology. The World Health Organization Classification of Tumours – Pathology & Genetics of Skin Tumours (Lyon 2006, Eds: P. LeBoit, G. Burg, D. Weedon, A. Sarasin) has become the standard reference book on the topic. Based on Life Science Citations in Dermatology, the Department of Dermatology in Zurich was ranked number 1 for several years among the Departments of Dermatology in Europe (according to the Ranking Evaluation of the Labor Journal). 250 to 450 thousand Swiss francs were acquired yearly from research funding grants during the evaluation period (1998-2002). R. Dummer organised a weekend once a year in Davos-Clavadel, devoted to Science, Skiing and Sun (SSS-Weekends), during which the research activities of the staff members and fellows were presented. Staff members have received many prestigious awards, honours and guest lectureships in the period from 1991 to 2006.

Teaching, continuing medical education and mentoring: In order to synchronise the postgraduate training with the outpatient department of the Triemli Hospital and the dermatology unit in Davos-Clavadel, a schedule for rotating through the various sub-disciplines of dermatology was elaborated. This schedule was subsequently recommended by the FMH as a guideline for other dermatological clinics in Switzerland. In 1991 a yearly Bruno Bloch Lecture was initiated for students. In 2001 the Department of Dermatology was appointed Leading

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House for the elaboration of the Swiss Catalogue of Learning Objectives in Dermatology. This catalogue provided the basis for the development of the e-learning platform Dermatology Online with Interactive Technology (DOIT, www.cyberderm.net), which has been very successful since its initiation in 2000, and has a high acceptance rate among students and teachers worldwide. It has won several awards, including the prestigious and competitive Medida Prix in 2009. The following colleagues passed their habilitation between 1991 and 2006 (alphabetical order; major research focus): B. Ballmer (food allergy), R. Böni (melanoma, PET-CT), A. Cozzio (lymphoma), R. Dummer (lymphoma, melanoma), P. Elsner (“Umhabilitation”; bioengeneering), J. Hafner (leg ulcers, dermatosurgery), A. Häffner (lymphoma), G. Hofbauer (nonmelanoma skin cancer in organ transplant recipients), W. Kempf (lymphoma, dermatopathology, viral infections), T. Kündig (with the Dpt.of Immunology; intranodal desensitisation), St. Lautenschlager (with Soc.-Prev.- Med.; infectious diseases), F. Nestle (psoriasis, dendritic cell- vaccination), P. Schmid-Grendelmeier (atopy, allergology) R. Trüeb (hair disorders, immunodermatoses), M. Urosevic (-Maiwald) (lymphoma, melanoma, HLA-G). Mentoring: BAER-Fellows ((Bicontinental Association for Education and Research; see below) were R. Dummer, A. Häffner, Anupama Salvekar and others. M. Gillet spent some years with M. Duvic at MD Anderson (USA) before becoming Head of the Department of Dermatology in Lausanne in 2010. F. Nestle trained at Yale, with B. Nickoloff in Ann Arbor and R. Steinman in New York, working on dendritic cells.

Track records of staff members

Prof. Dr. Renato Panizzon took over the position of Head of the Department of Dermatology, University Hospital, Lausanne in 1996. Prof. Dr. Peter Elsner took over the position of Head of the Department of Dermatology, University Hospital, Jena (Germany) in 1997. Prof. Dr. Leena Bruckner-Tuderman, after moving to Münster in 1996, was elected Head of the Department of Dermatology in Freiburg/Breisgau in 2003.

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Prof. Dr. Frank O. Nestle became a Mary Dunhill Professor of Cutaneous Medicine & Immunotherapy at King’s College in London in 2006 Prof. Dr. Reinhard Dummer, after having served as Interim Director of the Department of Dermatology in 2006, was elected Vice Chairman of the Department of Dermatology in 2008 and Head of the Skin Cancer Unit at the University Hospital Zurich Prof. Dr. Michel Gillet, following his dermatology training in Zurich moved to the MD Anderson Cancer Center in Dallas and was elected successor of R. Panizzon, Lausanne, in 2010

Congresses and other activities On a regional level, Continuing Medical Education (CME) activities lasting 3 hours each were organised 6-8 times a year, for the colleagues practising in the region. On a National Level the SGDV/SSDV annual meeting was hosted in 1994, 1999 and 2005. Once a year the Department of Dermatology and the Swiss Cancer League organised a Skin Cancer Awareness day, emphasising early detection of malignant melanoma. On an international level, about 20 congresses were organised, including the meetings of the International Societies for Immunology (1991), for Dermatopathology (1996), on Bio-engeneering (1996), Club Unna-Darier (2000), European Symposium on Teledermatology (2000), on Dendritic Cells (2000), the World Congress on Cancers of the Skin (2001), the European Hair Research Society (2005), on Cutaneous Lymphomas (2006) and others.

Partnerships The partnership with the Swiss Cancer League was intensified and Zurich was appointed Leading House for the Skin Cancer Section. International partnerships were established and held over many years with the RDTC (Regional Dermatology Training Centre) in Moshi/Tanzania (P. Schmid-Grendelmeier), Sofia/Bulgaria (G. Burg) and Kathmandu/Nepal (G. Burg). These partnerships were intended to provide support for self-help and many colleagues from these countries spend long term fellowships doing research, dermatopathology or clinical work at the Department of Dermatology in Zurich.

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The “Anonymous Gougerot Society” (GS) was in fact a loose consortium of internationally renowned representatives of dermatology (mostly Americans), who cultivated friendship in an intellectual and culinary atmosphere and met once a year during the AAD or an international congress. Mark Everett (Oklahoma) was the president and G. Burg served as the secretary of this distinguished association, which is no longer active since Marc Everett passed away. The GS gathered in Zurich in 1994.

Founding of associations and societies The BAER was initiated with David Bickers (Cleveland/Ohio) and Gerd K. Steigleder (Cologne) in order to foster international cooperation of young colleagues on both sides of the Atlantic. The BAER is no longer active. The International Society for Cutaneous Lymphomas (ISCL; http://www.cutaneouslymphoma.org/home), started in 1991 in New York during the CMD as an initiative of the Lymphoma Group in Zurich (G. Burg, R. Dummer et al.), has evolved into a strong and very active international organisation. The Schweizer Gesellschaft für Telemedizin (SGTM) (www. sgtm.ch) was founded 2001 (founding president G. Burg) for the promotion of telecommunication in medicine and eHealth. Due to an initiative of the Departments of Dermatology in Zurich and Jena, the European Confederation of Telemedical Organisations in Dermatology (ECTODerm) was founded in Jena (1999) and held its 2nd conference in Zurich in 2000. Thereafter the Society was renamed the International Society of Teledermatology (http://www.teledermatology-society.org/). The „Verein für Hautkrebsforschung“ (http://www.skincancer. ch/; G. Burg, R. Panizzon and R. Dummer, C. Frey-Blanc, R. Kaufmann) was founded in November 2004 during the EADV in Florence in order to foster research and clinical trials on skin cancer in Switzerland.

Information technology, EDV and teledermatology Due to the special personnel (2 information technology – IT – specialists) and financial endowment for EDV at the Department of Dermatology, the clinic was assigned the task of developing a “Clinic Information System” prototypically for all other

173 Spirit and Soul of Swiss Dermatology and Venereology departments of the University Hospital (P. Elsner, A. Häffner and J. Meyer) in cooperation with the Department of Informatics in Medicine (Blaser). This was the beginning of the use of KISIM (Klinisches Informationssystem) at the University Hospital. Teledermatology was cultivated in weekly teleconferences with the Department of Dermatology in Basel (Th. Rufli; L. Milesi: Derma NT) and across international borders with Moshi in Tanzania (P. Schmid-Grendelmeier) from 1995. The e-Learning platform DOIT (Dermatology Online with Interactive Technology; www.cyberderm.net) was initiated as a joint venture of the Departments of Dermatology in Switzerland and Jena (Swiss Virtual Campus (SVC)-project, #991017) in 2000 and meanwhile has evolved into a highly accepted basic learning tool for dermatology undergraduates worldwide.

Moulage-Collection In 1993, having been stored at a number of different locations, the 1,800 dermatological and surgical Moulages arrived at Haldenbachstrasse 14 in a modern museum room, with space for a permanent exhibition of around 600 Moulages. The Moulage Museum is open to the public and has been a member of the Association of Zurich Museums since 1996 and the Association of Swiss Museums since 1999. E. Stoiber was supported by the dermatologist and medical historian Michael Geiges from 1995 until 1999, when he became her successor as curator of the museum and the collection. The museum can be found on the internet since 1999: http://www.moulages.ch. Special exhibitions attract increasing numbers of visitors and there are around 100 tours per year outside of the regular opening times.

Additional activities in the context of the Faculty of Medicine of the University of Zurich G. Burg served the Faculty of Medicine as Vice-Dean and Dean respectively from 1998-1999 and from 2000-2004. Major special achievements during this time were: the implementation of the new curriculum for undergraduates with core and mantle curriculum and the Centre for Clinical Research. The Cancer Network Zurich (2001) was reorganised in 2005 to a Comprehensive Cancer Centre. M. Jäggi wrote A Chronicle of the Medical Faculty of

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Zurich (1933-2004) “in primo loco”, which was published in 2004. The Walter and Gertrud Siegenthaler Foundation and 2 other foundations (one for research and one for teaching and education) were established in the Faculty of Medicine.

Personal report on the activities of the Department of Dermatology at the University of Zurich between 2006-2013 by Prof L French

As of October 2006, subsequent to the retirement Prof Günter Burg as Head of the Zurich University Department of Dermatology, and a 6-month successful interim management period by Prof Reinhard Dummer, the Department has been directed by Professor Lars French. Building upon the internationally recognised strengths of the Department in the fields of cutaneous oncology and allergology, a certain level of organisational restructuring was implemented with the development of an additional focus on inflammatory skin diseases.

Figure 6. Team of physicians of the University Department of Dermatology of Zurich around 1925.

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Figure 7. Team of physicians of the University Department of Dermatology of Zurich 2013.

New clinical activities and structures were launched during 2007 and 2008, notably a pigmented lesion and skin cancer prevention clinic under the direction of the newly recruited PD Dr. Ralph Braun, and a weekly inpatient clinic – which provides short diagnostic workups and brief therapy possibilities adapted to the changing medico-economic environment – under the direction of PD Dr. Gunther Hofbauer. Our Department is devoted to providing sustained leadership in patient care, research and education in the fields of dermatology, venereology and allergology. Asa consequence of the above, and the conviction of the Department that highest quality patient care, teaching and research are dependent on a strong in-house Dermatopathology Unit, extra qualified personnel in Dermatopathology was recruit and also trained in-house, so that a team of currently 4 senior dermatopathologists successfully developed the activity from 14,000 referrals in 2006 to over 30,000 in 2012. As a consequence, the Dermatopathology Unit has been officially recognized as a dermatopathology training centre by the International Committee for Dermatopathology (ICDP) and the European Union of Medical Specialists (UEMS). Two further new specialised clinics were launched during 2009 and 2010, notably the paediatric dermatology clinic and the aesthetic dermatology and laser clinic. The paediatric dermatology clinic, under the direction

176 University Hospital of Zurich of Dr. Lisa Weibel and PD Dr. Antonio Cozzio, is the fruit of close collaboration with the Children’s Hospital of the University of Zurich, and benefits from the expertise of Dr. Weibel who is an expert with a unique level of training and board certification in both dermatology and paediatrics. In 2009, responding to the need for academic-quality post-graduate dermatology training in aesthetic dermatology and lasers, a new aesthetic dermatology and laser clinic was launched, directed initially by Dr. Inja Bogdan-Alleman, a board-certified dermatologist of ours who specifically trained in this field at the Cosmetic Dermatology Center of the University of Miami, and subsequently by Dr. Laurence Imhof and Dr. Bettina Rümmelein. The clinic has enjoyed a very successful start, and is currently conducting clinical trials in addition to the regular patient care and training of residents. To improve patient service and the quality of care, we have – as of 2008 – partially renovated and modernized our outpatient clinic (Policlinic), which receives 320 referred ambulatory patients per day, and installed two new “state of the art” machines for skin-directed radiotherapy, devices that we are increasingly using in face of the growing incidence of skin cancer and our focus on cutaneous oncology. Finally in 2011, and in the aim of standardising as well as certifying a high standard of quality of care, our Department has established extensive standard operative procedures and prepared our entire clinical services as well as our skin cancer centre for official certification under the direction of our Quality Manager Prof. Ralph Braun. As of November 2011 the Department has received official ISO Quality certification, and the skin tumour centre is also certified according to the stringent criteria of the German Cancer Foundation. As of 2013, the Department assures over 95,000 outpatient consultations per year and 1,100 inpatient treatments. In 2012, the DRG system for cost-coverage of inpatients was implemented in Switzerland, and thanks to the significant increase in efficiency of inpatient care implemented between 2006 and 2011 – including a reduction in average duration of inpatient stay from 11.5 to 6.9 days – this did not have negative consequences for the Department, at least in the first year! Our residency-program currently has 24 dermatology residents in training, and our team of 18 senior physicians offers a high level of specialised expertise in patient care and training covering the complete breadth of our specialty. Teaching of the

177 Spirit and Soul of Swiss Dermatology and Venereology basics of dermatology to 250 medical students yearly is based on an introductory course for 3rd year medical students, a 2 week “Themenblock Dermatologie” for 4th year medical students, a series of practical courses for 5th year residents, and 1-4 month internships for 6th year residents. The long-standing contribution of the Department in collaboration with the other Swiss Dermatology Departments, under the direction of Prof Burg and Mr Djamei, and thereafter in collaboration with Profs French and Schmid, to the development of an online interactive E-learning platform for undergraduate dermatology teaching named DOIT (“Dermatology Online with Interactive Technology”; www.swissdom.org) is highly utilised and cherished by students worldwide. In 2009 DOIT was selected as the winner among 20 finalists in Berlin for the renowned “Medida-Prize” or “mediendidaktische Hochschulpreis” of 50,000 Euro for innovative and sustainable implementation of digital media in university teaching. The main academic focal points of our department are dermatooncology, immuno-dermatology and allergology. 2007 and 2008 were extremely successful years for experimental and clinical research. The innovative character of the research produced by our highly productive research team of over 50 scientists and clinician-scientists is illustrated by several high impact publications, including an article concerning the mechanism of development of psoriasis in Nature Medicine in 2007, and the strong rise in the department’s cumulative impact factor between 2006 (IF: 190) and 2008 (IF: 355), followed by further increases in 2010 (IF: 469) and 2012 (IF: 900). The latter reflects the investment made in promoting research and development over the last years and places our academic team and department amongst the leading dermatology departments worldwide. This positive development was made by a currently strong, internationally renowned group of clinicians, clinician-scientists and scientists which was further strengthened between 2006 and 2012 by the recruitment to the department of Prof. Onur Boyman (recipient of a Swiss national Science Foundation Professorship), and Dr. Hans-Dietmar Beer and his group from the ETH in Zurich. Our capacity for innovation in immuno-dermatology has been considerably improved with these two groups. During the period from 2006 to 2013, Prof. Dr. Werner Kempf, Prof. Dr. Barbara Ballmer-Weber, Prof. Dr. Ralph Braun, Prof. Dr. Günther Hofbauer and Prof. Dr. Mirjana Maiwald were promoted to the position of Titular Professors by the University of

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Zurich. Furthermore, PD Dr. Gunther Hofbauer and PD Dr. Antonio Cozzio were promoted to the function of “Leitender Arzt” (head consultant) and PD Dr. Cozzio nominated director of our outpatient clinic (Policlinic). The academic activity of our team members has also been recognized by the attribution of several distinguished prizes and/or named lectures including the Georg-Friedrich Götz Prize of the University of Zurich in 2011 to Prof. O. Boyman, and in 2013 to Prof. M Maiwald; the prestigious Swiss Otto-Nägeli Prize to Prof. French in 2012; the ESDR Rudi Cormane Lecture given by Prof. French in 2009, the 61st Leo von Zumbusch Memorial Lecture given in Münich by Prof. French in 2011, the 36th MH Samitz Lecture in Cutaneous Medicine given in Philadelphia by Prof. French in 2011, and the 35th Kung-Sun Oh Memorial Lecture given at the Yonsei University in Seoul, South Korea by Prof. French in 2012.

Figure 8. Prof. Lars E. French, Director from 2006, Laureate of the Otto Naegeli Prize 2012, together with his wife, Dr. Katrin Kerl.

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The current opportunities and challenges of modern dermatology lie in the improved molecular understanding of oncological and inflammatory diseases and the research and utilisation of the unforeseen possibilities resulting from these developments. The prospect that the metastasised melanoma could be transformed into a stable disease through a combination therapy of targeted molecules no longer seems impossible, and the use of biologics opens up new dimensions for the treatment of inflammatory skin disorders. Not least due to these rapid advances, for which no end is in sight, as yet, the discussion of their use with regard to limited resources must be carried out transparently and according to democratic principles. Under consideration of the generally established medical ethics guidelines, physicians must bring their knowledge advantage into the social discourse at all costs. The unforeseen diversity of the specialty of dermatology continues to be its fascination. Of note are the variety of patients of all ages and both sexes, diversity of diagnoses, pathophysiological findings and diagnostic innovations and the variety of treatment options. The young dermatologists need to be not only good specialists in skin and venereal diseases, but also to have a solid knowledge of internal medicine and surgery. The challenge of modern dermatology is and remains the advancement of all aspects of this extremely diverse “organ specialty” without losing sight of the big picture and continued cooperation with the related specialties. Patients with skin disorders have profited from the manifold theoretical and practical advances in dermatology over the last decades.

Lars E. French, Günter Burg, Urs Walter Schnyder

180 4

The Six Public Outpatient Clinics

Aarau

The Department of Dermatology at Kantonsspital Aarau (KSA): 15 years old: finally grown up?

What does one of Switzerland’s largest hospitals do when it is providing highly specialised medicine at top level, but has to call an external consultant for any dermatological problem? The simplest solution: Create a dermatology department of its own. What sounds simple in theory can turn out to be a lengthy process of implementation taking years…

1. How everything began…

Doctors at the KSA with dermatological problems they could not solve themselves had to call a dermatologist in private practice or refer their patients to a university hospital centre in Zürich, Basel or Bern until the nineteen eighties. This was an unsatisfactory situation for Professor Dieter Conen, Head of Internal Medicine in one of the largest hospitals in Switzerland, in part for economic reasons: The Health Department of the Canton of Aargau calculated that around 1.2 million Swiss francs per year were spent outside the Canton on the treatment of patients with dermatological problems. With its own hospital Dermatology Department, savings of CHF 700,000 were expected. In 1987 the first plans for a Dermatology Department at Kantonsspital Aarau were submitted to the cantonal government,

183 Spirit and Soul of Swiss Dermatology and Venereology and in 1991 a specific budget proposal was presented by Professor Conen. It took another five years, however, for the cantonal financial administration to give its final approval in 1996 for dermatology at KSA. Professor Theo Rufli, then Head of the Clinic of Dermatology at the University of Basel, was consulted about establishing the department. Close cooperation with Basel seemed the best guarantee for a high medical standard in the future department. The plan was to integrate the new dermatology into the Department of Internal Medicine for administrative purposes, but otherwise the department was to act independently. The initial organisation chart provided for a full-time physician and a secretary and clinical nurse employed at 50% each. The tasks of the department remain the same today: patients with dermatological problems are assessed and treated by a dermatologist in an outpatient clinic. Patients are either referred to the KSA by external primary care physicians from the whole Canton of Aargau, or on request of the KSA’s own wards. Patients with severe skin conditions who require hospitalisation are admitted to the internal medicine ward. They are visited and treated by a dermatologist assisted by young colleagues from internal medicine.

2. The Peter Itin era In December 1997 the Department of Dermatology at KSA was opened in “Haus 6,” one of the hospital’s old buildings. P.D. Peter Itin, from the University Hospital in Basel, was the first Head of the Department, working half at KSA and half in Basel. Mark Anliker was resident from 1998 until he became the first senior physician in 1999. The first dermatological team was completed by nurse Christina Schwendener and Eveline Sommerhalder who worked in the secretary’s office. There was a real demand for dermatological expertise from the beginning. In the first year 1,640 patients were dermatologically assessed, and in the second year there were 2,350. The rising number of patients resulted in longer waiting times. Patients who were referred to the KSA by their primary care physicians had to wait 3 months and more from referral to consultation, which seemed too long for a public hospital. An additional senior physician was

184 Aarau employed in 2000 and another 80% position for a doctor was added in 2002 (Susanna Fistarol). Another issue the young department increasingly struggled with was the lack of space. Escalation of this problem resulted in the installation of four work stations in the office of the Chief Physican. The lack of individual space caused considerable stress for staff at peak periods. What made Dermatology Aarau attractive from the beginning were the very close links to all other disciplines in the Kantonsspital Aarau. The threshold for a case conference remains low, and there is an extremely high level of acceptance of the discipline in the whole hospital. Another attractive aspect is that patients referred by Argovian family physicians are an extraordinarily interesting dermatological patient population. Because most patients come to the hospital “unfiltered” and represent the general population of about half a million, very impressive and distinctive manifestations of dermatological diseases can be observed. A number of these rare cases have been published by Peter Itin and his co-workers.

3. The Department under Markus Streit In 2006 Peter Itin was elected Head of the Dermatological University Clinic in Basel. His successor was Markus Streit, a longstanding senior physician from the University Hospital in Bern. His main goal was the continuation of Peter Itin’s work. Nevertheless, there were changes to key positions in the department: Nursing management was taken over by Christine Niggel, a skilled dermatological nurse who had worked with Markus Streit at the Inselspital in Bern for years. Anita Richner, the new secretary, became the administrative manager of the department for the future. The new team continued the work of their predecessors successfully and managed to consistently increase turnover figures. The demand for clinical dermatological expertise continued and latency times for patients again reached 3 months and more. Another additional position for a senior physician was established. From now on, three senior physicians worked alongside the Chief Physician, all of them trained dermatologists. The “group practice at the hospital” was perfect!

185 Spirit and Soul of Swiss Dermatology and Venereology

Not only was the turnover of patients high, but the turnover of female senior physicians was too. One reason was that many female colleagues became pregnant during their engagement. One of the examination rooms at “Haus 6” must have had a magical fertile aura. After the fourth female senior physician became pregnant, having newly moved into this room, closing the room for women was seriously considered… An attractive innovation for referring physicians was the initiation of specialised consultation hours led by chief and senior physicians: Special consultation hours still exist for pruritus, hyperhidrosis, complex ulcers, vulvar dermatoses, dermatopediatric problems, and hair and nail diseases. In the specialised field of allergology (see below), a consultation hour for patients with mastocytosis has to be emphasised. The most unique feature of KSA dermatology under Markus Streit remained the integration into an internal department. Interdisciplinary cooperation is not just a slogan but an obligation: monthly conferences are held with rheumatologists and infectiologists to discuss shared patients. An interdisciplinary tumour board was established for the large number of patients with skin tumours, where once a week dermatologists, plastic surgeons, radiation and medical oncologists examine and assess patients (about 350 per year) to find the ideal treatment. A fruitful collaboration with Basel University’s Clinic of Dermatology continues. A weekly colloquium takes place at KSA’s pathological department for dermato-histopathological investigations. Peter Itin and Peter Häusermann from Basel examine the sections from dermatological patients with all the dermatologists and the attending pathologist. Clinical-pathological correlation is important; the corresponding clinical picture to almost every histological slice is shown. The increase in the dermatological staff and the rising number of patients required structural measures. “Lambarene conditions” were found, when in the same small treatment room – separated only by curtains – patients with foetid ulcers were lying next to others who were completely nude for phototherapy, and yet others who were sitting in front of the UV hand and foot devices. Allergy testing was performed in a tiny room without ventilation and with no space to lie a collapsing patient down. It was mainly

186 Aarau because of such hygiene and safety aspects that the architectural expansion of the department was finally implemented. In 2009 the entire ground floor at Haus 6 was reconstructed to become the new dermatological outpatient clinic, with enough space for allergological testing, wound care, and balneo- and phototherapy.

4. Dermato-allergology becomes a subunit of its own There was a great demand for allergology from the early days of the Dermatology Department. In order to manage the increasing number of allergological referrals, Peter Itin ordered that one of his co-workers with an allergological background dedicate 50% of his activity to allergogical problems. Mark Anliker became the first dermato-allergologist at KSA. Paul Scheidegger, Christian Schuster and Marianne Lerch were his successors. A wide range of allergogical tests has been established for patients with drug reactions or suspected allergies to inhalatory and nutritional allergens in recent years. Ultra-rush desensitisation was inititated after the identification of an unexpected number of Argovian patients with proven allergies to bee and wasp stings. In order to satisfy the growing demand for allergological expertise and testing, a full-time allergologist had to be found. It was possible to retain Professor Jürgen Grabbe – a dermato- allergologist from Germany and former Deputy Director of Dermatology at the University Hospital in Lübeck – for this position in 2009. Under Jürgen Grabbe testing procedures have been extended and standardised, provocations have been fully included in the programme, and it was now possible to perform ultra-rush desensitisation, which had till now been performed in the intensive care unit of KSA, in the department with the appropriate monitoring. These improvements were also possible because specialised nurses were now fully engaged in allergology. Initially Barbara Murri, an experienced nurse, took on this task alone. After she left a small new allergological nursing team was formed. The great achievements of allergology in the last few years were honoured by the hospital management: In 2012 Jürgen Grabbe became physician in charge of allergology. Allergology has definitely become a subunit of its own.

187 Spirit and Soul of Swiss Dermatology and Venereology

5. The new Dermatology-Allergology Department at “KSA am Bahnhof”

In 2009 KSA bought a complete level of 3,500m² in the new station building of Aarau. Outpatient clinics were to be located in this building to make more space in the hospital’s original estate. The rebuilding of dermatology in Haus 6 had just been completed when the hospital management announced that the Department of Dermatology was to move to the new branch establishment at “Bahnhof Aarau.” This was bad news for the dermatological team, which had just found ideal operating conditions in a central section of the hospital. The hospital’s decision also compromised the peculiarities of the department with its interdisciplinary integration within the hospital. The decision of the management also opened up new perspectives, however; the prospect of a further enlargement of the department which meant more jobs, more space and a technical upgrade with a new laser park. Planning for the new location proved to be debilitating. Shortly before the move into the new building in March 2012, the Head Nurse Christine Niggel died suddenly and unexpectedly. The new start at the station was only possible thanks to the hard work of the entire staff of the department. Fortunately it was no problem to find staff for the new team. It turned out to be an advantage that three new positions were planned for residents, and these were easily filled. It would have been much more difficult to to find trained dermatologists to work as senior physicians in today’s employment market. The desire for more resident positions in dermatology has also been expressed by the Swiss Society of Dermatology and Venereology, which aims for more educational places for dermatologists. Aarau went one step further: Two resident positions are kept open for KSA residents of internal medicine and for physicians of the “Hausarzt-Curriculum.” The latter has been newly established by the cantonal government to improve family doctor medicine. A third resident position is occupied by educational assistants from Basel’s Dermatology Clinic. With these new positions for residents, the Department of Dermatology has changed from a “group practice at the hospital,” to a “training department.”

188 Aarau

After one year of the “KSA am Bahnhof,” the situation looks promising: The demand for dermatological consultations by referring physicians is still growing. The turnover figures of consultations, new allocations, and generated tax points have continued to increase steeply. All this, despite the fact that changing into a “training department” has its price: the employment of residents starting from scratch requires a 1:1 supervision. This means that more consultation time needs to be planned for new referrals and this again has to be considered when calculating how to achieve budget targets. The question naturally arises whether patients accept three- quarters of an hour for a nevus check up which could be performed in just ten minutes by an experienced dermatologist. The question also arises as to whether these patients are willing to pay more for this extra time. Interestingly, until now there have been no objections from patients concerning these points. Apparently, many patients feel better recognised if consultations are longer and this seems to be worth the price for them. This is quite remarkable in times in which only turnover figures seem to count.

Conclusion In its 15 years of existence, the Department of Dermatology at the KSA has experienced a remarkable evolution. It has grown from a “one-man-enterprise” to a “training department” with eight physicians. The future will demonstrate whether the growth process will continue, or whether 15 years of history were enough to have reached a definite size and to be finally “grown up.”

Markus Streit, Peter Itin

Table 1: Annual number of consultations 1998: 3247 2000: 6202 2002: 8167 2007: 10287 2010: 11286

189 Spirit and Soul of Swiss Dermatology and Venereology

Table 2: Synopsis of all staff members Heads of Department: – Peter Itin (1997-2006) – Markus Streit (since 2006)

Head Consultant – Jürgen Grabbe (since 2012, OA/OAmbF since 2009)

Senior consultants (A=Allergologie)

– Marc Anliker (A) (1998-2003; Leitender Arzt Dermatologie, Kantonsspital St. Gallen) – Siegfried Borelli (2001-2; Leitender Arzt Dermatologie, Stadtspital Triemli Zürich) – Susanna Fistarol (2002-6; Oberärztin Universitätsspital Basel, Praxis Basel) – Thomas Gutersohn (2004-5; Praxis Zofingen) – Paul E. Scheidegger (A) (2004-5; Praxis Brugg) – Christian Schuster (A) (2005-6; Praxis St. Gallen) – Jean-Philipp Görög (2005-6; Praxis Bern) – Lisa Hohenstein (2006-9; Dermatologie Zuger Kantonsspital) – Jörg Galambos (2006-7; Oberarzt Universitätsspital Basel, Oberarzt Histologie Kempf und Pfaltz) – Clara Boudny (2006-9; Praxis Aarau) – Marianne Lerch (A) (2006-8; Oberärztin Dermatologie Kantonsspital St. Gallen, Leitende Aerztin Dermatologie, Kantonsspital Winterthur)

190 Aarau

– Beat Keller (2008-9; Praxis Wädenswil) – Barbara Fischer (2008-09; Praxis Zürich) Casagrande (A) – Christian Dietlin (2008-9; Praxis Liestal) – Valérie Krausz (2009) – Clarissa Huber (2009-12; Praxis Bern) – Tanja Graf (2009-11; Praxis Basel) – Anne Sonntag (since 2011) – Lisa Thiede (2010-12, Deutschland) – Claudia Blazek (since 2012)

Residents: Martin Keller, Lisa Thiede, Maja Wüest, Susanne Delmenico, Simone Huber, Anna Kirsch, Anja Amrhein, Philippe Cesano (B)

Nursing staff: Christina Schwendener, Rosaria de Lorenzo, Sandra Meyer, Helene Widrig, Birgit Raab, Barbara Murri, Christine Niggel, Ulrike Bindschedler, Marisa Bonnano

Nursing staff, allergology: Barbara Murri, Katharina Streit, Yvonne Bernasconi, Julia Lehmann

Empfang: Yolanda Brun, Tabea Franke, Hiltrud Neuenschwander, Brigitte Arcaro

Secretarial staff: Eveline Sommerhalder, Karin Seiler, Manuela Meier-Heinze, Rahel Willa, Therese Kunz, Andrea Felder, Anita Richner, Margrit Gurtner

191 Spirit and Soul of Swiss Dermatology and Venereology

Figure 1. Dermatology KSA 1999 (from left to right) Mark Anliker, Christina Schwendener (today Mark Anliker’s wife), Eveline Sommerhalder, Peter Itin.

Figure 2. Dermatology KSA 2003 (from left to right) Peter Itin, Rosaria de Lorenzo, Birgit Raab, Helene Widrig, Rahel Willa, Susanna Fistarol.

192 Aarau

Figure 3. Dermatology KSA 2007 (from left to right) Yolanda Brun, Anita Richner, Marianne Lerch, Barbara Murri, Jörg Galambos, Christine Niggel, Markus Streit, Elisabeth Hohenstein, Clara Boudny.

Figure 4. Dermatology KSA 2009 (back row, from left to right) Christian Dietlin, Barbara Fischer Casagrande, Christine Niggel, Hiltrud Neuenschwander, Beat Keller, Markus Streit. (front row, from left to right) Valérie Krausz, Margrit Gurtner, Anita Richner, Ulrike Bindschedler.

193 Spirit and Soul of Swiss Dermatology and Venereology

Figure 5. Dermatology KSA, physicians 2010 (from left to right) Markus Streit, Tanja Graf, Clarissa Huber, Jürgen Grabbe, Martin Keller

Figure 6. Dermatology “KSA am Bahnhof” 2013. (standing, from lef to right) Anita Richner, Margrit Gurtner, Marisa Bonnano, Yvonne Bernasconi, Jürgen Grabbe, Katharina Streit, Markus Streit, Hiltrud Neuenschwander, Philipp Cesano. (kneeling, from left to right) Claudia Blazek, Anna Kirsch, Anja Amrhein, Anne Sonntag. (not included in the photograph) Ulrike Bindschedler, Julia Lehmann, Brigitte Arcaro.

194 Bellinzona

Dermatology in the Ente Ospedaliero Cantonale

The Dermatology unit of the St. John Hospital in Bellinzona was founded by the dermatologist Dr. Fausto Tenchio in 1934. It was the first specialised independent unit of the Canton Ticino. The founder studied medicine in Zurich and Rome and completed his dermatology residency in Zurich (Professor B. Bloch and Professor G. Miescher). He held the offices of President of the Swiss Society of Dermatology and Venereology (SSDV) from 1963 to 1966 and of the Ticinese Society of Dermatology and Venereology (STDV) for many years. Doctor Tenchio, as a lieutenant colonel, was also drill-ground doctor in Bellinzona for decades, especially during the Second World War. He quite often saw his patients in uniform and went to the barracks in civilian clothes because of lack of time. His unique charisma and originality made him a much-adored dermatologist by his patients, who appreciated his practical approach to dermatology and his skill in treating skin infections. He was an athlete, and until the age of 90 you could meet him at the weekend running around the outdoor skating rink in Bellinzona. He left his position as Head of the Dermatology Unit at the age of 70. He continued to work successfully in his own practice until a few months before his death, in October 1999 at the age of 95. On his 90th birthday I asked him what the secret of aging so well was. He said, “A walk every evening after dinner!” In 1975 he was succeeded as Chief of the Unit by Dr. François Gilliet, who had studied medicine in Zurich and completed his

195 Spirit and Soul of Swiss Dermatology and Venereology residency in dermatology in Boston (Professor W.F. Lever), Lausanne (Professor J. Delacrétaz), and Zurich (Professor H. Storck). In his career he was appointed President of the STDV, member of the SSDV Board and the Swiss Foundation for STIs, and was awarded the title of honorary member of the SSDV in 2002. The Ticinese parliament founded the Ente Ospedaliero Cantonale (EOC) in 1983, bringing together all of the cantonal hospitals in Ticino, including the St. John Hospital in Bellinzona. During those years Dr. Gilliet developed an outpatient unit for the diagnosis and treatment of photodermatoses and inflammatory skin disorders with ultraviolets (PUVA). In addition, allergy testing and therapies, particularly for allergies to hymenoptera poison, were introduced to the outpatient unit. Dr. Gilliet was a very passionate dermatologist and also a great jazz fan. He loved to listen to the great classics of the New Orleans style. He played the piano and started up a band with some of his friends, playing in public regularly even at well-known social events such as Jazz Ascona. He passed on his passions to his children: Michel who is the Chairman Professor of Dermatology at the University of Lausanne and Nicolas who is artistic director of the Ascona Jazz Festival. Dr. Carlo Mainetti joined as a dermatologist in 1994. He studied medicine in Zurich and completed his residency in dermatology in Geneva (Professor J.H. Saurat). Back in Ticino he became a member of the Board of the Ticino Cantonal Medical Association from 1995 to 2000 and of the Bellinzona Medical Association from 1995 to 2002, holding the position of President between 1997 and 1998. In 2003 he was appointed member of the SSDV Board and the Swiss Foundation for STIs. From 2004 to 2008 he served as secretary and treasurer of the STDV. In 2011 he was appointed member of the Managing Board of the SSDV. Since 1996, after the increase of the activities in the inpatient unit of 12 beds and the above-mentioned outpatient clinic, the department was recognised as a training centre for dermatology residents and the treatment of chronic wounds became included in the unit’s activities. The dermatology unit was appointed a training unit (C level) for the FMH title of Specialist in Dermatology and Venereology in 1997.

196 Bellinzona

In 2001, Doctor F. Gilliet left the position of Head Physician and continued his job as a recognised dermatologist in his practice in Bellinzona until his death at the age of 74 in September 2011.

Dr. Mainetti has been in charge of the Dermatology Unit in Bellinzona since 2002. He was assisted in his duty by Dr. Patrizia Carrozza Merlani, who studied medicine in Zurich and completed her residency in dermatology in Bellinzona (Dr. F. Gilliet) and Zurich (Professor G. Burg and Professor A. Eichmann). In 2008, Dr. Carrozza Merlani left her position of Consultant Dermatologist in order to focus on her practice in Bellinzona and her family. She was appointed President of the STDV in 2012. Phototherapy has become an outpatient treatment for chronic wounds and chronic skin diseases because of the great demand over the last 3 decades. During those years the St. John Hospital was renamed the Regional Hospital of Bellinzona and its Valleys, with the acquisition of two peripheral hospitals in the Leventina and Blenio Valleys.

The Dermatology Unit changed its name to the Cantonal Department of Dermatology in 2004. In that year, cases were presented for the first time for posters at the Annual Meeting of the SSDV in Basel, and second prize was won for best poster for a study on the management of chronic urticaria. The new FMH residency standards encouraged the development of the outpatient unit in 2004. In 2005 and 2006 the ward was gradually reduced from 12 to 8 beds, allowing more resources for outpatient activities. In July 2005, an audit confirmed the Cantonal Dermatology Department as a C training centre for the FMH residency in dermatology and venereology. In September 2005 Dr. Mainetti was appointed Chief Physician. He is a passionate dermatologist with a particular interest in art, painting and history. Dr. Petros Michalopoulos was appointed as dermatologist in February 2006. He studied medicine in Bern and completed his residency in dermatology in Bellinzona (Dr. F. Gilliet) and Bern (Professor L.R. Braathen). In the same year the EOC board allowed the Dermatology Unit a second resident physician, a full-time secretary and three full-time nurses for the outpatient clinic. The activities of the outpatient clinic doubled.

197 Spirit and Soul of Swiss Dermatology and Venereology

In response to this growing demand, a second outpatient unit was opened at the Our Lady Hospital in Mendrisio in the autumn of 2007. The Cantonal Dermatology Department of Bellinzona presented its first cases at the Annual Meeting of the SSDV in Bern in October 2007.

The Allergy and Clinical Immunology Unit was incorporated into the Dermatology Department in January 2009, directed by the allergologist Dr. Silvy Bach Bizzozero as senior resident, who studied medicine and completed her allergology residency in Basel (Professor A. Bircher and Professor P. Itin). The activity of the outpatient clinic increased to 3,000 new cases per year, and as a consequence Dr. Cristina Mangas de Arriba was hired. Dr. Mangas de Arriba studied medicine and completed her residency in dermatology in Barcelona, Spain (Professor C. Ferrándiz). She is deeply committed to the cause of detection and treatment of malignant melanoma. In 2010 she initiated a prospective study on the genetics of malignant melanoma in southern Switzerland with the collaboration of the dermatologists of the STDV and the centre for malignant melanoma genetics research in Barcelona. The Dermatology Department was relocated to another building of the hospital and the number of beds of the inpatient clinic was reduced to 7 to cope with the great demand for beds by internal medicine in the context of the H1N1 pandemic in November 2009. The number of hospitalised patients remained stable over the following year despite the reduction of inpatient clinic beds. The team of senior dermatologists was enlarged by the arrival of Dr. Gionata Marazza in January 2010. He studied medicine in Lausanne and completed his residency in dermatology in Geneva (Professor J.H. Saurat), specialising in dermatological surgery. Thank to Dr. Marazza, micrographic surgery was performed in Ticino for the first time in June of the same year. In 2012 he was appointed to the Board and Managing Board of the SSDV. A new consultant was hired for paediatric allergology in July 2012. Dr. Giovanni Ferrari studied medicine and completed his residency in allergology in Aarau (Dr. P. Eng), in Zurich (Professor P. Schmid-Grendelmeier and Professor L. French) and in Perth, Australia (Professor P. LeSouëf).

198 Bellinzona

The designation of Cantonal Department of Dermatology was eventually changed into Dermatology EOC including the inpatient clinic and the dermatology and allergology units. In January 2013 the Managing Board of the EOC allowed the appointment of a senior resident for the Dermatology Division in Bellinzona and Mendrisio.

79 years have passed since its inception in 1934, and great changes have occurred in inpatient dermatology in Bellinzona, which began slowly, but now caters to a fast-growing demand. For a long time, until 1994, the entire activity was conducted by the chief physician with daily commitment. In recent years changes in society, the evolution of medicine and a constantly increasing demand has gradually allowed greater teamwork according to university models and in order to develop specific fields of expertise. Today our team includes a head of the division, three consultant dermatologists, an allergologist, a senior resident and two residents. There have been three chief physicians over the years; they are featured together in a picture taken at a scientific meeting honouring the ninetieth birthday of the founder, Dr. Tenchio, in 1995. Each has attempted to leave their mark with their knowledge and the daily care of the patients. I am honoured to be able to draw attention with these lines to those who preceded me devoting themselves, as I did, with much commitment to the Canton Ticino Department of Dermatology.

Carlo Mainetti

199 Spirit and Soul of Swiss Dermatology and Venereology

The three Chief Physicians, Dr. Tenchio, Dr. Gilliet and Dr. Mainetti, and some members of STDV, 1995.

200 Frauenfeld

Dermatology, Cantonal Hospital Frauenfeld

A dermatological outpatient clinic has been operated at Frauenfeld by the Spital Thurgau AG (STGAG) since March 2011. Until then dermatology had only been privately practised in the canton of Thurgau, and some of the practising dermatologists provided consultation services for STGAG inpatients. Due to the increased demand for dermatological services, a shortage both for outpatients and inpatients became apparent. This situation prompted the STGAG management to begin planning for the provision of dermatological services in close collaboration with the Dermatology Clinic of the University Hospital Zürich (USZ). The creation of a level 2 centre between primary dermatological care and a university clinic was appealing. The final agreement between the STGAG and the USZ was signed in October 2010. The new dermatological outpatient clinic was organisationally integrated into the medical clinic of the Cantonal Hospital Frauenfeld (chief physician Professor Beat Frauchiger). The rooms of the outpatient clinic were converted in the winter of 2010/2011 in the ARA building. In addition to examination rooms, a room for surgical interventions and a phototherapy unit were established. Under the lead of PD Dr. Cozzio, the USZ dermatologists Dr. Karin Schad, Dr. Katrin Baumann and Dr. Stephan Nobbe brought their ideas into the concept. Since the beginning, the clinic has been run by two senior consultants from the USZ Dermatology Clinic, who divide their hours between the USZ and the Cantonal Hospital Frauenfeld, working 50% at each. Dr. Karin Schad and Dr. Katrin Baumann were the first senior consultants to work in Frauenfeld. Together with

201 Spirit and Soul of Swiss Dermatology and Venereology two experienced practice assistants (Annette Fehr and Simone Varga), they were involved in the development of the clinic routine. Dr. Stephan Nobbe took over the position of Dr. Katrin Baumann (now privately practising in Lucerne) from July 2011, and PD Dr. Mirjana Maiwald that of Dr. Karin Schad (now senior consultant, USZ Dermatology Clinic) from October 2011. The allergology consultations which Professor Barbara Ballmer- Weber had been holding on a monthly basis for a number of years in Frauenfeld were integrated into the dermatological outpatient clinic in the beginning of 2012. In summer 2012 a further practice assistant (Daniela Meier) joined the team in order to manage the increasing number of dermatological and allergological consultations. From the physician’s side, PD Dr. Mirjana Maiwald (now senior consultant, USZ Dermatology Clinic) left at the end of March 2013. Dr. Isabel Kolm became the new senior consultant. In addition, a 6-month rotation for senior residents from USZ was introduced. The first dermatology resident at the Cantonal Hospital Frauenfeld was Dr. Romano Kasper (Figure 1). The outpatient clinic has been very popular since opening. The service covers a broad spectrum of outpatient dermatology, in both diagnostics and treatment. The majority of patients are referred by practising physicians, from both primary carers and specialists from the canton of Thurgau and neighbouring cantons. In addition, the outpatient clinic is responsible for all dermatological consultations in the whole STGAG (Cantonal Hospitals Frauenfeld and Münsterlingen, Clinic St. Katharinental Diessenhofen and the Cantonal psychiatric services). Furthermore special consultation hours are held on a monthly basis with head physicians from the USZ Dermatology Clinic to discuss patients with complex problems in the areas of dermatooncology, autoimmune dermatoses or phlebology. An extension of the clinic is planned, in particular a radiotherapy unit. After two and a half years of operation the results are very positive. Thanks to the constant exchange with the colleagues from the USZ, the STGAG dermatology team brings up-to- date knowledge to the cantonal hospitals of Thurgau and thus complements the dermatological services of the canton.

Stephan Nobbe, Mirjana Maiwald, Beat Frauchiger, Lars E. French, Antonio Cozzio

202 Frauenfeld

Figure 1. Dermatology Cantonal Hospital Frauenfeld Team June 2013 (from left): Dr. Isabel Kolm, Dr. Romano Kasper, Annette Fehr, Dr. Stephan Nobbe, Simone Varga (missing: Daniela Meier)

203

Lucerne

Centre of Dermatology and Allergology at Lucerne Cantonal Hospital

The first hospital in Lucerne was founded in 1286 by Benedictine monks; it was located in the west wing of the Knight’s Palace (Rittersches Palais) which is the city administration building today. In 1652, due to a generous gift from Mayor Heinrich of Fleckenstein from the Citizen’s Council, the foundation was laid for a new building in Obergrund; this new, large “Holy Spirit” City Hospital (Stadtspital “zum heiligen Geist”), which was completed in 1660. With the adoption of the Law for the Poor (Armengesetz), in 1899, Lucerne took on the responsibility of accepting all the poor people in the hospital. At that point, the old hospital could no longer meet its needs. The result was the construction of the new Cantonal Hospital under the management of Dr. Schmid. It was first occupied in 1902. The skin clinic was founded in 1936. The first head physician was Dr. Eduard Frei. He was followed by Dr. Max Winkler, who gained an enduring place in the literature with his description of chondrodermatitis nodularis helicis, along with Dr. Karl Baumann and Dr. Josef Kaufmann. Each of these physicians had an independent practice in the city of Lucerne in addition to their duties as the head physicians of the dermatological clinic. After the resignation of Dr. Josef Kaufmann in 2000, it was decided to ensure dermatological care at the cantonal hospital with

205 Spirit and Soul of Swiss Dermatology and Venereology a full-time position. Professor C. U. Brand (PhD), who started his position in February 2001, was selected to establish a dermatology department at the Lucerne Cantonal Hospital. As a first step, new private rooms for the support of dermatological patients were built and a first small outpatient department was created in an old ward room. The outpatient area was continuously expanded in the next few years, and following an initial relocation into the oncology building in 2003, it was possible in 2010 to reoccupy the rooms of the newly designed outpatient department in the renovated old Women’s Hospital (today the Academy of Medical Training and Simulation, Figure 1). In 2011, the Centre of Allergology and Dermatology was founded along with the newly joined allergologist Dr. Müllner. Dr. Müllner is a well-known allergist internationally and nationally, and manages this Centre with Professor Brand. The in-patients are provided with care on the internal medicine wards in terms of an integrated specialisation. In the Outpatient Departments of Dermatology and Allergoglogy, currently a head physician, two managing physicians, a chief

Figure 1.

206 Lucerne resident, two residents and three consulting physicians and eight MPAs have had office hours with approximately 25,000 consultations annually. All areas of dermatology and allergology except histology are offered in Lucerne. There is a narrow, simple networking system with the remaining specialities of the Lucerne Cantonal Hospital. This particularly includes oncology, plastic surgery and rheumatology. The clinic is well integrated into the Medical Department. The Centre is well represented in its departmental capacity with the head physician who also works as the administrative Head of Rheumatology and Oncology. In addition to the clinical activities, there is a lectureship by the Centre for the University of Berne and for the students from Berne, Zurich and Basle at the Lucerne Cantonal Hospital. In addition, a training function has been assumed for the assistant physicians of the cantonal hospital. The Centre of Dermatology and Allergology (Zentrum für Dermatologie und Allergologie) is a renowned category C training facility.

Christoph Brand

207

St. Gall

Centennial Dermatology/Allergology Clinic of the Canton Hospital of St. Gallen 2004-2013

Skin is our business. But it was quite unusual to stand in front of an empty clinic containing nothing but car-loads of cardboard boxes and minimal furniture on the morning of April the 1st 2004. This was the first day of the Dermatology/Allergology Clinic in the Canton Hospital of St. Gallen. Converted from a former kindergarten, a month before no one would have expected an operative clinic would be finished in such a short time (Figures 1 and 2). The Canton Hospital in St. Gallen was assigned by the state of St. Gallen to establish the smaller specialities of dermatology/ allergology, endocrinology and angiology by 2004/5 as the largest non-university hospital in Switzerland (after merging with the hospitals in Rorschach and Flawil); thus guaranteeing a broader and better base for the treatment of their patients. The introduction of our two fields of dermatology and allergology certainly makes sense and has been accomplished in practically every major hospital in Switzerland in recent years. It is also a great chance for us to bring dermatology back into general and internal medicine, and vice versa. Mark David Anliker was assigned as Head of Clinic, and with his representative Klaus-Dieter Loske we started the clinic with a team of just 5 (Figure 3); today it is hard to believe that a hospital of this size could do without a permanent dermatologist and allergologist, especially after already receiving a patient suffering from a toxic epidermal necrolysis on day 4.

209 Spirit and Soul of Swiss Dermatology and Venereology

Figure 1a. The former kindergarten of the Canton hospital…

Figure 1b. … converted into the Dermatology/Allergology Clinic in St. Gallen in one month.

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Figure 2. The first team, cover of Novum, the hospital magazine of 2005 (from left: C. Weibel, E. Wüthrich, K.D. Loske, S. Frey, M.D. Anliker, F. Mesou)

Figure 3. Still being playful in a former kindergarten; using everyday materials for an airplane.

211 Spirit and Soul of Swiss Dermatology and Venereology

Thanks to a broad dermatological training in the Dermatology Clinic (Head: G. Burg) and Allergology Clinic (Brunello Wüthrich) in the Zurich University Hospital; in histopathology (Renato Panizzon); in the Dermatology Clinic in Aarau (Peter Itin); and Mark David Anliker and Klaus-Dieter, trained in Münster, Germany along with Thomas Luger and Lea Bruckner- Tudermann, all brought something from their different schools of medicine/dermatology. The knowledge of their great teachers was incorporated. They all shared a comprehensive view on assisting the outpatient clinic with the help of systemic therapies, and on the interventional treatment of acute dermatoses on the ward internal medicine ward, where the nursing staff was educated in carrying out specialised treatments such as wet wraps, the use of dithranol etc.

Build up Dermatology and allergology were organised as part of the Interdisciplinary Medicine Department (IMD) led by Daniel Germann MD (and from 2010 by Susanne Diener MD) with the upmost autonomy and its own budget. Nevertheless, the cooperation between our clinic and all of the other clinics was actually intensified very quickly and the borders between skin disease, skin signs and internal disease were elaborated by both sides with great interest. For the CEO Hans Leuenberger and the later CEO (from 2010 on) Daniel Germann, performing interconnected/interdisciplinary medicine is one of the main goals in St. Gallen and we were glad we could build on synergies with other clinics as a small unit. These collaborations allowed us to review and evaluate our own histopathology by receiving the necessary laboratory work from the pathology, to examine leg ulcers, together with our angiologists, of patients with severe skin diseases who often bear internal medical problems on the internal medicine ward, and to treat advanced cancer and lymphoma in larger teams with plastic surgeons, radio- oncologists and oncologists. On the other side we needed specialised training in allergologic diagnostics and dermatological therapies for our nursing staff in the University Hospital of Zurich. But with all this help we were very rapidly practising in almost all fields of dermatology; performing skin surgery, skin testing of all kinds, as well as being very well

212 St. Gall positioned in the use of biologicals (in 2006 already 60 patients) and systemic therapies (CyA, Azathioprin, MTX, Fumaric acid, Mycophenolate mofetil, IVIG). This was mainly due to the high frequency of pre-treated patients who had failed to recover, since we accept only referred patients. The interconnection with practising dermatologists in the region was great from day 1 onwards, and we hoped we could contribute to their needs. A regular meeting to discuss special cases and for lecturing was scheduled by Anita Bon in St. Gallen and Martin Widmer in Rorschach and has continued until today. The rapid demand for dermatological services and allergologic testing, as well for interventions including the ultra-rush desensitisations of bee- and wasp venom led to an expansion of the team of doctors in 2006 by adding a resident (Caroline Gex-Collet) and beginning a training program for residents in dermatology. When the dermatologists first arrived in the hospital setting we found a lot of common problems, and we were glad to contribute to the surgeons’ needs such as fetching all the pyoderma gangraenosums from different hospitals who had not improved after surgical interventions (a process lasting several years and involving at least 50 patients), and in diagnosing vasculitis, calciphylaxis, autoimmune and allergic skin diseases. We just had to prove that we treat more than just pimples. Pimples can also be a sign of immune suppression, hormone disturbance, Behçets disease, or auto-inflammatory disease by the way…

Critical size: What starts small will eventually grow larger A critical size is reached when the number of patients rises too rapidly. For 8 years the numbers have been constantly been growing. The annual consultations have risen from 4500 (2005) to 16000 (2012); the staff from 6 to 25 (2012); certified dermatologists from 2 to 4; and residents from 0 to 3. Biopsies and excisions reach approximately 3000/year. These developments can lead to patients appearing on the wrong day, records that cannot be found and unwanted consultations with doctors never seen before. To avoid these kinds of everyday problems big institutions can experience is not easy. It afforded a substantial expansion of the administrative staff and certain principles such as returning all the documents

213 Spirit and Soul of Swiss Dermatology and Venereology back to the archive promptly, keeping the consultations of a patient with the same doctor etc. We are fortunate that things are well organised, but we still keep a watchful eye on proceedings…

Critical size is when enough room becomes a rarity. Due to increased activities and the growth of patient numbers and staff, a dramatic room shortage was reached in 2009. The nursing/testing area was so small that the patients would be seated back in the lobby until skin tests were ready to be evaluated. The waiting room was often overcrowded, and at times the atmosphere seemed very tense; this was evident as patients suffering from anaphylactic shock were gathered in that room. Basically everyone on the medical staff was acquainted with the use of adrenalin after that period. Theo Rufli (Head of the Dermatology Clinic at the University Hospital of Basel at the time) had already predicted at the opening ceremony in 2004 that these facilities would soon be too small. Well, the critical size was reached only after 5 years in 2009, and even forced us to partly work in shifts in 2009/10; these circumstances were finally resolved by erecting a sizeable container behind the existing clinic, tripling the waiting/observation area by opening 250 square meters for allergy testing facilities, and by opening a day care unit with bath and treatment facilities for wounds, ulcers and general skin diseases such as eczema and psoriasis.

A change of management Due to the liberal policy of granting licences to private practices in dermatology by the cantons, the number of dermatologists practising in the region of eastern Switzerland (the Cantons of St. Gallen, Appenzell, and Thurgau) has doubled between 2008 and 2013. This is excellent for our speciality and provides good dermatological services to all regions on the one hand, where the average waiting time for an appointment had been 3 to 5 months, and on the other hand this circumstance has curtailed the rather rapid growth of our clinic in the last few years from 10-20% annually to approximately 5% per year, although it has led to an even more select group of patients. The percentage of second opinions, patients with a need to be seen by several specialities, a need for systemic therapies and biologics, or patients with internal diseases and complex or severe skin disease, is fairly high.

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This is a great opportunity for senior residents to focus on these groups and work on their skills in managing more complex skin diseases and has led many residents to St. Gallen to complete their training in dermatology, much to our luck. Not less than 6 residents have passed their board exams in the speciality of dermatology and venereology while working in our clinic, a high rate considering that we can only provide one official position for dermatology residents.

The liberal policy of granting licences to private practice has also led many of our dermatologists to choose their own practice, many of which are still in the region and with whom we enjoy good further cooperation: Uwe Hauswirth in Wattwil, Susanne Kristof and Eva Sailer in Rapperswil, Valerie Hauser in Rorschach, André Surovy in St. Gallen, Damian Bühler in Gossau and Philipp Fritsche in Appenzell. Klaus-Dieter Loske had opened the Klinikum Bamberg by the end of 2007, and Marianne Lerch a new Dermatology Clinic in the Canton Hospital of Winterthur in 2011, which are both positive for the further integration of our field in larger hospitals. This has made us feel proud, even though we very much regret that they are not practising in St. Gallen anymore. But due to the all-too frequent rotation of the medical staff from 2007 to 2012 (4 teams in 6 years!) it has led to a change of management in which the processes had to be defined and the management of diagnostic and therapeutic interventions had been standardised, utilising therapeutic regimes from Zurich, Basel, Munich and Muenster, scoring systems and a high rate of interaction, supervision and teaching, as well as mentors for new staff. Time slots for each doctor provide room for emergencies, supervisory activities, consultations on the ward, and paper work.

Today, we have a wonderful team with Birgit Ichters (formerly from Ulm, Davos, specialising in autoimmune disorders, pediatrics dermatology, and allergology), Teresa Jaeger (formerly from St. Gallen and Munich; autoimmune disorders, pediatrics dermatology, histopathology, and allergology), Rainer Hügel (from Kiel and Feldkirch; autoimmune bullous diseases, autoimmune disorders, and melanoma), and Barbara Gaus (from Heidelberg;

215 Spirit and Soul of Swiss Dermatology and Venereology skin tumours and clinical trials). Everyone treats a broad spectrum, and still cultivates their favourite fields of interest.

Specialties and science

What was begun by Klaus-Dieter Loske and Susanne Haug was expanded siginificantly by Uwe Hauswirth, namely dermatological surgery. By bringing along skills from the Dermatology Clinic of Stuttgart and Hamburg, Uwe Hauswirth introduced a number of surgical interventions in 2009 such as the sentinel node biopsy, axillary suction-curettage, the major excision of tumours, utilising a variety of surgical flaps, and surgery on hidadrenitis suppurativa, all in tumescent local anaesthesia, thus allowing these procedures to be performed in a day-care setting to the benefit of the patient and health care costs. These activities were continued and processed further by Damian Bühler, who is still conducting these operations today in our clinic while being in private practice, and by Birgit Ichters. The development of dermatological surgery would of not have been possible without the cooperation with the surgical department, plastic surgery clinic, and the ENT clinic, who enabled us to co- use the operation facilities to perform dermabrasion, CO2-lasering, and major operations in tumescent anaesthesia without giving up our autonomy. Clinical studies were started substantially in 2009 and were mainly introduced by Lucie Heinzerling, who had plenty of experience; national and international clinical trials were conducted in conjunction with practically all the dermatology clinics in Switzerland on psoriasis, melanoma, actinic keratoses, hidradenitis suppurativa, pyoderma gangraenosum and several more. More thrilling are our own studies if they pass the Swissmedic board. Seeking the possible positive influence of acid coated textiles on atopic skin in a placebo controlled setting was one of them. Twenty blue shirted subjects came to our clinic every week, clogging up our narrow aisle while waiting for biophysical skin testing. Indeed the acid treated textiles did improve the biophysical parameter after one week. In the second, however, the hottest week of the summer, everyone was covered in sweat, so we couldn’t

216 St. Gall standardise the readings anymore and measurements were rendered useless. Further highlights were the clinical and histopathologic analysis of a new entity; the pressure induced angio-keratoma plaques in patients confined to hospital beds over a long period of time; new combination therapies for acne keloidalis nuchae with clindamycin and rifampicine; granulomatous diseases with dapsone and doxycycline, and so on.

Together with the surgical department, a laser centre was created in 2011 to share the costs and the use of IPL, Nd-YAG, pulsed dye, argon, factional and CO2- lasers which were especially needed for the treatment of scars, genetic disorders (pigmented, hair, vascular lesions), the side effects of steroids and autoimmune diseases, as well as for training purposes. Drug reactions have always been a major focus and are an ideal field for a clinic servicing dermatology histopathology and allergology all in one. Together with a diagnosis-based registry of all patients since 2004 we were able to extract, analyse and publish (Heinzerling L, et al.) one of the largest populations to date, including pathology, skin tests and LTT. In addition, since 2010 we have been mapping all exanthemas to distinguish between drug reactions and rashes from other origins. Further publications on drug reactions, the side effects of tumour therapies and unusual findings were finalised in the last few years. Systemic therapies are another hallmark in St.. Gallen due to the frequency of severe skin diseases, and cover not only targeted treatments, but also all immune-suppressants, IVIG and older drugs such as colchizine and thalidomide. Allergologic diagnostics have been consistently increased. Marianne Lerch has improved the management of contrast media intolerance/allergy and drug allergy testing, and we have introduced several innovative test series including cereals, salads and aroma substances (with an emphasis on food intolerance/ allergy), and prosthesis materials in patch testing to mention a few. These additions are greatly needed for collaboration with anaesthesiologists, surgeons and gastroenterologists. The synergy with the angiology clinic and the surgical department enables us to train residents in phlebology and proctology; we also

217 Spirit and Soul of Swiss Dermatology and Venereology can be part of the further efforts in the diagnosis and therapy of our patients if necessary. Interdisciplinary boards (the melanoma board, rheumatologic board, wound care board, and pathology board) have facilitated communication between clinics, learning from other disciplines and ensure that patients are provided with the specialists they need. Education is another great ambition of our clinic and it wouldn’t be St. Gallen without the weekly rounds, reviewing all the photographic material, histopathology slides and the latest journals once a week. For the region with approximately 25 participants we have established a regular on-going education every 6 weeks with the possibility of presenting cases from private practice. Christian Schuster formed the DGO, the Dermatologists Society of Eastern Switzerland in 2012, which meets every year, and has created an online platform including a library and all the scientific activities, studies and events the DGO or the Dermatology/Allergology Clinic undertakes.

Prospects for the future Until now the experience in St. Gallen and work has been rich and rewarding. Not without gaining some grey hair along the road in convincing other departments that our specialties, and in particular the Dermatology/Allergology Clinic in St. Gallen, are part of the larger picture; in the Canton Hospital in St. Gallen we act and treat patients as one clinic. Even though reaching a considerable size we are still a small clinic compared to the clinics in the university hospitals in Switzerland and Germany, and we are reliant on cooperation and working in larger, multi-speciality teams and in conjunction with other dermatology and allergology clinics in Switzerland. The further outlook in that respect is rosy and we are looking forward to further integration into the fields of wound care management, histopathology, dermatological surgery, clinical trials, pediatric dermatology, and drug reactions; all fields where we are badly needed, in our opinion. The more medicine is specialised, the more pinpointed treatment is needed, as well as an awareness of interacting medications and the side effects of targeted therapies. More interdisciplinary work is needed, especially in systemic diseases.

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The more patients undergo organ transplants, the more we will be confronted with the immediate and late side effects of immune suppression. The more the population ages, the more we will have to deal with aging skin, different therapeutical approaches than we are used to, and more skin cancers to be prevented and treated. We have great dermatologists in our clinic and great dermatologists in practices in eastern Switzerland. We look forward to further interaction, activities, bright therapeutic decisions and diagnostic novelties in facing the prospects above. Hopefully we will continue with heart (for the patient) and mind (for logical approaches and innovation), and leave some room for humour (Illustration 3) too.

Mark David Anliker

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Zurich Triemli

Centenary of the Zurich Municipal Policlinic (1913-2013)

The founding dates for the Municipal Policlinic for Dermatology and Venereal Diseases (since 1995, the Outpatient Dermatology Department of the Triemli Municipal Hospital), and those of the Swiss Society of Dermatology and Syphilology, the subsequent Swiss Society of Dermatology and Venereology (SGDV), are almost contemporaneous.

1. Reasons for the creation of the Municipal Policlinic for Dermatology and Venereal Diseases The incidence of venereal disease was high in Switzerland at the start of the 20th Century, particularly so in Zurich. At this time, only Bern had a special policlinic for dermatology and venereal diseases. The epidemiological problems underlying these venereal diseases – mainly syphilis and gonorrhoea – were judged to be a priority in the poorer population in Municipal Districts 3, 4 and 5 and, furthermore, there was a certain reticence among these classes to present at the Cantonal Hospital in District 6 on the Zürichberg. The City Council, therefore, exhibited much foresight in deciding to set up a specialised institution where its services were required. In 1913, the Zurich City Council made the decision to make the premises of the Medical Policlinic at 82 Hohlstrasse available to Max Tièche for dermato-venereological consultations and patient demonstrations for students. At this time, Max Tièche already had

221 Spirit and Soul of Swiss Dermatology and Venereology a flourishing practice for dermatology and venereal diseases on Bahnhofstrasse in Zurich. The first consultation at the premises of the Medical Policlinic at 82 Hohlstrasse (Figure 1) took place on the 1st of October 1913.

Figure 1.

2. The influence exerted on the Municipal Policlinic by the different directors and head physicians (Table 1) In his position as the founder of the policlinic, Max Tièche (Figure 2) clearly dictated the institution’s line of development. This included the provision of open access to poorer patients in Municipal Districts 3, 4 and 5, and the treatment of such patients free of charge in an emergency. His main concern was to contain venereal diseases. Other infectious skin diseases were of secondary importance, whereby Tièche was particularly interested in smallpox and chickenpox.

Tièche was from the Berner Jura and achieved international renown with his dissertation, in which he gave the first description and characterisation of blue naevus. Within only a few years he had

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Table 1 Head Physicians of the Municipal Policlinic (from 1995, Outpatient Dermatology Department)

– Max Tièche 1913-1938 – Walter Burckhardt 1938-1971 – Kaspar Schwarz 1971-1988 – Alfred Eichmann 1988-2002 – Stephan Lautenschlager 2002- turned the Policlinic into a social institution. The population greatly appreciated the extended consultation hours, which often lasted until 10 or 11 pm. His medical demonstrations for students and doctors were held in increasingly high esteem. Among other things, this led to growing competition with the Dermatology Clinic at the Cantonal Hospital that had been set up three years later. The Policlinic soon became too small due to the increase in the number of patients attending, and Tièche was forced to search for larger premises, which he found in the old powder magazine at 119 Hohlstrasse. These premises were provisionally converted into a policlinic and acquired as an interim solution in January 1923. At the time, 1,533 patients were treated in 9,432 consultations. However, the premises and facilities were highly inadequate, such that the population became increasingly dissatisfied, and the institution was also criticised by the Borough Council. The funding for a new building was not authorised until 1934. These new premises were acquired in 1936 at 70 Herman Greulich-Strasse, where the clinic remains today. Particular features of Tièche’s headstrong character were his keen desire for independence and his sense of justice. In addition to his compassion for the needy, he played a pioneering role through his recognition of socio-preventative medical relationships. His annual reports addressed to the City Council reflected his understanding of epidemiological relationships. Tièche died of complications associated with acute pancreatitis in 1938 at the age of 60, only two years after the acquisition of the new premises. He was not commemorated by the City of Zurich until the 1950s,

223 Spirit and Soul of Swiss Dermatology and Venereology when Tièche-Strasse near the Waid Hospital was named after him as a small memorial. Tièche had found a worthy successor in the form of Walter Burckhardt (Figure 3), aged 33 at the time. His professional mentors, Bruno Bloch and Guido Miescher, held the first two Chairs for Dermatology in Zurich. Burckhardt was selected from six applicants and started his new job on the 1st of October 1938. Burckhardt lived and breathed dermatology, whereby he was particularly fascinated by his two preferred areas, work-related dermatoses (occupational dermatology) and venereal diseases. In his professorial dissertation “Bricklayers eczema,” he summarised his main research on cement eczema. Over time, Burckhardt turned the Policlinic into a renowned specialist centre for consultation. His work ethic meant that he was extremely productive and efficient, as is demonstrated by his comprehensive list of around 200 publications. Numerous well-known medical practitioners completed their dissertations under his guidance, of which the legendary dissertation written by Urs Peter Hämmerli, the subsequent Head Physician at the Medical Department of the Triemli Hospital, is given here as just one example. Hämmerli gave the first description of the circumstances in Lake Zurich that caused cercarial dermatitis and its development.

The dermatological and venereological case presentations given by Burckhardt on Friday evenings, into which he incorporated his entire didactic ability and enthusiasm for the subject area of dermatology, became legendary among students. Burckhardt himself was hero-worshipped by many students – a role model to be emulated. His textbook with its clear colour photographs was a standard for generations of future medical practitioners Figure 2. and was also translated Prof. Dr. med. Max Tièche into English and Spanish.

224 Zurich Triemli

Patient numbers continued to rise; 5,439 patients were treated in 36,500 consultations in 1945. Burckhardt died of heart failure at the age of 66 in October 1971, shortly after his retirement. The City Council appointed Kaspar Schwarz, Consultant at the Dermatology Clinic at the Zurich Cantonal Hospital, as Burckhardt’s successor. In contrast to his two predecessors, Schwarz was a rather more introverted and retiring person. The main concern during his era was to consolidate standards at the Policlinic and to strengthen its position as a medical institution in the City of Zurich. Schwarz showed an early interest in dermatological radiotherapy, in keeping with the traditions of the Dermatology Clinic at the Zurich Cantonal Hospital. A further focus of his work was on photosensitive dermatoses, which were also the topic of his professorial dissertation. He and his wife, who worked with him as a chemist, published a number of highly regarded papers on photo-allergic reactions.

Figure 3. Prof. Dr. med. Walter Burckhardt

Venereology reached new significance thanks to new epidemics. For example, according to the annual report, 2,065 cases of gonorrhoea and 294 syphilis patients were treated in 1974. Over the course of his lengthy service as the Secretary of the Swiss Society of Dermatology and Venereology, Kaspar Schwarz worked tirelessly on political and specialist medical issues. Kaspar Schwarz retired

225 Spirit and Soul of Swiss Dermatology and Venereology after 17 years in the position, lived a withdrawn life and died in Zurich in December 2011 at the age of 88 after many years of illness. The City Council appointed Alfred Eichmann as the new Head Physician at the end of 1988 (Figure 5). A. Eichmann had written his professorial dissertation on the topic of venereal disease under the guidance of U.W. Schnyder at the Dermatology Clinic of the Zurich University Hospital. The policlinic thus remained the leading “port of call” for venereal diseases in the German-speaking part of Switzerland. In addition, Eichmann increasingly focused on the new subsidiary specialties of dermatology – dermatosurgery, stomatology and nail diseases – such that the clinic became a highly regarded institution in these fields as well. In accordance with the institution’s traditions, Eichmann was very active in teaching, and the student course on Friday afternoons on the premises of the policlinic was of particular importance to him. After just under 14 years in the position as Head Physician, A. Eichmann retired early at the end of August 2002, as required by the law at the time, albeit against his own wishes. He then ran a popular private practice at the Zollikerberg Hospital until 2007. After the position had been advertised by the Triemli Hospital, Stephan Lautenschlager, Eichmann’s Deputy and Senior Consultant for many years, was named as his successor – now of the Outpatient Dermatology Department at the Triemli Municipal Hospital (Figure 6). Stephan Lautenschlager had completed his training in Dermatology at Basel University Hospital. Almost in keeping with tradition, Lautenschlager had completed his professorial dissertation on a venereological topic – Herpes genitalis – at the University of Zurich. On top of the pre-existing focus areas at the policlinic, Lautenschlager introduced paediatric, infectiological and gynaecological dermatology. The Outpatient Department was also expanded to become a point of contact for allergic disorders through the employment of a consultant specialising in allergology and immunology (Siegfried Borelli). The increased incidence of venereal diseases at the start of the third millennium facilitated the early recognition by the Outpatient Department of the current resurgence of sexually transmitted diseases in Switzerland. On the one hand, the custom of an open-access consultation period in the form of a walk-in clinic has been maintained, which allows the assessment and treatment of mainly acute skin diseases and, traditionally at a lower threshold, also of venereal infections. The

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Friday evening consultation period, in particular, is very popular. On the other hand, modern-day practice is characterised by an increase in interdisciplinary collaboration with the different clinics in the Municipal Hospitals, with correspondingly complex referrals and joint consultations. This interdisciplinary network has led to plans for the physical integration of the Dermatology Department into the new Triemli Municipal Figure 4. Hospital block in the neighbouring Prof. Dr. med. Kaspar Schwarz District 3, which is to be realised by 2017. The future will show to what extent the advantages of the, by then, over one hundred-year- old institution can be transferred to a large hospital. The constant rise in patient numbers, currently at around 25,000 consultations and 15,000 patients, has also required an increase in the number of medical practitioners employed. In addition to 2,500 surgical

Figure 5. Prof. Dr. med. Alfred Eichmann

227 Spirit and Soul of Swiss Dermatology and Venereology

Figure 6. Team of the Outpatient Dermatology Department at the Triemli Municipal Hospital 2013 Top row from left to right: Franziska Zimmermann, Barbara Trachsler, Christina Zehntner, Umijan Xheladini, Andrea Kadnar, Sandra Tiefenbacher, Sandra Burkart, Susanne Gutbrod, Annabelle Ettlin, Doris Sägesser Lower row from left to right: Med. pract. Daniel Fleisch, Dr. med. Barbara Fleisch-Laetsch, Prof. Dr. med. Stephan Lautenschlager, Dr. med. Siegfried Borelli, Dr. med. Isabelle Luchsinger, Dr. med. Dominic Reinhardt, Dr. med. Helen Köhl. interventions, numerous physical treatments are made available; in particular, soft x-ray radiotherapy is used for over 2,500 treatments annually. Lautenschlager also places great emphasis on teaching, which is reflected in the energy he invests in the Friday afternoon course that remains extremely popular with the students.

3. The socio-political importance of the Municipal Policlinic It is by no means pure chance that the policlinic is located on Herman Greulich-Strasse. Its location on this road, named after the famous Zurich socialist, is symbolic of its social functions. Since it was founded, innumerable patients have been treated here who had nowhere else to go. Even today, there are many patients

228 Zurich Triemli in our system who, for a variety of reasons, are rejected wherever they go. It is one of the obligations of a government-run policlinic to provide medical help for those patients who slip through the social net. The structure of this institution has changed over the years (Table 2). While the Policlinic has remained the property of the City of Zurich since its inception, the organisational responsibilities have changed. In Max Tièche’s time, the City of Zurich covered all the costs of the policlinic, and also paid the salaries of the medical practitioners and all other personnel. However, it had no say in its governance, as Tièche himself was not paid by the City of Zurich. Tièche’s successors as Head Physicians were official, full-time employees of the City of Zurich. The authorities tried to close down the Policlinic three times during the Eichmann era, from 1988 to 2002, for political and financial reasons. In the end, the power play between Canton and City and the medical profession and health insurance companies resulted in the survival of the policlinic. This was at a time when many hospitals and medical institutions in Switzerland disappeared as part of a drive towards rationalisation. This instance of multiple attempts to shut down the policlinic in spite of high patient numbers is yet another example of the lack of a clear concept of the modern-day healthcare system in our country. Eichmann was responsible for the organisational integration of the Policlinic into the Triemli Municipal Hospital, from its previously rather isolated administrative position within the Municipal Medical Services. In recent years, the Outpatient Department has been turned into a profitable institution under Lautenschlager, while still fulfilling its social obligations. Unfortunately, however, the demand for examinations and treatment far outstrips the capacity of the personnel to provide these services.

4. Relevance to teaching and education Teaching and education come under the remit of the Canton of Zurich (Table 3). However, in addition to the mediation of theoretical knowledge, medical students also require practical and realistic education involving patients, which cannot be replaced by computer-assisted learning. This type of teaching was cultivated in the tradition of Tièche and Burckhardt, and has developed further. The inclusion of resident dermatologists as lecturers has fostered

229 Spirit and Soul of Swiss Dermatology and Venereology an even greater in-depth relationship to practice. The institution also provides 12 internships per year, giving these candidates an insight into the subject of dermatology. Due to the shortage of medical specialists in dermatology/venereology in Switzerland, the provision of dermatological services in many parts of the country is inadequate, in particular outside the large cities. In the form of a B Clinic, the policlinic currently provides three positions to train as a specialist in dermatology/venereology. Three of the required 5 years of training can be completed in the Outpatient Dermatology Department.

Table 2 Organisation and structure of the Municipal Policlinic

Proprietors Employers City of Zurich 1913-1938 M. Tièche (Landlord) City of Zurich 1938-1994 City of Zurich (Municipal Medical Services) City of Zurich 1994- City of Zurich (Triemli Hospital)

Table 3 Teaching and education at the Municipal Policlinic

– Dermatological group tutorials (Master’s course in human medicine) – Clinical dermatology and venereology (Master’s course in human medicine) – Positions to train as a specialist (Dermatology/Venereology) (3 years = B Clinic) – Medical training positions (Internal Medicine/General Practitioner) – Positions for 12 internships per year

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5. Medical relevance In addition to its educational function, the quintessential interdisciplinary nature of this specialist area means there is a requirement for a dermatological consultation service for the approximately 800 beds in the municipal hospitals that provide acute care, as well as for healthcare centres. Furthermore, the institution has become a leading point of contact for the diagnosis and treatment of venereal diseases through the work of its head physicians, with the greatest numbers of patients with sexually transmitted diseases in the whole of Switzerland. The institution is now, once again, fulfilling one of its most important original functions, given the renewed rise in venereal diseases since the start of the third millennium.

In addition to its social obligations, the policlinic places great emphasis on the importance of the education of our future medical practitioners in dermatological and venereal diseases. Given the high numbers of patients attending the policlinic, it will also be a requirement in the future to ensure that the supply of dermatological expertise is guaranteed in the Zurich agglomeration area, as is also reflected in the constant rise in the number of referrals from resident practitioners (apart from the basic care providers; mainly gynaecologists, paediatricians and dermatologists).

Stephan Lautenschlager

231 Spirit and Soul of Swiss Dermatology and Venereology

References 1. Furrer HP, Tièche M, Dermatologe und Gründer der Städtischen Poliklinik für Haut- und Geschlechtskrankheiten der Stadt Zürich, Zürich, Med. Dissertation, 1992. 2. Wicki-Bühler B, Leben und Werk des Dermatologen Walter Burckhardt 1905-1971. Zürich, Med. Dissertation, 1995.

232 5

The Presidents of the SSDV

1975-1978

The memories of my time as President of the SSDV are altogether positive. Looking back, it was a “golden period.” The physician practised independently in his/her practice under the auspices of a liberal society and the legal concept of a free and responsible professional life. The practice was the dermatological point of reference for all of the cantonal residents, and the physician had a respected and favourable position in society. There were very few political attempts to limit the physician in his/her freedom of choice and responsibility, or to impose quality controls, let alone to prosecute or hold liable. The interpersonal relationships in healthcare politics were ordered and the SSDV was able to focus on its congresses and the professional get-togethers. Looking back on my time as President brings to mind two particularly impressive meetings. We organised a wonderful cultural tour via Yucatan and a number of Central and South- American countries for a decent-sized group of colleagues and senior consultants following the Dermatological World Congress in Mexico City in 1977. The participants retained lasting memories and friendships within the SSDV were cemented. A further highlight was the festive spring colloquium in June 1978 in Schloss Wolfsberg in Ermatingen. An outing in 35 coaches took us via the castles of Arenenberg (and the Napoleon Museum) and Lilienberg (classical concerts) to Weinfelden, where the lord of the manor, Baron August von Fink, personally showed us his collection of paintings. However, the academic part of the colloquium in Schloss Wolfsberg was run by the big names of that time too: R. Schuppli, U.W. Schnyder, T. Hardmeier, E. Frenk,

235 Spirit and Soul of Swiss Dermatology and Venereology

L. Olmos, H. Storck and A. Krebs all gave brilliant talks, causing this event to go down in the annals of the SSDV as an all-round success. A short while ago I remembered a sentence by Michel de Montaigne: “Mortals among themselves by Turns do live, and Life’s bright Torch to the next Runner give.”1 I was privileged to celebrate my ninetieth birthday in good health this year. Looking back on my rich life as physician, father, and grandfather, as Swiss citizen and Colonel (Oberst) in the Swiss army, I am filled with gratitude and satisfaction. I would like to extend this gratitude to the SSDV, which gave me the wonderful and honourable role of President from 1976-1978, at a time when the world looked a bit different, although it wasn’t so long ago.

Paul Bigliardi

1 The Essays of Michael Seigneur de Montaigne, 7th ed. Translated into English. Ballard, London 1759.

236 1975-1978

Figure 1. Dr. Bigliardi sen. and the daughter of Prof. Storck

Figure 2. Spring Colloquium 1978: Dr. Bigliardi sen. and his wife in the leading coach

237 Spirit and Soul of Swiss Dermatology and Venereology

Figure 3. Spring colloquium 1978: Prof. Krebs and his wife

Figure 4. Spring colloquium 1978: Prof. Schuppli and his wife

238 1981-1984

A President from 30 years ago. Un presidente di trent’anni fa

Now that I have been invited to return to my memories of the time when I was President of the Swiss Society of Dermatology and Venereology, I have found that not a single document from that time remains in the boxes of files in my practice. 30 years ago I was very active in many areas of my life – career, politics, the military, sport, society – which forced me, from time to time, to throw away old files and make room for current issues. I am therefore not in a position to chronicle all of the details of my time as President of the Society accurately. If I were to begin to list people, I would surely forget one or other of those who supported me with advice and deeds and their friendship, which I would find very unpleasant. Nevertheless, I would like to attempt to reconstruct the style that was expected of a former President. I am consciously using these words, because thanks to the events of recent years we live in a completely different world today than we did then. How could the President of a specialist association even survive back then without a fax, computer, email and mobile phone? Our professional world was not affected by the breathtaking advances of modern science and modern dermatology, but it was also free of the corset of over-regulation and bureaucratic in(ter)ventions which afflict our modern society, and constitutes the majority of the workload for the President of a specialist association today. In my time, the colleagues in the clinic and in free practice actually did feel much independent, and were not suffocated by

239 Spirit and Soul of Swiss Dermatology and Venereology thousands of rules and regulations. I do not dare list all of the state controls and constraints which infiltrate our professional lives on all levels and make life unnecessarily difficult. The list alone would fill a number of pages. You all know exactly what I am talking about. Of course all of the rules make sense on some level, but I cannot escape the feeling that in some respects we have lost all sense of proportion. All of the commissions, controlling organs, the specific rules and the proliferation of working groups for new specialties and sub-specialties have caused us to lose sight of the big picture. And all of the rules and restrictions, some of which we are not totally convinced by, rob us of our sense of initiative and responsibility. It would therefore be easy to talk today of the “good old days,” when the President of a specialist association wrote to the board once or twice a year, could leave the clinics in peace and called a board meeting twice a year – on the occasion of the spring colloquium and the annual general meeting in the autumn. Only once was it necessary to call an extraordinary general meeting in the whole of my time as President – of course it was held in the “Schweizerhof” in Bern, and of course everyone paid their own travel expenses – in order to discuss the recommendations for the clinical use of retinoids, if I recall rightly. In those days we all profited from the professional freedom in the clinic, in practice and in the cantonal medical societies, and the duties of a President were more the writing of a greeting for the foreword of the congress programme or preparing a dignified and entertaining talk for one of the then very important Society banquets. The experiences I most enjoyed and appreciated were perhaps the opportunities to represent our Society on a national and international level, from which innumerable friendly contacts with diverse personalities within our wonderful and fascinating specialty developed.

Rodolfo Mazzi

240 1987-1990

Memories of a young President of the SSDV (1987-1990)

Writing this chapter, remembering and consigning those memories to the archives… What a refreshing exercise! Doing so took me back 25 years, to when I was only 39 years old. Indeed, I was given the privilege of presiding over the SSDV at an unusual age. To my great advantage I had the drive and the audacity of youth. According to the new statutes of the SSDV, this committee comprised the 5 heads of university departments of dermatology, one director of a cantonal clinic and 7 practitioners. The President of the SSDV had three-year tenure at that time, which was a heavy responsibility without any form of allowance such as secretarial support or general help. The President even paid all of the expenses related to the mandate, including postage stamps! The next few lines constitute a synthesis of the time period mentioned above, focusing solely on the main events. May the reader judge this past him-/herself!

1. Under the reign of the FMH 1.1. FMH in dermatology When I was elected President of the SSDV in 1987, I was immediately asked by the Swiss Medical Association (FMH) to submit a postgraduate education programme in dermatology within quite a short time (less than one year).

241 Spirit and Soul of Swiss Dermatology and Venereology

I was surprised by this mandatory requirement, but also to discover that several written promises had been made by some of my predecessors, who had not even begun to write such a programme. At the time, the title of Specialist in Dermatology was accorded on recommendation from the Professor after several years of dermatology training (initially at least 3 years, thereafter 4). In addition, candidates had to take a radiotherapy course and practise radiotherapy for three months. A small taskforce composed of Professors U.W. Schnyder and T. Rufli, Doctors François Favre, and Fluck (a delegate of the FMH) and myself met several times in Bienne in order to draw up a draft. The main challenge was clearly the great diversity of the dermatology traditions of the 5 university departments. Indeed, the Swiss-German part of the country was largely involved in allergology and phlebology, whereas the Swiss-French part had stronger interests in dermatosurgery and mycology. Therefore a common ground had to be found for all the clinics, and this was for the two following reasons: – On the one hand, saving the different fields of dermatology, such as dermatosurgery, allergology, histopathology, phlebology, venereology, mycology, or andrology was a priority. Indeed, the FMH programme was the right opportunity for us to demonstrate the scope of our speciality. – On the other hand, the 5 university clinics had to be recognised as full education centres, even though not all of the subspecialties of dermatology were practised in each. This ineluctable trade-off was cleverly solved. We defined 9 dermatology subspecialties and it was decided that each clinic would have to teach at least 6 of these subspecialties in the FMH framework. This solution had numerous advantages. Firstly, it became possible to explain the broad scope of the abilities of the dermatologist to the other specialties. Secondly, each academic clinic kept its pride. Lastly, a common doctrine was established. Our project was quickly accepted by the FMH secretariat, only requiring minor amendments. However, acceptance by the Medical Chamber was more difficult. General and plastic surgeons were thoroughly opposed to dermatosurgery, particularly with regard to elementary procedures such as ingrown-nail surgery…

242 1987-1990

Negotiations followed and two hard-talk sessions in Bern were needed to see our project accepted without any modifications! This FMH programme has since been revised, unfortunately without always maintaining the subtleties that would allow for an efficient defence of our specialty. The 4 initiators of this newly created FMH course have wonderful memories of this time period, during which they became good friends.

1.2. Conflicts about the FMH subspecialty allergology A large number of appeals followed the refusal of the FMH to award many dermatologists this new subspecialty. We supported these appeals, often successfully, thanks to the commitment of Dr. Walter Kuhn, who kindly devoted a lot of his energy to this cause. We found that the devil is in the details, especially in transitory dispositions and tried (in vain) to avoid such events in regard to the subspecialty of angiology.

1.3. The FMH subspecialty of angiology After long discussions, and despite the reluctance of some major vascular specialists, the SSDV succeeded in joining the project created by the Swiss Societies of Angiology (SSA) and Phlebology (SSP) since 1985. It was then decided that the subspecialty could be awarded to internists and dermatologists who had a suitable complementary education in angiology. The transitory dispositions had been considered in-depth, yet they had been simplified and altered so much by the FMH authorities that the title was also given to practitioners and hospital- based dermatologists with poor phlebology skills. This did not give us much credibility in the eyes of the angiologists, creating further issues. Subsequent revisions to the programme (at the time the subtitle became a main FMH specialty) therefore penalised dermatologists, and access to the programme consequently became rather difficult for our members.

1.4. Tarmed Even though Tarmed was not the word initially used, the idea of a national insurance rate had already been widely discussed in Bern. Thus, our preliminary work (that is, inter-cantonal rate

243 Spirit and Soul of Swiss Dermatology and Venereology comparisons of well-defined clinical situations) proved most useful thereafter!

1.5. And so many other activities … It is worth mentioning the development of the Swiss Contact Dermatitis Research Group, enthusiastically led by Professor Nicole Hunziker (we are indebted to her, as well as to Daniel Perrenoud and Hans Suter, for the instructional leaflets for patients), the revision of the postgraduate FMH training, the attribution of professional awards, the first drafts of continuous medical education controls, aerosol regulations, the controversy regarding etretinate, the settlement of the issue of women doctors and the development of cantonal societies among others. We also regularly had to fight attempts made by the FMH to centralise our activities and to patronise medical specialties.

2. International relations

2.1. Celebrations and meetings… Swiss dermatologists have always loyally attended the meetings held by other national societies, our neighbour countries’ organisations (such as the JDP in Paris and the Munich training courses) and international gatherings (like the World Congress, the Association of the French-speaking Dermatologists, the DDG, the ADA and the AAD). It made sense for the President to regularly and officially attend such meetings. Indeed, I experienced some extraordinary privileges: representing our Society at the 100th birthday of the DDG in Munich in 1988, the French Society in Paris in 1989, and the Austrian Society in Vienna in 1990. Dermatology is nevertheless much older than 100 years. In fact, 1990 celebrated the 150th anniversary of the death of Laurent- Theodor Biett, who was the second historical Head of French Dermatology after Baron Alibert. Born in S-Chanf (Graubünden), Biett studied and lived in Paris until his death on the 13th of March 1840. He never forgot his roots and came back every year to the village where he was born, and built the Chesa Biett house there (Figure 1).

244 1987-1990

Figure 1. House of L.T. Biett in S-Chanf (Graubünden, Switzerland).

On the 9th of March 1990, a delegation of the SSDV and the French Society of Dermatology History went to the Père Lachaise cemetery in Paris to put flowers on the presumed grave of Laurent- Theodor Biett, and Gebhard Blum recited a prayer in Romansh (Figures 2 and 3). Similarly, a delegation of the SSDV and of dermatology historians went to S-Chanf to visit the house of our acclaimed predecessor on the 7th of July 1990 to remember him with dignity. These are emotional memories for our dear Society…

2.2. … And conflicts We nonetheless faced much greater issues. The European Academy of Dermatology and Venereology (EADV) was founded in October 1987 in Luxembourg. To our surprise, we discovered that only dermatologists who practised in a country of the European Community (as defined at that time) could become ordinary members of the Academy, with the respective voting and eligibility rights. Dermatologists from other European countries could only become extraordinary members, with no such rights.

245 Spirit and Soul of Swiss Dermatology and Venereology

Figure 2. Delegation of the SSDV and the French Society of Dermatology History at the entrance of the Père Lachaise cemetery in Paris (from left to right: R. Mazzi, G. Blum, S. Gilardi, U.-W. Schnyder, D. Wallach, A.A. Ramelet, G. Tilles).

We thoroughly opposed the above status because the European Community is not fully representative of Europe in terms of geography, history and culture, and consequently asked the Academy to make amendments. The EADV reluctantly revised the status, allowing dermatologists from all European countries to become full members, regardless of the European Community membership status of their country. The first congress of the EADV in Florence, which was superbly organised by Emiliano Panconesi, was consequently a celebration with no regrets and no humiliations. It could be argued that the Swiss Federal Council could somehow learn from our Society’s history…

3. The SSDV, a real family The SSDV is a family: leading it allowed us to get to know most of our colleagues. The annual spring meetings, such as the one organised by Paul Bigliardi in 1988 in Schaffhausen, helped us meet each other.

246 1987-1990

Figure 3. Presumed grave of L.T. Biett with both Societies’ remembrance flowers.

In the same vein, Henri Perroud and I organised a totally new event in June 1990 (Figure 4). It consisted of a one-week course in Leysin, covering dermatosurgery (with practical exercises) and phlebology topics. This second part was shared with angiologists as we needed to take a compulsory course in order to obtain the new FMH subtitle angiology. It was a wonderful experience. The programme was as follows: work in the mornings, group lunch, work until 3pm, then sports activities (including paragliding, tennis, golf, climbing, shooting and even jogging with an Olympic champion). Evening celebrations, conferences and various dinners followed.

247 Spirit and Soul of Swiss Dermatology and Venereology

4. Newspapers Since the SSDV was founded, fees have included membership to the international multilingual journal Dermatologica. This was considered controversial at the start of my mandate, which was the same time that the journal turned to English and was renamed Dermatology. Professor Saurat’s remarkable work gave him a great deal of influence. Nevertheless, dermatologists in private practice did not feel appropriately represented in this new approach. They did not seem to realise the advantages for the SSDV and its members. Dr. Francois Favre, one of the most outgoing characters in the history of the SSDV, had a stroke of genius. He proposed creating a Swiss supplement to Dermatology, to be named Dermatologica Helvetica. This was to be written in the Swiss languages and include summaries of articles, comments and updates from the Society among others. This journal initially replaced the short- lived SSDV Bulletin and still exists, to the delight of our members!

5. Conclusions These few lines provide a brief overview of three wonderful years of activity. I must confess it proved to be a demanding exercise, but it was also a great learning opportunity and an overall success. This was thanks to the great teamwork of a united Committee, which benefited from a friendly and entrepreneurial state of mind. After a legitimate appraisal period, the SSDV members quickly and fully supported us. Such support allowed us to properly address the main challenges that the SSDV was facing, leaving me with bright memories of the honour I was given in being its President. I am most grateful to the SSDV members and for the numerous and long-lasting friendships which resulted from those three years.

Albert-Adrien Ramelet

248 1987-1990

Figure 4. Front cover of the programme of the Leysin training course.

249

1993-1996

Having served as President of the SSDV between 1993-1996 and looking back on 35 years of private practice has given me some insight on my professional life as a dermatologist in Switzerland

The centennial jubilee is an opportunity to appreciate the accomplishments of our SSDV and to express admiration and gratitude to an organisation that has served Swiss dermatologists well over the years. The main pillars of the SSDV rest on the five Swiss university hospitals with their teaching hospitals and clinics in dermatology and venereology; they rate among the best in the world and have successfully pursued the extraordinary development in clinical and scientific research. These centres of excellence have always attracted to dermatology highly talented and ambitious physicians. They have also selected the best of them for a career in private practice throughout our country. Our patients, as well as our referring colleagues in other fields of medicine, recognise and respect our professional competence and efficiency to treat a vast array of skin conditions and sexually transmitted diseases.

What helped the SSDV to succeed in the many challenges it had to face over time were, in my opinion, the following factors: its reasonable size of a few hundred members, strong local cantonal associations, persistent bonds of friendship among the members, as well as trust and collaboration with the chairs and staff of the university hospitals, where almost all of the practising dermatologists have trained. Despite the strong individualistic character of most practising dermatologists, they identify with their

251 Spirit and Soul of Swiss Dermatology and Venereology society and do not hesitate to serve on the board and committees of their professional organisation. The SSDV had to undergo many changes to adapt to the ever- growing bureaucratic and centralising demands of the Federal Swiss Medical Society (FMH) in regards to training requirements, diplomas and certificates, and continuing medical education. It was in 1995 that the SSDV introduced the first program for the mandatory continuous medical education for dermatologists. It then amounted to a minimum of 80 credits per year. This unpopular yet sensible program was to a large part formulated by Professor E. Frenk, who held the office of Secretary of the SSDV for over 10 years, thus guaranteeing continuity and efficiency (without any compensation at that time). In 1996, the first examination to obtain the FMH diploma (board certificate) as dermatologist was organised and held at the Department of Dermatology at the University of Basle by Professor Th. Rufli. The emergence and variety of new therapeutic modalities produce groups of interest and even subspecialties with inevitable centrifugal tendencies (dermatosurgery, laser medicine, phlebology and esthetic medicine). The SSDV has always succeeded in giving them appropriate recognition and attention. Various new trends in dermatological therapies were first initiated by practising dermatologists. For instance, in 1995, a group of active dermatosurgeons (Drs. E. Kueng, W. Thuerlimann and W. Bayard) organised workshops and efficiently promoted office surgery. Consequently, they helped to firmly assert our competence and cost efficiency in treating skin tumors and in carrying out various aesthetic procedures. Laser therapy underwent a similar development and expansion during my chairmanship. In order to improve the quality of these procedures, the SSDV set up a joint committee (SALCH) composed of dermatologists, surgeons, gynecologists, ENT-specialists and other interested physicians. It organised training workshops and also issued an officially recognised certificate in laser therapy. The use of lasers is nowadays part of the standard surgical tools of dermatologists. Dr. M Adatto, a practising dermatologist in Geneva, has since shown great leadership in exploring, as well as in promoting laser therapy.

252 1993-1996

Phlebology has traditionally been an important part of the activity of many practising dermatologists. Our society has produced outstanding physicians in this field: Dr. R. Muller, who invented the ambulatory phlebectomy, and later Dr. A.A. Ramelet, who devoted much of his professional life to the study and practice of phlebology. He thus greatly contributed to the progress of this long neglected field by his scientific work and teaching. In addition, as President of the SSDV, he fought for the access and proper training of dermatologists to the wider field of angiology. Well before the introduction of a new national reimbursement scheme (TARMED) in 1998 our society was given the very challenging responsibility of defining and coding every single medical act provided by dermatologists. Many colleagues (Drs. B. Tapernoux, M. Guetling, F. Gueissaz, J.P. Gabbud, J.F. Vulliemin, F. Gilliet and M. Pletscher) invested enormous time to accomplish this most ambitious task. Their careful preliminary work, as well as constant attention by the board of the SSDV over several years, proved to be worthwhile. Swiss dermatologists continue to benefit from an above average income, even after the introduction of the national tariff. Throughout the years, the SSDV has always viewed itself as an organisation of all Swiss dermatologists-academics as well as practitioners. Therefore, the nominations of Members of the Board and of the Chairman usually respect this alternating pattern. The SSDV has consequently remained united, has showed leadership in times of uncertainties and has adapted to the ever-changing social and professional environment in Switzerland. To me, these accomplishments reflect our democratic tradition, a sense of duty and responsibility that still prevails in the culture of our country. Long live the SSDV!

Henri Perroud

253 Spirit and Soul of Swiss Dermatology and Venereology

Caption to photo 1. Cover picture (by D. Frey) of the program of the 1993 Spring Meeting of the SSDV organised in the Canton of Grisons by Drs. C. Burri, W. Frey and R. Meyrat; a scientific and recreational highlight of that year!

Caption to photo 2. H. M. Perroud at the Laufen Castle on the Rhine in the autumn of 1994, bestowed with the title and mission to serve and defend the SSDV.

254 1996-1999

The President’s View: Jean-Paul Gabbud 1996-1999

Introduction 09/09/99 in Zurich was a sunny, warm autumn day. I remember this date well, because it was the date of the last SSDV Board meeting I chaired during my SSDV presidency. I was the President of our Society from 1966 to 1999, a period of transition for the SSDV in many respects. The changes in the SSDV were part of the changes occurring in the FMH with regard to undergraduate and postgraduate training and CME- CPD (Continuing Medical Education – Continuing Professional Development). The syllabi of the specialty societies were overhauled, Board examinations were introduced, and rules established for compulsory CME-CPD. And last but not least: we created the present logo: SSDV got a new identity! The same procedures took place in other EU countries, but we can say that the Swiss medical authorities, under the leadership of the FMH, were trendsetting in many ways. I was a member of the committee of the KWFB (Institute for under- and postgraduate training) of the FMH over the next decade.

“Freedom is the recognition of necessity” (Friedrich Hegel) This was a period when many of our colleagues critically questioned the necessity of structured under- and postgraduate training, of a structured Board examination and of compulsory

255 Spirit and Soul of Swiss Dermatology and Venereology continuing medical education or, better: continuing professional development – this is the term now also being used in our national law for medical professions. It was argued that we had been given the competence to be doctors and experts in our specialty by political, professional and academic authorities. Things had been running smoothly for decades, so why should we change anything and introduce controls? We were grown-ups and knew best what we did and how we did it (but unfortunately not always why we did it). It was at this time that evidence-based medicine became a theme and the idea of guidelines came up. Many questioned whether it was really necessary to impose rules on ourselves for practising our specialty. We had “always” done things as they were and there had been no problems with doing things “as usual.” People involved in creating these new rules were, in the eyes of many of their peers, traitors accused of pre-emptive obedience. The invasive, surgical specialties such as gynaecology, surgery, plastic surgery, ophthalmology and others were the first to accept the new rules of a structured postgraduate training programme with a Board examination and with controlled CME-CPD. They had realised that the new rules were also in their interest for legal reasons. At any rate, as mentioned above, Switzerland was one of the first countries in Europe to introduce a compulsory, controlled CME- CPD in 2003.

Of Money and Science In 1987, the FMH got in touch with the representatives of the insurance companies in order to revise the medical fee structures (initially GRAT, later and still: Tarmed). The negotiations started in 1989.

The first thing to do was to define the territory of each specialty and to make a catalogue of all medical procedures included in each specialty. The first difficulties appeared because, obviously, plenty of medical procedures were performed by several specialties!

256 1996-1999

For dermatology and venereology, this concerned above all activities in dermatoallergology, dermatosurgery, dermato pathology, venereology and andrology.

The discussions that followed were almost endless, laborious and very time-consuming.

Allergology and clinical immunology had simply been a subspecialty of dermatology and venereology, internal medicine, paediatrics and otorhinolaryngology until now. When it became a full specialty in the 1990s, the question was what should happen with the specialties which had practised allergology and clinical immunology until now. The negotiations to keep this subspecialty within our curriculum led to my suggestion to change the name of our specialty to “Dermatology, Venereology and Dermatoallergology.” This was rejected by the FMH who criticised our expansive dreams!

The title of our specialty is Dermatology and Venereology, as it is in most European countries and all over the world. The exceptions are England and Ireland, where in 1916, during the First World War, due to the large prevalence and incidence of venereal diseases, Dermatovenereology was split into Dermatology and Genitourinary Medicine. We wanted to keep the status quo but the Society of Urology saw it differently. Their President attacked me in a rather cynical way with regard to private parts and which society they were considered to belong to… More or less the same happened with andrology. Another delicate issue was dermatosurgery, especially the advanced transplantation and flap techniques. The plastic surgeons wanted to deny us the right to perform such surgery without a basic curriculum in general surgery. Although these surgical procedures remained in our curriculum, the discussions lasted well into the new century!

Difficult negotiations with the pathologists regarding dermatopathology were also required. The Swiss Society of Pathology argued that, of course, dermatopathology had been de facto included in their syllabus forever. Thanks to Professor G. Burg we now have a 2-year curriculum in dermatopathology

257 Spirit and Soul of Swiss Dermatology and Venereology in our postgraduate programme. A European syllabus in dermatopathology was created in collaboration with the German (Professor H. Gollnick) and Austrian (Professor H. Kerl) dermatovenereology societies. It was obvious that besides the technical and medical demands made by our colleagues from other specialties, the “scent of money” was a motivation to restrict the others’ activities! In summary, with the strong determination to retain the integrity of dermatovenereology, we decided to include all the traditional subspecialties in our Postgraduate Programme or curriculum.

The Following Years: SSDV and Europe

In 2001, as a delegate of the SSDV, I was elected to the UEMS (Union Européenne des Médecins Spécialistes), the European organisation for professional policy. In contrast, the EADV, the European Academy of Dermatology and Venereology, is the scientific body. I was elected to be a Director of the EADV Board representing the SSDV in 2006. In the UEMS, which was founded in 1958, we were aware that our specialty could only survive in some European countries if all our subspecialities were better defined in an obligatory catalogue. Having gathered some experience in the elaboration of under- and postgraduate rules and CME-CPD in SSDV and later in the FMH, I felt motivated to cooperate on similar projects of the UEMS and EADV. In collaboration with Professor H. Gollnick’s working group, we also introduced a European Board Examination in Dermatology and Venereology, which will possibly replace our national examinations in the future. This is already the case in several medical specialties throughout Europe and in Switzerland.

The Future of Dermatovenereology

The situation and facts regarding our speciality outlined above remind us that we have to be very cautious and attentive to the future medico-political trends in Switzerland and Europe.

258 1996-1999

In Russia, for example, the dermatovenereological society is already called the “Russian Society of Dermatovenereology and Cosmetology,” and representatives of certain European countries are pushing for more corrective, aesthetic and cosmetic dermatology courses in the EADV Spring Symposia and Annual Congresses. I managed to introduce an EADV “Blueprint” for the programming committee based on the UEMS catalogue, containing the percentage of the core topics and all our subspecialties represented in an average dermatovenereological practice.

In other words, we have to be attentive not only to trends from outside, but also prevent the corrosion of dermatovenereology from the inside!

Some years ago a patient told Professor Epstein in San Francisco: “I didn’t know that dermatologists are doctors!” Let our dermatovenereological departments and private practices remain medical centres of competence for sick (and healthy) skin!

I hope to have been able to contribute at least a little to what should be the common aims of those holding responsible positions in dermatovenereology, and I am proud to have received a “Certificate of Appreciation” from ILDS in Seoul in 2011 for my humble efforts.

Jean-Paul Gabbud

259

1999-2002

Renato G. Panizzon, President of the Swiss Society of Dermatology and Venereology (SSDV) 1999 to 2002

1999 At the General Assembly of the SSDV in Zurich I was elected President of the Society. The Committee and the Society had already been perfectly organised by my predecessor, Dr. Jean- Paul Gabbud and his secretary Prof. Alfred Eichmann. For the first time the President was paid. I used this money to pay my department secretary for the extra time she needed for all the paperwork. As President, I introduced the “President’s Page” to the Society’s journal Dermatologica Helvetica: my first article ended with a quote from H. Wildbolz: “Indebted to tradition, open to change, but always committed to the community.” The topics which occupied our Society at that time were, for example, the dermatologist’s prize settlements, “Tarmed,” the certificate for the subspecialty “Phlebology,” and the position of cosmetic dermatology (a topic already discussed in our Society in 1952 and 1958!). In 1999 a working group called “Dermatopathology” was initiated in order to finalise a certificate with the general pathologists. The Society’s homepage was initiated in the same year, and two new working groups were founded, i.e. “Trichology” (Professor R. Trüeb) and “Andrology” (Dr. C. Sigg). A quality

261 Spirit and Soul of Swiss Dermatology and Venereology control group “Dermato-Mycology” (Dr. F. Baudraz) was also started. For the first time credit points were given for postgraduate meetings. And finally, the department chairs had their first reunion and discussed in English!

2000

The topics of the “President’s Page” during that year were quality management in dermato-mycology, UV passports, melanoma guidelines, lasers used by technicians, and prescription formulary of topical agents and orphan drugs. The Society founded a media commission, and participated for the first time with a regular annual co-sponsoring of the “Regional Dermatology Training Centre” in Moshi/Tanzania, a centre with which the Department in Zurich had collaborated before and also sent dermatologists to. Professor J.H. Saurat successfully organised the 9th EADV Congress in Geneva, with Dr. A.A. Ramelet and the President. In order to defend the position of dermatological treatment with emollients, I wrote a report and participated in an important meeting with the insurance companies. We were able to ensure reimbursement for this important treatment modality by the insurance companies. For the first time, the compulsory course “Physical Modalities in Dermatology SSDV” took place in Lausanne, having been held in Zurich for many years (since 1945), with two exceptions in Bern. From then until 2010 the course was organised alternately every two years by Zurich or Lausanne. The spring reunion was held in Locarno with the main topic “Dermatology and Flora.” The Annual SSDV Meeting took place in Basel, the main topic being “Dermatology and Internal Medicine Today” (Professor Th. Rufli), and also in Basel the Allergology Outpatient Clinic (Prof. A. Bircher) celebrated its 50th anniversary. Professors E. Frenk (Lausanne) and E.G. Jung (Mannheim) were elected honorary members of the Society.

262 1999-2002

2001 My contributions to the “President’s Page” dealt with Internet use and dermatology offices, and physical equipment (Photo-, Laser-, and Radiotherapy) in private dermatology offices and clinics. The main topics discussed by the Society were the collaboration with surgical societies, the acceptance of the German guidelines for our society, and finally the revision of the Society’s statutes. Lausanne organised the SSDV Spring Symposium on the topic of “Paediatric Dermatology” (Professor D. Hohl). The Annual SSDV Meeting was held in Geneva (Professor J. H. Saurat) with “Topical Treatment” as the main subject. Doctors J.M. Paschoud, H. Perroud and A.A. Ramelet were elected honorary members.

2002 In the “President’s Page” I mentioned the prevention campaign of the Swiss Cancer League, the national exhibition “Expo 02”, and the Society’s statutes. Among the important topics discussed by the Society was a “Blueprint” as a basis for the board examination (Dr. P. Bloch), which for the first time was eliminatory. The position of Secretary was now called Vice-President (Professor A. Eichmann). On February the 2nd, the Society held an extraordinary general meeting in Bern. The draft minutes were: Continuation of the collaboration with the surgical societies, the creation of the position of a General Secretary, and the regulation of the annual fees and contributions. All these points were carefully prepared by the President elect Dr. F. Gueissaz and fully supported by the President. After intense discussions all the points were accepted! New working groups were founded, such as “Paediatric Dermatology” (Professor D. Hohl), “Aesthetic Dermatology” (Dr. Ph. Kreyden), and “Dermatological Nursing” (Dr. M. Gütling and the President). It must also be mentioned that the course “Radiotherapy/ Radioprotection SSDV” (part of the SSDV course “Physical

263 Spirit and Soul of Swiss Dermatology and Venereology

Modalities in Dermatology”) was approved by the Swiss Health Authority, after Professors R. Dummer and R.G. Panizzon prepared the content. The course “Dermatoscopy” (Professor R. Braun) was declared compulsory by the Society. The Spring Meeting SSDV took place at the site of “Expo 02” (the Swiss National Exposition) i.e. in the “3-Lake-Area” and was organised by the Neuchâtel group of dermatologists. The Annual SSDV Meeting took place in Bern (Professor L.R. Braathen) on the subject of “Photodynamic Therapy.” The Society named Doctors F. Gilliet, Bellinzona as honorary member. At this Annual General Meeting the President came to the end of his term and wrote in his last “President’s Page” the citation modified after J. F. Kennedy: “Don’t ask what the SSDV can do for you, but rather ask what you can do for the Society.” With this in mind I gave my successor Dr. F. Gueissaz my best wishes and handed him (for the first time) the SSDV flag.

Renato Panizzon

264 2002-2005

President of the SSDV from 2002 to 2005

“Entering politics is easy. The hard part is not to miss the best moment to leave,” said a former Vaudois Councillor, Member of the Federal Parliament and Federal Councillor. His motto: “Serve and disappear” (ed. note: Jean-Pascal Delamuraz). Everything has a beginning. For me it was my nomination in 1986 by Professor Edgar Frenk, successor to Professor Jean Delacrétaz, as assistant doctor for the Department of Dermatology of the CHUV. So for 26 years, dermatology has filled my days. Passionate about my profession I just had to join the Swiss Society of Dermatology and Venereology, the SSDV! Just a few days after starting in the dermatology department I attended the 67th annual meeting of the SSDV organized by Professor Théo Rufli in Basle. I was there and I remember it very well. Since then times have changed. In 1986, mobile phones were the size of a suitcase, the Internet did not exist and the globalisation of science and medicine was unknown. When I was an assistant doctor, the SSDV was for me principally the opportunity and the privilege to present clinical cases at the annual meetings to the society members. I especially remember the Spring Symposium of 1990 organized by Dr. Albert-Adrien Ramelet. It was a unique combination of continuing medical education, interesting practical exercises, informal get-togethers and the magic of the Vaudois mountains in Leysin.

265 Spirit and Soul of Swiss Dermatology and Venereology

1991 marked the year that I started as a dermatologist in Neuchâtel. The same Dr. Albert-Adrien Ramelet, member of the Board of the EADV (European Academy of Dermatology), proposed me in 1993 as treasurer for this young academy. As the Swiss banks in those days still had the reputation of being infallible, all the members of the Board of the EADV were sure that a Swiss treasurer would guarantee a good start! It was enriching to experience the development of this European society from the inside and to participate in the successful candidature of Geneva as the host of the EADV congress in 2000, masterfully organized by Professor Jean-Hilaire Saurat. From 1993 to 2000, initiated by Professor Frenk, a new “Practitioner Forum” found its place at the annual meetings of the SSDV. This forum, chaired by Dr. Christian Sigg and myself, allowed a number of practitioners to present clinical cases or to talk about specific dermatological subjects. Later on, the Federal Health Insurance Act (KVG, LaMal) was introduced and the discussions about a new tariff structure (TarMed) began – it became an important forum for discussions about professional politics. Special highlights of these forums were the talks given by Mr. Yves Seydoux, then Spokesperson of the Swiss Health Service, and by Dr. Hans Heinrich Brunner, then President of the FMH. In light of the upcoming fundamental changes in health and economic policy, physicians in general, and dermatologists in particular, felt the need to defend their interests and to develop a vision for the future. At the 1993 annual meeting in Lausanne, I was elected as a member of the committee of the SSDV, then presided over by Dr. Henri Perroud from Fribourg. For three years, Dr. Perroud invested much of his energy into editing the nomenclature of all the actions of the dermatologist in the framework of the “GRAT,” the complete revision of the medical tariff. At that time, only very few people could imagine that one day every medical action would be tariffed in the same way throughout Switzerland. Indeed, this was the beginning of the fundamental transformation of the health system, which still continues today. It was a difficult time for the Society, and even the tradition of electing the head of a university clinic after a practitioner as the President of the Society was broken. So in 1996 a practitioner, Dr. Perroud, was followed by Dr. Jean-Paul Gabbud from Bern with Professor Alfred Eichmann from Zurich as Secretary.

266 2002-2005

In fact, who would have been better placed than a practitioner, and specifically Dr. Gabbud, to guide the Society through this time of change? A society like the SSDV has many different faces and represents sometimes widely diverging interests: first, the five university clinics represent the orientation towards research and science. Second, the Society defends the position of dermatology among the other medical specialties – mainly within the framework of FMH. And third, the Society – like a labor union – defends the interests of the practitioners. The overseeing of the continuing medical education, revision of the postgraduate training program, but mainly GRAT and the evaluation of the expenses of the medical practice (ROKO) were the principal tasks when, in 1996, I was elected into the new executive office of the SSDV committee, the “Ausschuss.” During my three years in the executive office of the SSDV, until 1999, I was able to appreciate the work of Dr. Gabbud, his vision of dermatology, as well as his engagement at a European level, first in the EUMS (European Union of Medical Specialists) and later the EADV. He added a fourth dimension to our society: The integration of Swiss dermatology into the European context. Again, his vision was providential for the future of the SSDV. Let’s recall the atmosphere in which we were living: a L’Hebdo headline, as early as 9.5.1996, “Towards a rationing of health services in Switzerland? No treatment if it’s too expensive…” The Tribune de Genève followed up on 30.3.1998, “the medical doctors are allergic to the tariff revision. Even though this tariff revision is not yet in place it already provokes great uncertainties. Medical doctors fear losing up to half of their income, their autonomy and to have less time for their patients.” Finally, on 31.8.2001 Le Temps concluded “It’s done! The FMH has signed the new Medical Tariff. While the partners finally agreed to accept it after 14 years of negotiation, the medical doctors who actually perform the medical actions announced their refusal of the TarMed.” While the Swiss physicians lived through a time of incredible concern and uncertainty, a small group, composed of Professor Panizzon, Dr. Gabbud and myself, negotiated the TarMed position “Examination by the specialist in dermatology (04.00.10).” Undeniably, this tariff position still allows the dermatologists today to invoke the specific acts/interventions of their specialty.

267 Spirit and Soul of Swiss Dermatology and Venereology

In these few short lines I have covered almost 15 years of rapid change. The world of the year 2000 was not the same as before and the SSDV had evolved with it. And when in 2001 the SSDV committee began the search for the new President from 2002, all of a sudden the parts of the puzzle fell into place and the idea of reforming the structure of the Society was born. In my view of professional politics, in order to be on equal terms with our negotiation partners from the health insurance companies, the Swiss Health Service and the FMH, the interests of a profession such as dermatology should be defended by professionals. The profession of the medical doctor is to heal disease and not to defend his specialty. It was certainly not excessive to ask for about 0.5% of the income from all of our colleagues for this purpose. With my candidature for the Presidency of the SSDV for 2002- 2005 I submitted the proposal “Reforms SSDV 2002.” This project was presented at the General Assembly in Geneva on September the 28th 2001. It provoked an extended debate and it was wisely decided to organize an extraordinary general assembly on February the 7th 2002 in Bern. The three main objectives of the reform were the creation of a General Secretariat, including the employment of a General Secretary, the compensation of the President, and hourly remuneration for the committee members. Basically, one person was to be employed permanently to take care of the Society and the 90-year-old voluntary system was given up. The consequence of these modifications was a very substantial increase of the annual membership fee from Fr 450 to Fr 1000. In this context – I will always remember it with emotion – I was elected as the President of the SSDV on Friday, November the 1st 2002 in Bern. The executive office was composed of the Vice President (a new function) Professor Alfred Eichmann from Zurich, and the past Presidents Professor Renato Panizzon from Lausanne and Dr. Jean-Paul Gabbud from Bern. Step by step the General Secretariat was established. Initially an administrative secretariat was created and we were able to engage Mrs. Monica Pongratz as administrative secretary. Over the years she developed what was to become in 2010 the General Secretariat of the SSDV.

268 2002-2005

As in every period, multiple themes were managed. The most important event was certainly the introduction of the new Medical Tariff TarMed in 2004. This enormous task had already caused lots of discussion, which still continues today in 2013. I still believe in the ideas behind the concept conceived by the then President of the FMH, Dr. Hans Heinrich Brunner. The tariff remains an innovative and flexible tool, which has provided a “dictionary” of the medical interventions of Swiss doctors and has allowed the Swiss health system to survive the exploding health costs of recent years much better than many other countries! Next, the statutes were revised, including the mandates of the committee members, which were reduced from three to two years but with the option of reelection, and a newly initiated postgraduate training program. This work raised the awareness of the Society for the diversity of the dermatology sub-specialties and the difficulty of providing training in all of those fields in all postgraduate training centers. The members of the Society also experienced the first certification of their continuing medical education during this period. Information and communication were a permanent issue. The Internet site www.derma.ch continues to evolve today. The Society’s expectations with regard to the journal Dermatologica Helvetica, the scientific journal Dermatology and the publishing house Karger were redefined. The automatic subscription of all SSDV members to Dermatology ended and the current format of Dermatology Helvetica was introduced. These were the successes. But honesty requires that the failures be reported too. One of them was the demographic study “How many dermatologists are needed in Switzerland?” We defined the requirements and approached the Institute of Social and Preventive Medicine of the University of Zurich directed by Professor Felix Gutzwiler. Professor Robert Steffen started the project but for several reasons, mainly because of the expense, this study was regrettably not completed. Equally, the efforts of the SSDV to intervene responsibly in the context of the health system unfortunately had only limited success. Some examples:

269 Spirit and Soul of Swiss Dermatology and Venereology

– The reintroduction of the depot form of penicillin onto the list of pharmaceutical specialties (LS) for the treatment of syphilis. – The reimbursement of numerous products for the treatment of pediculosis. – The reintroduction of Efudix® (5 fluorouracile) onto the list of pharmaceutical specialties for the treatment of actinic keratosis. – Reimbursement for two pairs of elastic compression stockings per year for patients suffering from chronic venous insufficiency. Discussions about a tariff for services not covered in the Federal Health Insurance Act (KVG, LaMal) based on the German “IGEL” (individuelle Gesundheitsleistung) remained in draft stage. This discussion was aimed at activities of the dermatologist which are not covered by the gigantic catalogue of reimbursable services according to KGV/LaMal. In the same mode, I also have to talk about a debate we tried to initiate regarding the responsibility of trained dermatologists to actually practice in dermatology at least part of the time. In fact, we were concerned that some colleagues, once they finished their training, would only practice in aesthetic medicine. This was a very delicate topic. At that time, it was not yet a topic in the university clinics and it remained a great taboo during the meetings of the committee. It is well known that we grow as much through our failures as our successes. The three years of Presidency were an extraordinary personal experience. I appreciated the intense collaboration with my different colleagues and the permanent support of Professors Alfred Eichmann, Peter Itin and Renato Panizzon. I owe special thanks to Dr. Jean-Paul Gabbud. He skillfully moderated my enthusiasm, helped me to improve my undertakings and always encouraged me. Thanks to the dedication of these outstanding personalities, the extraordinary General Assembly organized on June the 11th 2005 in Bern approved the outcome of the reforms started in 2002 and agreed to continue in the same direction. The three years of my Presidency were full of positive encounters and constructive relationships, in spite of two isolated incidents, which still mark me today.

270 2002-2005

After ten years, now that I am retired from the politics of our profession, I ask myself if I accomplished what needed to be done. Certainly not! More should have been done and better! I will always untiringly strive to improve the situation of physicians. Nevertheless, I have contributed a little piece of the puzzle and this is what counts most. My credo is still the same: All of us have many great ideas but in a voluntary system we often lack the time and perseverance to put them into practice. Volunteering is a special and valuable concept, but we should supplement it with appropriate operational resources to become effective. Defending the interests of our profession in the period in which we live is a permanent challenge. I am still skeptical whether the physicians have all the necessary tools in place to be a principal actor in the big debate regarding tomorrow’s health system. There are two more unique events which stand out for me in the period 2002-2005. First, the SSDV Spring colloquium 2002, organized by the Groupement des dermatologues de Neuchâtel et environs (GDNE) in five parts on theArteplages Bienne, Neuchâtel, Morat and Yverdon of Expo.02, the Swiss National Exhibition held in 2002, was a memorable experience for all the colleagues. All the participants will remember how Mr. Laurent Geninasca from Neuchâtel, one of the three initiators of Expo.02, talked about “How Expo.02 was born in the region of the three lakes,” and Professor Eduard Grosshans from Strasbourg’s keynote talk entitled “Dermatology, nature and artifice,” a very philosophical reference to one of the main themes of Expo.02. The second exceptional event was the celebration in 2004 of the 90th anniversary of the SSDV (March 24, 2003). Professor Edgar Frenk edited an anniversary book on the history of dermatology and venereology in Switzerland published by Alphil. The challenge, engagement and successes gave me a deep satisfaction and were a great motivation to work for what I thought to be the best for our Society. Therefore, I would like to conclude by expressing my profound gratitude to all the members of the SSDV. Felix Gueissaz

271

2005-2007

The President’s view, Peter Itin, 2005-2007

I had the honour and the pleasure of being President of the Swiss Society of Dermatology and Venereology (SSDV/SGDV) in the period from 2005 to 2007. For me this was a very interesting time because previously I had not spent very much time concerning myself with the political issues of our Society. Therefore I was highly challenged and I had to work on numerous extremely important projects for our Society. During this period, the final revision of the curriculum for dermatology was just in the process of being approved. This major revision had resulted in numerous discussions and controversies. On the one hand it was important that the dermatology curriculum also provided specific education in allergology, dermatohistopathology, dermatosurgery, angiology and other topics most relevant for daily practice. Only with this documentation could we ensure that dermatologists would be compensated for their work in the future. On the other hand, creating such a diverse curriculum meant that the university hospitals had to be prepared to provide a very broad education, which was and still is a challenge. On the 3rd of December 2005 I was present at the founding meeting, when the Swiss Society of Dermatology and Venereology was accepted into the FMCH. This step meant that dermatologists were committed to dermatosurgery, which in fact gave an important stimulus to our Society. In Basel a new dermatosurgeon was hired from Germany and since then the level of dermatosurgery in Basel has increased remarkably.

273 Spirit and Soul of Swiss Dermatology and Venereology

At the same time the communication strategy for the Swiss Society of Dermatology and Venereology was redesigned. The printed communication organ switched from Karger, which was too expensive for the SSDV, to another publisher under the direction of Professor Jean-Hilaire Saurat. The new communication organ was again called Dermatologica Helvetica and still works very well. This change saved the SSDV a significant amount of money, and it still receives an annual fee from Dermatologica Helvetica. In 2005 the Society decided to have a fixed Secretary in Neuchatel and stopped the practice of changing the Secretary with the President. This was an important step and brought a marked improvement in quality and continuity for the different affairs of the SSDV. Monica Pongratz fulfils the role in an extremely efficient and friendly way, and the SSDV can be glad that she continues this work. Within the communication project, direction of the website changed from Karger AG to Vahid Djamei and Monica Pongratz, and under these new leaders the website is consistently updated and current. During the period from 2005 to 2007 a forum was founded for political topics; this idea was promoted by Dr. Grillet. Nowadays, the political forum gets a slot for a talk at the annual general meeting of the Swiss Society of Dermatology and Venereology. In 2006, with Dr. J.P. Grillet as President, DermArena started with new software (Adobe connect), which greatly improved image and sound quality. Vahid Djamei made an enormous effort to get this project up and running. It is now free for all Society members and a transmission is organised almost every month, along with a regular part of the continuous medical education. Other topics dealt with in 2005: The SSDV historical archive: The SSDV has numerous important documents which had been stored unprofessionally. The Medical History Department of the University of Zurich was interested in cooperating with PD Dr. Geiges from the Department of Dermatology in Zurich to organise the SSDV archive. All the papers were transferred from the Stadtspital Triemli to the Institute for Medical History in Zurich. This was an effective preparation for our Society’s centennial celebration. SSDV and the election of new chairs at the university hospitals in Switzerland: In the period from 2005 to 2007 new chairs were elected in Basel, Zurich and Bern: Professor Rufli was followed by

274 2005-2007

Professor Itin, Professor Burg by Professor French, and Professor Braathen was succeeded by Professor Borradori. In the period from 2005 to 2007 the subject of Critical Incidence Reporting was discussed and also introduced with the aim of making a quality improvement. However, this SSDV database was not used very consistently. In the meantime, all hospitals have installed their own CIRS database, so that at least the hospital-affiliated dermatologists enter their CIRS cases directly into the hospital database. During my presidency I had several disputes with the pathologists in order to get our curriculum for dermatopathology accepted. My successor Dr. Hofer was able to finalise the process. In 2006 I had to defend systemic retinoid therapy on TV (Rundschau), because some emotional press were focusing on the issue of depression as a possible adverse effect. I was able to state that although such a reaction rarely occurs, retinoid therapy for acne will prevent many more suicides than it will induce. In 2006 Professor Schnyder sponsored the Schnyder Poster Prize, with the aim of promoting research on genodermatoses in Switzerland. This prize is announced at the SSDV annual general meeting and includes SFR 5,000 for the winner.

Peter Itin

275

2007-2009

The President’s view: 2007-2009

My report will not comprise a detailed account of my activities as president. It should rather display information about me; how I structured my time in office, how I experienced it, and how I remember it. Back then I had been in private practice for many years. The first years were dedicated to its development and financial consolidation. There followed a time during which I was intensively involved in publicising the everyday observations of a dermatologist in private practice to a wider audience of specialists. I drafted contributions to health-political issues, mainly concerning a critical discussion of the planned, countrywide introduction of Managed Care in Switzerland. It was a complete surprise for me when I was then approached by the SSDV (Swiss Society for Dermatology and Venereology), inquiring if I would be willing to be President of their Society for a limited time, concurrent to my work as a practising dermatologist. What an honor, was my first thought, and then: what a challenge, if I should accept! In spite of encouragement from family and patients, (self-?) doubts and eagerness for appreciative recognition conflicted while I pondered my own worthiness.

Of all the places in Switzerland, what a coincidence that I was elected for the duties of the future President of the SSDV in the region where I had suffered the greatest injury to my self-esteem on my path to becoming a dermatologist (“You are not part of my staff, you are simply expendable material,” a previous director had

277 Spirit and Soul of Swiss Dermatology and Venereology once thrown in my face). Thus, I remained contemplative on the issue. It was my lack of competence in the French language, though, that provided sleepless nights after my election to the Presidency. I quickly decided to participate in a two-week French language immersion course in Tours.1 Since then I have weekly one-hour conversations with my French teacher via Skype, which have served their purpose well. Thus it came as no surprise that one of my first acts in office was in the interest of maintaining Swiss multilingualism during SSDV educational events. This was in danger of being sacrificed in lieu of use of (poor) English, following global trends without further reflection. A survey among practising dermatologists in Switzerland, with a participation rate of 84%, showed that 91% were against such a trend! Thus it became clear that from then on Swiss speakers would present their contributions in their own mother tongue and therefore in one of the Swiss languages. My term of office coincided with an era of generational change at the level of the medical directors of our university dermatological clinics. In Basel Professor Peter Iten had just replaced Professor Theo Rufli, in Zürich Professor Lars Frech followed Professor Günter Burg, and in Berne Professor Luca Borradori took the place of Professor Lasse Braathen. The resulting dynamics were inspiring for all who dealt with the SSDV. In addition to the already existing diverse working groups within the SSDV, which by definition were deeply absorbed in the various subspecialties and problem areas of our specialty, further groups were established, such as the AG Transplantation,2 the Swiss Group for Esthetic Dermatology and Skin Care (SGEDS), the AG Dermatoradiotherapie,3 and the AG Dermatoallergologie.4 The introduction of Tarmed in 2004, a Swiss-wide valid tariff regulating the reimbursement of physician outpatient services by cost carriers (e.g., insurance companies), brought with it the incontestably positive fact that dermatology had been included in the group of surgical societies. Our continuing education

1 France. 2 Working group transplantation. 3 Working group dermatoradiotherapy. 4 Working group dermato allergology.

278 2007-2009 was correspondingly revised and the training facilities in the universities expanded the necessary staff and spatial capacities to meet the educational requirements. Thus, looming turf wars with plastic or facial surgeons were successfully avoided. A negative impact, however, was that dermatopathology was under threat of being removed from our field of specialty. All the greater was the relief, when on January 1 2009 Schwerpunkt Dermatpathologie5 was implemented. This provided structure to dermatopathology education and added additional significance to our field of specialty. Regarding phlebology, which had been “stolen” from dermatologists as a compensatable rendered service by the introduction of Tarmed, it was possible to recover some ground in tough arguments with the angiologists. The tariff service of the FMH (Swiss Medical Association) itself was briefly the source of considerable consternation among dermatologists because they planned a recertification of our practice operating rooms. This would have caused unnecessary difficulties and stress for dermatosurgery, which is primarily performed on an outpatient basis. After persistent intervention by the SSDV, the FMH was finally convinced of the senselessness of this measure. One topic of health politics that proved to be a long-term issue was the “Managed Care Proposal,” which intended to restrict free, direct access of the Swiss population to dermatologists by enforcing financial reimbursement sanctions. Luckily, the proposition was overruled by a clear majority in a referendum by the Swiss population on June 17 2012. The burden of work as President of the SSDV corresponded to about a third of a full workload. A lot of routine work was cleared by intensive e-mail correspondence with the General Secretary Ms. Monica Pongratz, often even concurrent with consultation hours, or by regularly-held dialogues via Skype, these most often during lunch over an enjoyable plate of sausage and cheese salad or some other delicacy. Deeper reflection occurred on the bike- ride to work, while horse riding, or in the evening after dinner at the computer with a glass of wine, from where a large part of the written documentation resulted.

5 Subspecialty dermatopathology.

279 Spirit and Soul of Swiss Dermatology and Venereology

The work never felt burdensome. I remained confident that my efforts would continue to be appreciated and supported by all those involved with me and this helped sustain my motivation. The feeling of comforting support in the innermost circle of a primarily scientifically and medically, and therefore not politically, defined group of physicians with the welfare of their own medical specialty, and thus the welfare of their patients, as its undivided goal remains overwhelming. I was affected by and concerned about the health politics of our confederate nation as well as by the federal cantons, because both the training of future physicians and specialty training were being compromised by arrogant-seeming savings measures. These measures were implemented for opportunistic political reasons and are upheld to this day with the consequence that only about a third of the young people wishing to study medicine in Switzerland are even granted access, while 40% of the physicians employed in hospitals in Switzerland are from foreign countries. The CEO of one large hospital, driven by economic zealousness, went as far as mandating that only fully specialised dermatologists (who are recruited, of course, from the surrounding EU-regions), be employed in the dermatological department of his hospital in an attempt to optimise revenue. Only after being threatened with the loss of accreditation of his hospital as a teaching hospital should he continue to refuse to employ residents in training, did he sway from this approach. The two years of my presidency ended at the General Assembly of September 4, 2009. It was an enriching time and I continue to hold dearly all the intensive and new personal contacts that ensued while I held that office. As President, I was “forced” to attend all official occasions, and now and then to give a short speech. I did this with pleasure and always tried to provide a humourous note to my conversational topics, which to my knowledge was appreciated by those compelled to listen. And last but not least: I never would have dreamt that on the occasion of a gala event in Lausanne I would get to hold the presiding Miss Switzerland in my arms for a short moment…. I am happy to return to the back row again; a place where I always felt at home and where my new challenge beckons: learning how to play music on my newly acquired french horn!

280 2007-2009

I hope that through my activities I was able to make a beneficial contribution to the Society. Perhaps some expected more, less or something different from me. In these cases I can only say: Luckily the term of office only lasts 2 years.

Thomas Hofer

281

2009-2011

Dr. Jean-Pierre Grillet Past-President

Presidency of the SSDV 2009 to 2011

It was August the 31st 2008, 3pm and I was walking the streets of Zermatt with friends in beautiful weather. We had gathered there to celebrate one’s 50th birthday. That’s when the President of the SSDV, Tom Hofer, called to tell me that the committee had proposed me as future President. I asked Tom for a few hours of reflection… On the one hand, after more than 10 years in the committee and as an honorary member of the Society, I wanted to

283 Spirit and Soul of Swiss Dermatology and Venereology step back and get some distance; on the other, I was very touched by the trust my colleagues and friends put in me. While the position of President has never been a goal for me in itself, the idea of being “in command” for once pleased me. Finally, I gave in to my desire to experience new challenges. Not everyone gets the unique chance to lead a society growing to over 500 members in their career and I accepted. My trepidation about what awaited me during these two years was attenuated by the promises made by my wife (for whom it was also a sacrifice), by my colleagues in the committee, and especially those from the executive office, and most importantly by our secretary, Ms. Monica Pongratz, who promised to stay on board. Thus, I could fully count on the unwavering assistance of my close friends André Skaria, Carlo Mainetti and Peter Bloch and the permanent support from Tom Hofer, Jürg Hafner and Lars French, all of whom I thank wholeheartedly. It cannot be the aim here to report everything that happened during those two years, one can easily consult the minutes of the general assemblies. I shall, however, comment on some of the events from my point of view and highlight some significant moments.

Firstly, it was extremely pleasant to take over from a colleague I had always held in the highest esteem, and with whom I share the same sensitivity and in general the same points of view. This allowed me to continue in the same style. In fact, I had the same feeling in handing over the presidency to Professor Jürg Hafner. While coming from academia he still represents the same vision and was able to turn ideas into reality that I had lacked the time to carry out. As I’m not blessed with the talents of my predecessors like Albert-Adrien Ramelet or Félix Gueissaz, I didn’t aim for great reforms. No, I just wanted to guide the Society well, provide the resources for it to operate smoothly, and give it its place among the other specialties, all the while defending medicine in the service of the patient in the political arena. It was therefore a great pleasure to promote Ms. Monica Pongratz from Secretary to General Secretary and increase the employment rate of the General Secretariat. In fact, “Monica” has progressively become the heart and soul of our SSDV. She fulfills her role perfectly, with intelligence, and by contributing exactly the right amount of advice. She is a capital ally for the President.

284 2009-2011

This is the occasion to note the extreme increase in administrative processes which societies have been forced to take on in recent years. The various requirements and directives for control and administration have grown exponentially. Like his predecessors, Jean-Paul Gabbud took on the Presidency and the Secretariat with his wife in 1996. Today, 15 years later, this would be impossible: the Secretariat processes more than 40 emails per day, numerous letters, phone calls and faxes etc. The SSDV now maintains a secretariat with two permanent positions (equivalent to 150% full- time posts).

285 Spirit and Soul of Swiss Dermatology and Venereology

An amusing anecdote: When I joined the committee of the SSDV in the same year as Jean-Paul Gabbud, I gave a small speech entitled “Let’s return to simplicity.” I explained that if we continued in that direction we would not have enough resources for control and administration and that nothing would be left for the provision of medical care! The start of my Presidency was marked by an important first challenge for the SSDV: We launched the “Swiss Dermatology Network for Target Therapies” (SDNTT) on September the 3rd 2009. This great idea and audacious long-term observational study brought about by Professor Saurat convinced me immediately: This registry would allow the long-term follow-up of psoriatic patients undergoing systemic treatment in the “real world.” The registry, fully in the hands of the dermatologists, creates a network among practitioners and hospital departments, sound and transparent contacts with the industry, but most of all it guarantees a high quality follow-up for the patients. Additionally – and this should not be underestimated – this registry demonstrates our competence in dermatology and immunology to other medical specialties, insurance companies and health politicians. This project is undeniable proof that the dermatologists are trustworthy medical doctors who assume their responsibilities cost-consciously. The downside of the project was the initial high cost of at least CHF 150,000 per year and we didn’t have one single franc yet! This was the first uncomfortable situation for the new President… Was it right to rush the SSDV into this venture? Based on the great experience of Professor Saurat, common sense and the trust of the colleagues in the executive office and the committee we made the right decision: To go ahead!!! This was the beginning of an enormous effort to raise the necessary funds from the industry and to obtain countless authorisations: 26 ethical committees in 26 cantons were going to comment and file requests, some of which were even contradictory. Mr. Vahid Djamei needed all his patience and perseverance to fulfill these formalities and to begin to register the patients. Meanwhile, the registry is fully operational and the number of patients is steadily growing. My next challenge was the remodeling of the websites of the Society and of dermArena. In such cases, one wants everything, and everyone has very good ideas… but it was necessary to stay on budget! Practically speaking we were trying to square the circle,

286 2009-2011 and again the support of Ms. Pongratz and Mr. Djamei was essential. Countless hours were necessary to build this website. In addition to the information for the public and for the members, it encompasses complex subsites such as dermatosurgery or dermArena. The latter has been completely restructured and continues to attract numerous colleagues for live sessions in continuing medical education over the Internet. We should also take this opportunity to mention the efforts of Professor Burg for the websites “DOIT” and “Dermokrates,” tools managed in cooperation with our German and Austrian colleagues. Both have become indispensable for continuing medical education and postgraduate training. I had been aware for several years that the heads of the university clinics did not have enough contact and shared neither their concerns nor their successes. I was convinced that the SSDV should be an institution the members could rely upon in case of “attacks” (and they occurred, such as attempts to dismantle the dermatology departments in the hospitals!). It was a pleasure, therefore, to reactivate the “committee of the heads of the university clinics” (which had existed before) – with for the most part new heads of the university clinics who had only recently been appointed. It was very good news for the SSDV that in Professor Michel Gilliet a highly reputed scientist was nominated at the Faculté de Lausanne and in the CHUV. I had the honour of introducing him to the SSDV. I remember our first meeting in Lausanne very well, which was marked by friendliness and openness. In Geneva, however, still no new head had been named, and in spite of very limited room to manoeuver, Doctor Prins managed the department as efficiently as possible ad interim. I’d like to express my gratitude to the heads of the university clinics for their support, their trust and their favourable mindset during my term of office. In fact, I knew each one of the new professors from their time as assistant doctors – all of them are younger than me! The reorganisation of medical education by the Federal Office of Public Health (FOPH) and the Swiss Institute for Medical Education had considerable repercussions. It was necessary to determine the contours of the specialty, define precisely the procedures and techniques which are part of dermatology, and prepare a catalogue of postgraduate training for dermatologists. My friend Peter Bloch put in considerable effort and a great amount of patience to complete this project successfully. He defended our specialty

287 Spirit and Soul of Swiss Dermatology and Venereology with finesse, diplomacy and resoluteness, and the SSDV owes him recognition! After this great success on a national level, we are very happy that he has agreed to continue in the executive office and to represent us internationally in the committees of the EADV and the UEMS with Professor Daniel Hohl. In my opinion, contact with international societies is essential, as all decisions taken at this level have always had an impact on the practice of our specialty in Switzerland. André Skaria, another close friend and splendid representative of our Society, defends dermatological surgery with enthusiasm and success. It’s exasperating and unacceptable to see surgery, a central discipline of dermatology, the target of violent assaults, principally by the insurance companies, based solely on criteria of cost control. Enormous energy is needed to defend this fundamental part of our activities! André not only contributes a lot to the Society with his common sense and intelligence, but he also organises seminars and conferences dedicated to dermatological surgery, such as the one for the International Society of Dermatosurgery in Lucerne in 2012, organised with Professor Hafner and the members of the working group on dermatosurgery. An unresolved cause of discontent is the deplorable handling of pharmaceuticals by Swissmedic and the FOPH. It’s inconceivable that Switzerland with its pharmaceutical industry is not able to provide adequate treatment for illnesses such as syphilis or scabies, to name but a few. So far all initiatives for change – directed at regulatory authorities and politicians – have been in vain. Even interventions in parliament were without effect and neither benzathine penicillin nor ivermectin are available in Switzerland today. In other areas, Swissmedic is overeager: While certainly conforming to European directives, their regulation concerning the sterilisation of equipment is applied nowhere else with such rigour. Again, much effort has been wasted on a procedure which, at least in Geneva, hasn’t caused a single incident over the last ten years. It is costly and doesn’t provide added value to the patients! Nevertheless: After ten years of battle with the Swiss Society of Pathology, we finally obtained accreditation for dermatological pathology, which is performed by certified dermatologists who have completed additional training.

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Tarmed was advertised as a flexible tariff, which would be easily and rapidly adjusted and take the economic situation of medical practices into account. However, as I predicted, the Tarmed system is too complex and has obstructed itself. It has deviated to such a degree that even the federal authorities have qualified it inept. Finally, none of the contracts signed by Santésuisse have been respected. While the situation of the dermatologists is not the worst, the introduction of Tarmed was nevertheless accompanied by endless administrative intricacies and a net decrease of revenue for physicians. The revision of the tariff (Tarvision) unfortunately will not improve this situation. This new episode began during my Presidency and I was grateful for the efficient support of Tom Hofer. The DRG were introduced in a great hurry. Their introduction required enormous investments of time and energy from the hospital departments. Additionally, they appear to be too rigid and entirely inflexible. In the coming years we will have ample opportunity to discover the downsides of this system, advocated by the insurance companies with the objective of increasing their profit. Unfortunately, I did not succeed in two important items during my time as President. The first was the clarification of the position of cosmetic dermatology within the Society. In fact, no other specialty is better placed to defend this theme, which is growing in importance year after year. It’s very important to handle it with exactly the same rigorous scientific approach as any other aspect of our specialty. It’s therefore essential to include this part of dermatological practice in training programmes. Slowly, this idea is gaining acceptance, and today practically all hospitals have a department for cosmetic dermatology. In addition, the Swiss Group of Esthetic Dermatology and Skin Care (SGEDS) is developing well under their President Olivier Kreyden. The other subject I did not succeed was the introduction of young colleagues in training to the life of the SSDV. It’s true they are very busy filling their logbooks with their daily activities, preparing for their specialty exams, following additional training, etc. Indeed, they have little time left to get involved in professional politics. Nevertheless, they need to understand that their professional future is decided a long time in advance and not caring about it today can have consequences for their later activity.

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Two preeminent personalities from Romandy- and French- speaking dermatology left us during my term: Professor Paul Laugier (99 years) and Professor Jean Delacrétaz (89 years). They took an important part of the living history of dermatology in the twentieth century with them. Without a doubt, the referendum against the healthcare networks was the most significant event at the end of my term. It wasa great adventure and an unforgettable experience in multiple ways! First, we won this referendum with the exceptional result of 76% of the votes! All the cantons accepted it. What a contrast to the fifteen people around a table who started it all and brought about this change, thus proving the efficiency of Swiss democracy! The decision had been made by a large majority in parliament, and it had been supported by the President Jacques de Haller (even though I addressed words of caution to him as my former fellow student), the Central Committee and the Medical Chamber of the FMH. But one had to be on guard with a system so easily accepted by the insurance companies…. In fact, this project was one of the most revealing demonstrations of the dysfunction and the self-interest pursued by the health economists. We were promised a system, magnificently disguised, which would limit costs and improve patient care. In reality, it was planned as a system which would disconnect healthcare from its real value and turn the healthcare networks into profit centres. Money would have flowed into their pockets instead of being used to provide healthcare for patients. The main risk to the healthcare networks was that the control of the entire system would have been turned over to a small minority, which was completely commercially oriented, instead of engaging in good patient care. The collection of signatures started slowly, but bit-by-bit we collected more than 130,000 (certainly almost 150,000 if those blocked by the town halls are counted) – a record! Next followed the political debate; more and more parties joined our cause and in spite of being divided, gave out the recommendation to vote “yes for the referendum.” A large majority of the citizens finally supported the referendum. In my view, this result reveals a fundamental insight: physicians have a largely underestimated and unused political power. We shouldn’t be afraid to raise our voices and defend our cause. It was my great fortune that I could count on the full support of the executive office, the committee, and most of all Jürg Hafner.

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We also opened the debate at the general assembly and the majority supported the referendum. It’s important to note the major role the fmCh played in the collection of signatures. One may regret that the fmCh was very slow to get involved. However, the fmCh is an association of societies and it can only start to act once the societies of surgeons have made their decisions, which often takes a long time…The fmCh would be well-advised to position itself more clearly in the political arena, and could be more efficient in the defense of our interests. So we experience increasing complexity, which will strangle us in a short time and render it more and more impossible to provide healthcare. Energy is wasted on controlling instead of being used for medical care. Physicians might even begin to hesitate about taking care of certain patients or providing certain treatments in order to avoid all this bureaucracy. We need to understand that the objectives pursed by the “promoters of quality” who are organising all these controls will turn out to be counterproductive. A real improvement of the health system can only be obtained by increasing efficiency and therefore by simplifying the procedures. The system cannot be improved by increasing the control of physicians after they have established their medical practice. Instead, it’s necessary to provide outstanding and exemplary basic training of the highest level in ethics and in science. This is where the skill and good habits are acquired. It’s interesting to note that the same people requesting quality improvements are denying the resources to achieve them at the same time, for example in the framework of the DRG. The mentoring of assistant doctors must absolutely be improved. We need to give them the opportunity to learn to practise superior medicine under the constant guidance of their university supervisors. Once the physicians have acquired a solid scientific and ethical basic training and the habit of participating in continuing medical education, it will no longer be necessary to execute so many controls! The requirements of the health system have also opened the door for “vultures” of many kinds – and these lead an easier life than the doctors, for much less important work. Due to Tarmed we had to invest in information technology and subscribe to many costly maintenance contracts. We also had to join multiple associations with ever-increasing costs. In short, “simplification” should be the keyword for the coming years! It will not be possible

291 Spirit and Soul of Swiss Dermatology and Venereology to impose more and more requirements on physicians and reduce their remuneration whilst salaries in the administrative sector continuously increase. Only by standing up with determination against all inadequate constraints can we command respect. We need to fight for the resources to flow into medical care instead of administration! Towards the end of my term, I realised that physicians are disrespected for their daily work, primarily by the health economists. What counts today is the short hype in the media and social networks. Our daily work, be it excising a basal-cell carcinoma of 3 cm from a cheek, or succeeding in healing a psoriatic patient or the like, is not very popular. However, every procedure and its costs are closely monitored by staff whose professional qualifications we don’t know, and who generate costs themselves (of course they don’t work for free and their costs are added to the total cost of the health system!). We live in society of mistrust, wisely orchestrated by those who profit from this situation. Finally, these controls come at a prohibitive cost. A good physician is never too expensive, even if the price may seem high. However, if this doctor fills out forms for the controls, his tariff is in any case exaggerated. The insurance companies’ lobbyists in parliament were able to slip many elements into the Federal Health Insurance Act (KVG, LaMal), which gave them total control over the health system. They cleverly avoid any control because they are judge and interested party at the same time. The policymaker should never have accepted this. Just a final word dedicated to common sense: Without itno society can function. Over the last twenty years it has been replaced by more and more laws and rules. Today we find ourselves with excesses, such as the remuneration of managers or court rulings, which cannot be understood by the common man any more. Without common sense there is no coherent or efficient medicine. Let us attempt to appreciate and reinstate common sense! My aim as President was to maintain unity in our specialty, to have a Society where everyone feels well and correctly represented, and to ensure a clear and determined defense of our dignity as dermatologists providing patients with good healthcare. I hope I have at least partially delivered on these goals.

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I cannot express my appreciation and gratitude enough for this uncommun experience first to my wife for her patience and support, then to the SSDV, its members, my colleagues and friends in the executive office and the committee, to the working groups, Mr. Vahid Djamei and of course Ms. Pongratz for their support and trust. Very special thanks go to Tom Hofer for preparing the way so well and to Jürg Hafner for keeping on going in a particularly difficult period. Long live the SSDV!

Jean-Pierre Grillet

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The President’s View

President of the association of a medical specialty – who takes on such a task? This question varies, depending on the cultural background. In some countries, one is considered crazy, in other countries, for example Anglo-Saxon cultures, those “serving” or doing a good turn are respected. I personally believe that the “return on investment” of voluntary work is generally underestimated. The rewards are largely non-material, in the form of friendship and recognition. A large part of what we consider to make sense and find satisfying in our lives has to do with just these non- material values. I can’t exactly say when the SSDV board had the crazy idea to approach me for this office, but I’m sure it was Jean-Pierre Grillet, who put the question to me and who has been a constant and friendly support throughout my time in office. It was also clear that Monica Pongratz, General Secretary and hub of the SSDV, completely supported my candidacy, and I will never forget her loyalty. A number of other characters and friends supported my start, last but not least my boss in the clinic, Lars French, who allowed me to pass on the supervision of the ward (after 18 years as consultant) to Karin Schad, an extremely experienced internist and dermatologist. Over the preceding years, my predecessors had all worked through a to-do list of excellent ideas, which were either close to completion or simply needed to be put into practice. Much of what Monica Pongratz and I implemented in my first two years in office

295 Spirit and Soul of Swiss Dermatology and Venereology was therefore already well advanced and simply needed finalising. In addition to the major focal points, a few goals soon became apparent: the general secretariat needed to be released from their extreme financial responsibility; the website (a major project by Vahid Djamei), which was almost completed, as well as the member database, needed to be fully functioning; the general secretariat needed to be relieved of constant new major “side-projects,” such as the running of complete congresses and large-scale projects, in order to be able to focus on its core tasks; and the General Secretary needed support staff who would be able to stand in for her.

Figure 1. Board of the SSDV (June 20, 2013) Behind, left to right: Peter Bloch, Carlo Mainetti, Gionata Marazza Front, left to right: Lars French, Jürg Hafner, Jean-Pierre Grillet.

Structures

The member database and the accounts and finances are the backbone of the general secretariat. The existing electronic database was built using simple software and needed constant manual updating. The exchange of data with the SSDV website, which has its own member database, was continually breaking down. In order to simplify contact with the most important healthcare partners we purchased the same software as that used by the Swiss Medical

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Association (FMH), the Swiss Institute of Medical Education (SIME) and the Swiss College of Surgeons (fmCh). At the same time, we began to actively invite all dermatologists practising in Switzerland who were not yet members of the Society to join: “Schwarzfahren ist unfair!” (“Fare evasion is unfair!”) In the years 2010-2011 the SSDV website was completely reprogrammed thanks to the efforts of the companies Netcetera (Skopje, MZD) and swiss4ward (Zurich, technical responsibility and owner Vahid Djamei). As a result, it had far more diverse functions and was more effective for dealing with the core Society business. The general secretariat was able to send members mails and newsletters directly; external visitors found all relevant information and contact details. Secure areas for members were created making it possible to upload documents in preparation for board meetings and the AGM, thus saving time-intensive postage of large envelopes and folders (except for those members without Internet access). Specialist information for dermatologists, all quality assurance documents and the CIRS (Critical Incident Reporting System) for the practice were also set up in a secure area. Direct links were set up between the SSDV core area and “Dermokrates” (comprehensive online reference source) and “Dermarena” (online live training), and also providing access to the software for the administration of the clinical cases for the dermatology specialist exam and the therapy register SDNTT (Swiss Dermatology Network for Targeted Therapies). The constant expansion of the activities of the Society in past few years, which most recently culminated in the activation of the SDNTT, led to a corresponding expansion of the annual budget. This development necessitated involving an external accounting office, which Monica Pongratz rapidly carried out in 2011. After an initial analysis the accountant recommended consolidating the numerous existing Society accounts, and from then on the SSDV had a single set of accounting records and a single bank account as a single legal entity. The account consolidation and harmonisation of the books enabled a much better overview of the finances – not least for the controlling authorities – and was one of Monica Pongratz’s major achievements in the years 2011-2013. A number of members expressed the need to focus discussions on the major issues of the future during the course of the first board meeting. In the first half of 2012 four focussed afternoon sessions

297 Spirit and Soul of Swiss Dermatology and Venereology were held at which one “hot topic” was discussed each time. In this context the organogram of the Society was updated. Up to then it had been a long and relatively confusing list of people who had been entrusted with a position. It was thus high time that the SSDV set up a proper organogram which defined responsibilities and functions independent of the individuals in office.

Continuing and further education

The trend across Europe is towards larger, concentrated continuing education days or weeks, to replace the single hours or Thursday afternoons. It was therefore obvious that the large regions (A) western Switzerland, (B) central Switzerland, Bern and north-east Switzerland and (C) Zurich and eastern Switzerland would each set up a few days of continuing education in the first half of the year. Zurich set the example, once Erich Küng, President of the Zurich Dermatological Society (Zürcher Dermatologengesellschaft, ZDG), was able to convince the newly elected professor of the Zurich University Clinic, Lars French, to join ranks. The Rencontres Romandes de Dermatologie et Vénéréologie (RRDV) were inaugurated in Geneva in 2011 shortly before Zurich, and the annual Swiss Derma Day in January in Lucerne (central Switzerland, Bern and north-east Switzerland) followed in 2012. Naturally this situation could be seen as competitive, so it was important to organise a board meeting in order to discuss the future of the major dermatological continuing education sessions in Switzerland and the possibilities for optimising coordination. The consensus reached was that the three concentrated cross- regional continuing education sessions should replace the traditionally strongly SSDV-oriented spring meeting of the SSDV, but that the SSDV AGM should continue to be hosted by the five university clinics in time-honoured fashion according to the rotation principle. It was necessary to review the cost of participation, as free attendance for SSDV members no longer corresponded to the sound modern concept of separating material interests from academic content. In this respect, the Guidelines of the Swiss Academy of Medical Sciences (Schweizerischen Akademie der Medizinischen Wissenschaften, SAMW) are valid in Switzerland.

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Focussed courses

During the specialist training for dermatology and venereology, residents must complete at least six of the eight focussed courses regularly offered within five years. They are dermatopathology, venereology, x-ray/light/laser therapy, allergology, dermatosurgery, dermoscopy, paediatric dermatology, dermatological angiology/ phlebology. When a large number of residents participated in the courses their absence in the clinics regularly caused noticeable delays. For this reason the board and the heads of departments had a number of meetings in order to work out a schedule for the next few years which would enable the young dermatologists to complete their training courses without difficulty.

Electronic platform of the SIME

From 2011-2013 the Swiss Institute of Medical Education (SIME; Schweizerisches Institut für Weiter- und Fortbildung, SIWF) established an electronic platform which enables all Swiss specialists to enter the credit points for the training courses they have attended, and thus manage their recertification independently and earn their continuing education diploma after three years. This tool minimises the administrative work of the specialist societies and the SIME with regard to recertification.

Tariff

After a preparation phase of several years (2007-2011), the flat rate per case system (SwissDRG) for inpatients was introduced in January 2012. The first year was relatively uncomplicated for the five Swiss dermatological university clinics. However, an unpopular cut is planned, of the flat rate for the DRG J61C (complex dermatological treatment), against which the dermatological clinics have registered their opposition. The first major revision (“Tarivision”) of the outpatient tariff system “Tarmed” was performed in 2012-2013 by the FMH tariff office in cooperation with the specialist societies. The system has been operating for 10 years, and until now revision has been minimal because of the rule that all four tariff partners must agree.

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This is also an opportunity to reorganise tariff sections which dermatology shares with other disciplines. These include allergological skin tests, and both prick and epicutaneous tests.

Quality Almost all Swiss physicians agree that quality assurance in medicine is a job for physicians. Valid and very large registers have existed for over 20 years in surgery, obstetrics and gynaecology, anaesthesia and intensive care medicine. These include the prosthetics register of the Maurice Muller Institute, the working group Quality in Surgery (AQC), and specific registries for quality assurance in the disciplines of obstetrics and gynaecology, anaesthesia and intensive care medicine. Nevertheless, the subject has been the focus of attention in politics in the last few years and a Swiss office for quality in medicine is planned within the Department of Internal Affairs. In the eyes of the physicians, it would make much more sense to utilise the available data and to support and expand the existing registers. Under the guidance of the Swiss Medical Association, FMH, Swiss physicians founded the independent Swiss Institute for Quality in Medicine (Schweizerische Institut für Qualität in der Medizin, SAQM) in autumn 2012. The SSDV was not inactive in the face of these warning signs. The founding of the Swiss Dermatology Network for Targeted Therapies (SDNTT), planned initially as a registry of biologics used in Switzerland for the treatment of inflammatory skin disorders, was a major step. It would, however, be possible to expand the registry and use it for all other indications. Data exchange with the German PsoBest registry (CVderm – Competenzzentrum Versorgungsforschung in der Dermatologie; Centre of Excellence for Health Services Research in Dermatology), which is ten times the size, is planned and technically simple to realise. Carpe is the second diagnosis registry, and was created in 2011 for the diagnosis of chronic hyperkeratotic hand eczema. Under the umbrella of Patient Safety Switzerland and the fmCh, the interventional specialist societies have committed themselves to comply with the “Safe surgery saves lives” SOPs of the WHO. These guidelines are naturally valid for the SSDV. Further projects are planned relating, for example, to margin controlled skin cancer surgery and other subjects.

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Psoriasis Day The annual Psoriasis Day (Psoriasistag) was initiated at the time of the successful operational start of the SDNTT registry. Monica Pongratz organised the première alone in 2011, for which all were very grateful. Psoriasis Day is now rotated through the clinics, which have also taken over full responsibility for organising it. At this meeting experts share their experiences in the use of biologics and create the latest guidelines for the clinical application of newly introduced substances or for therapy adjustments.

Skin Cancer Day To begin with, National Skin Cancer Day was carried out for a number of years in successful cooperation with the Swiss Cancer League (Krebsliga Schweiz). In most western countries skin cancer day is known as “Melanoma Day” or “Melanoma Monday,” respectively. The aim is to increase awareness in order to support early diagnosis and prevent serious harm. Screening of index lesions which the patients had noticed themselves made up the core of the action. In addition, the Swiss Cancer League operated a skin cancer bus for mobile examinations in the community for many years. If a suspicious skin lesion was found on examination by the dermatologist, the concerned person was counselled on where and how she/he could get the suspicious lesion removed. Secondly, every person checked received oral and written information on the importance of protection against the sun, particularly for children (primary skin cancer prevention) and on self-control of the entire skin surface on a regular basis (secondary skin cancer prevention). The Cancer League changed its strategy in 2012 from secondary prevention to direct primary prevention (the campaign “Stay in the shade” – “Am Schatten bleiben”). The old form of cooperation with the SSDV was cancelled from their side. In order to remain internationally compatible and continue the sensible campaign of raising skin cancer awareness, the SSDV took over the complete organisation of National Skin Cancer Day. Again, Monica Pongratz alone was responsible for the première in 2012. From 2013 she was supported by Ms. Ruth Barbézat, who had previously worked for the Cancer League. Monica Pongratz again deserves extra thanks from the SSDV for her wonderful work.

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Managed care bill: referendum and vote on 17.06.2012

After seven years of preliminary consultations, in which the Swiss Medical Association (FMH) was involved for years, the Swiss parliament decided to pass the so-called “managed care bill” in autumn 2012. The gist of the bill is that in Switzerland one is free to choose one’s own physician except for those people who voluntarily take part in the managed care model of a health insurance company. This is currently about 35% of the population. Parliament, however, hoped that as many people as possible would sign up for a defined “physician network” of general practitioners and specialists and planned strong financial support for this health insurance model. The networks would have had the responsibility for the budget and therefore a strong motivation to save it. Three cantonal physician’s associations and three specialist societies initially opposed this bill. In a ballot, a large majority (against the recommendation of their board) voted to hold a referendum about the planned bill. Instead of the required 50,000, Swiss physicians collected 132,000 certified signatures within 100 days! On June the 17th 2012 the bill was very clearly rejected by a 76% majority of the Swiss population. The main arguments were that the majority didn’t want to give up their free choice of physician, that the practical implementation of the bill was unclear and that it wasn’t at all clear whether the bill would effectively reduce healthcare costs. What was clear was that the implementation of the bill would have been very complex, there would have been a great deal of unnecessary switching of health insurance companies, the bill would have been used as a powerful one-sided instrument against the physicians, both GPs and specialists, and it would have exerted a strong and unwelcome influence on medical practice and led to an arbitrary rationing of medical services. All in all it is likely that patients would have suffered a relative worsening of what is currently a very good situation. The savings – assuming there were any – would have probably been expended on the development of the administrative monitoring system. This vote was surely one of the most significant political successes for the SSDV in recent years. My predecessor, Dr. Jean-Pierre Grillet, who campaigned determinedly for the referendum at the so-called “round table,” earns a special thank you here.

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Outlook A specialist society has the task of serving its members and their professional core competencies in order to provide modern medical care nationally to the fairest possible conditions for all involved. Firstly, the structures of the society have to be adapted to the multiple challenges of modern medicine and the rapidly changing conditions in health politics. The SSDV has set up an extremely well- organised general secretariat (Monica Pongratz and more recently Mrs. Barbézat) in the last few years, a comprehensive website with all the necessary functions including member information, cooperation between board and committee, specialty exam and continuing education, including the interactive electronic tools “Dermokrates” and “Dermarena” (responsible: Vahid Djamei), and the board has been reorganised into task forces able to respond to the latest challenges in modern dermatology and current health politics issues. Our specialist Society contains an incredible potential of professional and practical knowledge and skills. We just need to apply it cooperatively and cleverly. This should be our common aim, for the good of our patients and our fascinating profession.

Thanks Fulfilling the office of President is a great obligation, but also a great joy. For sure, a President must “pull the wagon,” but he is only a “Primus inter pares,” or “first among equals.” The achievements of a specialist society are always joint achievements. For this reason it is very important to me to list a number of people – without claiming to be exhaustive – who I would like to personally thank. Firstly, I would like to express my personal and heartfelt thanks to Monica Pongratz, the soul of the SSDV and the personified hub of our general secretariat. Without her huge willingness and availability for our needs the SSDV would not be what it is today. Secondly, I would like to thank the board and the committee. They are (in alphabetical order): Enrica Bianchi, Peter Bloch, Wolf- Henning Boehncke, Luca Borradori, Konstantine Buxtorf-Friedli, Lars French, Michel Gillet, Jean-Pierre Grillet, Daniel Hohl, Rosmarie Holzinger, Peter Itin, Stephan Lautenschlager, Carlo

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Mainetti, Gionata Marazza, Christian Schuster, Andreas Skaria, Elisabeth Toszeghi, Gion Tscharner. Moreover, and in the greater context of the Swiss Medical Association, I would like to express my thanks to Jürg Schlup (President of the Swiss Medical Association, FMH) and the FMH central office, to Urban Laffer (President of the Swiss College of Surgeons, fmCh), Markus Trutmann (General Secretary of the fmCh) and the fmCh crew, as well as to Werner Bauer (President of the Swiss Institute of Medical Education, SIME), and Christoph Hänggeli (General Secretary of the SIME) and the SIWF team for their indispensable support. Finally, I would like to personally thank all of our members, who express their trust in the board year after year, and thanks to their personal involvement at innumerable opportunities play their role in the success of our discipline.

Jürg Hafner

304 Secretary

SSDV – Structure and Organisation 1913-2013 The SSDV was founded in 1913 with the name Swiss Society for Dermatology and Syphilology. In 1917, the name was changed to Swiss Society for Dermatology and Venereology. The society continues to be incorporated as an association today. The association (etymology: “action of coming together,” from the Medieval Latin associationem) stands for a voluntary and durable union of persons and/or legal entities with the aim of achieving a certain purpose and which is independent from changes to its members.1

The first scientific societies – associations for the sciences or humanities – were founded in the 19th century. Their purpose was to represent their field, discuss current themes of research, and publish scientific articles. Several additional societies were founded in a second wave from the middle of the 20th century because networking amongst specialists became increasingly important.1 Establishing and nurturing solid relationships on a national and international level also became more important in dermatology. The objective of the foundation of the SSDV was to promote research and scientific exchange in the field of dermatology in Switzerland.2 It was founded shortly after neighbouring countries such as Italy,

1 Wikipedia (26.4.2013). 2 „Dermatologie in der Schweiz – ein historischer Rückblick“ Prof. E. Frenk.

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France and Germany had founded their dermatological societies. In the beginning, the SSDV mainly offered the publication of scientific articles and promoted scientific exchange at the SSDV meetings. Scientific exchange is of course the main purpose of a medical society. However, scientific exchange and communication can only occur in a society if it is based on a solid structure and organisation. Dermatology has seen fantastic advances over the last 100 years – and as a consequence, the organisation of the society has needed continuous adaptation. At the founder’s meeting in 1913 a President, a Vice President and a Secretary-treasurer were installed as the board of the society. These members of the board were elected for a one-year term. In 1932, the term of office was prolonged to three years. The main task of the board was to organise an annual conference and additional scientific meetings. The President was responsible for all operational tasks. In 1940, in addition to the board, a committee composed of the following nine members was installed: the five heads of the university clinics and four practitioners. Throughout the year they dealt with urgent matters and reported to the General Assembly. In 1987 the committee was enlarged to eight practitioners and five directors of clinics, one of whom was to be from a non- university clinic. The committee became more autonomous, in that approval by the General Assembly was only needed for those matters explicitly stated in the statutes. 1996 saw the foundation of an executive office composed of the President, the Secretary and one member of the committee. In 2003 the Vice President replaced the Secretary in the executive office and an additional clinic representative joined. In the same year, the committee was further enlarged to 16, namely five heads of university clinics, two heads of non-university clinics, eight practitioners and either the President elect or the outgoing President. Autonomous working groups have been formed since 1993, and in 2003 five permanent commissions were part of the society. In order to ensure communication, all these bodies were included into the enlarged committee, which meets once a year at the annual assembly. In 2002, President Dr. Félix Gueissaz proposed that the President and the members of the committee – who had worked on a voluntary basis until now – be compensated, and that a permanent office be created for the society. The terms of office were shortened from

306 Secretary

3 times 3 years to 3 times 2 years. In 2013 the terms will increase to 3 times 3 years again. There were no written records from the board or the committee meetings until 1966. The archive contains committee minutes from 1977, and these provide an insight into its work. Scientific papers have been published since 1913 in the Korrespondenzblatt für Schweizer Ärzte, which was replaced by the Schweizerische Medizinische Wochenschrift in 1920. According to the minutes, the members criticised the fact that the articles were published too late in the Wochenschrift and that they were too expensive. Professor Ramel’s proposal in 1940 to publish the articles in Dermatologica was contested by Professor Miescher. In the end, a typically Swiss compromise was found and the scientific papers were published in Dermatologica and the minutes continued to be published in the Schweizer Medizinische Wochenschrift. In 1945, Dermatologica became the official publication of the SSDV and from 1959 the members were even obliged to subscribe to this journal. In 1989 Dermatologica became the scientific journal Dermatology and was supplemented with Dermatologica Helvetica. The latter is still the official publication of the SSDV and is included in the membership fee. For many years both publications were produced by Karger from Basel, until the longtime editor-in-chief, Professor J.H. Saurat, offered to produce Dermatologica Helvetica in Geneva. This offer was very welcome to the SSDV, as the journal had become too expensive. The members of the SSDV have profited from the Dermatologica Helvetica being produced in Geneva for almost 10 years. Every year, editor-in-chief Professor J. H. Saurat, deputy editor-in-chief PD Dr. M. Harms, sales manager Ms. Carine Herreras, and designer Xavier Didierjean are responsible for the publication of ten issues. The content is composed of announcements for events for continuing medical education, minutes of the SSDV general assemblies, news from the society and scientific articles. Dermatologica Helvetica remains a very valuable publication as it allows all of its members to receive important information in paper form, especially today where more and more information is only available in electronic form. The structure of the society was rigorously adhered to from the beginning. Efficient organisation was necessary to ensure an equally flawless operation. Minutes needed to be written, and invitations and additional correspondence to be mailed. One can

307 Spirit and Soul of Swiss Dermatology and Venereology assume that until 2002, when the permanent office was installed, the Secretary of the society was responsible for editing the minutes. The additional correspondence was handled by the President, his assistant, wife or other members of the committee. The register of members was probably initially managed and written by hand, later with typed index cards and finally computerised in the 1990s. The SSDV office began managing the members with an Excel database in 2002. With the growth in the number of members, the importance of the membership register has continuously grown. During the last 40 years the number of members has more than tripled: • April 24, 1913: 10 members (membership fee CHF 10.-) • 1943: 96 members (membership fee CHF 15.-) • 1973: 159 members (membership fee CHF 150.-) • 2003: 385 members (membership fee SSDV CHF 1000.- + FMS, now fmCh CHF 250.-) • April 24, 2013: 566 members (membership fee SSDV CHF 500.- + fmCh, EADV, UEMS, ILDS CHF 250.- and Dermarena CHF 50.-)

The management of the members was only one of the reasons for installing a permanent office. In 1932 the medical specialties were introduced, followed by the medical specialties FMH in the 1990s, the creation of the program for postgraduate training (1993) and the program for continuing medical education (1996). Additionally, the introduction of Tarmed in 2004 and other questions in health policy required an adaptation. It became critical that the SSDV have a permanent office to facilitate communication with other specialty societies and institutions such as the FMH. As secretaries changing with every new President were not able to keep up with the increasing volume of administrative work, there was finally no alternative than to install a permanent office. The office of the SSDV was installed in Neuchâtel during the presidency of Dr. Félix Gueissaz. Initially a secretary with a good knowledge of German and French, he worked at 50 per cent. During the first year, it was not possible to find somebody

308 Secretary with the initiative to set up the office properly, and the job had to be advertised three times in a row. Indeed, the job description chosen by the recruiter was not very attractive: “Secretary 50% for a society. Job description: secretary work and writing of committee minutes. Please apply to….”. Still, I applied for the job and as I had the necessary qualifications (as a Swiss German living in Neuchâtel), I got the job and started on January the 1st 2004. Initially it was very important to set up a register of the members in order to be able to access and use the data. While writing minutes and preparing meetings for the committee and the General Assembly were indeed part of my tasks, the job was much more interesting than the advertisement had promised. For the preparation of my first committee meeting, which was held on Mayth the5 2004, I needed approximately two days to copy all the documents for the 16 participants: Each participant received one complete folder (agenda and annexes) weighing about 1.3 kg. By chance the FMH had just begun distributing the documents on CD-ROM. The President asked me if it would be possible to do the same for the next committee meeting – and we rapidly switched to electronic documents. The preparation time was reduced to half a day, and instead of 16 folders, 16 CD-ROMs were mailed, thereby reducing time and postage costs. One more improvement came 6 years later, and thanks to the new society website the meeting documents can now be directly uploaded onto the committee space on the websites – and the distribution of the documents can be taken care of by sending a hyperlink by email to the participants. The same change was made for the documents for the General Assembly. In 2004 they received an envelope weighing about 500g, and from 2005 we switched to CD-ROMs, which are still used today. The tasks of the SSDV office have grown constantly. In 2006 my workload was increased to 70 per cent. In 2010 I was named General Secretary and an assistant of 10 per cent was added. The latter was replaced in 2012 by a permanent employee of 40 per cent, Ms. R. Barbezat. There are many duties: – Register of members: in 2008 the first professional database was set up and 2012 we switched to a database based on our own website. Currently, we are switching to a membership register, which is also used by FMH, FmCh and other medical societies. The new solution will allow cross-checking and updating of the data across these multiple databases.

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– Accounting: In 2008 the General Secretariat took over all the accounting, which had previously been kept by the treasurer, Dr. Carmen Laetsch – and I would like to thank her for her great work. With the increasing number of members it became important to centralise the organisation in this field. Between 2008 and 2012 the General Secretariat kept the books for the SSDV, the General Secretariat, the SDNTT (Swiss Dermatology Network for Targeted Therapies) and the foundation for fighting STI (Sexually Transmitted Infections). Due to the growth of the society and the increase in complexity, the employment of staff, etc., it became necessary to outsource the accounting to an external accountant who took over part of the accounting work in 2012. The responsibility for the accounts continues to lie with the treasurers. – Postgraduate training and continuing medical education: The General Secretariat has been responsible for the organisation of the specialty exams (applications, planning of the exams, evaluation of the exams) in close collaboration with the president of the commission for specialty exams, Professor Luca Borradori, since 2008. Until 2011, the SSDV was fully responsible for the compulsory proof of the continuing medical education for dermatologists. Since the introduction of the platform for continuing the medical education of the FMH (an electronic information system), its responsibility has only been indirect. The General Secretariat also always supports the organisers of events for continuing medical education. – Dermatologica Helvetica: Transmission (and partial compilation) and review of all articles for the news published in DH. – Website: The first SSDV website went online in 1998 and was operated by a webmaster from Lucerne. In 2003 it was moved to Geneva and a new webmaster in order to improve the synchronisation between the website and Dermatologica Helvetica (both were run by Professor J.H. Saurat). At that time, the domain name of the website was changed from www.sgdv.ch to www.derma.ch. In 2009 both Dermarena and the SDNTT register needed a new website and the commission for specialty exams needed a database of medical cases.

310 Secretary

This was used as an opportunity to remodel the webpage. Mr. V. Djamei, who was already active in many SSDV IT projects, submitted a proposal for a platform containing all of the above elements. Due to the high cost, the project was discussed for a long time before execution. Today, having overcome some “teething problems,” the SSDV has a modern website with a secure member area, sub-sites for Dermarena, SDNTT and several working groups, and a public area which is constantly growing and improving.

It is not possible to list all the tasks of the General Secretariat, but one thing is obvious: The SSDV has not escaped the general trend towards increasing administrative work and bureaucracy (e.g. quality controls etc.). The General Secretariat has evolved into the administrative centre of the society, and in recent years has become an increasingly professionally managed company. The success at mastering this fundamental change is also due to the strong commitment and motivation of many great members. The scope of the work is very wide and diverse. Of course, change also comes about because of the change of President every two years. So far, from 2004 till 2013 I have had the honour of working with five different personages (Dr. Félix Gueissaz, Professor Peter Itin, Dr. Thomas Hofer, Dr. Jean-Pierre Grillet and Professor Jürg Hafner). Each term had its demanding, but also its great periods – cheerful laughter was part of each single term. I’d like to express my heartfelt gratitude to each of the five Presidents for their good collaboration!

Monica Pongratz Guntli

311

Dermatological research in Switzerland one hundred years ago

The first scientific congresses of the Swiss Society of Dermatology and Venereology (SSDV)

What was the status of dermatological medicine at the time the Swiss Society for Dermatology was founded? What medical problems confronted the patients and the specialists for skin and venereal diseases caring for them? How were they discussed and communicated? The following, and in some cases commented upon, compilation of the published scientific protocols of the first four annual general meetings (AGMs) of the Schweizerische Gesellschaft für Dermatologie und Syphilidologie (SGDS)/Société Suisse de Dermatologie et de Syphiligraphie (SSDS)/Swiss Society of Dermatology and Syphilology (SSDS) gives an idea of the physician’s point of view on these issues. In order to give an unadulterated impression of the significance of the various concepts and approaches at the time, the protocol content is summarised completely rather than just as an excerpt of those reports which are “important” and “interesting” in retrospect.

Status of dermatological science in 1913 The science of skin diseases was only developed 200 years ago on the basis of a morphological system, and its foundations were still anchored in antique humoral pathology. One hundred years later, around 1900, at the time at which dermatology in Switzerland was becoming a specialty and beginning to be institutionalised,

315 Spirit and Soul of Swiss Dermatology and Venereology experimental pathophysiological approaches, histopathological staining methods, and in particular the new concept of infectiology, altered the fundamental understanding of skin disorders. As a result of the scientific investigation of skin changes, knowledge about immunology, metabolism and genetics was increasingly applicable to the whole body. Dermatology and venereology, which had been unappealing until then, became increasingly attractive fields of research. The career path of the Jewish dermatologist Bruno Bloch is a perfect example of this transformation. Wilhelm His Jr. advised the young resident in internal medicine to specialise in the field of dermatology because this specialty, shunned by many, would offer Bloch (as a Jew) the best career opportunities. Bloch qualified as a professor in 1908 with his thesis “Zur Lehre von Dermatomykosen” [“On the science of dermatomycoses”], although he’d been advised not to, as research into mycology was considered to be complete and had been concluded. The revised attitude on the study of dermatomycoses based on experimental functional approaches contributed fundamentally to the understanding of the immune system in the defence against pathogens, and also to allergy and immunisation. When Bruno Bloch refused the offer of a professorship at the University of Berlin and the Chair of the Dermatology Department of the Charité in 1931, the students organised a torchlit procession in his honour. Hundreds of students participated and the streets were lined with thousands of people. The faculty sponsored a banquet, which the government attended and expressed their appreciation/gratitude for the decision of the renowned scientist.1 For the first time, at the beginning of the twentieth century, new technical and biochemical discoveries and developments in medicine provided physicians, whose methods had until then been characterised by therapeutic nihilism, with effective treatment methods, the potential and dangers of which were being tested: physical radiation therapies (light, x-ray, radioactivity) and chemical treatments were available from 1891 using dyes; chemically modified arsenic derivatives (Salvarsan) from 1910; and later followed by the sulphonamides (1932) and penicillin (1946).

1 Geiges M, Bruno Bloch, in Löser C, Plewig G, Burgdorf W, Pantheon of Dermatology, Springer, Berlin, Heidelberg, 2013, p. 107-113.

316 The first scientific congresses of the SSDV

In addition, the perception (whether real or imagined) of a massive increase in sexually transmitted diseases and the medical professionalisation of the fight against them by raising awareness gave the dermatologists and venereologists a new and important socio-political role in society.

The members of the Schweizerischen Gesellschaft für Dermatologie und Syphilidologie The Swiss Society of Dermatology and Syphilology was founded by dermatologists who helped shape the development of dermatology in Europe and worldwide with their research. The most important was Josef Jadassohn, at that time Director of the Dermatological Clinic in Bern, whose work has never been adequately honoured since his death as a result of his Jewish heritage. His importance is best documented by the 41-volume Handbuch der Haut- und Geschlechtskrankheiten (Handbook of Skin and Venereal Diseases) he published in the years 1927 to 1934. He was nominated as founding President of the SSDS, but refused, partly due to the additional workload, and suggested his renowned and oldest colleague, Hughues Oltramare, Clinic Director in Geneva. The inaugural meeting in 1913 therefore took place in Geneva, “wenn auch etwas abgelegen”2 [“if somewhat out of the way”]. The founding of the Society had the following aims: „Demonstrationen von Kranken und Präparaten, Besprechung von Standesfragen, Abhilfe gegen Missstände in der Praxis“.3 [“Presentation of patients and samples, discussion of professional issues, the remedying of irregularities in practice.”] “Das hauptsächlichste Ziel dieser Zusammenkünfte ist, die Schweizer Dermatologen zusammen zu bringen, damit sie in jährlichen oder zweijährlichen Sitzungen ihre Ideen austauschen und etwas an der Entwicklung der dermatologischen Wissenschaft arbeiten können.”4 [“The main aim of these meetings is to bring Swiss dermatologists

2 Letter from Bloch to Jadassohn from 14.2.1913 and letter from Jadassohn to Dind from 24.1.1913, SSDV archive. 3 Protocol of the inaugural meeting on 24.4.1913, SSDV archive. 4 Correspondenz-Blatt für Schweizer Ärzte n° 28,1913, p. 883.

317 Spirit and Soul of Swiss Dermatology and Venereology together so that they can exchange ideas and work on the development of dermatological science at annual or biennial meetings.”] It was considered very important that practising dermatologists should be allowed to join, as a letter from Bruno Bloch to Josef Jadassohn illustrates: «Nur gegen die Beschränkung der Mitgliederzahl möchte ich auf’s Schärfste protestieren. Ich finde es ein grosses Unrecht, nur Vorsteher von Spitalabteilungen und Dermatologen von “Ruf” zuzulassen und begreife noch gar nicht den Zweck einer solchen Massregel, als ob nicht manchmal ein stiller, zurückgezogener praktischer Arzt viel wissenschaftlicher sein könnte als mancher Klinikchef. Wenn die Engländer und die Amerikaner bei sich zu Hause solche Gebräuche für notwendig finden, so sollen sie sie ruhig durchführen: sie auf internationalen Kongressen zu sanktionieren, haben wir keinen Anlass.”5 [“I would only argue very strongly against limited membership numbers. I find it extremely unjust only to allow heads of hospital departments and ‘renowned’ dermatologists to join, and still do not understand the purpose of such a distinction, as if a quiet, reserved practitioner cannot sometimes be far more scientific than some hospital chairs. If the British and Americans find such customs necessary at home, they can do so, we have no need to sanction them at international congresses.”] In the end, membership to the SSDS was open to “All established Swiss physicians particularly interested in dermatology, and the residents of the Swiss dermatological university clinics.”6

The scientific meetings 1913: Inaugural meeting, Geneva The following scientific subjects were discussed at the constitutional meeting of the Swiss Society of Dermatology and Syphilology on April 24, 1913:7

5 Letter from Bloch to Jadassohn from 2.1.1913, SSDV archive. 6 Protocol of the inaugural meeting on 24.4.1913, SSDV archive. 7 Correspondenz-Blatt für Schweizer Ärzte, n° 28, 1913, p. 883-885.

318 The first scientific congresses of the SSDV

Figure 1. First page of the protocol book with the invitation to the inaugural meeting, 1913, SSDV archive.

Figure 2. Second page of the protocol book with the first statutes, 1913, SSDV archive.

319 Spirit and Soul of Swiss Dermatology and Venereology

Figure 3. First page of the cashier’s book with the founding members, 1913, SSDV archive.

Charles du Bois, from the clinic in Geneva presented the successful treatment of a young patient who had been treated with X-Strahlen [x-ray radiation] for a mykosischer Geschwulst (bone tuberculosis) on her right leg seven years earlier. [Tuberculosis of bone and soft tissue was also known as surgical tuberculosis and was very difficult to treat, attempts to do so often led to severe complications.] Telangiectasias were now evident at the location of the ulcers. [It is not clear from the text whether these were already perceived to be a result of the x-rays.] Warm water was suggested for treatment of the telangiectasias: “als starker Regen auf die Teleangiektasien gespritzt.” [“sprayed onto the telangiectasias like heavy rain.”] In a second contribution, Charles du Bois presented microscopic samples of scales from “Pityriasis rosea von Gilbert [sic],” in which he had found the “cryptogamischen Agenten Mikrosporon Dispar.” [It is very likely that the Mikrosporon Dispar corresponded to what is today known as the yeast fungus Malassezia furfur.] It quickly becomes clear from the discussion about the aetiological significance of the fungus, however, that the specialists were already disagreeing about the clinical definition of the disease.

320 The first scientific congresses of the SSDV

Nevertheless, even then the majority of the dermatologists present were of the opinion that Pityriasis rosea was caused by a parasite. The comprehensive report from Hughues Oltramare from Geneva on his experiences and the results of the treatment of syphilis with the arsenic compound Salvarsan and its derivative Neo-salvarsan, developed by Paul Ehrlich and Sahachiro Hata, clearly illustrated the difficulties of the long-term therapy, which was often accompanied by severe side effects. Dosages, application methods, possible combinations (e.g. with mercury) and difficulties in evaluating the success (clinical and serological, using the Wassermann-reaction) were discussed. [In the following decades the cure rate continued to be worse than the public was led to believe.]8 Thus, the three contributions covered the most important medical achievements of the previous years: the new concept of infectious diseases, the intensive search for pathogens, which has continued since then, and the new effective treatment modalities of radiation and chemotherapy.

1914: Second meeting, Bern The same subjects were still current a year later at the second annual meeting in Bern, from July the 23rd 1914. In addition, two further areas of scientific research were discussed which were typical for this time period: allergies and vaccination.9 21 members and a number of guests were present at the congress led by Josef Jadassohn, clinic director in Bern. Numerous clinical cases were presented during the scientific meeting by demonstration of patients, and in addition moulages and histological specimens were displayed. Bruno Bloch from Basel presented a 12-year-old girl with Pseudoxanthoma elasticum. He doubted it was a tumour and, based on the histology, suspected toxic decay of the elastic tissue. He also

8 In the propaganda film of the Schweizerischen Gesellschaft zur Bekämpfung der Geschlechtskrankheiten “Feind im Blut” [blood-borne enemy], which was the first talking film shown in cinemas from 1931, the impression is given that Salvarsan treatment always leads to a cure without major side-effects. 9 Correspondenz-Blatt für Schweizer Ärzte, n° 47, 1914, p. 1473-1481, n° 49, 1914, p. 1537-1544, and n° 11, 1915, p. 346-348.

321 Spirit and Soul of Swiss Dermatology and Venereology presented a 67-year-old patient with Kraurosis penis and a 38-year- old woman with Pityriasis lichenoides chronica, described by Josef Jadassohn for the first time asDermatitis lichenoides chronica. Smear preparations and cultures were shown, which were taken from the blisters and blood of two cases of Dermatitis herpetiformis Duhring. In the process, a previously unknown gram-negative bacterium was grown in a strictly anaerobic medium. Whether this was a chance discovery, or whether, as Bloch supposes, the bacteria had an aetiological significance for the dermatoses, would need to be clarified by further research. Max Tièche from Zurich asked whether the renewed progression in a patient with an extensive neck keloid after a neck boil 24 years before could be interpreted in the context of atypical tuberculosis. He then showed photos of thoracic chondromas, the origin of which he deduced to be the branchial arch. Josef Jadassohn demonstrated the practical application of Thorium-X-Salbe for the treatment of chronic Lupus erythematodes. Varying results, some extremely good, were achieved in the therapy of Psoriasis, Verrucae planae, Sykosis non parasitaria and Lichen Vidal. Depending on the required dose, the cream was applied to the area to be treated in varying thicknesses for a long period (usually 48 hours). Oskar Naegeli and Max Jessner in Bern wrote about the possibility of Thorium-X therapy in a cream form. [The solution, which was produced in Berlin, contained the radioactive alpha and gamma ray emitter Thorium. Thorium was commercially available for topical application as “Doramad” until 1945. Doramad became known in particular as a toothpaste for bright white teeth, thanks to its bactericide action and enhanced immune defence through radioactive radiation. Prominent reports had been published as early as 1902 about the possible after-effects of radioactive and x-ray radiation, first on chronic x-ray dermatitis and x-ray carcinoma, in particular in x-ray technicians.10 Bruno Bloch presented his experiments at the seventh annual meeting of the SSDV in Lugarno in 1923, in which he proved for the first time in animal experiments that cancer could be caused experimentally

10 Dommann M, Durchsicht, Einsicht, Vorsicht – Eine Geschichte der Röntgenstrahlen, 1896-1963, Chronos, Zürich, 2003.

322 The first scientific congresses of the SSDV by x-rays.11 12 Nevertheless, pedoscopes using x-rays were still being used in shoe shops to check shoe size in the nineteen sixties.] Josef Jadassohn presented two patients with “Sarkoiden” or Lupus pernio and described 3 other cases. None of the patients were sensitive to tuberculin (Pirquet test), not even those with a history of tuberculosis. In addition to the absent allergy, they had raised sensitivity to Neo-salvarsan (increased local reaction after an injection of 0.15ml with no therapeutic effect). He discussed the potential relationships between tuberculosis, leprosy and syphilis, and the necessity of performing further modern functional tests (complement fixation test, animal testing). [At the beginning of the 20th Century it was recognised that the body can be immunologically reorganised and react with oversensitivity (Idiosynkrasien). In 1906, Clemens von Pirquet defined the term “allergy” as a specifically altered reactivity due to the effect of foreign substances, antigens or allergens.13 In 1907 Pirquet also developed a tuberculin skin test, the so-called Pirquet reaction.14] Josef Jadassohn showed two Swiss patients who had contracted leprosy abroad, one in the French Foreign Legion. Finger and leg amputations were necessary. Jadassohn used this opportunity to demonstrate samples from a case of the tuberculoid leprosy he described. Further patient demonstrations involved: – Generalised scleroderma in a 15-year-old girl. – Poikiloderma or possible scleroderma in a 13-year-old girl. – Naevi with depigmentation: Jadassohn establishes that there is little literature available on naevi with depigmented haloes.

11 Bloch B „Die experimentelle Erzeugung von Röntgen-Carcinomen beim Kaninchen, nebst allgemeinen Bemerkungen über die Geneses der Experimentellen Carcinome“, Schweizerische Medizinische Wochenschrift, n° 54, 1924, p. 857-865. 12 Vereinsberichte: VIIème Congrès de la Socieété Suisse de Dermatologie et de Vénéréologie. Schweizerische Medizinische Wochenschrift, n° 33, 1924, p. 753- 757. 13 Pirquet C, Allergie. In: Münchener Medizinische Wochenschrift, Band 30.1906, Finsterlin: München 1906, p. 1457-1458. 14 Pirquet, C Tuberkulindiagnose durch cutane Impfung, in Berliner Klinische Wochenschrift, Band 44.1907, Hirschwald, Berlin, 1907, p. 644-645.

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There do not appear to be any links to actual vitiligo. The patient Jadassohn had numerous such naevi on his trunk and one could clearly see the progression of the depigmentation from the edge. The process has not been adequately investigated histologically and the significance is still completely hypothetical. [Two years later Richard Lightburn Sutton published his observations of two patients with Leucoderma acquisitum centrifugum. He described the histology, not seeing the central melanocyte mass as regressive naevus, but instead as a tissue mass of endothelial origin. Sutton interpreted the halo naevi as an unusual variation of vitiligo.15] – Psoriasis caused by tattooing. An unsuccessful experiment was performed in Bern to cause psoriasis through scarification and rubbing in of psoriasis material. Bruno Bloch from the clinic in Basel reported on a case of Lichen ruber planus on a tattooed Swiss coat of arms which appeared to be restricted to the red section. – Urticaria pigmentosa adultorum of a 43-year-old woman with characteristic histological evidence of mast cells. – Anetodermia maculosa post syphilitica in a 50-year-old man. – Familial Hyperepidermidotrophie with Ichthyosis-like eczemas. – Unusual granulation growth in a 56-year-old farmer’s wife with large, pale cells showing blister-like nuclei histologically. Treatment with radiotherapy and Neo-salvarsan brought about a slight improvement. – Paraffin-Granulationstumoren on the face of a 36-year- old patient who had allowed doctors in Berlin and Warsaw to inject paraffin subcutaneously a year before because she was too thin. From a distance her face had the appearance of tuberous leprosy. So far no improvement under treatment with hair-dryer, diathermy, mesothorium, radiotherapy and damp bandages. – Kolossale angiome on the ears of a four-month-old baby, which spontaneously regressed leaving scars.

15 Sutton RL, “An unusual variety of vitiligo (leucoderma acquisitum centrifugum)”, J Cutan Dis, n° 34, 1916, p. 797-801.

324 The first scientific congresses of the SSDV

– GB Antonietti from Lugarno presented a 14-year-old girl with vaccinia (smallpox) inoculation on the vulva which imitated a syphilitic chancre.

Max Tièche from Zurich demonstrated four tables of allergic reactions which he had provoked with Varioloid, Varicella- and Erythema (exsudativum) multiforme material, and recommended this technique for differential diagnoses of different diseases. Preserving suspicious material in ether for 24 hours would undoubtedly suffice to prevent infection. In the discussion Bruno Bloch considered that this method could cause variola infection; Tièche did not believe there was a risk. Bruno Bloch expressed criticism of published successes in the vaccination therapy of gonorrhoea. The discussion showed that the experiences in the different clinics were sometimes successful and sometimes not at all. Emile Dind from Lausanne reported on the treatment of Lichen planus and special forms of eczema with Salvarsan. The successful treatment with the arsenic-containing Fowler’s Solution is also discussed. Jadassohn is of the opinion that the successful treatment of Lichen Vidal indicates that it was not chronic eczema, but Lichen ruber. Charles du Bois from Geneva demonstrated both statistically and experimentally that angiokeratomas were not, as previously assumed, of a tuberculoid nature, and also not necessarily directly linked with perniosis. He asked the Swiss dermatologists to keep statistics on the incidence of perniosis and possible links to tuberculosis. Arthur Guth from Zurich advised against the use of the so- called Claviblen-Stäbchen for male sufferers of gonorrhoea and recommended the more hygienic and far less irritating conventional injection therapy. [Carl Bruck from Breslau had presented Claviblen- Stäbchen for the treatment of gonorrhoea at the 9th congress of the German Dermatological Society in Vienna in 1913. They were 6cm (for women) to 18cm (for men) long – 6mm-wide rods made of a thin wax casing filled with a disinfecting silver salt which melted at body temperature after insertion into the urethra and should in this way kill gonococci locally. Practical sets of 10.6cm-long Claviblen- Stäbchen for disinfection of the anterior urethra were available with

325 Spirit and Soul of Swiss Dermatology and Venereology an antiseptic lubricant in a small matchbox-sized metal box for prophylactic use after extramarital intercourse.]16 Finally, Guth reported a neurological recurrence of syphilis after treatment with Salvarsan. Max Winkler from Lucerne brought up an unusual condition of the external ear which he had only observed in men until now. The cause of chondrodermatitis nodularis helicis was unknown. Winkler suspected a traumatic or chemical irritant which caused a secondary infection and local degeneration of the cartilage. The cartilage then acted as a foreign substance and sustained the chronic inflammation. He recommended excision as therapy. To finish, Winkler showed histological samples of a case of polyotia (auricular attachment) on the neck of a 10-year-old girl. A number of already published cases were to be found in the exhibited moulages: a case of myxoedema17 and an “Aleppobeule”18 observed in the Bern clinic. A case of skin psammomas was presented next. The first published case was described by Max Winkler in Bern. Further cases have since occurred, making it clear that the tumour is not as rare as previously thought. Further moulages and samples illustrated a foreign substance tumour on the hand of a milker, caused by penetration of a cow hair, and a sweat gland adenoma. [The moulages presented had most likely been created by Josef Jadassohn himself. Unfortunately, only a very few moulages signed by Jadassohn still exist today. Most had to be disposed of because of lack of room in 1961 by Alain de Weck, at that time “scientific Oberarzt” at the Clinic in Bern.]19 To finish, Josef Jadassohn gave a short summary of the findings Dr. Inga Saeves made in his clinic in her experimental studies on dermatomycoses. These were later published in detail in Archiv

16 Bruck C, “Neue therapeutische und prophylaktische Versuche bei Gonorrhoe”, Deutsche Medizinische Wochenschrift, n° 43, 1913, p. 260-262. 17 Correspondenz-Blatt für Schweizer Ärzte, 1913, p. 241. 18 Correspondenz-Blatt für Schweizer Ärzte, 1912, p. 1084. 19 Alain L. de Weck, Memories: Failures and Dreams. Vol. 1: One life, many dreams. Pro Business: Berlin, 2008, p. 56.

326 The first scientific congresses of the SSDV

Figure 4. Wax moulage n° 3914: Scalp psammoma (probably made by Josef Jadassohn in Bern), Institute for the History of Medicine, University of Bern. für Dermatologie und Syphilis.20 The young doctor referred to the work of Bruno Bloch. Key points of Inga Saeves’ research were: – Incubation time. – Reinoculation of pre-treated animals. – The question of the haematogenous origin of trichophytoses. – The attempt to establish trichophyton depleting enzymes with Abderhalden’s method. – To investigate, following Abderhalden’s principles, why human fungal pathogens are not pathogenic for animal skin.

[It was not possible to demonstrate trichophyton-depleting enzymes using Abderhalden’s method. Today that does not surprise us. The German physiologist Emil Abderhalden postulated that a host produced specific proteases, similar to antibodies, on coming into contact with foreign proteins (pathogens). Abderhalden was an extremely renowned scientist: habilitation at the age of 27, a total of over 1,300 publications, President of the Leopoldina during

20 Archiv für Dermatologie und Syphilis, n° 121, 1915 p. 161-236.

327 Spirit and Soul of Swiss Dermatology and Venereology

National Socialism, professor and honorary professor in Zurich from 1946. The Abwehrfermentreaktion he developed in the period between 1902 and 1908 attracted great scientific interest and was even used as a pregnancy test. Although it was not possible to reproduce the method correctly in the following decades, it was still used for years and hardly questioned publicly. In the end it is not possible to determine whether this huge construct was simply a case of self-denial and aberration or a deliberate fraud.]21, 22

1917: Extraordinary meeting, Bern An extraordinary meeting took place in Bern on July the 22nd 1917, at which the name of the Society was changed into Schweizerische Gesellschaft für Dermatologie und Venerologie (SGDV)/Société Suisse de Dermatologie et Vénéréologie (SSDV), Swiss Society for Dermatology and Venereology (SSDV). As was common at that time, in addition to moulages and histological sections, for “live” patients to be presented. At this meeting in Bern, therefore, an application was made that 50% of the transport costs for patients be paid from the congress takings. The presentation of patients was replaced by slide clinics in 1970. Clinical cases from the University of Bern Dermatological Clinic were presented and discussed.23 – The following clinical cases were shown by Josef Jadassohn: – Kleinzelliges Lymphosarkom of the skin in a 55-year-old woman, treatment with arsenic and radiation. – Multiple tumour-like xanthomas of the skin and tendon sheaths in a 55-year-old man. – A 41-year-old female patient with Erythrodermie congénitale ichthyosiforme. – A middle-aged man with an unusual oblique forehead and side furrows.

21 Mir Taher Fattaahi Abderhalden E, Die Abwehrfermente. Ein langer Irrweg oder wissenschaftlicher Betrug? Diss Med. Ruhr-Universität Bochum, 2005. 22 Biometrisches Kolloquium Wuppertal, 20.3.2003, Vortrag Köbberling, Die Abderhalden’schen Abwehrfermente, (accessed on 29.6.2013): http://www. klinikberatung.de/JK/Biometrisches%20Kolloquium.pdf 23 Correspondenz-Blatt für Schweizer Ärzte, n° 13, 1919, p. 450-461.

328 The first scientific congresses of the SSDV

– A diffuse scleroderma with diffuse skin atrophy in a 28-year- old female patient. – A 16-year-old boy with congenital syphilis. – A 22-year-old woman with genital-anal vitiligo and pruritic dermatitis following 6 months of unsuccessful treatment with creams, quartz lamp, radiation and arsenic. Currently being treated with Neo-salvarsan. Due to fear of irritation and provocation of an epithelioma [epithelioma today = basal carcinoma] treatment with CO² snow has not been attempted. – Successful treatment of a boy with facial Verrucae planae juveniles using Hydrargyrum jodatum flavum and Thorium-X (Doramad unter Mosetig-Battist und Collodium). – A further case of mutilating leprosy with amputation of the fingers and lower leg in a Swiss man who had joined the foreign legion 12 years before. – Lichen scrofulosorum in a 13-year-old girl. – Papulo-necrotic tuberculides in a 50-year-old woman, possibly caused by the tuberculin therapy and radiotherapy of the tuberculosis of the neck lymph nodes. – The possible relationship between sarcoidosis and tuberculosis was discussed again at this meeting with regard to patients with sarcoidosis and Acnitis [facial] or Lupus pernio. Common to all cases was a negative or weak tuberculin reaction. [In addition to Bruno Bloch, Felix Lewandowsky, the newly appointed clinic Director in Basel, took part in this discussion. His standard work on skin tuberculosis “Tuberkulose der Haut”24 had been published a year earlier.]

1919: Third meeting, Lausanne The third SGDV/SSDV congress took place from the 16th to the 17th of July 1919 in Lausanne, under the presidency of Emile Dind,

24 Lewandowsky F, Die Tuberkulose der Haut, Mit 115 zum Teil farbigen Textabbildungen und 12 farbigen Tafeln, Springer, Berlin, 1916.

329 Spirit and Soul of Swiss Dermatology and Venereology with Charles du Bois as actuary. Josef Jadassohn became the first honorary Society member.25 Hughues Oltramare gave a lecture in the scientific part on hereditary physical characteristics and dystrophies of syphilis. [According to Alfred Fournier’s theory from 1883, parental syphilis could be passed on genetically over several generations, which was demonstrated by corresponding stigmata and signs of degeneration.] Oltramare posed the question of whether the differences in facial characteristics between races could be the result of the incidence of syphilis in earlier times. Conversely, the “beautiful” antique depictions could be an indication that the Greek-Latin races were free of syphilis. [The judgmental comparison between “beautiful Europeans” and “ugly foreign races” and the hunt for medical explanations corresponded to the scientific understanding in Western Europe at that time.] In the patient presentations, a female patient with facial sarcoidosis, two cases of lichen, one male patient with Pachyonychia congenita and generalised alopecia areata (Pelade), and a further male patient with tuberculoid leprosy from Central America were presented. Bruno Bloch from Zurich presented his observations on different forms of trichophytes [explained by Josef Jadassohn as allergic reactions to trichophytes], some illustrated with moulages: Lichen trichophyticus, Erythema nodosum trichophyticum, scarlatiniformes Trichophytid, Erythema exsudativum multiforme trichophyticum.

Bloch also showed Zurich moulages of rarer cases of skin diseases: – A Boeck’sches Sarkoid of the face and head of a 41-year-old woman after injury with a hatpin. – A case of Sarcoma multiplex idipathicum haemorrhagicum on the sole of the foot of an 81-year-old woman. – The case of a 15-year-old patient with a Calcinosis cutis.

25 Schweizerische Medizinische Wochenschrift n° 39, 1920, p. 871-874, and Schweizerische Medizinische Wochenschrift, n° 40, 1920, p. 895-900.

330 The first scientific congresses of the SSDV

Figure 5. Wax moulage n° 207: scalp microsporidia after radio- epilation. Made by Lotte Volger, Dermatology Clinic, Zurich 1918, shown at the SSDV meeting in 1919, Museum of Wax Moulages, University and University Hospital, Zurich.

– A ring-shaped Porokeratosis Mibelli on the back of the hand of a 70-year-old farmer’s wife. – Microsporidia on the too-smooth scalp of a two-year-old as an example of the relationship between topography and special forms of dermatoses: it healed easily after radiation-induced epilation. “Es hat also in diesem Falle der behaarte Kopf durch die Röntgenepilation temporär, auch in der Reaktion gegenüber Krankheitserreger, den Charakter einer nicht behaarten Haut angenommen.” [“In this case of a head of hair, it temporarily took on the character of bald skin as a result of radiation- induced epilation, also in the reaction to pathogens.”] – The case of a radiation ulcer after technically incorrect radiation on the right lower leg of a 58-year-old man, which was resistant to all possible physical and chemical therapies. Pepsin and trypsin were applied in a last attempt before amputation and which finally led to a cure. Bruno Bloch reported on the founding of the Schweizerischen Gesellschaft zur Bekämpfung der Geschlechtskrankheiten [Swiss Society Against Venereal Diseases], which was raising awareness and informing GPs, the public, and those in the army by means of public lectures, informative brochures, a leaflet in three languages, moulages, slides, and demonstration tables. The practising dermatologists were asked to play an active role.

331 Spirit and Soul of Swiss Dermatology and Venereology

Oskar Naegeli from Bern presented Naevi anaemici in Morbus Recklinghausen. He also showed a moulage with a tertiary erythema on the ulnar side of the left palm in a woman with syphilis after combined therapy with Altsalvarsan, mercury thymol, Neo- salvarsan and finally sodium silver salvarsan. A second moulage depicted Hyperkeratosis palmaris, scroti glandisque gonorrhoica. A differential diagnosis of psoriasis was discussed. Charles du Bois from Geneva presented his epidemiological research on plaque-like alopecia. His focus was on syphilitic alopecia, and the hereditary forms of syphilis were once more discussed, referring to Oltramare’s lecture, for example the associations with other hereditary syphilitic stigmata (missing earlobes, facial dystrophy, collapsed nose, le signe d’Oltramare, etc). The potential risk that the modern treatment with Salvarsan could accelerate progression to stage III syphilis with neurological damage was then discussed. This problem was particularly relevant as discussions were being held at that time regarding the possibility that the prophylactic administration of Salvarsan [in cases of extramarital sexual intercourse] could eliminate syphilis. A further contribution dealt with intra-muscular therapy with sulphur (camphor in Guaiacol and eucalyptus in sesame oil) for gonorrhoeal epididymitis. A few hours after the injections extreme pain and fever of up to 39° set in. The treatment appeared to be successful after a few days in most cases. Max Tièche from Zurich asked whether the abortive therapy of syphilis (Neo-salvarsan combined with mercury-salicyl) in patients who also have tuberculosis was acceptable. A worsening of tuberculosis had been observed, in particular in combination with mercury. Was it acceptable, if a patient had both diseases, to heal a primary syphilis, which could also be treated later, at the expense of the more insidious and almost untreatable tuberculosis? W. Dössekker from Bern presented 10 cases of Mykosis fungoides which he had observed and treated in the clinic and in Josef Jadassohn’s private practice over the previous nine years. He found the disease to be more common than frequently assumed, and particularly elderly men of the upper classes to be affected. The treatment of choice was radiotherapy (with various creams and

332 The first scientific congresses of the SSDV compresses or with internal arsenic). Radiotherapy is so effective that if no improvement occurs it is not a case of Mykosis fungoides. P. Narbel from Lausanne reported on heliotherapy for Lupus. He was enthusiastic about the excellent success rate of systemic heliotherapy achieved by Auguste Rollier in Leysin [the idea was of an internal, systemic readjustment of the organism, as opposed to the local light therapy for tuberculosis which Finsen proposed]. He suggested that the other treatment modalities common at the time, such as pyrogallic acid, cauterisation, radiotherapy, creams, and even the Finsen-Therapy would be judged in 50 years just as he and his contemporaries rated the treatment modalities from Molière’s time. It was clear to him that systemic diseases such as tuberculosis and syphilis needed to be treated systemically. Thus, skin tuberculosis should be treated with systemic heliotherapy. Max Winkler reported a microsporidia epidemic in Lucerne. Lasseur from Lausanne shared his experiences of the treatment of syphilis with Luargol, which was developed as “102” at the Pasteur Institute in Paris and introduced in 1915. The effect is similar to that of Salvarsan and Neo-salvarsan, but it is less toxic. [Luargol consisted of a combination of silver salt, antimony und arsphenamine.]26 L. Helg from Montreux reported two cases of gonorrhoeal pyelonephritis. The diagnosis was made cystoscopically via catheterisation of the urethrae. The treatment included cystoscopic lavage of the renal pelvis with silver nitrate, bladder instillations of silver nitrate, and Arthigon intramuscular injections [a polyvalent gonorrhoeal immunisation, which caused fever and sweating]. Success varied (from rapid healing in one week to incomplete healing after months). Rüdisühle from Bern reported on cosmetic problems after treatment with mesothorium and the possibility of their prevention: pressure marks from the casings, pigmentation, depigmentation and blood vessel dilations. He recommended distance therapy. Guido Miescher from Zurich spoke about his suspicions regarding the causes of “x-ray hangover” (Röntgenkater): cell

26 Bonard N, “A new remedy for syphilis, Luargol or ‘102’”, The Lancet, n° 188, 1916, p. 554-558.

333 Spirit and Soul of Swiss Dermatology and Venereology destruction, gases in the x-ray room (nitrous, ozone). Miescher pointed out, however, that the side effects only occur if the stomach has been irradiated or inadequately protected, and presumed therefore primarily a direct link to irritation of the stomach nerves.

1920: Fourth meeting, Zurich The fourth meeting of the Swiss Dermatological Society was held from the 10th to the 11th of July 1920 under the Presidency of Bruno Bloch in Zurich, with Guido Miescher as actuary. 27 The scientific part began with a contribution from Hughues Oltramare. He reported that in the five years since 1915, over 200 cases of hepatic icterus had been seen in the Geneva clinic following Salvarsan therapy, whereas until 1915 this had been an absolute rarity. As all of these cases occurred in the clinic or general policlinic, but not in the private consultations of Oltramare or du Bois, a link between the extremely poor, fat-deficient diet in the clinic was postulated. Emile Dind from Lausanne reported on the various forms of the trichophytin reaction, depending on the part of the body affected. Felix Lewandowsky from Basel showed moulages, photographs and histological samples of the following cases: – An unusual congenital skin affliction in a 29-year-old female patient for which he suggests the name epidermodysplasia verruciformis [The photos were also printed in the original paper published posthumously in his memory two years later.28] – Erythema bullosum vegetans after a severe case of influenza in a 36-year-old female patient. – Lichen ruber planus annularis in a 40-year-old female patient. – large papular crops of tuberculides in an open lymph gland tuberculosis.

27 Schweizerische Medizinische Wochenschrift, n° 5, 1921, p. 113-117, and n° 6, p. 135-143. 28 Lewandowsky F, Lutz W, „Ein Fall einer bisher nicht beschriebenen Hauterkrankung (Epidermodysplasia verruciformis)“, Arch Dermatol Syph, n° 141, p. 193-203.

334 The first scientific congresses of the SSDV

– A typical case of lupus miliaris faciei interpreted as tuberculoid, in a 41-year-old female patient with papulo- necrotic tuberculides. – Akneiforme Tuberkulide. – The terrible facial destruction in a 70-year-old patient caused by an epithelioma which she has had for 15 years. – Unusual changes to the skin of the face of a 16-year-old boy with a suspected inner secretory disturbance: swelling, teleangiectasias, thin, lamellar scaling, general ichthyosis, rachitic teeth, hypoplastic genitals, still no sign of puberty. – A comedo naevus on the back of a 27-year-old woman. – A hair pigment anomaly in a 10-year-old boy which reminded Lewandowsky of pictures from Meirowsky’s work. [The Cologne dermatologist tried to explain the biological evolution of birthmark development by making complicated comparisons between patients with naevi and animal fur patterns: birthmarks are atavisms, that is, phylogenetic relapses in which the original animal qualities which humans still possess come to the fore again.]29 – A rosary-shaped lymphangitis tuberculosa of the lower leg healed with tuberculin treatments. – Two cases of lupus erythematodes, healed with the application of dry ice for at least a minute and consecutive ulceration.

Patient demonstrations of the following diseases followed: – Unusually extensive serpiginous skin tuberculosis in a 22-year-old female patient (differential diagnosis: syphilis) with therapy resistance to tuberculin vaccines, radiation with artificial sunray lamp and local treatment with pyrogallol, radiation and quartz lamp. [The toxically corrosive benzol derivative pyrogallol, pyrogallic acid, was used for a long time as a developing agent.]

29 Meiroswsky E, „Über die Entstehung der sogenannten kongenitalen Missbildungen der Haut“, Archiv für Dermatologie und Syphilis, n° 127, 1919, p. 1-192.

335 Spirit and Soul of Swiss Dermatology and Venereology

Figure 6. Glass slide of the female patient with epidermodysplasia verruciformis, probably shown at the meeting in 1920, photo archive of the Dermatology Clinic of the University of Basel.

Figure 7. Wax moulage n° 244: porokeratosis Mibelli. Made by Lotte Volger, Dermatology Clinic Zurich, 1919, shown at the SSDV meeting in 1919 and discussed again at the SSDV meeting in 1920, Museum of Wax Moulages, University and University Hospital, Zurich.

– A 50-year-old patient with psoriasis with blistery-erosive exanthema, possibly pemphigus or dermatitis herpetiformis Duhring. – A 27-year-old female patient with akrodermatitis suppurativa continua (Hallopeau).

336 The first scientific congresses of the SSDV

– A mesothorium tumour after 10 radiation treatments of healthy skin for experimental purposes, and the rapid healing after internal administration of pepsin. – A 16-year-old boy with an epidermolysis bullosa hereditaria (Köbner) with no family history till now and unsuccessful radiation and arsenic treatment. – A 10-year-old girl with pyodermite végétante (Hallopeau). – A 7-year-old girl from a healthy family with lots of children with progressive pityriasis rubra pilaris (Devergie) since birth. – A case of pemphigus vegetans in a 51-year-old Italian man, which responded well to Salvarsan, Solarson (arsenic preparation), silver nitrate compresses and radiotherapy. – Cases of tar acne in workers in a briquette factory with melanosis and comedo development. – Two cases of Mongolian spots in babies with a discussion of the histology. – A case of Lupus erythematodes combined with Lichen scrophulosorum, papulonekrotischem Tuberkulid and Lymphomata colli in a 16-year-old girl. This raised the question of the link between Lupus erythematodes and the tuberculides. – Lupus erythematodes combined with Erythema induratum (Bazin), papulo-nekrotischem Tuberkulid and Lymphomata colli. – A 32-year-old male patient with Urticaria pimgentosa. – A 38-year-old male patient with a case of Parapsoriasis en plaques which has lasted 20 years. In two other cases the recommended injections with Pilocarpin were unsuccessful, but protracted and repeated radiation with a quartz lamp led to a complete cure in one case. – A female patient with Porokeratosis Mibelli, a moulage of whom had been shown at the last congress in 1919. It healed under radium therapy; a recurrence has since developed in the atrophied scar tissue. – Cases of developmental defects of the ectoderm. – A case of a congenital lack of sweat glands in combination with complete anodontia and rudimentary hair formation.

337 Spirit and Soul of Swiss Dermatology and Venereology

– A 27-year-old man with Epidermolysis bullosa congenita and defective tooth enamel. – A case of congenital anonychia. – A nail mycosis acquired in Manchuria with previously unknown fungi and secondary cutaneous spread. – A microsporidia-like trichophytosis of the beard of a 35-year- old caused by Trichphyton rosaceum. Bruno Bloch spoke about hair-greying and was able to prove a link to the lack of oxidase using the dopa reaction he had discovered in grey hair. White hair is caused by trapped air. In a second lecture, Bloch reported on his experiments with intravenous trichophyton injections, with which trichophytes of the genus Lichen trichphyticus were successfully produced.

Figure 8. Wax moulage n° 215: Lichen trichophyticus, made in Zurich in 1919 by Lotte Volger at the Dermatology Clinic, probably shown at the SSDV meeting in 1920, Museum of Wax Moulages, University and University Hospital, Zurich.

Charles du Bois from Geneva presented a moulage of an unusual gonococcal dermatitis which had only been described in this form in 17 cases previously: papular, pustular, and crusted elements with three ring-shaped zones found predominantly on the trunk. The second case du Bois presented was a girl with symmetrical tumours on her arms, the result of injections of camphor oil mixed with paraffin. Radiotherapy led to an improvement. Finally du Bois spoke about the results of the Swiss-produced arsenic compound “Novarsol,” which was as well-tolerated as Neo-salvarsan. Interestingly, icterus never occurred under Novarsol treatment, as opposed to Hughues Oltramare’s earlier report in the case of Neo- salvarsan therapy.

338 The first scientific congresses of the SSDV

Max Tièche from Zurich suspected an aetiological link between a case of Leukoplakia penis in a patient one and a half years after balanitis and self-treatment over a long period with iodine tincture and brandy. His second case involved a 25-year-old female patient with disseminated skin tuberculosis, a severe herd reaction to intravenous Salvarsan and a marked progression in winter, which Tièche believed to be the result of failed antibody production during the bad season. Next, a case of Cutis verticis gyrata was presented, and a patient with chronic, ulcerous, hypertrophying Plaut-Vinzent’schen balanitis. Wilhelm Lutz from Basel, using photographs, moulages and samples, gave an account of a 35-year-old woman with Melanosarkomatose, which had developed from a Melanosarkom 5 years earlier on the top of her left foot. An autopsy revealed disseminated metastases throughout her whole body, which led Lutz to conclude that the spread was lymphogenous. The second case he presented was that of an 8-year-old girl with Aplasia pilorum intermittens (Monilethrix). As he had expected, therapy for this congenital defect with radiation, quartz and Thyreodin was unsuccessful. Max Winkler from Lucerne presented a case involving a systematised naevus in a 3-year-old girl, which the child’s mother blamed on a shock she had received on account of a mouse (a “Versehen”) during pregnancy. For that reason, and because of its greyish-black colour, she called it “mouse birthmark” (“Mäusemuttermal”). Winkler presented the contemporary theories on the evolution of birthmarks (Metamerentheorie according to Blaschko, and Meirowsky’s keimplastische disorder). The second case involved a 51-year-old man with a thoracic morphea, and Winkler discussed a possible traumatic cause. Although the patient had participated in a boxing course, he was unable to recall a serious trauma to this area. Winkler considered an assessment by the accident insurance company advisable in such cases, as he had had experience with characteristic cases which he would term liability cases. [Max Winkler was a specialist for skin and venereal disease from 1905, with special notification for light and radiation therapy. He was intensively involved in occupational dermatoses and questions of insurance, particularly in relation to the SUVAL.30]

30 Protokolle der Jahresversammlungen der SGDV, Archiv der SGDV.

339 Spirit and Soul of Swiss Dermatology and Venereology

In closing, Winkler presented histological samples from a case of extreme syringoma in a 42-year-old ironing woman. W Dösseker from Bern gave a lecture on syphilitic re- and superinfection, and the difficulty of proving a cure with the Wassermann-reaction. Arthur Guth from Zurich gave a report on issues concerning syphilis and compared the various clinical forms of the primary affect with the course and prognosis. Further cases from Zurich were presented by de Gamrat (xanthoma with diabetes and urobilinuria; Dyskeratosis follicularis vegetans; black hairy tongue) and Merian (radiotherapy for Induratio penis plastica; Alopecia atrophicans; gummata of the scalp; animal skin diseases which can be passed on to humans). Stettler, from Basel, presented six cases of Granuloma annulare [sic], in which tuberculous structures were found histologically, leading him to suspect a link with tuberculosis. Hubert Jaeger of Zurich presented two new cases of fatal ulcero- gangrenous vaginitis caused by mercury poisoning as a result of syphilis therapy (combination therapy of Neo-salvarsan and mercury). Guido Miescher of Zurich presented two cases of congenital familial Akanthosis nigricans, combined with diabetes mellitus and general developmental disorders. [The unusual course of this case, in which the young man was later hospitalised in psychiatric care for exhibitionism, and eventually castrated, which cured his diabetes mellitus, was again published in 1933 with photographs of the moulages, some of which still exist in Zurich.31] Finally, a patient with pustular dermatitis, caused by Oidium [known today as Candida albicans], was discussed. The annual meeting closed with a lecture by Bruno Bloch on melanogenesis in vertebrates’ eyes, on the basis of the dopa reaction he had discovered.

Michael Geiges

31 Quelle 1933 und Geiges M, Holzer R, Dreidimensionale Dokumente – Moulagen zeigen Tierversuche, Selbstversuche und klinische Forschung. Moulagenmuseum der Universität und des Universitätsspitals Zürich, 2006.

340 7

Subspecialities and Working Groups

Acne

The Acne Association of the Swiss Society of Dermatology and Venereology

Initially, the need for a better understanding of acne and its treatment led to the creation of an acne consultation at the Geneva Hospital Dermatology Department (started in the nineteen-nineties, Professor Saurat). The aim was to study and apply new findings on the pathogenesis of acne. The advantages of a close collaboration with all clinics in Switzerland rapidly became evident, and the Swiss Acne Association was created in 1995. Meetings were held once a year, where the participants discussed new treatment schedules, side effects and problems encountered. The treatment with oral Isotretinoïn in the nineteen-eighties, for instance, gave rise to establishing guidelines, which frequently needed to be updated. Dosage and side effects had to be reconsidered quite often, and discussion and exchange on practical experience were important topics. For many years Hoffman-la-Roche (Laura Milesi) was of great help in organising these meetings. The organisation also became a platform for enquiries from patients, and feedback which I handled and reported. In 2003 the Association was formally closed down, but the activities continue in a working group of the Swiss Society of Dermatology.

Monika Harms, Martin Kägi, Jean-Hilaire Saurat

343

Allergology

History of Dermatology in Switzerland – Subspecialty Allergology

Introduction In this overview the emergence of the field of allergology mainly in the context of dermatology is presented. Allergology as a transversal specialty has been developed within dermatology clinics as well as in independent allergy units often associated with clinical immunology services, but also basic research immunology has been amalgamated with the two clinical specialities, particularly through the foundation of a common Society of Allergology and Immunology. However, in the centennial year of the Swiss Society of Dermatology and Venereology, here the main emphasis is put on the role of dermatologists in advancing this specialty in Switzerland. This shall, however, not underestimate the important role of many others who have played or still have an important role in the closely related fields of allergology, and clinical and basic immunology. The first discoveries in the fields of allergology and immunology were made at the beginning of the 20th century. As one “side effect” of the development of vaccinations, such as against tetanus and diphtheria, adverse reactions, particularly from the passive sera produced in horses, have been observed. In 1902, Charles Robert Richet (1850-1935) and Paul Portier (1866-1962) coined the term “anaphylaxis,” and in 1903 Maurice Arthus (1862-1945) observed the phenomenon of local immune complex reactions, which still

345 Spirit and Soul of Swiss Dermatology and Venereology carries his name today. Clemens von Pirquet (1874-1929), head of the Pediatric Clinic in Vienna, and Bela Schick, a pediatrician of Jewish origin (1877-1967), introduced in 1905 the term “allergy” for these hypersensitivity reactions such as serum sickness and other allergic reactions they observed in their pediatric patients treated with horse sera against diphtheria. Paul Ehrlich (1854-1915), who as a student discovered and described the mast cell and the eosinophil granulocyte, proposed the side chain theory, implicating that antitoxins may bind to toxins by a specific receptor, which he called an amboceptor. For his important discoveries, including the development of Salvarsan®, the first chemotherapeutic drug to treat syphilis, he received the Nobel Prize in 1908. Already in 1911, Leonard Noon (1877-1967) and John Freeman (1877-1962) introduced the concept of hyposensitisation by using a crude pollen extract. In 1921 Carl Prausnitz-Giles or Otto Carl Willy Prausnitz (1876-1963) passively sensitised the skin in his forearm to fish by injecting serum from his fish-allergic co-worker Heinz Küstner (1897-1931). The following day, Prausnitz had an immediate-type wheal and flare, later called the Prausnitz-Küstner reaction, after the injection of fish extract into the same site of his skin [1]. This test became famous as the P-K reaction and was clinically and experimentally used for many years. The term “atopy” was introduced in 1922 by the two American physicians Arthur F. Coca (1875-1959) and Robert A. Cook (1880-1960), depicting patients who had positive skin tests to inhalant allergens, who suffered from hay fever, asthma and/or infantile eczema, and in whom apparently something was not in place (α toπoc) in their immune response [2].

The emergence of allergology in Switzerland The specialty of dermatology has many facets including immunological and allergic causes of skin diseases. In particular the different types of eczema, e.g. contact dermatitis and atopic dermatitis, as well as urticaria, angioedema and autoimmune disorders, but also the infectious diseases and tumors require an extensive knowledge of immunology. Therefore it is not surprising that dermatologists were among the first who became interested in this new field of medicine. Two dermatologists can be looked upon as the grandfathers of the field of allergology in Switzerland,

346 Allergology both of whom worked clinically and experimentally on allergy topics. Josef Jadassohn (1863-1936), who worked as Director of the Dermatological Clinic in Bern from 1896 until 1910, is considered to be the father of the patch tests. In 1895 he first reported this diagnostic instrument for the testing of contact allergy to mercurial salts, when he was still working in Breslau [3]. Bruno Bloch (1878-1933) first investigated the concept of contact allergy using iodine derivatives, when he was head of Dermatology in Basel, [4]. Later on, when he was Director of the Dermatology Clinic in Zurich he performed studies on the sensitising capacity of primine from Primula obconica in guinea pigs as well as on himself [5]. Several moulages showing patch tests and eczema on his arm (among these no. 347-349 from the year 1925) are still kept in the Museum of Moulages at the University of Zurich. Bruno Bloch was also among the first who established a patch test series to detect contact allergens in patients. Poul Bonnevie, a former assistant of Bruno Bloch in Zurich, became later Professor of Occupational Medicine in Copenhagen. He expanded Bloch’s limited standard series of tests and published it in his famous textbook on environmental dermatology [6]. Already in 1926 Werner Jadassohn and Margarete Zaruski described for the first time an allergic reaction to cooked celery [7]. In 1933 Bloch died unexpectedly due to agranulocytosis from the analgesic drug Allonal (pyramidone and phenobarbital) he took for frequent headaches, at that time an unrecognised side effect. A few weeks later this side effect was published in the JAMA, which could have saved his life, if it had been recognized earlier [8]. It is evident that many dermatologists became interested in the field of allergology at an early time. This is reflected by the extensive clinical and research work on eczemas, already started by Bruno Bloch, based on his experiences with Josef Jadassohn, later pursued by Werner Jadassohn in Bern, and driven again by Alain de Weck in Bern until the foundation of the Institute for Allergology and Clinical Immunology. In Zurich, it was Guido Miescher and then particularly Hans Storck who established allergology as a subspecialty in dermatology by also creating a special allergy outpatient clinic in 1949. In Basel, it was Wilhelm Lutz, who was primarily interested in eczema, and who also published a statement on the concept of atopy where he criticised the term for being too narrowly based on a pathogenetic approach

347 Spirit and Soul of Swiss Dermatology and Venereology instead on the morphological approach. In this publication “Zum Begriff der ‘Atopic Dermatitis’” [9] written during the years of the Cold War and the arms race, the misspelled “atomic dermatitis” was overlooked by the author, the lecturer, as well as the proofreader [10]. In Basel, it was Rudolf Schuppli who opened the first allergy consultation in 1949, which he supervised for some years as an attending physician from his private practice, and which was taken over by Ferdinand Wortmann when Schuppli became director of the Dermatology Clinic in 1956. In the French part of Switzerland, Geneva and Lausanne, allergology was more embedded into the emerging field of clinical immunology, which was incorporated into internal medicine. Therefore, in Geneva Jean-Pierre Girard, and in Lausanne Philippe Frey established the first Allergy Units within the Clinical Immunology Units of the University Hospitals. However, dermatologists in both university clinics were very engaged in contact allergy and in Geneva also in drug allergy issues (Table 1, 2, 3).

Allergology in Basel

After the short period with Bruno Bloch as the Head of Dermatology in Basel (1913-1916), Felix Lewandowsky (1879-1921) took over [10]. He was Director from 1917 to 1921, when he died at a young age from colonic cancer. In 1922, Wilhelm Lutz (1888-1958) became Director. As was the case in Zurich for Guido Miescher, he was very interested in the aspects of clinical dermatology, and has published in virtually every major field of dermatology. He was also particularly interested in the different types of eczema, as well as in the classification of diseases. This culminated in the publication of a textbook on dermatology. During this period, Rudolf Schuppli (1915-2006) became registrar in 1944 and started unofficially in 1949 the first Allergy Outpatient Clinic. Officially, it was opened in 1951 – when he was already in private practice but was still the responsible Head of the Allergy Unit as external consultant. In 1947 his habilitation “Klinische und experimentelle Studien zur Pathogenese allergischer Vorgänge” was accepted, demonstrating his genuine interest in this field.

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In 1951, Ferdinand Wortmann (1919-1991) became the next responsible registrar for the Allergy Clinic after Rudolf Schuppli. Apart from dermatological issues he was also particularly interested in allergic disorders. When Wilhelm Lutz retired for personal health reasons, Rudolf Schuppli, who was at that time in private practice, was elected Director of Dermatology in 1956. Ferdinand Wortmann then became the Head of the Allergology Policlinic. For the first time in 1966, Dorothee Sommacal(1925- 2004) was mentioned as part-time allergology resident. She remained an important support of the Allergology Clinic in Basel until her retirement in 1986. Ferdinand Wortmann remained Head of the Allergology Policlinic in Basel as attending part-time physician besides his busy private practice until 1986. Because of his extensive clinical workload he was not able to pursue an academic career, but he still performed a lot of scientific work, particularly large studies on hyposensitisation in pollen allergy, but also in many other fields of allergology. He also introduced the concept of oral hyposensitisation by the gastrointestinal route, a concept that has again emerged through the establishment of sublingual immunotherapy. He retired in 1986, still remaining available as an external consultant to the clinic. He unexpectedly died from a heart attack in December 1991, returning from a committee session of the Swiss Society of Allergology and Immunology. In 1987, Martin Pletscher (born 1950) took over as Head of Allergology. He had received his training in Basel under Ferdinand Wortmann, as well as in New York and Denver, Colorado in the United States. In 1989 he left the clinic and opened a private practice for dermatology and venereology, as well as allergology, in Binningen. The clinic was then managed during 1990 by Claudia Schülin (born 1958), a registrar in dermatology and venereology. Thereafter, she took over the private practice of Ferdinand Wortmann. In 1991 Andreas Bircher (born 1953) became head of the Allergology Unit, at first as a part-time registrar supported by a 50% residency from dermatology [10].

349 Spirit and Soul of Swiss Dermatology and Venereology

Allergology in Bern

In Bern, the dermatologist Hans Kuske (1909-1970) worked on phytophotodermatitis and photosensitivity. His results were acknowledged as habilitation in 1950 and published in 1954. In 1961, Alain L. de Weck (1928-2013) established an allergy/ immunology research group. In 1963, an Allergy Unit was opened within the Dermatology Department, which grew fast and was opened for outpatients in 1965. In 1967, the Department of Allergology and Clinical Immunology (“Abteilung für Allergologie und klinische Immunologie”) was founded, which later became part of the newly-founded Institute for Clinical Immunology. Alain de Weck became the first Director of the Institute for Allergology and Clinical Immunology in 1971. Under his directorship, the institute gained worldwide recognition in basic and clinical immunology and allergology [11]. Among many other topics he mainly contributed to the identification of the relevant allergens in IgE-mediated penicillin allergy [11]. In 1993 when Alain de Weck retired, Werner Pichler, who is well-known for his research on the basic mechanisms of drug allergy, became Head of the Allergy Clinic. In Bern, basic and clinical research on drug allergy has always been a major issue. In the Department of Dermatology, Alfred Krebs (1923-2011) together with Kaspar Zürcher, an internist in private practice, worked on dermato-allergic issues, which culminated in a standard textbook on drug hypersensitivity (“Hautnebenwirkungen interner Arzneimittel,” Karger, 1980). The internist Rolf Hoigné (1923-2004) habilitated at the University Department of Internal Medicine on Drug Allergy in 1964 and described the so-called Hoigné syndrome, a toxic reaction to accidental intravascular injections of crystalline solutions. In 1966 he was elected as Head Internal Medicine at the Zieglerspital in Bern, but continued his work on drug allergy as a professor at the university. He founded the “Comprehensive hospital drug monitoring Switzerland” in cooperation with other university centres. He contributed important studies on the prevalence of adverse drug reactions in hospitalised patients, among others in collaboration with Thomas Hunziker, associate professor at the Department of Dermatology in Bern.

350 Allergology

The internist and allergologist Ueli Müller, one of the world- leading experts in hymenoptera allergy, published the first controlled study on venom immunotherapy in Europe in 1979. He closely collaborated with Bob Reisman in Buffalo, USA, and Kurt Blaser and Cezmi Akdis at the SIAF in Davos. He retired at the end of 2006, and Arthur Helbling, associate physician in the Allergology section of the Rheumatology, Immunology, Allergology Clinic at the University Hospital in Bern took over the Allergy Station of the Clinic of Internal Medicine at the Zieglerspital. In the Department of Dermatology, research on drug allergy has been continued by the dermatologist and allergist Nikhil Yawalkar, who focused on basic immune mechanisms in various types of drug hypersensitivity. In recent years, a unit for skin testing, as well as special clinics for patients with allergic skin diseases have been set up under the supervision of Dagmar Simon, which are well integrated in national and European networks and are a prerequisite for epidemiological and clinical research.

Allergology in Zurich In 1933 Guido Miescher (1887-1961) became Director of the Dermatological Clinic in Zurich after the unexpected death of Bruno Bloch. His main emphasis was on the interrelation of skin and ultraviolet and x-rays. However, he also supported research on different forms of eczema and made important contributions to erythema nodosum, first described granulomatous cheilitis and granulomatosis disciformis, a variant of necrobiosis lipoidica. Hans Storck (1910-1983) took over the clinic from Guido Miescher in 1958. He himself suffered from atopic dermatitis and was particularly interested in the newly emerging field of allergology. As a registrar he had already established an allergy unit in 1948. He gave his academic introductory lecture on the topic “Bedeutung der Allergie im Krankheitsgeschehen” [12]. When he returned as Director of the Clinic, he focused again on allergology, including the classical diagnoses and treatments of rhinitis, bronchial asthma and atopic dermatitis. His monograph on “Allergie – Theorie und Praxis,” published in 1972, was illustrated by himself and included many anecdotes and various swift observations on rare allergological case vignettes.

351 Spirit and Soul of Swiss Dermatology and Venereology

His successor Urs Walther Schnyder (1923-2012) took over as Director of the Dermatological Clinic in Zurich in 1972. In 1960 he too had written a habilitation with a theme on allergy: “Neurodermitis-Asthma-Rhinitis – eine genetisch-allergologische Studie,” [13] and had published a large epidemiological study on the frequency of atopic allergy. During this period, Brunello Wüthrich (born 1938) became registrar in 1971, and in 1975 Head of the Allergy Station. In 1975 he received the venia legendi for Dermatology and Venereology especially for Allergology, again for a habilitation with a main focus an allergy: IgE and its meaning in atopic dermatitis (“Zur Immunpathologie der Neurodermitis constitutionalis, Hans Huber). He then established the Allergy Station of the University Hospital Zurich as one of the leading clinics dealing with the whole field of allergology. He has published numerous articles, case reports and reviews on the whole field of allergology, with main emphasis on atopic dermatitis (separated into an “extrinsic” and an “intrinsic” type), food allergy (“Celery-Mugwort-Spices-Syndrome”), epidemiology of allergic diseases, and desensitisation. In 1985 he received the “Extraordinariat ad personam.” In 2003 he retired and Peter Schmid-Grendelmeier took over the “Allergiestation.” He received the venia legendi in 2004. His main interests lie in topics such as the molecular and epidemiologic aspects of respiratory allergy and atopic dermatitis. Barbara Ballmer-Weber the co-leader has been working since 1997 in Zurich; her main scientific focus is on food allergy. She participated in many studies on a European level and brought this scientific topic to a worldwide recognised level. A successful research group on allergological topics, particularly new applications and dosing schemes for specific immune therapy, is headed by Thomas Kündig and Gabriela Senti.

Allergology and clinical immunology in Lausanne In the French part of Switzerland the field of allergology and clinical immunology developed in a slightly different way. In dermatology the main emphasis was on infectious diseases, however, the description of chromium salts as an allergen in cement in 1950 by Hubert Jaeger and E. Pelloni reflects also the interest on allergological issues [14].

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Later contact allergology was mainly represented and realised by Daniel Perrenoud in the 1990s until he left the clinic, and from 2005 to 2011 by Paul Bigliardi, when he left for a position in Singapore. A Clinical Immunology Unit was created in the years 1962 to 1964 within the service of internal medicine, by Philippe Frei (born 1933), then registrar, with the support of Professor Alfredo Vannotti, Head of Internal Medicine. The unit included first a research lab and a lab for the diagnosis of immunological diseases. An outpatient clinic was also intended for patients with allergies. In the 1970s, the unit became a division with a full-time team of internists and technicians and started transplantation immunology. In the 1980s, the division also included a pediatrician who was in charge of immunological diseases in children. In 1998, when Frei retired, the division was a “Service d’immunologie et allergologie” with 50 co-workers. His successors were Giuseppe Pantaleo, Head of the Service and ordinary professor, and François Spertini, associated professor and responsible for all the clinical activities including allergology and clinical immunology. This independent service is still a part of the Department of Internal Medicine.

Allergology and Clinical Immunology in Geneva In Geneva, it was the dermatologist Werner Jadassohn (1898-1973), originally from the Bloch school in Zurich, who started in around 1950 to promote allergology and who was also very interested in allergic disorders [15]. Experimental studies on eczema were performed by Nicole Hunziker (born 1927) during his directorship. The patch test clinics were run by Werner Jadassohn himself, Nicole Hunziker, the allergologist Emile Musso (1919-1979) and the chemist Robert Brun (1926-2011). In dermatology it was still Nicole Hunziker, who contributed during the directorship of Paul Laugier (1910-2009) to the knowledge on contact dermatitis. In 1980, she founded a research group on experimental contact dermatitis to bring together people with different backgrounds such as dermatologists, immunologists, toxicologists, chemists, and biochemists to share experiences on experimental animal sensitisation. Among the first members were Claude Benezra (Université Louis Pasteur, Strasbourg), Ladislav Polak (F. Hoffmann-La Roche), and Thomas Maurer (Ciba-Geigy). The first meeting took place 1980 in Geneva, and further meetings

353 Spirit and Soul of Swiss Dermatology and Venereology followed in Basel and Strasbourg with about 20 participants each. Because of its success, annual meetings were planned, and in 1983 in Amsterdam the name “European Research Group on Experimental Contact Dermatitis” (ERGECD) was coined. From the initial intention of gathering people from the “Basel- Strasbourg, Geneva” area, it was then welcoming people from many other countries, including the USA. The number of participants was increasing from 20 to more than 100 participants. In 2012 the 24th meeting took place in Trier reflecting the ongoing interest and success of this informal group. In 1986 Nicole Hunziker was also the founder and first president of the Swiss Contact Dermatitis Research Group (SCDRG), a group of dermatologists interested in the clinical aspects of contact dermatitis. In the Department of Dermatology emphasis was again on severe drug hypersensitivities such as toxic epidermal necrolysis. For example, important contributions have been made by Jean- Hilaire Saurat (born 1943), the successor of Laugier, and Lars French (born 1963) with regard to the treatment with immune globulins of this often lethal adverse drug reaction. A consultation “Dermatologie- Environnement” was started first by Nicole Hunziker and Jean-Pierre Grillet (born 1952). After she became Professor Emeritus in 1991, Contact Allergology in Dermatology was mainly represented and supervised by the attending physicians Pierre Piletta (born 1962) and Florence Pasche-Koo (born 1964), who also both have a private practice. In Geneva, similar to Lausanne and in the same period (1962-1964), a Division of Clinical Immunology was created by André Cruchaud (born 1928), within the Service of Internal Medicine with the support of its Head, Professor Alex Müller. The Division (headed by André Cruchaud) was soon organised into three units: (1) Clinical immunology, headed by André Cruchaud himself; (2) Transplantation immunology headed by Michel Jeannet (born 1932) and (3) Allergology headed by Jean-Pierre (Othenin)-Girard (1923-1996). The division included a diagnostic laboratory, first headed by Jean-Pierre Despont, and since 1996 by Pascale Roux- Lombard, who is still in charge today. The unit of transplantation immunology functioned as a histocompatibility central laboratory for Switzerland; Michel Jeannet during these years being thus responsible for transplantation immunology for the whole country.

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In 1988, when Jean-Pierre Girard retired, Barbara Polla (born 1950) took over the Allergology Unit. Jean-Michel Dayer joined the Division in 1980 on his return from Massachusetts General Hospital. In 1993 he succeeded André Cruchaud as Head of the Division. At the same time, when Barbara Polla left, the Allergology Unit was taken over by Conrad Hauser, again a dermatologist, and later Carlo Chizzolini joined, being responsible for clinical immunology. Conrad Hauser left the Allergology Unit in 2008 to pursue a career in the industry after Jean-Michel Dayer retired in 2007, and Jörg Seebach became Head of the Division of Clinical Immunology. From 2012 Thomas Harr took over as Head of the Allergology Unit.

Dermatology Clinics with allergology sections in other hospitals (Table 4) The Städtische Poliklinik in Zurich was founded in 1913 by Max Tièche (1878-1938) to improve the dermatological patient-centered care for the underprivileged people of the city. Walther Burckhardt (1905-1971), who received his formation by Bruno Bloch and Guido Miescher, became in 1938 Head of the Städtische Poliklinik. He introduced the alkali resistance test of the skin, worked on occupational dermatoses and eczema due to sensitisation to cement, and worked on other aspects of allergy. Kaspar Schwarz (1923-2011) became in 1971 successor of Walther Burckhardt, and contributed remarkable publications on light dermatoses and photoallergy. His successor was Alfred Eichmann from 1988-2002, followed by Stephan Lautenschlager from 2002. Both have their focus on venereal diseases; however, allergology is covered by specialised registrars [14]. Other dermatology clinics have been established in several hospitals in Switzerland. The first was founded in1934 at the Ospedale San Giovanni in Bellinzona by Fausto Techio (1904-1999). In 1975 Francois Gillet (1937-2011) took over and established as special topics allergology and venereology. In 2001 Carlo Mainetti (born 1958) took over, his interest being cutaneous autoimmune disorders and dermatological surgery. In 2007 Silvy Bach Bizzozero, specialising in allergology and clinical immunology, established an outpatient clinic for allergology at the hospital. From July 2012 Giovanni Ferrari, a pediatrician and allergologist trained in Aarau

355 Spirit and Soul of Swiss Dermatology and Venereology and at the Zurich Allergy Unit, was appointed to a common Allergy Unit for the hospitals of Bellinzona and Lugano. At the Kantonsspital in Luzern in 1934 a Dermatology Department was already opened in Internal Medicine, which was headed by Eduard Frei. Today, the division has two full-time head physicians; Christoph Brand in dermatology, and Gerhard Müllner in allergology. In 1997 a Dermatology Clinic was established at the Kantonsspital in Aarau, headed by Peter Itin until 2006, followed by Markus Streit. Allergology was overseen first by Mark Anliker, then Marianne Lerch, and since 2009 by Jürgen Grabbe. In 2004 a Dermatology Clinic was opened at the Kantonsspital in St. Gallen, headed by Mark Anliker, which also takes care of patients with allergic disorders. Also the Kantonsspital in Schaffhausen has had a small Department of Dermatology and Allergology, which was first overseen by attending physicians. From 1999 Paul Bigliardi junior headed a small unit from his private practice while he led a research group in Basel. His habilitation on opiate receptors of the skin was accepted in 2003. In 2005 he became Associate Professor at the Dermatology Clinic at the CHUV in Lausanne. His practice and the consultation at the hospital in Schaffhausen were taken over by two German dermatologists Michael Buslau and Teodor Karamfilov. The most recent Department of Allergology/Dermatology was opened within the Department of Internal Medicine in 2011 at the Kantonsspital Winterthur headed by Marianne Lerch. In addition, numerous practising dermatologists such as Annemarie Benz in Zurich and Stefano Gilardi in Locarno have promoted allergology within dermatology. Many more have obtained a double formation in dermatology/venereology and allergology/clinical immunology (Table 5) and have delivered high quality care to their patients, or are still promoting allergological care for many patients and their referring general practitioners.

The Swiss Contact Dermatitis Research Group (SCDRG) The interest in contact allergology resulted in the foundation of a working group on contact dermatitis in 1986 by Nicole Hunziker, who also became its first President. The founding members

356 Allergology included Florence Pasche from Geneva, Daniel Perrenoud from Lausanne, Leena Bruckner-Tuderman from Zurich, Theo Rufli and Andreas Bircher from Basel and Thomas Hunziker from Bern, as well as several dermatologists in private practice. The first multicentre publication in 1989 was “Sensitization to Kathon CG (a mix of chlormethylisothiazolinone and isothiazolinone) in Switzerland: Report of the Swiss Contact Dermatitis Research Group” (in Current Topics in Contact Dermatitis, Springer, 1989). Methylisothiazolinone, a part of this preservative mixture, which increasingly caused contact allergies during these years, emerged again in 2012 as a relevant contact allergen. Later, this informal group was presided over by Andreas Bircher, Daniel Perrenoud, Paul Bigliardi, Dagmar Simon and again by Andreas Bircher. For many years Rita Sigg (at a private practice in Luzern) served as secretary. It is a small working group of interested dermatologists with a main focus on contact and occupational allergy. It is well connected to the SUVA by Hanspeter Rast, who has been an active member in the group for many years. It has strong links to the European Society of Contact Dermatitis (ESCD), where it is represented on the Council as well as in the European Contact Dermatitis Research group (ECDRG), a group of European dermatologists from Sweden, Denmark, Great Britain, France, Germany Italy, Spain and Switzerland dedicated to contact allergy.

The Dermato-Allergological Commission In 1999 the foundation of a Dermato-Allergological Commission was proposed by Lasse Braathen, Director of Dermatology in Bern. Its main purpose was to establish a platform for postgraduate and continuing education in allergology for dermatologists. Every second year a course in dermatoallergology was organised by one of the University’s Dermatology Clinics. The first official course took place in Lausanne in 1999 (organised by Daniel Perrenoud), the second in Bern 2001 (Lasse Braathen); the third course in 2003 in Basel (Andreas Bircher); the fourth in 2005 in Geneva (Conrad Hauser); the fifth in 2007 in Zurich (Peter Schmid- Grendelmeier); the sixth in 2009 in Lausanne (Paul Bigliardi); and the seventh one in 2011 in Bern (Dagmar Simon). It now is a well-established and highly regarded course, still taking place every two years. In 2011 it was decided to merge the SCDRG and

357 Spirit and Soul of Swiss Dermatology and Venereology the Dermato-Allergological Commission to unite all allergological issues of interest in dermatology into one group. Currently the Commission is presided over by Andreas Bircher (Basel), and other members include Dagmar Simon (Bern), Barbara Ballmer- Weber (Zurich), and Philippe Sprung (Lausanne), and Pierre Piletta and Florence Pasche-Koo (Geneva). Currently it is the managing group of the SCDRG for the organisation of the course on dermatoallergology (Table 6).

The Swiss Allergy Society An important step for the establishment and development of Allergology in Switzerland – also within dermatology – was the foundation of the Schweizerischen Gesellschaft für Allergie (SGA) on February the 25th 1950 in Zurich. Among the founding members were also many dermatologists such as Werner Jadassohn (Geneva), Guido Miescher and Hans Storck (Zurich), and Alain de Weck (Bern) [11]. The statutes, the names of the founding members and the presentations were published in International Archives of Allergy, Vol. 1, Karger Verlag, 1951. A major factor in the establishment of a Swiss Allergy Society, as it was named in 1950, was the necessity to have an organising host society for the First International Congress of Allergology, which was held in Zurich on 23-29 September 1951. The principal organiser of this Congress was A. Grumbach, Professor of Microbiology in Zurich. Thirteen national allergy societies participated and on that occasion the “International Association of Allergology” (IAA) was founded, a further milestone for the promotion of allergology in Europe (S. Karger, Proceedings, Basel-New York, 1952). By the early 1960s, immunology was increasingly emerging as a new medical and scientific discipline, breaking old ties with microbiology and seeking independent recognition. First, a number of self-appointed “immunologists” from different scientific backgrounds including Henri Isliker (biochemistry), Ernst Sorkin (microbiology), Alfred Hässig (blood transfusion) and Alain de Weck (dermatology) wanted to create an independent immunological society. Instead, it was finally decided to combine the disciplines of allergology and immunology within one single society; the SSAI. This fruitful cooperation and combination of two closely related interdependent fields is still active and prosperous today.

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Allergology and Clinical Immunology as a medical specialty After some discussions among the different “main” specialties involved in managing allergic patients, first in 1977 a “Fähigkeitsausweis für Allergologie und klinische Immunologie”, and then in 1984 the subspecialty in allergology and clinical immunology, were created as an add-on formation of two years duration to the main specialties of dermatology, internal medicine, ENT, or pediatrics. In 2001, all the subspecialties of internal medicine became full specialties and allergology and clinical immunology was also transformed into a full specialty title with a formation of 6 years. Nevertheless, most physicians, who have so far acquired the specialty title in allergology and clinical immunology, still have a second specialty, either in internal medicine, dermatology, pediatrics or ENT. Currently in Switzerland approximately 184 holders of a specialty title in allergology and clinical immunology are active and members of the Swiss Society of Allergology and Immunology. Among these, 49 also have a title in dermatology (see Table 5), 87 in internal medicine, 26 in pediatrics, and 9 in ENT.

Outlook This short overview is far from complete and we apologise if I have inadvertently omitted any people who have contributed to the field of allergology in dermatology, or if there are any mistakes with regard to names or birth years etc. It is obvious that many dermatologists have played an important role in the development of allergology, which has emerged over the last 100 years, and which is now an independent medical specialty. This is not surprising since many inflammatory dermatoses, such as eczema, drug exanthems, urticaria, and cutaneous autoimmune disorders, but also tumors and infections, have a relation to the immune system. This close interrelation has resulted in many dermatologists also specialising in allergology and clinical immunology, and particularly in the German-speaking part of the world, many dermatologists are heading allergology units and departments, or are taking care of allergy patients in private practice. With the emergence of new aimed treatments

359 Spirit and Soul of Swiss Dermatology and Venereology with biological drugs in most medical specialties, the transversal specialties of allergology and clinical immunology have received a new stimulus and will remain important specialties in clinical medicine and research.

Andreas Bircher1, Barbara Ballmer-Weber2, Dagmar Simon3, Peter Schmid-Grendelmeier2, Brunello Wüthrich4

1 Allergy Unit, Dermatology Clinic, University Hospital Basel, Switzerland. 2 Allergy Unit, Department of Dermatology, University Hospital Zürich, Switzerland. 3 Department of Dermatology, Inselspital, Bern University Hospital, Bern, Switzerland. 4 Emeritus. Faculty of Medicine, University of Zürich.

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Table 1: Representatives in the field of allergology in Switzerland – The grandfathers (first half of the 20th century) • Josef Jadassohn, Bern (1863-1936) • Bruno Bloch, Basel/Zürich (1878-1933)

– The founders of allergology/clinical immunology (from the 1950s) • Basel - Wilhelm Lutz (1888-1958) - Rudolf Schuppli (1915-2006) - Ferdinand Wortmann (1919-1991) - Theo Rufli (1940-2008)

• Bern - Hans Kuske (1909-1970) - Alain L. de Weck (1928-2013) - Rolf Hoigné (1923-2004) - Alfred Krebs (1923-2011) - Ueli Müller (born 1941)

• Zurich - Guido Miescher (1887-1961) - Hans Stork (1910-1983) - Walther Burckhardt (1905-1971) - Brunello Wüthrich, Zürich (born 1938)

• Lausanne - Philippe Frei (born 1933) - Alain Pécoud (born 1946)

• Geneva - Werner Jadassohn (1897-1973) - Nicole Hunziker (born 1927) - Jean-Pierre (Othenin)-Girard (1923-1996) - Hubert Varonier (born 1932) - Jean-Hilaire Saurat (born 1943)

361 Spirit and Soul of Swiss Dermatology and Venereology

Table 2: The successors (from the 1990s to 2000) • Basel (Allergology in Dermatology) - Martin Pletscher (born 1950) 1986-1990 - Claudia Schülin (born 1958) 1990 - Andreas Bircher (born 1953) from 1991

• Bern (Allergology in Rheumatology) - Werner Pichler (born 1949) from 1994 - Arthur Helbling (born 1955) from 1995

• Bern (Dermatology) - Thomas Hunziker (born 1948) retired 2011 - Lasse Braathen (born 1942) retired 2007 - Nikhil Yawalkar (born 1962) from 1995 - Dagmar Simon (born 1960) from 2000

• Zurich (Allergology in Dermatology) - Peter Schmid-Grendelmeier (born 1959) from 2003 - Barbara Ballmer-Weber (born 1963) from 1997

• Zurich (Dermatology) - Leena Bruckner-Tudermann (born 1952) until 1993 - Peter Elsner (born 1955) until 1997 - Frank Nestle (born 1964)

• Lausanne (Allergology in Internal Medicine) - Francois Spertini (born 1955) from 1991 - Annette Leimgruber (born 1947)

• Lausanne (Dermatology) - Daniel Perrenoud (born 1959) - Paul Bigliardi (born 1964)

• Geneva (Allergology in Internal Medicine) - Barbara Polla (born 1950) - Conrad Hauser (born 1954) - Jörg Seebach (born 1964) since 2008

362 Allergology

• Geneva (Dermatology) - Pierre Piletta (born 1962) - Florence Pasche Koo (born 1964) - Lars French (born 1963) until 2007

Table 3: The University Clinics for Allergology and Clinical Immunology and their staff in 2013

• Basel (Dermatology Clinic) - Andreas Bircher - Kathrin Scherer

• Bern (Clinic for Rheumatology and Allergology) - Werner Pichler - Arthur Helbling

• Zürich (Dermatology Clinic) - Peter Schmid-Grendelmeier - Barbara Ballmer-Weber

• Zürich (Children’s hospital) - Alice Koehli-Wiesner - Roger Lauener

• Lausanne (Internal Medicine) - Francois Spertini - Annette Leimgruber

• Geneva (Internal Medicine) - Jörg Seebach - Thomas Harr

• Geneva (Children’s Hospital) - Philippe Eigenmann

363 Spirit and Soul of Swiss Dermatology and Venereology

Table 4: Other clinics with allergy sections • Aarau (Dermatology, Kantonsspital) - Jürgen Grabbe

• Aarau and Luzern (Pediatrics, Kantonsspital) - Peter Eng

• Bellinzona (Dermatology, Ospedale Regionale di Bellinzona e Valli) - Carlo Mainetti from 2001 - Silvy Bach-Bizzozero - Giovanni Ferrari

• Geneva (Hôpital de la Tour) - Pierre Gumowski

• Lausanne (Pediatrics CHUV) - Michaël Hofer

• Lugano (Servizio di Allergologia e Immunologia clinica, Ospedale Regionale di Lugano – Civico e Italiano) - Gianluca Vanini - Giovanni Ferrari

• Luzern (Dermatology, Kantonsspital) - Christoph Brand - Gerhard Müllner

• Mendrisio (Servizio di Allergologia e Immunologia clinica, Ospedale Regionale di Mendrisio Beata Vergine - Massimiliano Fontana

• St. Gallen (Dermatology, Kantonsspital) - Mark Anliker

• Winterthur (Internal Medicine, Kantonsspital) - Marianne Lerch (from 2011)

• Zürich (Triemlispital) - Stephan Lautenschlager - Siegfried Borelli

364 Allergology

Table 5: Double title holders in Dermatology and Allergology (members of the SSAI and/or FMH, in private practice or in Dermatology clinics, not mentioned in the text) Blank Armin, Zürich Bloch Peter Heinrich, Feldbrunnen Büchner Stanislaw, Basel Cajacob Andreas, Schaffhausen Disch Rainer Wolfgang, Davos Platz Dummer Reinhard, Zürich Egli Marja-Leena, Sissach (retired) Emmenegger Véronique, Lausanne Fäh Jürg, Wetzikon Fierz Ulrich (retired) Fischer Casagrande Barbra, Zürich Frey Werner, Chur (retired) Grillet Jean-Pierre, Genève Grob Martin, Dübendorf Gutzwiller Peter, Liestal (retired) Häffner Andreas, Zürich Hofbauer Günther, Zürich Huber Hanspeter (retired) Huwyler Toni, Wohlen AG Imhof Gex-Collet Caroline, Brig Inauen Patricia, Bern Kägi Martin, Zürich Kuhn Walter, Zürich Langauer Messmer Sabine, Basel Mazzi Rodolfo, Locarno (retired) Meyrat René, Chur (retired) Nestle Frank, London UK Pletscher Martin, Binningen Rüdlinger Rene, Zürich Scheidegger Paul, Brugg

365 Spirit and Soul of Swiss Dermatology and Venereology

Schuster Christian, St. Gallen Somazzi Stefano, Pregassona Stäger-Kosinski Joanna, Zürich Thürlimann Wolfgang, Zürich Torricelli Rocco, Lugano-Paradiso Trüeb Ralph, Zürich Tschannen Tanja, Zürich von Schulthess Zortea Anne, Baden Wyss Myriam, Meilen Zortea-Caflisch Claudia, Rapperswil

Table 6: The divisions for Contact Allergology and Occupational Dermatology in 2013

Basel (Dermatology Clinic, University Hospital) Andreas Bircher Kathrin Scherer-Hufurcier

Bern (Dermatology Clinic, University Hospital) Dagmar Simon

Zurich (Dermatology Clinic, University Hospital) Barbara Ballmer-Weber

Lausanne (Dermatology Clinic, CHUV) Philippe Sprung

Geneva (Dermatology Clinic, HUG) Pierre Piletta Florence Pasche Koo

Acknowledgement We are grateful for all the information and contributions kindly provided by Nicole Hunziker, Beat Imhof and Pierre Gumowski (Geneva), Philippe Frei (Lutry) and Ulrich Müller-Gierok (Bern).

366 Allergology

References 1. Prausnitz C, Küstner H, „Studien über die Überempfindlichkeit“, Zbl Bakt, n° 86, 1921, p. 160-169. 2. Coca AF, Cooke RA, “On the Classification of the Phenomena of Hypersensitiveness”, J Immunol, n° 8, 1923, p. 163-182. 3. Foussereau J, “History of epicutaneous testing: the blotting-paper and other methods”, Contact Dermatitis, n° 11, 1984, p. 219-223. 4. Bloch B, „Experimentelle Studien über das Wesen der Jodoformidiosynkrasie“, Z Exp Pathol Ther, n° 9, 1911, p. 509-538. 5. Bloch B, Steiner-Wourlisch A, „Die Sensibilisierung des Meerschweinchens gegen Primeln“, Arch Dermatol Res, n° 162, 1930, p. 349-378. 6. Bonnevie P, Aetiologie und Pathogenese der Ekzemkrankheiten. Klinische Studien über die Ursachen der Ekzeme unter besonderer Berücksichtigung des diagnostischen Wertes der Ekzemproben, Leipzig: Johann Ambrosius Barth Verlag, 1939. 7. Jadassohn W, Zaruski M, „Idiosynkrasie gegen Sellerie“, Arch Dermatol Res, n° 151, 1926, p. 93-97. 8. Geiges M, Bloch, B in: Löser C, Plewig G, (éd.), Pantheon der Dermatologie, Heidelberg/New York: Springer-Verlag, 2008. 9. Lutz W, „Zum Begriff der ‚Atopic Dermatitis‘“, Dermatologica, n° 115, 1957, p. 586-595. 10. Rufli T,Die Geschichte der Dermatologen und der Dermatologie an der Universität Basel 1460-1913. Die Geschichte der Dermatologischen Universitätsklinik Basel 1914-2005, Basel: Verlag Schwabe, 2008. 11. From Allergy to Immunology and back. 50 years Swiss Society for Allergology and Immunology. http://www.ssai-sgai.ch/index. php?id=275&L=0 “route” email %40hotmail.fr, (database on the Internet), 2012. 12. Storck H, „Bedeutung der Allergie im Krankheitsgeschehen“, Schweiz Rundschau Med, n° 32, 1948. 13. Schnyder UW, „Neurodermitis – Asthma – Rhinitis. Eine genetisch- allergologische Studie“, Int Arch Allergy Appl Immunol, n° 17, 1960, p. 100-106. 14. Frenk E, Dermatologie und Venerologie in der Schweiz. Ein historischer Rückblick, Neuchatel: Editions Alphil, 2004. 15. Hunziker N, Experimental Studies on Guinea Pig’s Eczema. Their Significance in Human Eczema, Berlin – Heidelberg – New York: Springer-Verlag, 1969.

367

Andrology

Andrology in Switzerland – the history of a fast growing discipline

If one were to compile a hierarchy of the most important medical disciplines today according to sociobiological criteria, gynaecology and its masculine counterpart andrology would have to be given first place. Both focus on women’s, or rather men’s, health and place top priority on the continuation of the human race. Although medicine is traditionally, and continues to be, a masculine domain, and andrology counsels almost 54% of humanity on the not unimportant questions of sexuality, reproduction and hormonal health, in many western countries it is still easily possible to count the number of andrologists on the fingers of one hand. The divergence of interest in women’s or rather men’s issues in the sciences, politics and society is reflected in the number of hits on a scientific database: the proportion of publications in the last 10 years in gynaecology vs. andrology comprises a remarkable 38:1. Andrology is by nature an interdisciplinary field in which endocrinologists, human geneticists, urologists, dermatologists, sexual and reproductive health physicians, oncologists, infectiologists and psychiatrists cooperate. The enormous diversity of andrology in particular initially hampered its independence. It has been practised as a subspecialty since around 1960, and although the overlap between the powerful gynaecologists, urologists and endocrinologists has at times at least partially furthered interests, it has at the same time, however, provoked unexpectedly strong professional conflicts of interest.

369 Spirit and Soul of Swiss Dermatology and Venereology

In the history of andrology in German-speaking countries the nice-sounding fairy tale is still peddled that it was the important links between venereal diseases and male infertility, which led to andrology becoming part of dermatology 50 years ago. It was and is clear to all venereologists, however, that this was not true then and is still not. It was more the case that a small number of excellent dermatologists attended to the orphaned young andrology. In particular the Kiel dermatologist Carl Schirren has earned great merit. His interest in reproductive medicine led him to establish the German Society for the Study of Fertility and Sterility, and then ultimately in 1976 he founded the German Society of Andrology (DGA). It was under his energetic leadership that the DGA had the additional term “andrology” accepted by the German Medical Association. Carl Schirren has always fought devotedly for his vision of an independent andrology. As so often in the past in politics and society, the history of andrology in Switzerland follows the German example exactly and with the proper time lag: It was mostly the dermatologists in German-speaking Switzerland, or rather the dermatological university clinics of German Switzerland, who offered at the very least rudimentary and quite straightforward further education possibilities and performed some research into the nineteen-nineties of the last century. The founding of the Swiss Society of Fertility-Sterility and Family Planning (SGFSF), as a melting pot of all those interested in reproductive questions, gave the few pioneering andrologists such as Alfred Eichmann a home. The SGFSF became the Swiss Society for Reproductive Medicine (SGRM) during Christian Sigg’s presidency, as a result of the success of artificial reproductive technology (ART). As in Germany, the founding of the Swiss Society for Andrology (SGA) in 1994 was the next logical step of independence. The protocols of the SGFSF from the founding year of the SGA give testament to the fact that professional conflicts of interest were also provoked in Switzerland. The gynaecologists demanded the suspension of Christian Sigg from the SGFSF, and the prohibition of an independent society of andrologists. Luckily this negative attitude was not accepted by the members. Over many decades the dermatological university clinics and the SGDV had the unique opportunity to take firm control of the promising and rapidly growing discipline of “andrology.”

370 Andrology

Despite all of the warning calls, the Swiss dermatologists – be it the university clinics themselves, the SGDV or individuals – were unable to take consistent professional and political action. Instead, training, research and clinic were relinquished to the gynaecologists, urologists and endocrinologists without a fight. As a result, none of the dermatological university clinics today offer a basic education in an andrology deserving of this name. A meaningful subspecialty could have been claimed however, which would have offered young dermatologists in particular a secure income and an extremely satisfying occupation in the increasingly difficult battle of skill distribution. The independent SGA must today, therefore, be given the competence to establish and strengthen the field of andrology. Perhaps young dermatologists will decide to establish themselves in “the new andrology,” however, in which case the last chapter of the history of andrology in dermatology may not yet have been written.

Christian Sigg

371

Angiology, Phlebology, Leg Ulcers

Vascular Medicine: Dermatologic Angiology and Phlebology

Vascular medicine in general and phlebology in particular are essential elements of dermatology. Until well into the nineteen- seventies, chronic venous insufficiency (CVI) was responsible for both very high healthcare costs and a very high burden of disease in western countries. The majority of these patients were treated by dermatologists, general practitioners and surgeons. It wasn’t until thrombosis prophylaxis was broadly introduced in all typical risk situations, and minimal invasive varicose vein surgery became more available that a notable reduction in severe venous disorders occurred. However, trophic skin disorders affecting the lower leg have persisted, although the causes are different. Arterial and arteriolar origins in particular are on the increase. The skin is also one of the most commonly affected organs in circulatory disorders of the smallest blood vessels, in conjunction with vasculitides, clotting disorders and haematological diseases. Non-dermatologists find it difficult to evaluate these results clinically and histologically, so that dermatology can and does play a large role in the diagnosis and treatment of microcirculatory disorders. Despite being a comparatively small nation, in the past 50 years Switzerland has made important contributions towards the research and treatment of cardiovascular disease and, perhaps as a reflection of these favourable circumstances, also in the area of phlebology described.

373 Spirit and Soul of Swiss Dermatology and Venereology

In the era before and around the founding of the Swiss Society of Phlebology in 1961 (Schweizerische Gesellschaft für Phlebologie; SGP), practical phlebology was primarily and very successfully carried out by practising dermatologists and general physicians based on empirical know-how. Without claiming to be exhaustive it is worth mentioning: Karl Sigg (Binningen), Alfred Bolliger (Zürich, not to be confused with the famous Zurich professor of angiology, Professor Alfred Bollinger), Léon Nencki (Bern), André Rétornaz (Fribourg), Igor Berson (Lausanne), Benjamin Aubort (Vevey), and François Gilliet (Bellinzona). Walter Goor (Zurich), Werner Blättler (Zurich), Reinhard Fischer (Wattwil) and Andreas Oesch (Bern) contributed greatly to the prosperity of the discipline and the specialist society in the first three decades of the SGP. Robert Muller (1919-2012) deserves particular mention, as he is to be credited for the reintroduction of ambulatory phlebectomy to modern medicine. With his characteristic down-to-earth modesty, Muller named his method “Celsus phlebectomy,” as he was familiar with classical ancient writings and was aware that the Romans had already mastered a similar technique. In the early years, many colleagues dismissed Muller, but this did not discourage him from tirelessly publicising his method in publications and innumerable lectures. Today the Muller phlebectomy counts indisputably as one of the most important principles of modern phlebology. It was adopted and further developed by a number of his students, including Ramelet.

Figure 1. Dr. Robert Muller

374 Angiology, Phlebology, Leg Ulcers

Albert-Adrien Ramelet, (*1948), practising dermatologist/ venereologist and angiologist, has himself written or edited a number of standard texts on phlebology. In his original work he focussed particularly on ambulatory phlebectomy, dermatological manifestations of venous disorders, and veno-active drugs. Due to his charisma and excellent leadership qualities, Ramelet was a member of the boards of innumerable specialist societies, including President of the Swiss Society of Phlebology (SGP; 1996-2004), and honorary SGP President since 2004, President of the Union of Swiss Societies for Vascular Medicine from 1996-1997 and 2000-2003, President of the Swiss Society of Dermatology and Venereology from 1987-1990 (and honorary member since 1991), President of the Association of French speaking Dermatologists from 2001-2005 and Chair of the financial committee of the European Academy of Dermatology and Venereology from 1996- 2001. A. A. Ramelet is an honorary member of numerous national societies for phlebology; he won a prize from the International League of Dermatological Societies in 2009, and also from the Australasian College of Phlebology. He was awarded an honoris causa doctorate from the University of Bern in 2012 for his extraordinarily impressive contribution to vascular medicine and phlebology. Thomas Hofer (*1952), practising dermatologist and phlebologist in Wettingen, made his name in the world of phlebology in particular as a result of his extremely thorough studies on recurrence rates and on peri- and pre-operative complications in everyday practice after varicose vein treatment. In addition, he has published on dermatological disorders, which he observed in conjunction with venous pathologies. Hofer was President of the Swiss Society of Dermatology and Venereology from 2007-2009 (and honorary member since 2013), board member of the Swiss Society of Phlebology from 2010-2013, and honorary SGP member since 2013. Walty Bayard (*1951) is a practising dermatologist and dermato-surgeon with the sub-specialty angiology. He was a board member of the Swiss Society of Phlebology from 1998-2008 and also the congress leader in this period. He contributed to the spread of the method of minimal invasive treatment for varicose veins, and that of cryo- and laser stripping through numerous lectures in Switzerland and abroad. He also contributed significantly to the

375 Spirit and Soul of Swiss Dermatology and Venereology creation of the sub-specialty angiology during this time period, so that dermatologists could also take on this title. He became an honorary member of the Swiss Society of Phlebology for his work in these areas, and also of the American Society of Phlebectomy. Following this period he was one of the founding members of the dermato-surgery working group of the SSDV and also organised a number of their events. Walty Bayard sees himself as a “bridge- builder” with the neighbouring disciplines and countries, a concept which is strongly supported in his biennial summer academy. Jurg Hafner (*1962), dermatologist and dermatologic surgeon, in addition angiologist and phlebologist, chose an academic path. He played a significant role in the development of dermatologic surgery at the University Dermatology Department of Zurich. His scientific interest reaches from the field of general dermatology and dermatologic surgery to vascular medicine and wound healing. In angiology and phlebology he contributed several original papers on new ways of compression therapy for chronic venous insufficiency, on Martorell hypertensive leg ulcer, calciphylaxis and the link to the Martorell pathology, and the complete array of differential diagnoses of leg ulcers, again with an emphasis on arterial disease in wound healing. He has been honoured with a scientific prize four times for his most important publications (twice from the SGP, once from the ÖGP and once from the SGA). Hafner has been a board member of the Swiss Society of Phlebology since 1999 and President of the Working Group for Dermatologic Angiology of the German Society of Dermatology (DDG) from 2001-2005. Since 2011 he has been the President of the Swiss Society of Dermatology and Venereology. These successes cannot hide the fact that phlebology has forfeited its earlier importance in dermatology. Dermatology and venereology have developed almost spectacularly in other areas, in particular in those of dermato-surgery and dermato-oncology, and also in the understanding and modern treatment possibilities of inflammatory skin disorders. On the technical side, the widespread introduction of duplex sonography in vascular medicine around 25 years ago led to the complete transfer of the diagnosis and treatment of phlebology from dermatology to angiology and vascular surgery. A dermatologist has to make substantial investments of both time and money for

376 Angiology, Phlebology, Leg Ulcers training if s/he wants to master duplex sonography alongside his/ her core profession. Reputable phlebology is inconceivable these days without duplex sonography. Of course “aesthetic phlebology,” which is the treatment of superficial varicose veins (or “spider veins”) with sclerotherapy, was a relevant aspect of phlebology in dermatological practice 20 years ago. Due to the rapid spread of “aesthetic medicine” (fillers, botulinum toxin, laser) a completely new field has opened up for practising dermatologists, which allows them to secure their material existence with services not covered by health insurance. This is one of the reasons phlebology has become less interesting in dermatological practice.

Figure 2. Phlebology in Dermatology (June 01, 2013) Left to right: Thomas Hofer, Jürg Hafner, Albert-Adrien Ramelet.

However, other innovations could help to bring phlebology back into the focus of dermatology in the future. Endovenous thermal ablation and foam sclerotherapy have superseded classical blood vessel surgery in the treatment of large calibre varicose veins. Those European countries which are harmonising their continuing education with the UEMS recommendations offer duplex sonography courses for non-angiologists. They are time-intensive,

377 Spirit and Soul of Swiss Dermatology and Venereology but offer a respectable introduction to vascular medicine, also for disciplines such as dermatology. Those SSDV dermatologists active in phlebology agree, that under the current conditions Swiss dermatology should make the effort of undertaking measures to once more anchor modern phlebology more securely in our discipline. Dermatology has an important role to play in the treatment of skin diseases associated with vascular disorders. Many of these clinical pictures require a multidisciplinary treatment approach. Young dermatologists with a good command of vascular medicine and vascular dermatology are necessary for the sake of the affected patients and to permit a satisfactory exchange with the neighbouring disciplines. The heads of the dermatology clinics and departments should aim to support young dermatologists with an interest in vascular medicine and phlebology, and the active dermatological opinion leaders of the SGP can do their bit to reinforce the presence of phlebology in dermatology and thus give dermatology active control over this interesting field.

Jürg Hafner, Thomas Hofer, Walter Bayard, Albert-Adrien Ramelet

378 Aesthetic Dermatology

tempora mutantur, nos et mutamur in illis – times change and we change with them

Development of Aesthetic Dermatology in Switzerland

Before 1995 aesthetic dermatology was almost unknown – then the lasers came up! Before 1995 aesthetic dermatology was in its infancy. At congresses only brief communications were presented, mainly on topics of aesthetic dermatological surgery, if ever. Deep peelings, as described by Baker and Gordon in the early sixties, were not very common in Europe and are still neglected today unfortunately. Dermatology was involved in a broad range of skin diseases and specialised in so many related fields such as allergology, andrology, venereal disease (STDs), phlebology, immunology, oncology, dermato-histopathology, and also interventional areas such as radiotherapy or (as mentioned) dermatological tumour surgery. Plastic surgeons were responsible for all kinds of aesthetic corrections including face-lifts, nose corrections and breast augmentation, not forgetting reconstructive surgery after injuries. The division of responsibility was unquestionable: dermatologists took care of ill patients, and plastic surgeons the aesthetic clients. There was a strong trend in other fields of medicine to find conservative alternatives for the sometimes risky and expensive surgical solutions (for example, gastrectomy after Billroth for ulcus ventriculi), and this trend did not stop at dermatology. As early

379 Spirit and Soul of Swiss Dermatology and Venereology as the mid-seventies, pioneers like L. Goldman or M. Landthaler recommended laser treatment for aesthetic skin disorders [1,2]. One can say that with the introduction of ablative lasers in the mid nineteen eighties and their worldwide spread at the beginning of the nineteen nineties, the first step in the evolution of aesthetic dermatology was taken. We had an alternative to surgical face- lifts for wrinkle treatment, and once the doctors had been trained, the results of the full-face ablative laser treatments (full-face resurfacing) were excellent. The discussion was no longer whether to use lasers to treat wrinkles or not, but which kind of laser is best for which indication. However, these treatments remained semi-surgical, requiring anaesthesia and full surgical equipment, and patients suffered from a very long recovery period. The price patients had to pay for undergoing full-face resurfacing was bleeding and crusting which lasted many days and several weeks, and sometimes even months of erythema. With the increasing popularity of ablative laser treatment physicians with poor or even no surgical or dermatological qualifications became interested in this technique, which led to a steep rise in complications such as milia, persistent erythema or even disfiguring scarring. This in turn discredited the whole laser community. Non-ablative systems which were more powerful and less likely to lead to side effects, in particular burning of the skin, were developed for pigmented lesions, hair removal or erythema and telangiectasia. These laser units were extremely expensive and physicians had to buy a separate unit for every single indication, which necessitated a significant investment for the treating doctor (laser clinics). The machines had to be amortised, and some physicians here and there tended to amortise first before making a correct diagnosis and therefore a correct indication. With the further development of lasers and the introduction of the so called IPL-technology (Intense Pulsed Light), the problem of the cost-intensive laser clinic was solved. These units – unlike lasers – had the advantage of managing all non-ablative laser indications with one single platform, as the filters of the treating head can be exchanged. The first generation of these machines was called “Photo-Derm,” and as skin burns with consecutive pigment alteration occurred on a regular basis, we used to call the unit “Photo-Burn!” Nowadays, with the processing of laser technology and the increased experience of treating dermatologists, such side-effects or complications are very rare. In order to protect patients from unprofessional treatment, however,

380 Aesthetic Dermatology dermatologists in Switzerland must be certified by the laser society. Societies and organisations for dermatology, laser and/or aesthetic dermatology must guarantee a complete and on-going regulation of the use of lasers. Nowadays lasers and IPL are very important tools in aesthetic dermatology.

Then along came Botox®! A milestone in aesthetic dermatology Botulinum toxin A was already well-known! In the late nineteen sixties Dr. Allan Scott, an ophthalmologist from San Francisco, developed a conservative drug treatment for strabismus as an alternative to the risky operation in those days (see above). The first monkey was successfully treated with botulinum toxin A in 1973, and two years later the first human being. Although the drug was recognised as being very potent for various neurological diseases, i.e. spasticities such as blepharospasm or torticollis, commercial success failed. Moreover, Scott had difficulties obtaining the brand name Occulinum®! However, in 1989 he succeded in getting FDA approval for strabismus and blepharospasm. It was his young assistant, Dr. Jean Carruthers, who discovered that patients treated with Botox® for blepharospasm had a relaxed and smooth face on the treated side compared to the non-treated side. Alan Scott reports in his publication “Development of botulinum toxin therapy” in 2004: “For many years, blepharospasmus patients returning for injection around the eyes and upper face would mention as a joke that they were back to get the wrinkles out…” Jean Carruthers reported her findings to her husband Alistair, a dermatologist from Vancouver, Canada. It was he who had the idea and the vision of treating healthy patients for their wrinkles with the most potent toxin known to mankind (next to nicotine). Under the title “Aesthetic indications for botulinum toxin injections,” Jean and Alistair Carruthers wrote a short note (without any abstract!) describing the possibility of a medical non-surgical treatment of wrinkles for the first time [3]. Still its tremendous success failed to appear. Almost at the same time, in 1994 in Wisconsin, a very different part of North America, Bushara wrote about the possibility of using botulinum toxin against axillary sweating, as he had noticed that patients treated for blepharospasm ceased sweating in the treated area. Two years later he confirmed his findings [4]. It remains a subject of speculation as to who or which incident made Botox® so famous. Most probably

381 Spirit and Soul of Swiss Dermatology and Venereology it is a combination of different findings almost simultaneously. Undoubtedly, however, without the indication of hyperhidrosis, the drug would never have reached the overwhelming status it has today. The relatively easy to perform procedure of injecting Botox® for axillary hyperhidrosis led to enormous spread of the use of the drug at that time. Furthermore, we should not forget that in those days, every aspect of aesthetics was in the hands of the plastic surgeons, and the injection of botulinum into the facial musculature still remains a difficult procedure. The simple technique for the treatment of axillary hyperhidrosis, however, allowed many physicians the world over to become familiar with this specific drug, and through the experience gained by injecting many patients with hyperhidrosis they learned the skills to treat other indications such as aesthetic indications.

Technique follows clinic [5] The first indication for botulinum in aesthetic dermatology was the glabella. Many trials and studies were performed regarding this specific area. Due to the successful scientific reports, the drug received approval in the USA, Europe, the Middle-East and Asia for this specific indication. Even now all other indications remain off-label. At the beginning of the Botox® era, both physicians and patients were enthusiastic that it was possible to remove wrinkles with a simple injection, and this fact alone made an indication seem superfluous. In the first few years many treatments were performed without pre-defined indication or diagnosis. The possibility of treatment was indication enough! With experience, physicians extended their skills to other areas of the face. They began to smooth the forehead, crow’s feet and even tackled asymmetries. In the next step, dermatologists dared to inject the lower part of the face, with its sensitive balance of agonists and antagonists of the expressive muscles. It was even discovered that a lifting effect of the face could be achieved by treating the depressors of the lower face [6]. This was the first step towards treating the whole face. It also became clear that we cannot treat each patient according to the same injection scheme, but that the technique needs to be individually adapted in order to achieve excellent results [5]. The most important lesson is, however: no therapy without a diagnosis

382 Aesthetic Dermatology and treatment plan! This is what demonstrates the in-depth knowledge of dermatologists and qualifies them to treat patients with botulinum toxin A in aesthetic indications. It is possible that in the years of enthusiasm these golden rules were neglected a little bit. With the years other brands exept Botox® (Vistabel® for aesthetic indications) came on the market. Next to the only available botulinum toxin B (Neurobloc®) two other botulinum toxin A are labelled for glabella treatment in Europe and Switzerland: Bocouture® (Xeomin® for medical indication) and Azzalure® (Dysport® for medical indication). Worldwide many different brands are available. It is strictly recommended to use only brands with enough clinical data and label from the authorities.

Wrinkles are not wrinkles! Fillers become more and more important Botulinum weakens the muscle by blocking presynaptic acetylcholine release from the nerve endings. This implies that with botulinum toxin A we can only treat expressive or dynamic wrinkles, in other words wrinkles caused by muscle activity. Therefore botulinum toxin A is not effective for static wrinkles due to volume loss and/or gravity. To treat this problem we need fillers. Fillers have existed for decades! The very first fat transplant was performed by Neuber in 1893 [7] on a patient with disfiguring tuberculosis of the face. At the turn of the century, heroic augmentation was performed with vaseline and paraffin, usually with disastrous results. Over 50,000 women in the US alone received silicon augmentation (mainly breast) in the nineteen fifties and sixties. In the nineteen eighties collagen implants were highly popular, mainly for lip correction. The first collagen filler to receive FDA approval was Zyderm®. Real complications such as disfiguring granulomas – although very rare – and “soft” complications such as overcorrections impaired the reputation of fillers. Production of the last commercially available collagen filler Evolence® was stopped in 2009. Hyaluronic Acid (HA) is a physiological protein (glycosaminoglycan) which occurs in the skin, the synovia or the corpus vitreum of the eye. The first commercially available HA for aesthetic use was introduced in 1996 under the brand name Hyaloform® for aesthetic use. Since then many different HAs in

383 Spirit and Soul of Swiss Dermatology and Venereology different viscosities have been developed for different indications and are on the market. As mentioned before, the learning curve in aesthetic dermatology was steep and still is. The knowledge gained from treating patients with botulinum was also very useful for filler treatments, and the steps were very similar: from one-wrinkle-concept (i.e. nasolabial folds or lip) to full face sculpturing (after Kreyden) [8]. This holistic point of view needed to be developed, however. The introduction by Dr. B. Hertzog, a plastic surgeon from Paris, France, of long blunt cannulas was another milestone in this trend towards a holistic approach [9]. These cannulas allowed a large area to be volumised from one injection point, instead of filling a small wrinkle for the first time. A homogenous augmentation of the whole cheek area was possible with this new technique for the very first time. Depending on the diagnosis and the indication, a combination of different tools (filler, botulinum, laser, peeling) did the rest: Modern aesthetic dermatology departed from the idea of correcting one single spot just because we have the tools to do so. Modern aesthetic dermatology acts to sculpt the face, or in other words to perform full face sculptering [8]!

SGEDS (Swiss Group of Esthetic Dermatology and Skincare) – aesthetic dermatology becomes acceptable For a very long time – and still sometimes today – aesthetic dermatology was not accepted by the Dermatological Departments of the University Faculties. The authorities feared that aesthetic dermatology would compete with classic dermatology. And in fact at congresses there was a strong tendency, mainly in young dermatologists, to follow more aesthetic topics than to present classical dermatology problems. So we can understand the arguments that dermatology will lose its good reputation when well- educated specialists begin to treat patients for aesthetic reasons, departing from the treatment of illness. The principal purpose of physicians, to cure patients, was considered to have been damaged. Therefore the predominant opinion was that the field of aesthetic dermatology should not be occupied by physicians, but only by cosmeticians as it had been years before. However, as mentioned before, the immense interest in aesthetic dermatology worldwide could no longer be stopped. In 2007 “Skin Care” was integrated

384 Aesthetic Dermatology into the catalogue of education for the qualification of young dermatologists in Switzerland. Young dermatologists in training are to gain “knowledge in practice for preventive procedures of the healthy and ill skin.” Therefore, in the autumn of the very same year, the author of this article was mandated by the President of the SSDV Professor Peter Itin to found a working group under the patronage of the Society. On Friday the 6th of June 2008, the first study group of aesthetic dermatology in Switzerland was founded by Dr. Oliver Ph. Kreyden. The group began under the motto: “Results are admired, projects are underestimated!” (Friedrich Nietzsche, 1844-1900). 9 dermatologists founded the SGEDS (Swiss Group of Esthetic Dermatology and Skincare). The criteria for membership were an interest and experience in aesthetic dermatology, or at least in a branch of the field (i.e. laser, peeling, skin care). We wanted to have a representative from each University Clinic (Basel, Bern, Geneva, Lausanne and Zurich), and it seemed important to integrate members of all three language parts of Switzerland (German, French and Italian). The aim of the group is teaching and research in the field of aesthetic dermatology. The SGEDS is active every year with a workshop at the Annual General Meeting of the SSDV. These workshops are very popular as each year a different topic is discussed with an international speaker panel or live workshops with a great “Take-Home-Message” impact. During the year the SGEDS organises several meetings and continuing education events in private clinic or other dermatological congresses (Hyperhidrosis Courses, Facial Courses, Peeling Courses). Most of the SGEDS- members are active in lecturing, both at national and international congresses; some of them are board members of important national or international societies such as ESCAD (European Society of Cosmetic and Aesthetic Dermatology), IPS (International Peeling Society) or SGML (Swiss Society of Medical Lasers). With seats in international societies and/or lecturing at international congresses the SGEDS represents Switzerland’s dermatological activity in foreign countries. The SGEDS is very interested in publishing practical papers for the practising dermatologist or the young dermatologist in training. Therefore we started a regular column in a dermatological paper, where all of the different facets of aesthetic dermatology are presented or critically discussed. The SGEDS has been open to all interested members of the SSDV since 2010. The SGEDS therefore established a board and created statutes. The main aim of the SGEDS is to become completely

385 Spirit and Soul of Swiss Dermatology and Venereology integrated into the education plan of young dermatologists with lectures at university. I would therefore like to conclude with Plato: The beginning is the most important part of any work. There are too many people around who start a project and do not finish it. We have to take it step by step; efficiently, determined and goal-oriented. Let’s go for it! Oliver Ph. Kreyden, Monika Hess, Philippe Lévy

386 Aesthetic Dermatology

Figure 1. For the very first time we could treat wrinkles without surgery using botulinum. This was a milestone in aesthetic dermatology

Figure 2. Next we treated asymmetries with botulinum

Figure 3. We began to correct unique folds or lips using fillers…

Figure 4. … Before we developed Full Face Sculpturing: A combination of possibilities with the aim of harmonising the whole face and not only correcting one single section [8]

387 Spirit and Soul of Swiss Dermatology and Venereology

References 1. Goldman L. Effects of new Laser Systems on Skin. Arch. Dermatol. 1973 Sep; 108(3): 38590. 2. Landthaler M, Haina D, Waidelich W, Braun Falco O. Therapeutic Use of Lasers in Dermatology. Hautarzt. 1981 Aug; 32(8): 397-401. 3. Carruthers A, Carruthers. Aesthetic indications for botulinum toxin injections. Plast Reconstr. Surg. 1995 Feb(2): 427-8. 4. Bushara KO, Park DM, Jones JC, Schutta HS. Botulinum toxin- a possible new treatment for axillary hyperhidrosis. Clin Exp Dermatol. 1996 Jul; 21(4): 276-8. 5. Kreyden OP. Botulinum and Men. Gender Specific Treatment Concepts. In: Fortschritte der praktischen Dermatologie und Venerologie. Band 21 (2008). Kurs 16 Botulinumtoxin A. p. 452-58. 6. Lévy Ph. The Neferditi lift: a new technique for specific re-contouring of the jawline. J Cosmet Laser Ther. 2007 Dec; 9(4): 249-52. 7. Neuber F. Fetttransplantation: Chir Kongr Verhandl. DtschGesChir 1893 22: 66. 8. Kreyden OP. Development of Aesthetic Dermatology. From the first Corrective Wrinkle Treatment to the Full Face Sculptering. Dermatologie Praxis 2011. (5): 12-15 9. Hertzog B, André P. The flexible needle, a safe and easy new technique to inject the face. J Cosmet Dermatol 2010. Sept. 9(3): 251-20

388 Genetic Diseases in Dermatology

Genetic Diseases in Swiss Dermatology

Descriptions of genetic skin diseases date back at least 2000 years. There are about 10,000 monogenic diseases described and a third of them feature cutaneous manifestations. Swiss dermatology has contributed greatly to this field. Interestingly, the Swiss Society of Genetics was only established in 1941.

In 1895 Joseph Jadassohn described nevus sebaceous, which is now recognised as a somatic mosaicism due to postzygotic HRAS and KRAS mutations. Josef Jadassohn was born 1863 in Liegnitz, Schlesien. In 1896, he was elected to extraordinarius and Director of the University of Bern Dermatology Clinic. As a student of Neisser in Breslau, he promoted the application of laboratory techniques to drive dermatological research, an aim which he transmitted to his many scholars, among them also Bruno Bloch. In 1906 Jadassohn and his student Lewandowsky first described pachyonychia congenita. This autosomal dominant inherited disease is caused by mutations in keratin genes 6A, 6B, 16 or 17. Felix Lewandowsky was born in 1879 in Hamburg, Germany, he worked from 1903 to 1907 at the Dermatology Clinic in Bern, Switzerland, and then returned back to Hamburg. In 1917 he was invited to Basel as ordinarius and Director of the Dermatology Clinic but died in early 1921 in Basel. In 1922 Dermatologica received a manuscript on Epidermodysplasia verruciformis written by Lewandowsky and Lutz. This autosomal dominant genodermatosis is caused by mutations in the EVER genes. Lutz was the third Director of Dermatology in Basel and described

389 Spirit and Soul of Swiss Dermatology and Venereology in 1953, together with Miescher, elastosis perforans serpiginosa, which can occur in numerous genodermatoses including Ehlers Danlos syndrome, Marfan syndrome, pseudoxanthoma elasticum, Rothmund Thomson syndrome and osteogenesis imperfecta.

In 1926 Incontinentia pigmenti, an x-linked genodermatosis, was brought to literature by Bloch and Sulzberger, his younger American colleague and assistant. A mutation in the NEMO gene is the cause of the disease. Bruno Bloch, born 1878 in Endingen, Aargau was the first Head of Dermatology at the University Hospital in Basel, and was later appointed Director of the Dermatology Clinic in Zürich. In 1927 Oscar Naegeli from Bern described the chromatophore nevus, which today is called Naegeli-Franceschetti-Jadassohn syndrome. This original large family has been reinvestigated by Itin from Basel and together with Eli Sprecher a mutation in keratin 14 was found. In 1957 Sommacal-Schopf and Schnyder reported a large Swiss family with erythrokeratodermia figurata variabilis. With the help of this family the gene causing the mutation for this rare genodermatosis was found. It was the first connexin mutation reported (connexin 31), and was published in Nature Genetics in 1998 with the cooperation of Peter Itin and Daniel Hohl. Urs Schnyder, from Solothurn in Switzerland was a pupil of Miescher and Director of Dermatology in Heidelberg, and later at the University Hospital in Zürich. He made important contributions to the ultrastructure of genetic disorders of the skin. After him a benign variant of junctional epidermolysis bullosa was named, which he individualised together with his Japanese assistant Hashimoto from a pedigree in the Swiss Alps (Disentis type). Using electron microscopy together with Ewald Weibel, a prominent biologist from the University of Bern, he reported in 1966, “On the ultrastructure and histochemistry of granular degeneration in vesicular ichthyosiform congenital erythrodermia,” and postulated that a genetic modification in the tonofilaments was its cause. This hypothesis was confirmed only 25 years later by the identification of dominant negative mutations in keratin genes 1 and 10 as the cause of epidermolytic ichthyosis in families provided by Frenk and Hohl. Schnyder also described erythrokeratodermia with deafness, now known as KID syndrome, which is due to connexin 26 mutations. In 1969 Schnyder documented several families on the island of Meleda with the maladie de Meleda autochtone. In 2001 the group

390 Genetic Diseases in Dermatology around Judith Fischer, and in cooperation with Daniel Hohl, found SLURP-1 mutations in this entity. Finally, Schnyder observed that sporadic tumors occur alone and in adulthood, whereas autosomal dominant inherited tumors appear earlier in life and are often numerous. This fact has been called Schnyder’s rule. Finally, Urs Schnyder had many prominent pupils, among them also the well- known Erwin Schöpf and Leena Bruckner-Tuderman, a former and actual Chair of Dermatology in Freiburg im Breisgau in Germany. Edgar Frenk and his colleague Barukh Mevorah from Lausanne had a major interest in genodermatoses and contributed to the further histological delineation of Naegeli-Franceschetti-Jadassohn syndrome and mutation analysis in Hermansky Pudlak syndrome. In 1985 Huber and Hohl from Lausanne published on mutations in transglutaminase 1 in autosomal recessive lamellar ichthyosis. This group contributed to the elucidation of the cornified envelope and first described several of its protein components; notably loricrin and its flawed expression in this rare congenital ichthyosis. Mevorah and Hohl later first reported connexin 30.3 mutations to cause an erythema gyratum repens like a variant of erythrokeratodermia figurata variabilis, now known as the Cram-Mevorah type. In 1991 a new trichothiodystrophy subtype with neutropenia and mental retardation was described and referred to in the literature as Itin syndrome. In 2011 a mutation in SMARCAD was found to be the reason for isolated familial adermatoglyphia in a patient clinically investigated by Itin, and molecular genetic work was carried out by Sprecher in Israel. Isolated adermatoglyphia has been called Immigration Delay disease by the group of Itin et al. In 2012 the first inherited case of PENS was described by Tadini in cooperation with Itin.

Peter Itin, Daniel Hohl

391

Dermatological Immunology

Immunological Function of the Skin

The skin is the major interface between an organism and its environment. While previously thought to represent mostly a physical barrier, today it has become clear that the skin must be regarded as an important immune organ. The following will provide a brief overview of immunologically active cells present in the skin.

Keratinocytes The epidermis consists primarily of keratinocytes. In contrast to the previous belief that keratinocytes had a mainly mechanical function as “bricks in a wall,” today we know that keratinocytes actually produce an array of immune mediators. [1] In response to pathogen-associated molecular patterns (PAMPs), or danger- associated molecular patterns (DAMPs), keratinocytes produce anti-microbial peptides such as β-defensin and cathelecidin. Keratinocytes also produce pro-inflammatory cytokines such as IL-1α, IL-1β, IL-6, and TNFα. Such keratinocyte-derived pro- inflammatory mediators, together with chemokines such as CXCL8, act on post-endothelial venules to enhance the extravasation of immune cells from blood to skin, including neutrophils, monocytes, plasmacytoid dendritic cells (pDCs), natural killer cells (NK cells), and T cells.

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Langerhans cells (LCs)

LCs are localized in the basal epidermis, and their dendrites form a dense immunological filter for microbes that were able to pass the stratum corneum and have reached the live layers of the epidermis. LCs phagocytose microbes: via receptors recognizing pathogen- associated molecular patterns or dander-associated molecular patterns, as well as being mediated by the proinflammatory cytokines produced by activated keratinocytes, LCs become active and migrate from the skin into the regional draining lymph nodes. Once there, LCs mature to gain an enhanced capacity of antigen presentation to T cells. [2]

Dermal dendritic cells

While Langerhans cells are mainly involved in inducing T cell responses, dermal dendritic cells migrate to those areas of the lymph node that stimulate B cell responses and it is known that dermal DCs are important for the induction of humoral immunity. [3]

T cells

Th1 cells are characterized by IFN-γ and IL-2 production. [4] Th1 cells regulate immunity against intracellular pathogens, such as viruses and bacteria, but also against tumors. IFN-γ is important in stimulating macrophages to enhance their phagocytic activity. IFN-γ also enhances the killing of phagocytosed microbes by the induction of oxidative bursts. Furthermore, IFN-γ upregulates the expression of class I and class II MHC molecules and adhesion molecules on keratinocytes and dermal fibroblasts, thus enhancing their potential to present antigens to the immune system. On the other hand, Th1 cells are the main mediators of delayed type hypersensitivity such as allergic contact dermatitis.

Th2 cells are characterized by IL-4, IL-5, IL-10, and IL-13 production. [4] IL-5 stimulates the production of eosinophils in the bone marrow and in tissues it is chemotactic for eosinophils, so that Th2-mediated responses are characterized by an eosinophil- rich inflammatory infiltration. Th2 cells are important regulators of the humoral immune response. Also, IL-4 and IL-13 activate

394 Dermatological Immunology antibody class-switching to IgE. Th2 cells appear to play a critical role in atopy.

Th17 cells are characterized by the production of IL-17, IL-21, and IL-22. [4] Th17 cells are important effectors against bacterial and fungal infections. Both forms of IL-17, i.e. IL-17A and -17F, enhance protective immune responses by inducing the production of chemokines, G-CSF, and antimicrobial peptides. The Th17 cytokines IL-17 and IL-22 turned out to be important mediators in psoriasis.

Regulatory T cells (Treg) are CD4+ T cells which downregulate the immune system. [5] There exist naturally occurring Tregs, and Tregs induced by antigens. In the skin approx. 5-10% of all T cells are Tregs. Tregs inhibit and downregulate immune responses at several levels by the production of immune suppressive cytokines IL-10 and TGF-β, as well as by immunoregulatory surface molecules including CTLA-4.

CD8 T cells produce IFN-γ but cal also kill other cells via the so called killer molecules perforin, Fas-L, and granzyme B[4]. IFN-γ production and cytotoxic activity make CD8 T cells important effectors against virally infected cells and tumor cells. The presence of CD8 T cells in tumor tissues is a good prognostic factor for certain types of cancer, and the cytotoxic activity of CD8 T cells also plays a role in allergic contact dermatitis.

T cells, in contrast to the above T cells, which all have a T cell receptor consisting of an α- and a β chain, they express a T-cell receptor composed of a gamma and a delta chain. γδT cells reside in the epithelial tissues of the skin, gut, lung, and reproductive tract. Their function is to provide a first line of defense against pathogens. γδT cells in skin recognize microbial and stress- or damage- induced tissue antigens which are presented by non-classical MHC molecules, such as CD1 molecules and can therefore rapidly mount responses to pathogenic stimuli. [6]

Mast cells The skin contains a high density of mast cells. While well known for the production of histamine, mast cells produce a large array of immune mediators such as heparin, proteases, TNF-α, GM-CSF,

395 Spirit and Soul of Swiss Dermatology and Venereology

IL-3, IL-4, IL-5, IL-6, IL-8, and IL-13. Mast cells also produce prostaglandins and leukotrienes. Mast cells typically concentrate around blood vessels and they play an important role in causing the vasodilation and extravasation of immune cells into inflammed tissues. [7] When deregulated, mast cells play a central role in urticaria.

Adipocytes Beneath the dermis is the subcutaneous tissue, which consists mainly of adipocytes. Adipocytes express cytokines, chemokines, multiple receptors, cell adhesion molecules and MHC class II molecules capable of CD4 T cell induction. [8] It is well known that obesity induces chronic inflammation, which finally results in insulin resistance, type 2 diabetes, inflammation and cardiovascular disease. Obesity is also associated with psoriasis.

Antimicrobial peptides The skin is an important production site for antimicrobial peptides. These peptides exert their antimicrobial effects by disrupting the cell membranes of bacteria, fungi and viruses. The two best characterized antimicrobial peptides in the skin, cathelicidins and β-defensins, are mainly produced by keratinocytes, but also by many other cells. Cathelicidins are secreted as a precursor protein, which is then processed into the active form called LL-37. Any kind of infection or disruption of the epidermis causes upregulation of cathelicidine production. As an additional function, cathelicidins and defensins interact with various receptors on immune cells to enhance innate and adaptive immune responses. [9] Overexpression of antimicrobial peptides appears to play a role in the pathogenesis of psoriasis and rosacea.

The inflammasome Over the past decade the initial steps of starting inflammation have been elucidated. A large number of stimuli, typically present in pathogens, but also physical stimuli such as cholesterol or urate crystals lead to the oligomerization of a multiprotein complex promoting the maturation of the inflammatory cytokines IL-1β, IL-1α and IL-18. [10] In contrast to classical immune cells such

396 Dermatological Immunology as macrophages or dendritic cells, keratinocytes constitutively express inflammasome proteins, as well as pro-IL-1, pro-IL1. Physical stimuli and, for example, radiation with UVB induces the secretion of pro-IL-1 and of mature and active IL-1β. [11] This explains why various dermatoses can be aggravated or even provoked by physical stimuli such as scratching, and also explains how UV exposure can lead to the sunburn reaction.

The skin microbiome While historically the skin was regarded mainly as a physical barrier against microorganisms in the environment, today, with the development of molecular methods to more precisely identify microorganisms, a rather different picture has emerged, e.g. the perception of the skin as an ecosystem which provides diverse habitats for numerous bacteria. [12] These habitats include the skin surface, sweat glands, sebaceous glands, hair follicles, but also various skin regions, such as skin folds vs. other regions. These different habitats, as well as environmental factors such as body hygiene, significantly influence the composition of skin bacteria. The bacteria living on the skin are in a delicate balance with the skin’s immune system. On the one hand, the immune system modulates the skin microbiome, but on the other hand the skin microbiome also modulates the immune system of the skin. The fact that excessive bathing, washing, use of soaps vs. emollients etc. has an important influence on skin diseases can readily be observed, and it appears that these positive effects, at least in part, are explained by influencing the skin microbiome.

Immunology and Dermatology in Switzerland In the early 1970s the rapidly growing understanding of lymphocyte function led to an enormously growing interest in immunology, and numerous institutes were founded across Switzerland. These included the Institute for Allergy and Clinical Immunology at the University of Berne headed by Professor Alain de Weck, known for his pioneering work on penicillin and other drug allergies. At the University of Zurich Professor Jean Lindenmann headed the Institute for Immunology and Virology where, together with a British colleague, he discovered the first cytokine, i.e. Interferon. Professor Rolf Zinkernagel founded the Institute for

397 Spirit and Soul of Swiss Dermatology and Venereology

Experimental Immunology within the Pathology Department. His pioneering work on MHC restriction and the thymus led to the understanding of T cell function and was honored with the Nobel Prize for Medicine in 1996. The Institute for Clinical Immunology was headed by Professor Peter Grob, who was the driving force behind HIV prevention in drug users. In Geneva Professor André Cruchaud became Head of Allergy and Clinical Immunology, and Professor Jean-Michel Dayer performed ground breaking work on pro-inflammatory cytokines. In addition to the above university institutes, a number of independent immunology institutes were founded in Switzerland. These include the Institute for Immunology in Basel under the direction of Professor Niels Jerne, who proposed the immune network theory and was awarded the Nobel Prize in 1984. The later Director of the Basel Institute for Immunology Professor Fritz Melchers contributed much to our modern understanding of B cell function. The Ludwig Institute for Cancer Research founded a branch in Lausanne, headed by Professor Jean-Charles Cerottini, performing important work in cancer immunology. Also in Lausanne, immunologist Professor Henri Isliker became Head of the newly founded Swiss Insitutute for Experimental Cancer Research (ISREC). In Davos the Swiss Institute of Allergy and Asthma research (SIAF) was built and directed by Professor Kurt Blaser. The latest institute is the Institute for Research In Biomedicine directed by Professor Antonio Lanzavecchia. The above mentioned Swiss institutions have positioned Switzerland as a world leading nation in immunology, as recognized by Nobel Prizes and countless other international prestigious awards. The fact that the majority of allergologists and clinical immunologists in Switzerland are actually dermatologists by training has led to a strong cross fertilization of immunological know-how into Swiss dermatology departments, where the majority of researchers were trained or collaborated closely with one or more of these Swiss immunology institutes.[13]

Thomas M. Kündig

398 Dermatological Immunology

References 1. Nickoloff BJ, Naidu Y, “Perturbation of epidermal barrier function correlates with initiation of cytokine cascade in human skin”, J Am Acad Dermatol, n° 30, 1994, p. 535-546. 2. Igyarto BZ, Kaplan DH, “Antigen presentation by Langerhans cells”, Curr Opin Immunol, n° 25, 2013, p. 115-119. 3. Klechevsky E, Morita R, Liu M, Cao Y, Coquery S, Thompson-Snipes L, et al, “Functional specializations of human epidermal Langerhans cells and CD14+ dermal dendritic cells”, Immunity, n° 29, 2008, p. 497-510. 4. Muller SN, Gebhardt T, Carbone FR, Heath WR, “Memory T cell subsets, migration patterns, and tissue residence”, Annu Rev Immunol, n° 31, 2013, p. 137-161. 5. Ohkura N, Kitagawa Y, Sakaguchi S, “Development and maintenance of regulatory T cells”, Immunity, n° 38, 2013, p. 414-423. 6. Ferreira LM, “Gammadelta T Cells: Innately Adaptive Immune Cells?”, Int Rev Immunol, 2013. 7. Kumar V, Sharma A, “Mast cells: emerging sentinel innate immune cells with diverse role in immunity”, Mol Immunol, n° 48, 2010, p. 14-25. 8. Meijer K, de Vries M, Al-Lahham S, Bruinenberg M, Weening D, Dijkstra M, et al, “Human primary adipocytes exhibit immune cell function: adipocytes prime inflammation independent of macrophages”, PLoS One, n° 6, 2011, p. 17154. 9. Steinstraesser L, Kraneburg U, Jacobsen F, Al-Benna S, “Host defense peptides and their antimicrobial-immunomodulatory duality”, Immunobiology, n° 216, 2011, p. 322-333. 10. Strowig T, Henao-Mejia J, Elinav E, Flavell R, “Inflammasomes in health and disease”, Nature, n° 481, 2012, p. 278-286. 11. Feldmeyer L, Werner S, French LE, Beer HD, “Interleukin-1, inflammasomes and the skin”,Eur J Cell Biol, n° 89, 2010, p. 638-644. 12. Grice EA, Segre JA, “The skin microbiome”, Nat Rev Microbiol, n° 9, 2011, p. 244-253. 13. Adapted from http://www.ssai-sgai.ch/

399

Dermatology in immunosuppressed patients

Dermatology in the immunosuppressed patient

For the working group Organ Transplantation of the Swiss Society of Dermatology and Venereology.

Introduction Towards the end of the last century, after the wave of HIV and AIDS had defined new dimensions of skin disease, dermatologists started to notice a distinct group of patients characterised by a very high load of skin cancer, in particular squamous cell carcinoma of the skin. These patients frequently also suffered from inflammatory and infectious skin diseases beyond the scope of what is normal. While, at first, mainly surgeons in dermatology noticed that some patients showed disturbing numbers of invasive skin cancer, the notion of this particular risk group soon began to spread also among the more medically oriented dermatologists. Some clinician-researchers in the 1980s and 1990s delineated that chronic immunosuppression was a unifying risk factor for these patients. The main patient group became apparent as solid organ transplant recipients who, after receiving an allograft, were put on life-long immunosuppressive drugs to prevent organ rejection and maintain its function. Nowadays, other kinds of chronic immune dysfunction, mostly focusing on cellular dysfunction of the adaptive immune system, have been described, foremost chronic lymphatic leukemia (CLL), but also HIV infection, thymoma, with natural

401 Spirit and Soul of Swiss Dermatology and Venereology cellular immune deficiency, but also chronic inflammatory diseases in need of long-term immunosuppression such as psoriasis, arthritis and inflammatory bowel.

The past Solid organ transplant recipients (OTR) were first noticed as a patient group at risk in countries such as Australia and New Zealand where incidence rates for squamous cell carcinoma of the skin (SCC) reached 250 times the incidence in the general population. Data starting from the 1960s onwards showed that 80% of all OTR had suffered from SCC at least once in 20 years after transplantation. The hazard increased right after transplantation and remained high throughout the period of drug-induced immunosuppression.

Figure 1. Uncommon presentation of a common disease in the setting of organ transplantation: Triple fungal infection with onychomycosis, tinea corporis and granuloma trichophyticum Majocchi.

While organ transplantation became more and more successful and sustained by the improved matching of donor and recipient, advanced surgical techniques and the refinement of immunosuppressive regimens including the cornerstone of calcineurin inhibitors, the overall survival for each OTR increased. At the same time the indication for organ transplantation was

402 Dermatology in immunosuppressed patients extended, including older recipients for instance. These factors resulted in greatly increasing numbers of living OTR and in need of continued follow-up to secure the long-term success of transplantation. In Australia, thirty years ago, one quarter of all heart transplant recipients who reached a survival of four years or more after transplantation, and thus represented the real winners in organ transplantation lived just long enough to succumb to metastatic SCC, cutting an otherwise bright outlook on many years of life as an OTR short: Estimates from incidence data showed that up to 20% of all SCC occurring in OTR became metastatic and eventually were the leading medical concern in these patients. Younger OTR stuck out as particularly grim examples when organ transplantation allowed them a renewed lease on life, only to be set back by high numbers of metastatic SCC for which there was – and is – no established curative treatment.

Figure 2. Uncommon presentation of common disease in the setting of organ transplantation: Viral folliculitis barbae caused by molluscum contagiosum.

Registries such as the Cincinnati Transplant Tumor Registry established by I. Penn, MD, in 1970 and the Australian and New Zealand Transplant Registry were among the first to document the surge in skin cancer occurrence. Dermatological surgeons, and in particular micrographic surgeons, became overwhelmed with

403 Spirit and Soul of Swiss Dermatology and Venereology

Figure 3. Uncommon presentation of a common disease in the setting of organ transplantation: Field cancerisation of the skin with multiple rapidly arising squamous cell carcinomas.

the sheer numbers, the rapid growth and aggressive behavior of SCC in the group of OTR. The need for a structured approach was evident, and the interest of dermatologists confronted with OTR began to focus on the high-risk of malignant tumors. Informal networks arose and led to the establishment of the International Transplant Skin Care Collaborative (ITSCC), uniting mainly surgical dermatologists predominantly from Northern America and the establishment of the Skin Care in Organ Transplant Patients Europe (SCOPE), assembling mainly medical dermatologists from Europe.

The present Both ITSCC and SCOPE have devoted time and effort to structure the field of transplant dermatology. The output of these societies is considerable and reaches from case series highlighting special skin diseases in OTR, basic science elucidating mechanisms of action leading to skin cancer, clinical studies with high value for the practising dermatologist, and clinical practice guidelines for skin care in OTR. In the wake of these supranational interest

404 Dermatology in immunosuppressed patients groups, national interest groups sprouted in many countries with a predominantly Caucasian population, which is at particular risk for non-melanoma skin cancer and even more so following organ transplantation. The Swiss Departments of Dermatology took note of these international collaborative endeavors and the need for a unified concept of care in OTR at their institutions. Towards the turn of the millennium, OTR specialty clinics were installed. In Basel, Professor Thiel from Nephrology, Professor Mihatsch from Pathology and Professor Rufli from Dermatology worked together to install a follow-up regime for kidney transplant recipients. The Zürich Department of Dermatology formally grouped OTR patients in a dedicated OTR clinic in 1999, where Günther Hofbauer and later Werner Kempf contacted transplant physicians to offer dermatological care in a structured fashion starting with pre-transplant screening and aiming for a regular follow-up in close collaboration with other specialties involved in transplant medicine at their institution. Quickly, the other University Hospitals followed suit with Emmanuel Laffitte and Anne-Karine Lapointe in Lausanne, Peter Itin, Peter Häusermann and Andreas Arnold in Basel, Robert Hunger and Beat Keller in Bern. As the care for skin problems in OTR is not limited to tertiary referral institutions and cannot be delivered solely at these institutions, other colleagues practising in hospital or private practice such as Carlo Mainetti in Bellinzona, Markus Streit in Aarau, Mark David Anliker in St. Gallen, and Francesco Pelloni in Lugano joined forces to found the working group for organ transplantation of the Swiss Society of Dermatology and Venereology in 2008. T The first workshop of the newly founded working group for organ transplantation took place at the annual SGDV/SSDV meeting in 2008 and successfully reflected the breadth of this newly opened field from clinical case presentations to clinical and basic mechanistic studies of skin disease in OTR (cf. Table 1). One of the first joint activities was the draft of Swiss clinical practice guidelines for skin cancer in OTR published in 2009 and followed by a French version in 2010. Many other colleagues participated in this and the following annual meetings, as well as in clinical and basic science research projects on the topic of skin disease in OTR.

405 Spirit and Soul of Swiss Dermatology and Venereology

Cutaneous carcinogenesis

Azathioprine Immunosuppressants UV light Cyclosporine A

Immunomodulation

Mutations Human Anti-tumor Chronic ATF3 TGF beta p53, etc papilloma defense inflammation VEGF virus

Squamous cell carcinoma of the skin

Figure 4. Understanding the complexity of squamous cell carcinoma formation in organ transplant recipients: A differentiated picture begins to emerge towards the end of the first decade of the new millennium.

Members of the working group for organ transplantation have over the years published case reports underlining the uncommon presentation of common and less common diseases in OTR to educate each other, have written several articles finding a consensus on a unified concept of care in OTR, and have participated in and designed a number of clinical trials. Clinical studies demonstrated that photodynamic therapy (PDT) is effective in the treatment of SCC in situ in OTR. Some of these trials were highly practical, such as the observation that tenderness and pain of a skin lesion in OTR carries a likelihood of about 75% for the diagnosis of invasive SCC, a clear message, which can be spread in the community. Other OTR patients from Switzerland helped establish the switch from calcineurin to mTOR inhibitors as an effective prevention of future SCC in OTR, a finding tha t was well recognised internationally following its publication in the New England Journal of Medicine in 2012.

406 Dermatology in immunosuppressed patients

Table 1 Program of the inaugural workshop of the working group for organ transplantation spanning the whole range from clinical cases to basic science

SGDV Workshop AG OTR Program 4.9.2008 Time Presenter Duration

14.00 h Presentation task force Mark Anliker 0.05 h 14.05 h Clinical case skin cancer Werner Kempf 0.05 h 14.10 h Clinical case skin cancer Andreas Arnold 0.05 h 14.15 h Databases for OTRs Robert Hunger 0.20 h 14.35 h Clinical case drug side effects Mark Anliker 0.05 h Emmanuel 14.40 h Clinical case drug treatment 0.05 h Laffitte Progression from in-situ to invasive SCC: allelic 14.45 h Beda Mühleisen 0.12 h imbalance and inflammatory infiltrate Anne-Karine 14.57 h Clinical case infectious disease 0.05 h Lapointe Emmanuel 15.02 h Clinical case infectious disease 0.05 h Laffitte Guidelines skin cancer in Günther 15.07 h 0.20 h OTRs Hofbauer Future developments (clinical Günther 15.27 h 0.10 h studies, new drug regimes) Hofbauer 15.37 h Closure

An ongoing trial dispensing sunscreen to OTR with a history of skin cancer is addressing the need for unified care, aiming for the recognition of sunscreen not just as a cosmetic product, but as an active medical device in this high-risk group of patients, hoping to reach reimbursement for this much needed tool in the prevention of skin cancer. Recently concluded, and with its results eagerly awaited, a trial with internal sunscreen using a synthetic alpha- melanocyte stimulating hormone analogue was conducted with a majority of Swiss patients in an international setting and may prove efficient in preventing actinic keratosis and squamous cell carcinoma in OTR. In a blend of translational research, azathioprine

407 Spirit and Soul of Swiss Dermatology and Venereology was clearly linked to photosensitivity in our OTR patients, while a substitution of azathioprine normalised photosensitivity in kidney transplant recipients. Traces of azathioprine and persistent elevation of photosensitivity, however, remained detectable for years, a finding which also merits attention beyond the population of OTR. As Swiss dermatologists, we contributed to and coordinated the largest case series of primary cutaneous lymphoma in OTR to date, casting light on fundamentally different distributions in this rare disease entity. Expanding the scope of care beyond our institutional walls, members of the working group for organ transplantation have given numerous seminars to physicians, medical professionals and patients on the subject of OTR. Finished in 2012, a website (www.dermaguard.ch) was created which offers patient-centered access to background information and practical issues for OTR and healthcare professionals alike.

The future Since 2009, the Swiss Transplant Cohort Study has started to enrol prospectively 95% of all solid organ recipients in Switzerland. The current toll stands at over 1600 OTRs with a prospective follow-up from before transplantation to the latest visit. This cohort offers a unique opportunity for us dermatologists to unravel relationships between skin disease, drugs, demographic factors and – in the era of the genome – the genome, exome, transcriptome and proteome. Initial studies have allowed us to learn about the incidence of skin cancer in our OTR and to recognise alleles conferring an increased risk of skin cancer. In the future, we hope to not only benefit our patients by better describing risk for the individual OTR, but also by designing interventional studies which will help us to better serve our patients by primary and early secondary prevention. Beyond organ transplantation, we have begun to understand that OTR serve as a model population for skin cancer formation, in particular SCC. This population allows the study of mechanisms and interventions in much smaller numbers and a shorter time frame than it could ever be done in the general problem. We hope to be able to transfer much of the insight gained from OTR to the general population in the mid-term.

408 Dermatology in immunosuppressed patients

Mark Anliker St. Gallen Andreas Arnold Basel Günther Hofbauer Zürich Patrick Oberholzer Bern Werner Kempf Zürich Anne-Karine Lapointe Lausanne Emmanuel Laffitte Genève Carlo Mainetti Bellinzona Francesco Pelloni Lugano Markus Streit Aarau

Figure 5. Working Group for Skin Disease in Organ Transplant Recipients.

Conclusions Organ transplant recipients have been recognised as a high- risk group for skin disease, in particular neoplastic disease with squamous cell carcinoma of the skin at the front. The medical need of these patients has resulted in the establishment of structured follow-up in Switzerland much like in other countries. We have been able to contribute to and benefit from the cutting edge of clinical and laboratory research in this patient group and hope to further develop strategies and modalities for the prevention, early detection and treatment of skin disease in the group of OTR.

Mark Anliker, Andreas Arnold, Laurence Feldmeyer, Werner Kempf, Emmanuel Laffitte, Anne-Karine Lapointe, Carlo Meinetti, Francesco Pelloni, Patrick Oberholzer, Andreas Serra, Markus Streit, Günther Hofbauer

409

Infectious Diseases of the skin (except STI)

Infectious disease in dermatology and its Swiss representatives Skin infections with bacteria, virus, fungi, or parasites are of interest for the dermatologist because they comprise a major part of the spectrum of skin diseases. This chapter covers significant and emerging aspects of infectious skin diseases other than sexually transmitted infections, with a special regard to the situation in Switzerland and the contributions by Swiss dermatologists to this field. The first part summarises important aspects of the clinical and laboratory diagnosis of skin infections, followed by a second part with a synopsis of dermatologic manifestations during HIV infection (by Laurence Toutous, Hôpitaux Universitaires de Genève). The third part describes ectoparasitoses, which are still a major concern in dermatology (by Emmanuel Laffitte, Hôpitaux Universitaires de Genève). The fourth part portrays the epidemiological situation of Lyme disease in Switzerland and the research in this field over the last few decades (by Martin Glatz, University Hospital of Zurich).

Skin and infection: from clinical manifestation to laboratory diagnosis

1. Skin is a sweet home for microbes – skin is a warrior against microbes The skin is one of the main organs where infections occur. Indeed, this organ, or tissue, is organised as an interactive body envelope. The barrier function acts against physical and chemical aggressors

411 Spirit and Soul of Swiss Dermatology and Venereology and environmental microbial agents. Along with the respiratory tract, the skin is the main entry point into the body for microbial agents. Normal skin flora comprises bacterial (coryneforms and staphylococci) and fungal (Malassezia spp) agents. Components of the skin flora are mostly found on the skin surface and in the pilosebaceous ducts. The balance may be modified by physical (e.g. cutaneous pH), chemical, immunological and microbial disturbances. The specific host factors that lead to clinical infection are often ill-defined. Commensal flora is necessary to maintain cutaneous balance and skin functions. The density of skin flora modified by a physical imbalance (occlusion, moisture, temperature) may induce increased microbe density and infection. Endocrine and immune changes also induce the multiplication of microbes and pathogenicity. Indeed, the proliferation of Propionibacterium acnes in acne vulgaris or Pityrosporon sp. in some AIDS-associated folliculitis well illustrates this fragile balance.

2. The skin is an open book for diagnosis of infection Systemic infections or infection from another internal organ may be detected early and easily when expressed on the surface. Indeed, some viral infections with cutaneous signs make it possible for physicians to confirm the diagnosis on a simple clinical basis. When the virus invades the body, a reddish exanthema occurs and may be curiously typical for a defined virus, such as chicken pox, rubella, measles and even HIV primo-infection. The type or location of the pathogen’s entrance through the skin may also indicate the type of disease: erythema chronicum migrans and Borrelia spp, black eschars in rickettsial infections, genital chancre and Treponema pallidum. The visual aspect makes it possible for the patients to detect the early phase of the disease themselves, mostly before any systemic signs appear, and this is the key for management and healing success. Moreover, following the kinetics of the lesion and scar may be very helpful for a retrospective diagnosis. This is the reason why great physicians of the nineteenth and early twentieth centuries often owed their fame to their ability to diagnose infectious diseases with cutaneous manifestations. Later, the advent of tissue culture techniques made it possible to identify many “new” viruses that caused exanthematous illnesses.

412 Infectious Diseases of the skin(except STI)

Laboratory tools have been largely tested and validated for the skin. The skin’s easy accessibility encourages quick and varied samples. Most are painless and non-invasive. Cultivating a swab sample, skin scraping and direct staining may confirm the diagnosis. Skin biopsy and histology analysis with the help of immunohistochemistry, electron microscopy or polymerase chain reaction finally complete these tools. The application of molecular biology to human pathologies: the polymerase chain reaction (PCR) method has provided the opportunity to discover the aetiology of Whipple’s disease, for instance, and has exposed the diversity of mycobacterial species harboured in AIDS patients. This approach provides a new paradigm for the discovery of unrecognised pathogens, which is of value in other diseases with features suggestive of an infectious aetiology. Microbiological analysis of skin tissue necessitates adherence to a strict technical process using the correct techniques for sampling and transportation and the appropriate laboratory methods. The most recent and useful applications of molecular biology in cutaneous sampling are: – Mycobacterium tuberculosis PCR in latent tuberculosis with skin presentation. – Mycobacterium leprae PCR in paucibacillary leprosy. – Atypical mycobacteria PCR is not used routinely and is highly dependent on the laboratory. PCR may be more sensitive than culture for some species. For instance, Mycobacterium ulcerans PCR in the Buruli ulcer: the usefulness of M ulcerans PCR testing in clinical practice is currently being evaluated in an international study led by Médecins Sans Frontières- Suisse and Geneva University Hospital (HUG) in Cameroon (L. Toutous Trellu). Classical culture validation for these mycobacteria can take 2 to 6 months with a sensitivity of 20% to 60%; PCR sensitivity can reach 90%, may be positive in a few weeks, and is sometimes under empirical antibiotics. – PCR for rickettsial infections in fresh tissue samples. A real- time duplex PCR that amplifies (i) the DNA of any Rickettsia species and (ii) typhus group Rickettsia (R. prowazekii and

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R. typhi) has been evaluated in skin biopsies from patients followed in Lausanne and Geneva [1]. – Chlamydia trachomatis and Neisseria gonococcus PCR: probably the most widely used in clinical practice; screened in urine, oral and perianal samples. – Treponema pallidum PCR development: in order to facilitate the direct diagnosis in active syphilis, given that black field examination lacks sensitivity and specificity, and that indirect diagnosis with treponemal and non-treponemal antibodies may be disappointing in a high-risk population. Moreover, another interest for molecular biology was to confirm sensitivity to antibiotics against Treponema pallidum. We were able to show azithromycin resistance in some patients using 23 SRNA in direct smear genital ulcer samples [2]. – Borrelia spp: a biopsy sample may be taken at the margin of the erythema chronicum migrans for a direct diagnosis. – Leishmaniasis (Figures 1a and 1b) – Diagnosis of herpes simplex virus by PCR in fresh smear samples has become daily practice, as has varicella zoster virus PCR in suspected vesicles, ulcers and scabs. – HHV8 PCR in cutaneous fixed samples taken from patients suffering from Kaposi’s sarcoma is particularly useful when standard histology does not show the typical fusiform cell. We have shown that quantitative HHV8 PCR has a predictive value for disease in HIV+ patients in our centre. – Parvovirus B19 is sought by the highly specific PCR in peripheral blood and typical skin rash. – Dermatophytes, moulds and yeasts are also detectable by PCR, although clinically useful applications are still lacking. At time of writing in 2013, its usefulness does not justify the cost.

414 Infectious Diseases of the skin(except STI)

Figure 1a and 1b. Case of Post Kala-Azar dermal leishmaniasis in an HIV-infected patient. PCR has become the main diagnostic tool for cutaneous leishmaniasis and is more sensitive than culture or histopathology. Species identification by PCR makes it possible to optimise treatment.

– A more rapidly promising clinical interest for PCR in superficial skin samples could be the identification of Sarcoptes scabiei. Direct microscopic identification remains poorly sensitive; PCR was successfully tested in a few cases but data on more patients and other centres are required.

In conclusion, regardless of the specificity and the sensibility of modern and old tests, the eye and experience of the dermatologist remain irreplaceable. The diagnostic approach is led by the clinical process, which allows a targeted use of laboratory tools and thus better management.

Laurence Toutous-Trellu

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HIV infection: A marked image of an infection on skin

HIV infection has, for 30 years now, provided an unfortunate human model to evaluate the relationships between the human body and microbial agents. At the beginning of the HIV epidemic, dermatologists were largely involved in the diagnosis and management of AIDS patients, particularly before the HAART (highly active antiretroviral therapy) era, because of the primary skin disorders associated with the virus and the immune disturbance, and as a consequence of immunosuppression, frequent skin tropism by opportunistic agents. When HAART was widely introduced, new problems concerning the skin emerged: adverse drug reactions to antiretrovirals, lipodystrophy syndrome, and cancers.

Aging with treated chronic HIV infection: a new challenge With improved management of HIV infection, the number of AIDS-related deaths has dramatically decreased over the years. A corollary to this is that the median age of HIV-infected individuals has gradually increased, due to the massive reduction in AIDS-related mortality. Physicians are now following HIV- infected patients with a median age of between 40 and 50 years, and patients in their sixties or seventies are seen more and more frequently in HIV clinics.

1. Lipodystrophy The concept of non-infectious changes in patients living with HIV is strongly suggested in lipodystrophy syndrome. Indeed, the name “lipodystrophy syndrome” is actually too limiting. The fat distribution changes may be considered as the tip of the iceberg, and may partially correspond to a body-aging phenotype [3]. Genetic determinants have been researched but not yet elucidated. Lipodystrophy syndrome was described in treated HIV patients in 1998, a few months after the introduction of HAART. The first descriptions considered the morphological problems related to fat distribution, but the metabolic association with atherogenic lipid abnormalities, low HDL cholesterol, insulin resistance and hyperglycaemia was rapidly shown, leading to an increase in cardiovascular risk.

416 Infectious Diseases of the skin(except STI)

The causes of lipodystrophy have not yet been completely elucidated. The prevalence ranges from 20% to 70% after one year of antiretroviral therapy, with lower prevalence in more recent studies using newer agents. The pathophysiology of HIV-associated lipodystrophy is complex and involves multiple mechanisms: mitochondrial toxicity, abnormal adiponectin regulation, adipocyte apoptosis, and pro-inflammatory phenomena have been suggested. Management is primarily based on drug-related adverse effects. Nucleoside inhibitors have been associated with mitochondrial toxicity and facial lipoatrophy, while protease inhibitors have been linked to fat accumulation and hyperlipidaemia. When metabolic disorders are present, dietary modifications, lipid-lowering drugs and/or antidiabetics are prescribed. The impact on body fat distribution has also been evaluated. Changing treatment from one pharmacological class to another seems to be the best solution, and partial improvements were demonstrated in drug-switch studies. However, despite the new drug classes available and better lipodystrophy and/or metabolic-free drug associations, we still encounter patients suffering from this syndrome today. Aesthetic considerations are a source of anxiety and depression. Body image rehabilitation includes trust in life expectancy and scientific progress, social adaptation and a better quality of life during a communicable, chronic disease. HIV-associated facial lipoatrophy has thus been treated for several years using filling molecules and autologous fat. They are mainly used as cosmetic devices in HIV- negative people for aesthetic purposes and therefore do not require the strict development phases and evaluations used for therapeutic drugs. We provide support at a national level in order that HIV patients may benefit from these procedures more easily and in specialised care centres [4].

2. Skin carcinoma and HIV

An increased risk of developing several types of skin cancer, excluding the common squamous and basal cell carcinomas, has already been comparatively established in HIV and solid-organ transplant recipients. The role of immunosuppression could be strongly suggested in such cohorts. HAART does not influence this increased incidence of non-melanoma skin tumour, and this

417 Spirit and Soul of Swiss Dermatology and Venereology has also been shown for cancers of the cervix, liver, lip, mouth, pharynx, lung and bronchus in two other recent studies. Moreover, the prevalence of age-related malignancies is increased in older HIV-infected patients compared to age-related non-infected individuals. Non-melanoma skin cancers had already been observed in the Swiss HIV Cohort Study between 1985 and 2002 [5]. An elevated risk was outlined, as 26 basal cell carcinomas and 5 squamous cell carcinomas were observed. However, in this study no association with CD4 count or ARV therapy status was described. A recent American study showed a two-fold higher incidence rate of non- melanoma skin cancer in HIV-positive compared to HIV-negative subjects [6]. We regularly detect and treat skin cancers in HIV patients, sometimes with severe evolution. This hot dermatological topic was presented at the 2012 SSDV meeting. In conclusion, dermatologists have an active role to play in the area of HIV infection. Priorities are: – To prevent and treat sexually transmitted infections. – To diagnose HIV primo-infection and test for HIV when confronted with a possible associated skin disease. (see STI chapter). – To prevent and treat skin carcinomas. – To rehabilitate a deeply modified body image: aesthetic medical tools are becoming crucial in the long-term psychological and social follow-up of HIV.

Note This chapter includes “selected pieces” from my Privatdozent thesis entitled “HIV and skin.”

Acknowledgements I am grateful to Professor J.H. Saurat and Dr. M. Pechère for their constant support. I wish to encourage young physicians to explore this exciting topic of our specialty.

Laurence Toutous-Tréllu

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References for parts 1 and 2 1. Giulieri S, Jaton K, Cometta A, Trellu LT, Greub G, « Development of a duplex real-time PCR for the detection of Rickettsia spp. and typhus group rickettsia in clinical samples », FEMS Immunol Med Microbiol n° 64, 2012 p. 92-97. 2. Gayet-Ageron A, Ninet B, Toutous-Trellu L, Lautenschlager S, Furrer H, Piguet V, et al., « Assessment of a real-time PCR test to diagnose syphilis from diverse biological samples », Sex Transm Infect, n° 85, 2009, p. 264-269. 3. Caron-Debarle M, Lagathu C, Boccara F, Vigouroux C, Capeau J, « HIV-associated lipodystrophy: from fat injury to premature aging », Trends Mol Med, n° 16, 2010, p. 218-29. 4. Nikolic DS, Balague N, Campanelli A, Elias B, Calmy A, Toutous- Trellu L, « Injectable soft tissue fillers: are they medical devices or drugs? Implications for HIV lipodystrophy », Rev Med Suisse, n° 8, 2012, p. 747-753. 5. Clifford GM, Polesel J, Rickenbach M, Dal Maso L, Keiser O, Kofler A, et al., « Cancer risk in the Swiss HIV Cohort Study: associations with immunodeficiency, smoking, and highly active antiretroviral therapy », J Natl Cancer Inst, n° 97, 2005, p. 425-432. 6. Silverberg MJ, Leyden W, Warton EM, Quesenberry CP, Jr., Engels EA, Asgari MM, « HIV infection status, immunodeficiency, and the incidence of non-melanoma skin cancer », J Natl Cancer Inst, n° 105, 2013, p. 350-360.

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Ectoparasites in Switzerland: the struggle is ongoing

Ectoparasitoses are regularly encountered in daily practice. According to Theo Rufli, they can either be classified as permanent (a parasite is found on the patient) or temporary ectoparasitoses [1]. These ectoparasites are old companions of human beings: bed bugs have been found in Egyptian tombs dating back 3,500 years [2]. The “Su-Wen,” one of the oldest known medical books in China (2,600 years BC), contains probably the first description of scabies [3], and studies of fossils from the Cretaceous-Paleogene (65 million years ago) showed the presence of parasitic ancestors of lice [4]. These problems are still present, and Swiss dermatologists regularly have to deal with ectoparasites. Outbreaks of scabies have been reported in Switzerland [5, 6] and an alarming increase in cases of bed bug infestations is occurring in Geneva [7]. Treating ectoparasitoses is difficult since there is little epidemiological data on the subject and effective treatment, especially for scabies, is not reimbursed by health insurance companies, and is in fact no longer sold in Switzerland. We will describe the situation of scabies, pediculosis and bed bugs in Switzerland, according to three articles we published in the “revue médicale Suisse” [7-9].

1. Scabies in Switzerland [8] 1.1. Some epidemiological data According to epidemiological data from the WHO, the number of new cases of scabies in the world each year is about three hundred million. It affects both women and men of all ages, from all socioeconomic levels on all continents [10]. In industrialised countries, the epidemic outbreaks occur mainly in institutions (community care facilities, nursing homes, etc.). In temperate regions, the disease occurs mostly during the cold seasons, probably due to an increase in promiscuity. Two outbreaks of human scabies have been reported recently in Switzerland. The first was described by Felix Gueissaz in the canton of Neuchâtel in 1999 [5]. The index case was an alcoholic patient with crusted scabies who had stayed in a rehabilitation clinic for

420 Infectious Diseases of the skin(except STI)

11 months. Three healthcare institutions (the rehabilitation clinic, a 200-bed acute care hospital, and a hospital with a haemodialysis unit) were involved. Overall, 24 cases of scabies were detected, 12 among inpatients after exposure within the healthcare institutions, and 12 among household or other close contacts. More recently, in 2007, a second outbreak was reported by Peter Itin and co-workers in the Canton of Basel [6]. The index case was a patient with AIDS and crusted scabies who was admitted to the intensive care unit of the university hospital with severe sepsis. 19 cases of scabies were diagnosed within 7 months. A total of 1,640 exposed individuals underwent pre-emptive treatment. The highest attack rate of 26% - 32% was observed among healthcare workers involved in the care of the index patient. In both cases, the outbreak lasted for several months and was controlled only after the implementation of a special task force with experienced dermatologists and strict infection control measures. Local treatments (permethrin or lindane) and oral ivermectin were used to treat the patients, and the contact subjects (household members, healthcare workers) were treated pre-emptively. 229 cases were diagnosed between January 2011 and May 2013 in the dermatology outpatient clinic at the University Hospital of Geneva, mostly in community homes (centres for asylum seekers and student communities). During this period, 856 individuals required treatment (229 sources and 627 contacts). About half of the cases diagnosed in the corresponding year of observation occurred in the periods from October to December 2011 and from October to December 2012 (48% for 2011 and 52% in 2012; Figure 2). Two community-based cases in November 2011 and December 2012 were reported to the Federal Office of Public Health (BAG) in accordance with the regulations using the “outbreak of an unusual event” form. Ongoing monitoring in the canton of Geneva concluded the resurgence, as reported by the French Institute of Health Surveillance [11]. In addition, there does not seem to be any increase in cases of scabies in other Swiss cantons. Scabies also occurs in Swiss animals: sarcoptic mange has been endemic in Swiss wildlife for at least 30 years; infections with S. scabiei have been diagnosed in free-ranging red foxes, occasionally in stone martens, and more recently in free-ranging lynx in the Swiss Alps [12].

421 Spirit and Soul of Swiss Dermatology and Venereology

Nb of Scabies cases Nb of treated individuals

100 90 80 70 60 50 40 30 20 10 0 t t t t r r r s s s e e e e e e e e n n ai ai ai i i e r r r e r r e e e r r û û i i i vril vril vril .13 .11 .12 b b m ill ill m m j u j u v v v a a a a o a o vr vr vr o o ma r ma r ma r m b mb r m b m b m b m b t t j u j u é é é c c f f f e e e e e e ja n ja n ja n t t c c v v o o é é o o d d n n se p se p

Figure 2. Cases of scabies in dermatology outpatient clinic, HUG, from January 2011 to May 2013.

1.2. Two recent advances in the management of scabies In 1981 Jean-Hilaire Saurat described the burrow ink test to facilitate the detection of scabies with a microscope [13]. Since 1997, the use of the dermatoscope has allowed quick and direct visualisation of the mite, which saves considerable time compared to the use of the microscope [14]. In 2004, Christa Prins and Ralph Braun in Geneva (again, Jean-Hilaire Saurat was not far away) described the typical dermoscopic aspect of the scabies mite at a distance from the linear excoriations on a dermoscopy examination using a simple hand-held dermatoscope with a magnification of x10 [15]. The second major advance is the use of oral ivermectin for the treatment of scabies, described for animals in 1980 [16], and humans in 1995 [17]. The treatment is simple to administer, with better compliance compared to topical agents and is remarkably well-tolerated. Several controlled studies have since confirmed the benefit of this treatment administered at a dose of 0.2 mg/kg, with two doses 10 days apart [10].

422 Infectious Diseases of the skin(except STI)

1.3. A more recent decline in the management of scabies: we can no longer treat scabies in Switzerland With the withdrawal of lindane (Jacutin®) in 2008, health insurance companies in Switzerland no longer reimburse scabies treatment. Oral ivermectin and permethrin 5% are not commercialised in Switzerland; these treatments are imported from neighbouring countries through international pharmacies, sometimes at significant expense when a whole family requires treatment, which is a further factor for treatment failure. Although there have been several meetings between representatives of the SSDV and Swissmedic, the situation has not changed, and this constitutes a major obstacle to the control of this infection.

2. Pediculosis: something new? [9] Pediculosis, particularly head lice, are widespread parasites the world over. They affect between 0.8% and 9.9% of school-age children in Europe [18].

2.1. Are lice becoming resistant to treatment? Over the last twenty years, the development of lice genetically resistant to malathion and permethrin [19, 20] has been observed in Europe. Strains which are genetically resistant to permethrin are widespread in Europe (with a variable prevalence of up to 75.9% depending on the area studied), probably due to the strong selection pressure related to massive usage campaigns [21]. Genetic resistance to malathion has also been documented in France [22] and the UK [23], but there is no data for Switzerland. This data led the scientific community to question the effectiveness of insecticides. In terms of resistance, three notions are distinguished: genetic resistance, which is due to the presence of a mutated gene; parasitological resistance, which is defined by the detection of lice resistant to insecticides during ex vivo testing; and clinical resistance, which refers to the persistence of parasites after correct treatment. The correlation between genetic, clinical and parasitological resistance is not always established, and these notions of resistance to insecticides should be taken with caution.

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Resistance to Permethrin: Permethrin is a neurotoxic agent that blocks a sodium channel of nerve transmission, making it impossible for the lice to breathe [24]. In recent years, studies have demonstrated mutations in the gene encoding the alpha subunit of the sodium channel (kdr-like gene). The global prevalence of these genetically resistant strains varies from 10% in Japan to 90% in Denmark [25]. In the Paris region, it reaches 93% [25], as well as in Germany [26]. In theory, these mutations could cause a parasitological resistance and the clinical observation of treatment failure. However, recent European studies have showed that the correlation between genetic resistance and clinical resistance is far from certain and is still debated [22, 27]. In a recent study in the Paris region, the ex vivo study found a mortality of 85.7% of lice after one hour of exposure to permethrin when they were homozygous for the kdr-like mutation to 98.7% [22]. Similar results were obtained in Germany with a clinical eradication rate of 93% on strains carrying the gene to 93% [27]. Resistance to Malathion: Malathion is an organophosphate that is a cholinesterase inhibitor. Resistance to malathion is less common than resistance to permethrin, but has been reported in France and the UK [28]. However, the type of resistance is not well-defined, and literature on the subject remains poor. A recent study of note in Paris found no parasitological resistance to malathion [22].

2.2. New treatments? New treatments are available in addition to malathion and permethrin: dimeticone (polydimethylsiloxane, PDMS) essential oils and ivermectin. Dimeticone is a derivative of silicon, which eliminates lice by clogging their spiracles. This product has the advantages of being odourless, non-toxic and well-tolerated [28]. Its mode of mechanical action makes the development of resistance unlikely. There are no comparative studies of dimeticone and conventional insecticides. Its effectiveness varies between 69 and 97% [18], and its ovicidal activity is better at high concentrations [29]. Three preparations are available in Switzerland: Pedicul Hermal® (dimeticone 100%), Altopou® (dimeticone 5%) and Hedrin® (dimeticone 4%).

424 Infectious Diseases of the skin(except STI)

There is not enough data to recommend dimeticone products as a first-line therapy, but they represent an interesting alternative in cases of known resistance to conventional insecticides. Essential oils have often been used in traditional medicine to eradicate lice. The data available in the literature is limited, of poor quality and often dominated by commercial issues. In addition, there is great variability in composition among the products available on the market, and studies on products containing the same essential oils describe an efficiency ranging from 12% [30] to 92.3% [31]. The opinions about these “natural” treatments are divided, and there is no comparative data for Paranix, the only product available in Switzerland (coconut oil, tea tree, ylang ylang). This treatment may be useful as an alternative in cases where insecticides are refused and there is a desire for a “natural” treatment. It should not be forgotten however, that tea tree and ylang ylang essential oils are among the most frequently reported allergens in contact eczema [32], although to our knowledge no cases have been reported with anti-lice products. Oral ivermectin: A recent randomised controlled study [20] has demonstrated the superiority of ivermectin at a dose of 0.4 mg/kg, two courses at D0 and D10 against malathion for resistant cases, with 96.2% of clinical cures in one month in the ivermectin group as opposed to 87.9% in the malathion group. Doses of ivermectin used are double those used to treat scabies, and there is a very theoretical risk of hepatotoxicity and seizures for children under 15 kg or less than two years old [33]. This treatment is to be considered as a last resort for particularly resistant cases (and after the successful completion of local treatment and additional measures have been checked and supervised).

2.3. Conclusion and therapeutic strategy Lice infestation is a public health issue, particularly in schools and migrant populations. At present, the best validated treatments are permethrin and malathion. In the absence of Swiss data on any resistance, they are to be used as first line. The choice between these two insecticides depends on the knowledge of local resistance, side effects and individual tolerance. Dimeticone represents an interesting alternative in cases of resistance or contra-indication to conventional treatments. Essential

425 Spirit and Soul of Swiss Dermatology and Venereology oils should be used if the patient refuses “chemical” treatment; their efficacy is much discussed. Finally, oral ivermectin is a treatment as a last resort, when topical treatments have failed. It is essential to combine these treatments with mechanical treatments (the wet combing technique) and checking of the entire community to which the patient belongs to minimise the risk of treatment failure.

3. Bed bugs, an outbreak in Geneva?

Bed bugs are hematophagic brown arthropods, very flat and wingless (Figure 3). Two species are known, Cimex lectularius (temperate zones) and Cimex hemipterus (tropical) [2].

Figure 3. Cimex lecturarius.

Bed bugs usually feed at night or in low-light environments, attracted by body heat and carbon dioxide exhaled by humans. Their saliva contains vasodilating, anticoagulant and anaesthetic substances, allowing them to complete a meal in 10-20 minutes [34]. As they are active at night when the victim is asleep, their bites may not be detected immediately. Adult lice can live for up

426 Infectious Diseases of the skin(except STI) to two years in the appropriate environment (temperatures between 21 and 28° C). Bed bugs prefer places where they can easily hide and feed regularly, such as resting places (on sofas while watching TV, beds). Their flat bodies allow them to hide in tight spaces, such as wallpaper, behind picture frames, in electrical outlets, mattresses, bedside tables, in curtains, carpets, sofas and suitcases.

3.1. Epidemiology Bed bugs are cosmopolitan insects. All levels of contamination have been described: isolated cases, grouped cases (nursing homes, hotels, and hospitals), total contamination of a building or outbreak in a city (the UK in 1998 and 1999; Pisa, Italy in 2003; New York in early 2010…). There has been a three-fold increase in interventions against this insect in France since 2005 [35]. Cimex lectularius has always been present in large cities such as New York or Montreal. But it had become less prevalent in cities, where it had almost disappeared since the 1950s, while remaining fairly present in tropical environments. However, there has been a dramatic increase since 1990, related to the combination of two recent developments: increased international travel and the prohibition of potent pesticides such as dichloro- diphenyltrichloroethane (DDT). The development of tourism has fostered the passive transmission of bugs through the means of transport (planes, trains and boats) and also luggage. Promiscuity, migration, and selling of second-hand furniture or books are further risk factors [34]. In Geneva, as in the whole of Switzerland, bed bug bites in youth hostels or even luxury hotels have been observed in recent years. Skin lesions associated with their bites were the reason for consultation in primary care medicine or in the dermatology outpatient clinic at the University Hospital of Geneva. We have conducted a survey of bed bug infestations since January 2012 with the following classification: proven infection (clinically compatible, bug displayed), probable infection (clinically compatible, epidemiological context, no displayed bug), and possible infection (clinically compatible, no epidemiological context, no displayed bug). Since then, we have observed 26 proven and 40 possible infestations (Figure 4).

427 Spirit and Soul of Swiss Dermatology and Venereology

POSSIBLE PROBABLE PROVEN 8 77 7 7 6 6 5 5

4 3 3 3 3 2 2 2 2 2 2 2 2 2 1 11 1 1 1 1 11 1 1 1 1 1 1

Infestation possible (clinique. compat., 0 épidémiol.) Infestation probable (clin. compat.,épid.compat.,0 preuve) Infestation certaine (clin. compat., épid.compat.,+ preuve)

Figure 4. Cases of bed bugs in dermatology outpatient clinic, HUG, from January 2012 to May 2013.

But it is too early to conclude an outbreak of bed bugs, as described in France, where a national program has been launched to assess actual incidence and study C. lectularius- related diseases [35].

3.2. Clinical features Bed bugs cause extremely unpleasant skin lesions. The lesions are localised on exposed parts and are highly variable: urticarial, very itchy papules with a haemorrhagic centre in a linear arrangement (Figure 4). Fourteen days or more can pass between the bite and the onset of skin reactions; this period varies according to the subject. If bites can occur anywhere on the body, they are found most often on the face, neck, arms, legs and chest. While some people have no reaction to bites, others will have a mild skin reaction or, more rarely, a severe allergic reaction. Cases of anaphylaxis have been reported, probably due to an immuno-allergic reaction to the nitrophorine in the saliva [36]. This insect does not transmit any known bacterial or viral disease to humans. The psychological burden of bed bug infestation remains to be evaluated, but may

428 Infectious Diseases of the skin(except STI) be important in some patients [37]. Although the economic impact is not known, bed bugs result in a loss of productivity, and costs include those of pest control interventions and replacement of infested furniture

3.3. Diagnosis The diagnosis can only be made by identifying the parasite brought by the patient, or during an inspection of the home. In case of suspicion, the knowledge of a recent trip, a change in sleeping place, a move, or the acquisition of second-hand furniture are possible indicators. A formal identification of the insect should be made (adult bugs, young, eggs, excrement, blood stains) by checking all the sites where it could be present (bedroom and living room) such as mattresses, bed structures, objects close to the bed, sofa, curtains, ceilings, and floors. Special dogs have been bred and trained to detect the presence of bed bugs, with a reported reliability of 95% if regularly and seriously trained. They represent an interesting approach to detecting the onset of infection and accurately locating the infested sites.

Figure 5. Typical pruriginous papules with bed bug bites, in a linear arrangement.

429 Spirit and Soul of Swiss Dermatology and Venereology

3.4. Management of a bed bug infestation Treatment is symptomatic. Topical corticosteroids class III or IV can be applied in cases of severe pruritus. Bed bug control is difficult, mainly because of the parasite’s hiding behaviour, and also because chemical and non-chemical technologies need to be combined for optimal effect. Different mechanical and chemical methods can be used, well described in [7, 34]. They should be used in a targeted manner, with full knowledge of the characteristics of bugs and their habits. If the infestation is heavy, professional treatment of the site is necessary. The emergence of insecticide resistance is favoured by the inappropriate use of insecticides, and the use of professional pest control companies is highly recommended. Three interventions 10 days apart are necessary to eliminate immature forms of eggs that were not affected by insecticides before hatching. Finally, preventive measures such as information campaigns, maintenance of buildings and promotion of early detection and treatment of bugs are useful to avoid a heavy infestation.

3.5. Conclusion Bed bugs seem to be a real emerging public health problem. The majority of the affected patients are in a risky situation, but no one is immune to infestation. The cost of professional intervention is high and is generally borne by the people living in the infected areas. The autonomous and improper use of disinfestation products is common to avoid these costs. This has the effect of favouring the emergence of new resistance to insecticides. Targeted environmental management is essential and requires, as soon as the diagnosis has been made, the advice and intervention of competent professionals.

Acknowledgements Mrs Mélanie Michaud and Nicole Eicher, both Public Health Nurses in the Dermatology Outpatients Clinic; HUG, for their work and collection of data for scabies and bedbugs; and Dr. Pascal Delaunay, medical entomologist, Nice University Hospital for his advice on the management of bed bug infestation.

Emmanuel Laffitte

430 Infectious Diseases of the skin(except STI)

References 1. Rufli , T « Domestic ectoparasitoses, a review », Schweiz Med Wochenschr, n° 123, 1993, p. 1268-1273. 2. Delaunay P, Berenger JM, Izri A, Chosidow O, Les punaises de lits, Nice: Association des Naturalistes de Nice et des Alpes Maritimes, 2010. 3. Chevalier J, Histoire de la gale, available from: http://histoire- medecine.univ-lyon1.fr. 4. Smith VS, Ford T, Johnson KP, Johnson PC, Yoshizawa K, Light JE, « Multiple lineages of lice pass through the K-Pg boundary », Biol Lett, n° 7, 2011, p. 782-785. 5. Achtari Jeanneret L, Erard P, Gueissaz F Malinverni R, « An outbreak of scabies: a forgotten parasitic disease still present in Switzerland », Swiss Med Wkly, n° 137, 2007, p. 695-699. 6. Buehlmann M, Beltraminelli H, Strub C, Bircher A, Jordan X, Battegay M, et al, « Scabies outbreak in an intensive care unit with 1,659 exposed individuals--key factors for controlling the outbreak », Infect Control Hosp Epidemiol, n° 30, 2009, p. 354-360. 7. Sahil M, Laffitte E, Sudre P, Lacour O, Eicher N Trellu LT, « Bedbugs: know them better. Deal with them better », Rev Med Suisse, n° 9, 2013, p. 720-722. 8. Gaspard L, Laffitte E, Michaud M, Eicher N, Lacour O, Toutous- Trellu L, « Scabies in 2012 », Rev Med Suisse, n° 8, 2013, p. 718-722, 724-725. 9. Maillard A, Trellu LT, Eicher N, Michaud M Laffitte E, « Management of lice infestations, recommendations for 2012 », Rev Med Suisse, n° 8, 2012, p. 726-728, 730-733. 10. Chosidow O, « Clinical practices. Scabies », N Engl J Mde, n° 354, 2006, p. 1718-1727. 11. Castor C Bernadou I. Épidémie de gale communautaire. Guide d’investigation et d’aide à la gestion. Institut de veille sanitaire, 2008, Available from: http://www.invs.sante.fr/publications/2008/ epidemie_gale_commmunautaire/epidemie_gale_commmunautaire. pdf. 12. Ryser-Degiorgis Mp, Ryser A, Bacciarini LN, Angst C, Gottstein B, Janovsky M, et al, « Notoedric and sarcoptic mange in free-ranging lynx from Switzerland », J Wildl Dis, n° 38, 2002, p. 228-232.

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13. Woodley D Saurat JH, « The Burrow Ink Test and the scabies mite », J Am Acad Dermatol, n° 4, 1981, p. 715-722. 14. Argenziano G, Fabbrocini G Delfino M, « Epiluminescence microscopy. A new approach to in vivo detection of Sarcoptes scabiei », Arch Dermatol, n° 133, 1997, 751-753. 15. Prins C, Stucki L, French L, Saurat JH, Braun RP, « Dermoscopy for the in vivo detection of sarcoptes scabiei », Dermatology, n° 208, 2004, p. 241-243. 16. Kutzer E, « Treatment of sarcoptic mange in wild and domestic swine with ivermectin (Ivomec) », Dtsch Tierarztl Wochenschr, n° 93, 1986, p. 426-429. 17. Meinking TL, Taplin D, Hermida JL, Pardo R, Kerdel FA, « The treatment of scabies with ivermectin », N Engl J Med, n° 333, 1995, p. 26-30. 18. Tebruegge M, Pantazidou A Curtis N, « What’s bugging you? An update on the treatment of head lice infestation », Arch Dis Child Educ Pract Ed, n° 96, 2011, p. 2-8. 19. Chosidow O, « Pediculosis of the scalp and scabies. New guidelines and current stakes », Ann Dermatol Venereol, n° 131, 2004, p. 1041-1044. 20. Chosidow O, Giraudeau B, Cottrell J, Izri A, Hofmann R, Mann SG, et al, « Oral ivermectin versus malathion lotion for difficult-to-treat head lice », N Engl J Med, n° 362, 2010, p. 896-905. 21. Hodgdon HE, Yoon KS, Previte DI, Kim HJ, Aboelghar GE, Lee SH, et al, « Determination of knockdown resistance allele frequencies in global human head louse populations using the serial invasive signal amplification reaction », Pest Manag Sci, n° 66, 2010, p. 1031-1040. 22. Bouvresse S, Berdjane Z, Fontanet A, Durand R, Izri A, Chosidow O, « Résistance au malathion et aux pyréthrinoïdes des poux du cuir chevelu à Paris », Ann Dermatol Venereol, n° 13, 2011, Hors-série A58. 23. Idriss S Levitt J, « Malathion for head lice and scabies: treatment and safety considerations », J Drugs Dermatol, n° 8, 2009, p. 715-720. 24. Nutanson I, Steen CJ, Schwartz RA, Janniger CK, « Pediculus humanus capitis: an update », Acta Dermatovenerol Alp Panonica Adriat, n° 17, 2008, p. 147-154, 156-157, 159. 25. Durand R, Bouvresse S, Andriantsoanirina V, Berdjane Z, Chosidow O, Izri A, « High frequency of mutations associated with head lice

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pyrethroid resistance in schoolchildren from Bobigny, France », J Med Entomol, n° 48, 2011, p. 73-75. 26. Rutman HI, « Vermectin versus malathion for head lice », N Engl J Med, n° 362, 2010, p. 2426-2427, author reply p. 2427. 27. « Directive from the French High Commission of Public Health, transmissible disease section, regarding the measures to be taken with cases of pediculosis of the scalp (session dated June 27, 2003) », Ann Dermatol Venereol, n° 131, 2004, 1122-1124. 28. Frankowski BL, Bocchini JA Jr, « Head lice. Pediatrics, n° 126, 2010, p. 392-403. 29. Goldstein A, Goldstein B, Pediculosis capitis, in UpToDate, Basow D, Editor, UpToDate in Waltham, MA, 2012. 30. Burgess IF, Head lice, Clin Evid (Online), 2009. 31. Heukelbach J, Sonnberg S, Becher H, Melo I, Speare R Oliveira FA, « Ovicidal efficacy of high concentration dimeticone: a new eraof head lice treatment », J Am Acad Dermatol, n° 64, 2011, p. 61-62. 32. Uter W, Schmidt E, Geier J, Lessmann H, Schnuch A Frosch P, « Contact allergy to essential oils: current patch test results (2000- 2008) from the Information Network of Departments of Dermatology (IVDK) », Contact Dermatitis, n° 63, 2010, p. 277-283. 33. Vlckova J, Rupes V, Chmela J, Kensa M, Mazanek L, « In vitro efficacy of three novel delousing formulations against the head louse (Pediculus capitis L.) », Epidemiol Mikrobiol Imunol, n° 60, 2011, p. 41-42, 44. 34. Bernardeschi C, Le Cleach L, Delaunay P, Chosidow O, « Bed bug infestation », BMJ, n° 346, 2013, p. 138. 35. Levy Bencheton A, Berenger JM, Del Giudice P, Delaunay P, Pages F Morand JI, « Resurgence of bedbugs in southern France: a local problem or the tip of the iceberg? », J Eur Acad Dermatol Venereol, n° 25, 2011, p. 599-602. 36. Leverkus M, Jochim RC, Schad S, Brocker EB, Andersen JF, Valenzuela JG, et al, « Bullous allergic hypersensitivity to bed bug bites mediated by IgE against salivary nitrophorin », J Invest Dermatol, n° 126, 2006, p. 91-96. 37. Rieder E, Hamalian G, Maloy K, Streicker E, Sjulson L Ying P, « Psychiatric consequences of actual versus feared and perceived bed bug infestations: a case series examining a current epidemic », Psychosomatics, n° 53, 2012, p. 85-91.

433 Spirit and Soul of Swiss Dermatology and Venereology

Lyme disease in Switzerland

1. Epidemiology Lyme disease (LD) is the most prevalent tick-transmitted disease in the northern hemisphere, caused by infection with the spirochete Borrelia burgdorferi sensu lato [1]. It is probably the most common vector-borne disease seen by dermatologists in Switzerland, because the mild to moderate climate is an ideal habitat for the main vector tick Ixodes ricinus. This is substantiated by epidemiological facts: an estimated 254 tick bites/100,000 inhabitants in Switzerland and ~12,000 cases of Lyme disease each year. These numbers are voluntarily reported by primary care physicians within the context of the Swiss “Sentinella” program, running since 2008 [2].

2. Dermatological manifestations The skin, as the tick-host interface and site of pathogen transmission, is affected in 80% - 90% of all patients with Lyme disease [3]. The three characteristic cutaneous manifestations are erythema migrans, borrelial lymphocytoma, and acrodermatitis chronica atrophicans. Erythema migrans is the hallmark of early LD, appearing on average two weeks after an infectious tick bite either as single or multilocular, expanding, round-to-oval, red to bluish-red, and sharply demarcated, most commonly macular or a ring-like lesion (Figure 6; 4). Borrelial lymphocytoma is a B-cell pseudolymphoma and appears weeks to months after infection. It is commonly a solitary, soft, bluish-red nodule or plaque on the ear lobe, areola mammae, axillary fold, or scrotum [5]. Acrodermatitis chronica atrophicans is the cutaneous manifestation of late- stage disease, which develops on the extensor surfaces of the distal extremities months to years after infection. It begins with an inflammatory stage characterised by red doughy swelling of the skin, followed by a chronic atrophic stage with thinning and wrinkling of the skin due to loss of epidermal and dermal structures [6]. Untreated cases of cutaneous Lyme disease can lead to more harmful disorders of the musculoskeletal system, the nervous system and the heart [1].

434 Infectious Diseases of the skin(except STI)

Figure 6. Solitary annular erythema migrans on the left shoulder of a 61-year-old female patient (courtesy of Professor R. Müllegger, Wiener Neustadt, Austria).

3. Swiss contributions to Lyme disease research Swiss scientists have made important contributions to Lyme disease research. However, modern Lyme disease research began across the Atlantic in North America when, in the mid- 1970s, numerous children and adults living in three communities around the town of Lyme, Connecticut, USA, suffered from an endemic oligoarthritis. Allen Steere, then a postdoctoral fellow in rheumatology at Yale University, and his colleagues investigated this new entity termed “Lyme arthritis,” and suggested an infectious cause transmitted by an arthropod vector [7]. Interestingly, some of the arthritis patients in Lyme recalled an expanding, annular, red macule on their skin some weeks before the onset of joint problems. This skin lesion was identified as erythema migrans, which had been described for the first time in the United States only a few years before [8]. In Europe, erythema migrans was already a well-known disease. A thorough description of this skin lesion was published by the Swedish dermatologist Arvid Afzelius (1857-1923) in 1913 [9], together with the speculation of a tick-transmitted pathogen as the causal agent. Although Afzelius was quite close to Switzerland

435 Spirit and Soul of Swiss Dermatology and Venereology when he was a student of the famous Moriz Kaposi in Vienna, it was a Swiss-born scientist who succeeded in the identification of the pathogenic agent of erythema migrans and the whole complex of Lyme disease manifestations. Willy Burgdorfer (Figure 7) was born in Basel, Switzerland in 1927, and earned his PhD in zoology, parasitology, and bacteriology from the university of his home town. After completing his thesis on the life cycle of the relapsing fever spirochete, B. duttonii in its tick vector Ornitodorus moubata, he joined the Rocky Mountains Laboratories in Montana, United States in 1952. He worked on Rickettsioses, an important group of tick-transmitted diseases. In 1981, Willy Burgdorfer investigated I. scapularis ticks, the American pendant of the European I. ricinus, which had been collected in a Lyme disease endemic focus in the State of New York. Using immunohistochemistry and Giemsa staining he identified Treponema “ pallidum-like” spirochetes in the guts of these ticks. The spirochetes were isolated from ticks, cultivated and reacted with sera from Lyme disease patients indicating the presence of spirochete-specific antibodies in these patients. To confirm the pathogenic role of these newly discovered spirochetes in Lyme disease, rabbits were infested with the spirochete-infected ticks. Indeed, a few weeks after the tick bites the rabbits developed macules resembling erythema migrans [10]. Similar to human disease, the skin lesions developed predominantly at tick bite sites. The new spirochete was named after its discoverer – Borrelia burgdorferi. Willy Burgdorfer was not the last Swiss scientist to play a major role in the discovery of Lyme disease spirochetes. B. burgdorferi sensu lato indeed is a complex species comprising at least 18 genospecies [11]. Three of these genospecies have been confirmed to cause human Lyme disease, namely B. burgdorferi sensu stricto, B. afzelii – named after Arvid Afzelius, and B. garinii. Other genospecies such as B. valaisiana have occasionally been isolated from Lyme disease patients but their significance as human pathogens is still not confirmed. A group with Olivier Peter, formerly at the Institut Central des Hôpitaux Valaisans and today at the University of Neuchatel, characterised a new borrelia genospecies that they had discovered in I. ricinus ticks collected in the Swiss Canton of Wallis [12, 13]. The new genospecies was named after the canton where it was initially found – Borrelia

436 Infectious Diseases of the skin(except STI) valaisiana. Today, B. valaisiana is one of the major candidates for another human pathogenic borrelia genospecies. A number of Swiss physicians are active on the subject of Lyme disease. The internal medicine specialist Norbert Satz, with his private practice in Zurich, is certainly one of the most prominent and controversial Lyme disease physicians in Switzerland (Figure 7). Due to the dermatologic focus of this book, the following passages will describe some contributions of the dermatology community to Lyme disease research.

Figure 7. Willy Burgdorfer (right) and Norbert Satz (left) at the Borrelia symposium in 1996 in Graz, Austria (courtesy of Professor R. Müllegger, Wiener Neustadt, Austria).

Probably the most active research groups during the past decades were those of Professor Stanislaw Büchner (Figure 8), and Professor Theo Rufli in Basel, Professor Werner Kempf (Figure 9), and Professor Stephan Lautenschlager, both in Zurich. They were and are interested in several aspects of Lyme disease and B. burgdorferi infection, and the following passages will give an overview on their research in this field. For example, the relevance of B. burgdorferi infection in the pathogenesis of skin disorders outside the spectrum of classical cutaneous Lyme disease, such as localised scleroderma, granuloma annulare, atrophoderma, or lichen sclerosus, is still unclear. Stanislaw Büchner, Theo Rufli, and Stephan Lautenschlager

437 Spirit and Soul of Swiss Dermatology and Venereology

Figure 8. Professor Stanislaw Büchner at the ISDP conference 1996 in Zurich, Switzerland (courtesy of Professor W. Kempf).

Figure 9. Professor Werner Kempf (courtesy of Professor W. Kempf).

438 Infectious Diseases of the skin(except STI) found serum antibodies to B. burgdorferi in a high proportion of patients with atrophoderma of Pasini and Pierini [14] and localised scleroderma [15]. In conjunction with the improvement of the atrophoderma after antibiotic therapy and a significant lymphoproliferative response to B. burgdorferi in sera from patients with localised scleroderma, these findings suggested that some of these cases might be linked to borreliosis infection. More than a decade later, Werner Kempf and his colleagues in Zurich doubted a significant association between B. burgdorferi and these skin diseases. Using polymerase chain reaction and DNA sequencing they detected borrelia DNA in only three of more than 100 skin samples of granuloma annulare, localised scleroderma and lichen sclerosus [16]. However, a glance at the recently published literature on this topic shows that this question has not been finally answered. Specific immune responses to B. burgdorferi play a significant role in the development of clinical manifestations of Lyme disease. Two decades ago, Stanislaw Büchner and Theo Rufli were among the first to demonstrate the predominance ofT cells, especially of the cytotoxic and helper T cell phenotype, in erythema migrans and acrodermatitis chronica atrophicans lesions using immunohistochemistry. Together with the large number of Langerhans cells in erythema migrans samples, they suggested that the cell-mediated immune response played an important role in cutaneous Lyme disease [17, 18]. Years later, Werner Kempf and his colleagues continued this research, being interested in the interaction of skin lymphocytes and B. burgdorferi in the development of lymphomas other than the classical borrelial lymphocytoma. They described a diffuse cutaneous large-cell B cell lymphoma with borrelia infection [19] and a subcutaneous panniculitis-like T cell lymphoma in which spirochete-activated plasmacytoid dendritic cells contributed to lymphoma development [20]. The relevance of these findings is that antibiotics are a treatment option in these cases of lymphoma prior to more aggressive therapy regimens. Atypical clinical appearance of cutaneous Lyme disease is a diagnostic challenge for dermatologists, especially when serology is negative, histology is inconclusive and molecular methods are not available. Therefore, reliable diagnostic tools facilitating the diagnosis of such challenging cases are still in demand. Based on previous findings on the T and B cell response to B. burgdorferi

439 Spirit and Soul of Swiss Dermatology and Venereology from research groups in North America, Stanislaw Büchner and his colleagues isolated lymphocytes from patients with cutaneous Lyme disease and localised scleroderma and measured their proliferation rate in response to sonicated spirochetes. The proliferation rate was higher than those in controls, even in seronegative Lyme disease, suggesting a diagnostic relevance of this lymphocyte proliferation test in Lyme disease [21]. However, the usefulness of this test is still controversially discussed. In conclusion, Lyme disease is prevalent in Switzerland, and dermatologists frequently make the diagnosis. Furthermore, the skin as tick-pathogen-host interface is the site of the initial immune response to the vector and B. burgdorferi. Therefore, dermatologists should continue their research in this field.

Acknowledgements I am very grateful to Professor Werner Kempf and Professor Stephan Lautenschlager, both in Zurich, and Professor Robert Müllegger in Wiener Neustadt, Austria, for providing photographs and for their advice on the history of Lyme disease research.

Martin Glatz

440 Infectious Diseases of the skin(except STI)

References 1. Stanek G, Wormser GP, Gray J, Strle F, « Lyme borreliosis », Lancet n° 379, 2012, p. 461-473. 2. Altpeter E, Zimmermann H, Oberreich J, Peter O, Dvorak C, « Tick related diseases in Switzerland, 2008 to 2011 », Swiss Med Wkly n° 143, p. 13725. 3. Mullegger RR, Glatz M, « Skin manifestations of lyme borreliosis: diagnosis and management », Am J Clin Dermatol n° 9, 2008, p. 355-368. 4. Smith RP, Schoen RT, Rahn DW, Sikand VK, Nowakowski J, Parenti DL, et al, « Clinical characteristics and treatment outcome of early Lyme disease in patients with microbiologically confirmed erythema migrans », Ann Intern Med n° 136, 2002, p. 421-428. 5. Colli C, Leinweber B, Mullegger R, Chott A, Kerl H, Cerroni L, « Borrelia burgdorferi-associated lymphocytoma cutis: clinicopathologic, immunophenotypic, and molecular study of 106 cases », J Cutan Pathol n° 31, 2004, 232-240. 6. Asbrink E, Hovmark A, « Early and late cutaneous manifestations in Ixodes-borne borreliosis (erythema migrans borreliosis, Lyme borreliosis) », Ann N Y Acad Sci n° 539, 1988, p. 4-15. 7. Steere AC, Malawista SE, Snydman DR, Shope RE, Andiman WA, Ross MR, et al, « Lyme arthritis: an epidemic of oligoarticular arthritis in children and adults in three connecticut communities », Arthritis Rheum n° 20, 1977, p. 7-17. 8. Scrimenti RJ, « Erythema chronicum migrans », Arch Dermatol n° 102, 1970, p. 104-105. 9. A. A, « Erythema chronicum migrans », Acta Derm Venereol (Stockh) n° 2, 1921, p. 120. 10. Burgdorfer W, Barbour AG, Hayes SF, Benach JL, Grunwaldt E, Davis JP, « Lyme disease-a tick-borne spirochetosis? », Science n° 216, 1982, p. 1317-1319. 11. Stanek G, Reiter M, « The expanding Lyme Borrelia complex--clinical significance of genomic species? », Clin Microbiol Infect n° 17, 2011, p. 487-493. 12. Peter O, Bretz AG, Bee D, « Occurrence of different genospecies of Borrelia burgdorferi sensu lato in ixodid ticks of Valais, Switzerland », Eur J Epidemiol n° 11, 1995, p. 463-467.

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13. Wang G, van Dam AP, Le Fleche A, Postic D, Peter O, Baranton G, et al, « Genetic and phenotypic analysis of Borrelia valaisiana sp. nov. (Borrelia genomic groups VS116 and M19) », Int J Syst Bacteriol n° 47, 1997, p. 926-932. 14. Buechner SA, Rufli T, « Atrophoderma of Pasini and Pierini. Clinical and histopathologic findings and antibodies to Borrelia burgdorferi in thirty-four patients », J Am Acad Dermatol n° 30, 1994, p. 441-446. 15. Buechner SA, Winkelmann RK, Lautenschlager S, Gilli L, Rufli T, « Localized scleroderma associated with Borrelia burgdorferi infection. Clinical, histologic, and immunohistochemical observations », J Am Acad Dermatol n° 29, 1993, p. 190-196. 16. Zollinger T, Mertz KD, Schmid M, Schmitt A, Pfaltz M, Kempf W, « Borrelia in granuloma annulare, morphea and lichen sclerosus: a PCR-based study and review of the literature », J Cutan Pathol n° 37, 2010, p. 571-577. 17. Buchner SA, Rufli T, « Erythema chronicum migrans: evidence for cellular immune reaction in the skin lesion », Dermatologica n° 174, 1987, p. 144-149. 18. Buechner SA, Rufli T, Erb P, « Acrodermatitis chronic atrophicans: a chronic T-cell-mediated immune reaction against Borrelia burgdorferi? Clinical, histologic, and immunohistochemical study of five cases », J Am Acad Dermatol n° 28, 1993, p. 399-405. 19. Hofbauer GF, Kessler B, Kempf W, Nestle FO, Burg G, Dummer R, « Multilesional primary cutaneous diffuse large B-cell lymphoma responsive to antibiotic treatment », Dermatolog n° 203, 2001, 168-70. 20. Kempf W, Kazakov DV, Kutzner H, « Lobular panniculitis due to Borrelia burgdorferi infection mimicking subcutaneous panniculitis- like T-cell lymphoma », Am J Dermatopathol n° 35, 2001, p. 30-33. 21. Buechner SA, Lautenschlager S, Itin P, Bircher A, Erb P, « Lymphoproliferative responses to Borrelia burgdorferi in patients with erythema migrans, acrodermatitis chronica atrophicans, lymphadenosis benigna cutis, and morphea », Arch Dermatol n° 131, 1995, p. 673-677.

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Current diagnostic methods for mycoses in dermatology

1. Introduction Medical mycology began with dermatophytes, which are filamentous parasite fungi in the stratum corneum, nails and hair. In 1839, Schönlein, a Professor and Medical Doctor in Zurich from 1833 to 1839, described a fungus as the etiologic agent of a favus [1]. This fungus was first called Achorion schoenleinii in 1845 by Remak [2], then Trichophyton schoenleinii by Langeron and Milochevitch in 1930 [3]. The first systematic study of dermatophytes was made by the French Raymond Sabouraud in a work entitled “Les teignes” [4]. The dermatophytes were classified in the Ascomycetes in 1960 when it was shown that confrontations of dermatophyte strains of opposite mating types could generate small sexual fructifications containing asci. Until the nineteen eighties, dermatophytes and some tropical mycoses were the main representatives of medical mycology. There have been major developments since then, due to AIDS and the increasing numbers of neutropenic patients. In addition to dermatophytes, two fungal groups became more and more important: (i) Yeasts, in particular those of the genus Candida, which are fungi-making colonies of isolated cells. (ii) Moulds or non-dermatophyte filamentous fungi (NDF). The latter constitute a heterogeneous group of fungi to which Aspergillus, Fusarium and Mucor belong.

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Mycology is important in dermatology and concerns 5-10% of patient consultations. Mycosis cannot usually be diagnosed on the basis of clinical signs alone but needs both direct microscopic examination of dermatological samples and identification of the infecting species grown in cultures. In the majority of cases, the pathogenic fungi in dermatology are dermatophytes, but they can also be yeasts and moulds.

2. Direct mycological examination Various skin diseases look like, but are not mycoses. Before any drug prescription, a direct mycological examination of skin, nail or hair samples is an essential step to confirm the clinical diagnosis of fungus infection in dermatology. The traditional clearing solution still in use in many laboratories to dissociate dermatological samples is 10% KOH. Another solution for the dissociation of keratinised samples (10% Na2S in a mixture water/ethanol) was introduced by Dr. D. Grigoriu in Lausanne [5], where he developed and directed the Laboratory of Dermatology in the CHUV until 1986 with the support of Professor Jean Delacrétaz. When light microscopy is used without contrasting, it is difficult to detect fungal elements. Therefore, the useof fluorochromes, which specifically bind to vegetal and fungal cell wall polysaccharides, allow a considerable improvement in the diagnosis of mycoses [6]. When the preparation is illuminated by 400-440 nm light, the hyphae and spores become fluorescent and are immediately detected (Figure 1). Direct microscopic examination using fluorescence techniques is by far the most sensitive technique for detecting rare hyphae and spores in dermatological samples. In addition, fluorescence microscopy allows better observation of the fungus morphology.

3. Cultures and fungal identification in dermatological samples A given dermatological sample is often seeded onto a rich agar medium. A frequently used medium is that of Sabouraud plus chloramphenicol as an antibiotic. Two cultures are generally made at the same time, one with and one without actidione in the medium.

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Figure 1. Direct mycological examinations of clinical samples. (A) Tinea capitis, infected hair. (B) Hyphae in infected nails. (C) Hyphae and arthrospores from an infected guinea pig.

This compound is used to select the dermatophytes. Actidione inhibits the growth of moulds such as Alternaria spp., Penicillium spp. or Aspergillus spp, but not that of the dermatophytes. Two problems repeatedly occur with cultures from collected dermatological samples. (i) Negative fungal culture results are frequently obtained. In the case of onychomycosis, 30-40% of culture assays remain negative when the direct mycological examination is positive. (ii) Various non-dermatophyte filamentous fungi (NDF) are often isolated from abnormal nails. Whether an NDF is really the etiological agent or whether they have to be considered as casual and transient contaminants, often remains unanswered. Only repeated isolations of the same NDF indicate its involvement in nail infection with some certainty. PCR methods are now reliable and suitable for performing in situ identification of dermatophytes, yeasts and NDF in onychomycosis, provided that enough nail material is collected by the clinician [7-9]. The results of fungal identification in onychomycosis obtained by PCR are representative of the infection at the time when the nail sample was collected. Identification of fungi in nails using PCR provides significantly improved results for onychomcosis: (i) Fusarium spp., Acremonium spp. or Scopulariopsis spp. are often identified with certainty as the infectious agents of onychomycosis, and not as transient contaminants. (ii) It is possible to identify the infectious agent in at least 70% of the cases where direct nail mycological

445 Spirit and Soul of Swiss Dermatology and Venereology examination showed fungal elements, but negative results were obtained from fungal culture. (iii) Identification of the infectious agent can be obtained in 24 hours with PCR-RFLP, whereas results from fungal culture can take as long as 1-2 weeks. To validate the assays, the identification of a dermatophyte was confirmed in 99% of the cases when Trichophyton rubrum or Trichophyton interdigitale grew in culture [7-9].

4. Importance of fungal identification in onychomycosis

Many cases of well-documented onycomychosis were found not to respond to multiple classic systemic treatments with terbinafine and itraconazole. The identification of the fungus in situ in nails revealed that either Fusarium spp., Acremonium spp. or Aspergillus spp. was the unique infectious agent [10]. Neither T. rubrum nor T. interdigitale was identified, and insensitivity to treatment could not be attributed to resistant dermatophyte strains. Therefore, although the efficacy of standard oral treatments with terbinafine and/or azoles against dermatophytes is proven, itis useless to pursue these treatments in cases of NDF onychomycosis. An alternative therapy should be prescribed. Topical amphotericin B has been revealed to be an efficacious, safe, cheap and easy to apply treatment which should be considered as first line therapy for NDF onychomycosis (Figure 2) [11]. The efficacy of laser and photodynamic therapies (PDT) was recently reported in some cases of onychomycoses with T. rubrum and Fusarium spp. [12-14]. Both techniques have to be considered as alternatives to systemic treatments and appear to be suitable for all fungi [15-16].

5. Importance of dermatophyte identification in cases of skin and hair mycoses

The incidence of highly inflammatory skin and hair dermatophytosis mycoses has increased in the last decade because of the increasing number of pets. Most of these mycoses are due to three zoophilic dermatophyte species: Microsporum canis (from cats and dogs), Arthroderma benhamiae (from guinea- pigs) and Arthroderma vanbreuseghemii (generally from cats and dogs) (Figure 3) [17]. The two latter species were formerly called

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Figure 2. Effective treatment of non- dermatophyte mould onychomycosis with topical amphotericin B. before treatment (left side) and after treatment (right side). The infectious agent identified by PCR was Fusarium spp. in each case (A-C).

Trichophyton mentagrophytes. The decrease in frequency of inflammatory dermatophytoses caused by Trichophyton verrucosum, a species for which the reservoir is cattle, reflects a decrease of the rural population in some countries.

Figure 3. Arthroderma benhamiae (A) Tinea capitis (kerion). (B and C) Alopecia and scaling in a guinea pig.

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Dermatophyte identification is not imperative in most cases of tinea corporis, as these mycoses respond well to topical standard treatments, regardless of the incriminated species. In contrast, dermatophyte identification is particularly useful for tinea capitis, because effective treatment depends on the incriminated dermatophytes [18]. Of important note, only a systemic treatment can cure hair mycosis. In cases of highly inflammatory dermatophytosis in humans, it is important to identify with certainty the precise etiologic agent and identify the possible source of infection, which is often a pet. Adequately treating an affected pet and its environment can help in the prevention of recurrence or new infections, especially in children. Cooperation between the medical and veterinary professions is required in such situations. Also of important note, infected animals do not generally demonstrate obvious clinical signs. Asymptomatic carriers are frequent among small pets, especially guinea pigs, which are becoming more and more popular in Europe. Cats infected with M. canis, especially long-haired ones, may demonstrate very subtle clinical signs. The diagnosis of dermatophytosis in pets is therefore frequently not made until an infection has been diagnosed in a child or young person.

6. Conclusions Although there have been many changes and improvements in fungal identification and in research on new treatments for dermatological mycoses, direct mycological examination remains the first and mandatory laboratory analysis. “No mycosis without a fungus” was the rule in the nineteen sixties and it still holds today. In diagnosing mycosis, the result of a direct mycological examination is more significant than culture results. Direct mycological examination and cultures are routinely performed simultaneously by the laboratory in the CHUV for each suspected case of mycosis. However, provided sufficient material has been collected, PCR fungal identification is made in many cases of onychomycosis to demonstrate the presence of moulds (in particular Fusarium spp., Acremonium spp. and Aspergillus spp.), which are insensitive to standard oral treatments. The analyses performed in a mycology laboratory of dermatology cannot be automatised. The proximity of the laboratory to the

448 Dermatologic Mycology policlinic and direct contact with the MDs remain important for a better overview of the cases. The synthesis of patient history and laboratory results represents a real contribution to the quality of patient care.

Michel Monod, Florence Baudraz-Rosselet

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References 1. Schoenlein JL, „Zur Pathogenie der Impetigines“, Arch. Anat. Physiol. Wiss. Med., 1839, p. 82. 2. Remak R, Diagnostische und pathogenetische Unterschungen in der Klinik des Herrn Geh. Raths Dr. Schoenlein auf dessen Veranlassung angestell und mit Benutzung anderweitiger Beobachtungen veröffentlicht. Berlin: A. Hirschwald, 1845. 3. Langeron M and Milochevitch S, « Morphologie des dermatophytes sur milieux naturels et milieux à base de plysaccharides. Essai de classification (deuxième mémoire) », Ann. Parasitol. Hum. Comp, n° 8, 1930, p. 465-508. 4. Sabouraud R, Les teignes, Paris: Masson, 1919. 5. Grigoriu D, Delacrétaz J, and Borelli D, Traité de mycologie médicale. Lausanne: Payot, 1984. 6. Monod M, Baudraz-Rosselet F, Ramelet AA and Frenk E, “Direct mycological examination in dermatology: a comparison of different methods”, Dermatologica, n° 179, 1989, p. 183-186. 7. Monod M, Bontems O, Zaugg C, Lechenne B, Fratti M and Panizzon R, “Fast and reliable PCR/sequencing/RFLP assay for identification of fungi in onychomycoses”, J. Med. Microbiol., n° 55, 2006, p. 1211-1216. 8. Bontems O, Hauser PM and Monod M, “Evaluation of a polymerase chain reaction-restriction fragment length polymorphism assay for dermatophyte and non-dermatophyte identification in onychomycosis”, Br. J. Dermatol., n° 161, 2009, p. 791-796. 9. Verrier J, Pronina M, Peter C, Bontems O, Fratti M, Salamin K, Schürch S, Gindro K, Wolfender JL, Harshman K and Monod M, “Identification of infectious agents inonychomycoses by PCR-terminal restriction fragment length polymorphism”, J. Clin. Microbiol., n° 50, 2012, p. 553-561. 10. Baudraz-Rosselet F, Ruffieux C, Lurati M, Bontems O and Monod M, “Onychomycosis insensitive to systemic terbinafine and azole treatments reveals non-dermatophyte moulds as infectious agents”, Dermatology, n° 220, 2010, p. 164-168. 11. Lurati M, Baudraz-Rosselet F, Vernez M, Spring P, Bontems O, Fratti M and Monod M, “Efficacious treatment of non-dermatophyte mould onychomycosis with topical amphotericin B”, Dermatology, n° 223, 2011, p. 289-292.

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12. Piraccini BM, Rec, G and Tosti A, “Photodynamic therapy of onychomycosis caused by Trichophyton rubrum”, J. Am. Acad. Dermatol., n° 59 (5 Suppl), 2008, p. 75-76. 13. Watanabe D, Kawamura C, Masuda Y, Akita Y, Tamada Y and Matsumoto Y, “Successful treatment of toenail onychomycosis with photodynamic therapy. Photodynamic therapy of onychomycosis caused by Trichophyton rubrum”, Arch Dermatol., n° 144, 2008, p. 19-21. 14. Gilaberte, Aspiroz C, Martes MP, Alcalde V, Espinel-Ingroff A and Rezusta, A, “Treatment of refractory fingernail onychomycosis caused by nondermatophyte molds with methylaminolevulinate photodynamic therapy.”, J. Am. Acad. Dermatol., n° 65, 2001, p. 669-671. 15. Gupta AK and Simpson FC, “Medical devices for the treatment of onychomycosis”, Dermatol. Ther., n° 25, 2012, p. 574-581. 16. Ledon JA, Savas J, Franca K, Chacon A and Nouri K, “Laser and light therapy for onychomycosis: a systematic review”, Lasers Med. Sci, (Epub ahead of print) PMID: 23179307, 2012. 17. Drouot S, Mignon B, Fratti M, Roosje P and Monod M, “Pets as the main source of two zoonotic species of the Trichophyton mentagrophytes complex in Switzerland, Arthroderma vanbreuseghemii and Arthroderma benhamiae”, Vet. Dermatol., n° 20, 2008, p. 3-18. 18. Baudraz-Rosselet F, Monod M, Jaccoud S and Frenk E, “Efficacy of terbinafine treatment of tinea capitis in children varies according to the dermatophyte species”, Br. J. Dermatol., n° 135, 1996, p. 1011-1012.

451

Lasers in Dermatology

LASERS in dermatology: past, present and future

During the 20th century, tremendous progress in science allowed the discovery of lasers; complex machines that progressively invaded our daily environment. Lasers are nowadays in many sectors of our life as illustrated by bar code and compact disk readers, laser pointers, various systems of measurement, lighting sources (not only in discotheques), weapons, etc… However, large-scale use of lasers in medicine is very recent, accounting only for the 2010 created SSDV laser group, a newcomer in our society. Before this, laser use in dermatology was well established for a growing minority of SSDV members who had also developed an interest for new technologies. Teaching in laser science has been carried out in Switzerland since the middle of the nineties, and interactions with foreign laser societies have always been active. SSDV was also internationally represented by Maurice Adatto from Geneva as a former President of the European Society for Laser in Dermatology (ESLD).

A few words about the history of laser science. Lasers represent a very accomplished product in the old desire of humans to domesticate light sources. In early prehistoric sites, as illustrated by the southern England Stonehenge megalithic site, humans were trying to focus solar light for special events: sunrise solar rays directed specifically on the central altar stone every 21st of June at summer solstice. Stonehenge could therefore be considered as a very distant precursor of modern lasers, sharing with our current devices a very difficult recycling profile…

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More recently, the discovery of the visible light spectrum was a critical step before the description of wavelengths. Visible light was found to represent a tiny portion of the global wavelength spectrum, which includes ultraviolet, infrared, radio waves, etc… The theory of lasers emerged in the early 20th century and Albert Einstein was the father of the theory of Light Amplification by Stimulated Emission of Radiation (LASER acronym). The first lasers appeared around 1960 and numerous Nobel prizes were related to this nascent technology during those years. The principle of lasers consists of the continuous stimulation of electrons into a high energy state with the emission of a single wavelength photon (light) during the return phase to the low energy state. These produced photons are collected and amplified, and then directed in a certain way to produce a beam. The wavelength of the produced photons depends on the nature of the stimulated source, and so far, lasers were developed mainly in the visible range of light, but also in the ultraviolet and infrared domains. Lasers beams were tailored to fit the required mission: beam shape, diameter, intensity (fluence), duration (continuous or pulsed) are among the so many parameters, which can be modified to achieve the best results. The first laser applications were industrial, allowing the realisation of precise tasks in a very short time. In the nineteen sixties and seventies, most lasers were restricted to universities and research laboratories for civil and military developments. In Switzerland, the CERN (European Center for Nuclear Research) in Geneva contributed notably to developing lasers tools, in addition to creating the worldwide web and the countless fundamental science contributions in nuclear physics. Interest in lasers from the industrial and military environments was immediate: their financial support boosted the development of new tools, therefore contributing to the rapid innovation of laser use in other sectors such as medicine. Lasers have become attractive in many fields because they offer very precise, reproducible, rapid and strong tools. Our daily environment was irreversibly modified with laser mediated

454 Lasers in Dermatology compact disk readers, bar code readers, laser light sources, laser tools for precise measurements, laser pointers, laser weapons, etc… Early after the advent of lasers, medical uses were imagined and, comprehensively, thanks to the great accessibility of the skin as a therapeutic target, dermatologists were among the first medical users of laser sources.

The medical use of lasers became possible when the following conditions were fulfilled: Devices became smaller and mobile. The first lasers were cumbersome and fragile, incompatible with clinical settings. 1) Security issues were identified and controlled. Specific eyeshields and safety material were provided and allowed the large-scale use of laser tools. 2) Targets for lasers were correctly identified in human tissues. Depending on the type of laser used, appropriate targets are either with a high water content (for example in CO2 laser vaporisation) or rich in certain coloured pigments (such as melanin, hemoglobin, iron, etc). Pigmented targets were named chromophores. 3) The absorption curves of every chromophore were determined. Depending on the used wavelength, targets will absorb the laser source very differently: peaks of absorption (= energy deposition of the target) were identified and these peaks served to develop the right laser for a certain chromophore. In dermatology, vascular, pigmented, and hair removal lasers were designed, and machines build to fit best chromophore absorption peaks. Vaporisation lasers came for the destruction of high water content structures. 4) Finally, was the concept of selective photothermolysis described by Rox Anderson and co-workers. Dermatologists interested in laser science and well-educated in skin physiology and physiopathology were able to describe how a specific laser with its wavelength is able to heat the pigmented chromophore in a tissue without heating its environment. Selective heating of the target allows precise and safe treatments in vascular (chromophore = hemoglobin),

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pigmented (chromophore = melanin of lentigos for ex.) or hair removal (chromophore = hair melanin) conditions.

However, in reality, the coexistence of multiple chromophores in human tissue is not rare; for example blood vessels with hemoglobin are often present next to other pigments. Therefore the safety of the treatment will include the knowledge of the different chromophore absorption curves with the selected laser in order to avoid overheating unwanted coexisting targets. A learning curve is necessary before performing the right treatment with the right machine on the right patient. Perfect knowledge of the treated organ is a pre-requisite and therefore one should restrict use of the powerful lasers to specialists in the concerned tissue! In parallel to the growing enthusiasm related to therapeutic possibilities with the new technologies, an awareness of the risk and an ability to manage potential side effects have become a necessity. Scarring was not rare with first generation argon lasers; it should be exceptional with current devices. Many medical specialties have made their own developments and subspecialties in laser use. As dermatologists, we were early involved in laser use, and its development and skin-based studies often served as models to adapt into other specialties. In parallel to laser monochromatic sources (only one wavelength), other light sources became available, such as the polychromatic (multiple wavelength) Intense Pulsed Light sources (IPL). The spectrum of IPL therapeutic indications is close to lasers, with some differences in efficacy. The IPL sources and lasers used in dermatology belong generally to the powerful class 4 category and should therefore be used only by trained physicians or at least under their responsibility, as mentioned in legal directives in Switzerland. In case of problems with a treatment, device users (for example aestheticians) who do not fulfill these requirements might have difficulties in the event of legal procedures. Lasers and IPL’s, can be used traditionally or in a fractionated mode, leaving intact skin areas between the multiple mini laser wells. The concept of fractionation arose in the early 2000s, and fractionated devices already belong to standard equipment.

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Post-laser skin recovery is very short after fractionated therapy as compared with the non-fractionated mode (100% surface treated). Although a high percentage of treatments in dermatology is dedicated to aesthetic indications, a growing number of medical indications for laser therapy have been published. Lasers sometimes allow the avoidance of surgery or oral therapies, as illustrated in rosacea with the pulse dye laser. The future of lasers will bring new wavelengths in clinical practice and we will learn how to deal with shorter pulse durations (pico- or even femtosecond lasers) in order to selectively heat smaller targets (for example subcellular targets). Teaching the many medical indications for laser or IPL therapies in dermatological diseases to our colleagues will also reinforce the place of our laser group in the Swiss Society of Dermatology and Venereology (SSDV). The number of medical conditions improved by lasers use will continue to grow. Efforts must be made to publish these cases, to establish the growing role of lasers in dermatological therapy. Fractionated therapy allows the drilling of multiple holes into the skin, increasing many times the permeability of the skin to various medications. This laser mediated drug delivery and stimulated uptake will probably develop in the near future for conditions such as dermatoporosis, and therapies such as photodynamic therapy will illustrate the favourable influence of fractionated laser skin permeabilisation. In order to minimise health hazards, the SSDV laser group will: – continue to play a role in laser teaching for dermatologists, together with foreign and international dermatological laser societies, – help to maintain high levels of quality in dermatological laser treatments, – be a Swiss expert group for difficult cases in dermatology, – constitute a discussion partner for Swiss medical authorities, in order to represent the SSDV dermatologist’s vision of laser therapy. Joachim Krischer, Maurice Adatto, R. Rüdlinger, Peter Bloch

457

Cutaneous Lymphomas

Subspecialties – Cutaneous Lymphomas

Primary cutaneous lymphomas make up a group of disorders which initially manifest in the skin, and which can spread to blood, lymph nodes or internal organs in the course of the disease. Despite their rarity, with an incidence of ca. 0.5:100,000 inhabitants/year, they have attracted the interest of dermatologists due to their clinical variability and their often decades-long course. As the skin is simple to access, they can also be used as models in the study of the pathogenesis of lymphoproliferative disorders. The most well-known historical description of cutaneous lymphomas was made by Jean-Louis Alibert, who later became the personal physician of the French king Louis XVIII, and also by Pierre-Antoine-Ernest Bazin. The designation Alibert-Bazin syndrome did not persist, in contrast to the descriptive term coined by Alibert in 1835: Mycosis fungoides (MF). Further clinically descriptive names of cutaneous lymphomas are still in use today – despite improved understanding of the cellular causes of the disorder – such as: lymphomatoid papulosis, erythrodermic MF or pagetoid reticulosis. Due to the easy accessibility of the skin organ and advances in microscopy, it was possible to distinguish between a number of disorders over the course of the twentieth century with systematic morphological descriptions of clinical presentation and thanks to the advances in immunohistochemical cell-typing (for example, as a result of the publication by Sézary and Bouvrain in 1938 of the description of an erythrodermic patient with mononuclear blood count changes, later known as

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Sézary syndrome). Its affiliation to the reticuloses, disorders of what was then known as the reticuloendothelial system of the monocytes/macrophages/histiocytes and lymphocytes was, particularly in the 1950s, propounded by French [1] and German [2] authors and occasionally put forward in the Anglo-American literature [3], [4]. Based on the reinterpretation of cytomorphology thanks to immunohistochemistry and electron microscopy (Lukes and Collins in the USA, Lennert’s Kiel school in Europe) it was finally possible in the 1970s to differentiate the group of cutaneous T-cell lymphomas (CTCL) more accurately, analogous to the classification of nodular lymphomas. Furthermore, a B-cell infiltration pattern could be histologically distinguished from a T-cell infiltration pattern in the skin ([5]). Finally, the consensus for the classification of cutaneous lymphomas by the WHO-EORTC as a result of this combination of clinical presentation and immunohistochemistry in the last decade represented a major breakthrough in dermatooncology (LeBoit P, Burg G, et al., (eds), Tumors of the skin, Lyon: WHO Books, 2006 [6]). The Swiss have been actively publishing in the field of cutaneous lymphomas (CL) since the 1970s. Stan Büchner and Theo Rufli in Basel published histopathological analyses of stage-dependent enzymatic and cytochemical criteria of CTCL [7] [8], and on the pathogenesis of Sézary Syndrome after previous chemo-/ radiotherapy [9]. Since the appointment of Günter Burg as Chief Physician of the Department of Dermatology at the University of Zurich in 1991, the dermatological clinic in Zurich has become an active and internationally recognised research site for CL. Until the end of the nineteen nineties, the classification of lymphomas was mostly based on cytological criteria, which didn’t consider cutaneous lymphomas to be independent entities and thus did not do justice to the clinical, therapeutic and prognostic characteristics of CL. For example, primary and secondary CL used to be classified by pathologists according to the lymphoma classifications (e.g. [10], Kiel, Working Formulation, R.E.A.L) on the basis of the histological characteristics alone, until it became clear that the courses of primary cutaneous and primary nodal lymphomas differ dramatically despite having the same histological sub-type.

460 Cutaneous Lymphomas

In particular it became clear that many patients with primary CL needed protecting from aggressive, side-effect-ridden overtreatment with aggressive chemotherapy. Günter Burg’s scientific connections and the corresponding change in focus of the dermatological clinic in Zurich to dermatooncology, with particular emphasis on the study of CL (G. Burg, R. Dummer, W. Kempf, A. Cozzio, J. Kamarachev, K. Kerl), brought haematologists, pathologists and representatives of the International Society for Cutaneous Lymphomas (ISCL, http://www.cutaneouslymphoma.org/home), which Günter Burg founded in New York in 1992, to Lyon und Zurich in 2004 on behalf of the WHO. The foundations were created at these meetings for the harmonisation of the WHO haematopathological lymphoma classification with the EORTC dermatooncological classification for cutaneous lymphomas. It is only as a result of the combined classification of lymphomas, that the comprehension problems between the haematological, pathological and dermatological medical disciplines have largely been solved regarding this special group of cutaneous neoplasms (Table 1).This WHO/EORTC classification, which is based on clinical, histological and immune phenotypical criteria, allowed the comparability of patient groups and treatment options in the increasing numbers of the EORTC Cutaneous Lymphoma Task Force (CLTF) clinical studies for the first time. CL are also being studied in other Swiss university clinics: In Bern, in addition to autoimmune bullous disorders, dermatopathology is currently focusing on CL (Helmuth Beltraminelli), as illustrated by the cooperation with 2 CL study centres (Lorenzo Cerroni in Graz, and Group Français pour l’Étude des Lymphomes Cutanées). H. Beltraminelli was able to demonstrate the benign course of CD4+ small-/medium-sized pleomorphic CTCL in a large collective [11]. After his stay with Alain Rook in Philadelphia (USA), Lars French introduced multimodal therapy with the so-called “biological response modifiers,” i.e. the combination therapies with interferon, vitamin A derivatives and other modern immune response-modifying substances in Geneva [12]. His contributions on the apoptosis- resistance of T-lymphocytes in Sézary Syndrome provided a rationale for the application of pro-apoptotic substances such as interferon g in this group of disorders [13].

461 Spirit and Soul of Swiss Dermatology and Venereology

A total of over 150 articles on the study of CL have been published over the last two decades in Zurich with (in alphabetical order) Günter Burg, Antonio Cozzio, Udo Döbbeling, Reinhard Dummer, Andreas Häffner, Jivko Kamarachev, Werner Kempf, Mirjana Maiwald and others as first or last author. In addition, a large number of monographs have been written on this subject. Table 2 lists a selection of these publications. Following the era of cytology, histology and immunohistochemistry, an increasing number of molecular biological analyses of intracellular signal cascades and (surface) markers of single lymphoma entities have come under the focus of international studies. Corresponding targeted therapies become increasingly important with the improved knowledge of tumour cell surface markers (e.g. expression analyses of CD25, CD30, or CD52 on CTCL cells) or the recognition of the T-helper 2-skewed immunomodulation in CTCL. Thanks to the manifold connections with international medical research institutions and pharmaceutical centres, it is possible for Swiss CL patients to be included in prospective multicentre studies (for example the studies on anti-CD30 antibody Brentuximab- Vedotin in 2013), and thus profit early from the medical advances in this area. The programme “focus on skin cancer” also manifested itself in the certification of the dermatological university clinic Zurich with the label “Onkozert” in 2011. Weekly tumour boards coordinated by dermatooncology bring specialists from radiology, nuclear medicine, radiotherapy, (haemato-) oncology, transplantation medicine, HNO, psychooncology together. In this way, patients with complex lymphoproliferative skin cancers, e.g. an advanced stage of Mycosis fungoides IIB-IV, can in future also be offered an interdisciplinary therapy. It is very fortunate that the Swiss dermatological university clinics and the dermatopathologists continue to demonstrate great interest in the study of cutaneous lymphomas; the time is ripe for the foundation of a working group “cutaneous lymphoma” within the Swiss Society for Dermatology and Venereology (SSDV). We hope that our successors will be able to report on the advances of this working group in the next SSDV centennial jubilee book!

Antonio Cozzio, Reinhard Dummer, Lars E. French, Werner Kempf, Günter Burg

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Table 1: WHO/EORTC classification of cutaneous lymphomas Cutaneous T-cell und NK-cell Cutaneous B-cell lymphomas lymphomas Primary cutaneous marginal Mycosis fungoides (MF) zone lymphoma Mycosis fungoides variants and subtypes Folliculotropic MF Primary cutaneous follicle centre lymphoma Pagetoid Reticulosis Granulomatous slack skin Primary cutaneous diffuse large Sézary Syndrome B-cell lymphoma (leg type) Adult T-cell leukaemia/lymphoma Primary cutaneous diffuse large (HTLV+) B-cell lymphoma (other types) Primary cutaneous CD30+ lymphoproliferative disorders Primary cutaneous intravascular Primary cutaneous anaplastic large B-cell lymphoma large cell lymphoma Lymphomatoid papulosis Subcutaneous panniculitis-like T-cell lymphoma Haematological precursor neoplasms Extranodal NK/T-cell lymphoma Blastic plasmacytoid dendritic cell neoplasm (previously: CD4+, CD56+ haematodermic neoplasm, blastic NK-cell lymphomas) Primary cutaneous peripheral T-cell lymphoma, unspecified Primary cutaneous aggressive epidermotropic CD8+ T-cell lymphoma (provisional) Cutaneous γ/δ-T-cell lymphoma (provisional) Primary cutaneous small/ medium-sized pleomorphic T-cell lymphoma (provisional)

463 Spirit and Soul of Swiss Dermatology and Venereology

Table 2: Selected publications on cutaneous lymphomas from Swiss university clinics, listed chronologically from 1978 to 2013

Büchner SA, Rufli T, “Enzyme cytochemical studies of malignant cutaneous lymphomas using simple smear preparations”, Hautarzt, n° 6, 1978, p. 323-327.

Büchner S, Rufli T,“ Manifestation of a malignant lymphoma of high grade malignancy in the terminal stage of mycosis fungoides. Enzyme-cytochemical and immunocytological investigations”, Dermatologica, n° 159, 1979, p. 125-31.

Burg G, Dummer R, Wilhelm M, Nestle F, Ott MM, Feller A, Hefner H, Lanz U, Schwinn A, Wiede J, “A subcutaneous delta- positive T-cell lymphoma that produces interferon gamma”, N Engl J Med, n° 325, 1991, p. 1078-1081.

Burg G, Dummer R, Nestle FO, Doebbeling U, Haeffner A, “Cutaneous lymphomas consist of a spectrum of nosologically different entities including mycosis fungoides and small plaque parapsoriasis”, Arch Dermatol, n° 5, 1996, p. 567-572.

Kamarashev J, Burg G, Mingari MC, Kempf W, Hofbauer G, Dummer R, “Differential expression of cytotoxic molecules and killer cell inhibitory receptors in CD8+ and CD56+ cutaneous lymphomas”, Am J Pathlo, n° 5, 2001, p. 1593-1598.

Dummer R, Kamarashev J, Kempf W, Häffner AC, Hess- Schmid M, Burg G, “Junctional CD8+ cutaneous lymphomas with nonaggressive clinical behavior: a CD8+ variant of mycosis fungoides?”, Arch Dermatol, n° 2, 2002, p. 199-203.

Dummer R, Hassel JC, Fellenberg F, Eichmüller S, Maier T, Slos P, Acres B, Bleuzen P, Bataille V, Squiban P, Burg G, Urosevic M, “Adenovirus-mediated intralesional interferon-gamma gene transfer induces tumor regressions in cutaneous lymphomas”, Blood, n° 104, 2004, p. 1631-1638.

Willemze R, Jaffe ES, Burg G, Cerroni L, Berti E, Swerdlow SH, Ralfkiaer E, Chimenti S, Diaz-Perez JL, Duncan LM, Grange F, Harris NL, Kempf W, Kerl H, Kurrer M, Knobler R, Pimpinelli

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N, Sander C, Santucci M, Sterry W, Vermeer MH, Wechsler J, Whittaker S, Meijer CJ, “WHO-EORTC classification for cutaneous lymphomas”, Blood, n° 105, 2005, p. 3768-3785.

Urosevic M, Conrad C, Kamarashev J, Asagoe K, Cozzio A, Burg G, Dummer R, “CD4+CD56+ hematodermic neoplasms bear a plasmacytoid dendritic cell phenotype”, Hum Pathol, n° 9, 2005, p. 1020-1024.

Burg G, Kempf W, Cozzio A, Feit J, Willemze R, S Jaffe E, Dummer R, Berti E, Cerroni L, Chimenti S, Diaz-Perez JL, Grange F, Harris NL, Kazakov DV, Kerl H, Kurrer M, Knobler R, Meijer CJ, Pimpinelli N, Ralfkiaer E, Russell-Jones R, Sander C, Santucci M, Sterry W, Swerdlow SH, Vermeer MH, Wechsler J, Whittaker S, “WHO/EORTC classification of cutaneous lymphomas 2005: histological and molecular aspects”, J Cutan Pathol, n° 10, 2005, p. 647-674.

Cozzio A, Kempf W, Schmid-Meyer R, Gilliet M, Michaelis S, Schärer L, Burg G, Dummer R, “Intra-lesional low-dose interferon alpha2a therapy for primary cutaneous marginal zone B-cell lymphoma”, Leuk Lymphoma, n° 47, 2006, p. 865-869.

Zhang C, Toulev A, Kamarashev J, Qin JZ, Dummer R, Döbbeling U, “Consequences of p16 tumor suppressor gene inactivation in mycosis fungoides and Sézary syndrome and role of the bmi-1 and ras oncogenes in disease progression”, Hum Pathol, n° 7, 2007, p. 995-1002.

Urosevic M, Fujii K, Calmels B, Laine E, Kobert N, Acres B, Dummer R, “Type I IFN innate immune response to adenovirus- mediated IFN-gamma gene transfer contributes to the regression of cutaneous lymphomas”, J Clin Invest, n° 10, 2007, p. 2834-2846.

Contassot E, Kerl K, Roques S, Shane R, Gaide O, Dupuis M, Rook AH, French LE, “Resistance to FasL and tumor necrosis factor-related apoptosis-inducing ligand-mediated apoptosis in Sezary syndrome T-cells associated with impaired death receptor and FLICE-inhibitory protein expression”, Blood, n° 111, 2008, p. 4780-4787.

465 Spirit and Soul of Swiss Dermatology and Venereology

Beltraminelli H, Leinweber B, Kerl H, Cerroni L, “Primary cutaneous CD4+ small-/medium-sized pleomorphic T-cell lymphoma: a cutaneous nodular proliferation of pleomorphic T lymphocytes of undetermined significance? A study of 136 cases”, Am J Dermatopathol, n° 4, 2009, p. 317-322.

Beltraminelli H, Müllegger R, Cerroni L, “Indolent CD8+ lymphoid proliferation of the ear: a phenotypic variant of the small- medium pleomorphic cutaneous T-cell lymphoma?”, J Cutan Pathol, n° 37, 2010, p. 81-84.

Dummer R, Eichmüller S, Gellrich S, Assaf C, Dreno B, Schiller M, Dereure O, Baudard M, Bagot M, Khammari A, Bleuzen P, Bataille V, Derbij A, Wiedemann N, Waterboer T, Lusky M, Acres B, Urosevic-Maiwald M, “Phase II clinical trial of intratumoral application of TG1042 (adenovirus-interferon- gamma) in patients with advanced cutaneous T-cell lymphomas and multilesional cutaneous B-cell lymphomas”, Mol Ther n° 6, 2010, p. 1244-1247.

Kempf W, Pfaltz K, Vermeer MH, Cozzio A, Ortiz-Romero PL, Bagot M, Olsen E, Kim YH, Dummer R, Pimpinelli N, Whittaker S, Hodak E, Cerroni L, Berti E, Horwitz S, Prince HM, Guitart J, Estrach T, Sanches JA, Duvic M, Ranki A, Dreno B, Ostheeren- Michaelis S, Knobler R, Wood G, Willemze R, “EORTC, ISCL, and USCLC consensus recommendations for the treatment of primary cutaneous CD30-positive lymphoproliferative disorders: lymphomatoid papulosis and primary cutaneous anaplastic large- cell lymphoma”, Blood, n° 118, 2011, p. 4024-4035.

Dummer R, Quaglino P, Becker JC, Hasan B, Karrasch M, Whittaker S, Morris S, Weichenthal M, Stadler R, Bagot M, Cozzio A, Bernengo MG, Knobler R, “Prospective international multicenter phase II trial of intravenous pegylated liposomal doxorubicin monochemotherapy in patients with stage IIB, IVA, or IVB advanced mycosis fungoides: final results from EORTC 2012”, J Clin Oncol, n° 30, 2012, p. 4091-4097.

Rozati S, Kerl K, Kempf W, Tinguely M, Zimmermann DR, Dummer R, Cozzio A, “Spindle-cell variant of primary cutaneous

466 Cutaneous Lymphomas follicle center lymphoma spreading to the hepatobiliary tree, mimicking Klatskin tumor”, J Cutan Pathol, n° 40, 2013, p. 56-60.

Kempf W, Kazakov DV, Schärer L, Rütten A, Mentzel T, Paredes BE, Palmedo G, Panizzon RG, Kutzner H, “Angioinvasive lymphomatoid papulosis: a new variant simulating aggressive lymphomas”, Am J Surg Pathol, n° 1, 2013, p. 1-13.

Assaf C, Becker JC, Beyer M, Cozzio A, Dippel E, Klemke CD, Kurschat P, Weichenthal M, Stadler R, “Treatment of advanced cutaneous T-cell lymphomas with non-pegylated liposomal doxorubicin – Consensus of the lymphoma group of the Working Group Dermatologic Oncology”, J Dtsch Dermatol Ges, n° 4, 2013, p. 338-347.

Figure 1. Moulage und clinical picture of Mycosis fungoides, Stage IIB (cutaneous tumour) (Dr. Michael Geiges, head of moulage museum, University of Zurich).

467 Spirit and Soul of Swiss Dermatology and Venereology

References 1. Degos R, et al, “Cutaneous malignant histiolymphocytic reticulosis with monocytemia and lymphocytemia of the leukemic type”, Bull Soc Fr Dermatol Syphilig, n° 59, 1952, p. 445-447. 2. Gottron, “Retikulosen der Haut. Dermatologie und Venerologie”, GHSW Stuttgart Thieme IV, 1960, p. 501–590. 3. Main RA, Goodall HB, and Swanson WC, “Sezary’s syndrome”, Br J Dermatol n° 71, 1959, p. 335-343. 4. Taswell, HF and Winkelmann RK, “Sezary syndrome--a malignant reticulemic erythroderma”, JAMA n° 177, 1961, p. 465-472. 5. Burg G, et al, “Patterns of cutaneous lymphomas. Histological, enzyme cytochemical, and immunological typing of lymphoreticular proliferations in the skin”, Dermatologica n° 157, 1978, p. 282-291. 6. Willemze R, et al, “WHO-EORTC classification for cutaneous lymphomas”, Blood n° 105, 2005, p. 3768-3785. 7. Buchner SA and Rufli T, “Enzyme cytochemical studies of malignant cutaneous lymphomas using simple smear preparations”, Hautarzt, n° 29, 1978, p. 323-327. 8. Buchner S. and Rufli T, “Manifestation of a malignant lymphoma of high grade malignancy in the terminal stage of mycosis fungoides. Enzyme-cytochemical and immunocytological investigations (author’s transl)”, Dermatologica, n° 159, 1979, p. 125-131. 9. Buchner SA and Rufli T, “Malignant histiocytosis with cutaneous involvement: enzymecytochemical and immunocytological studies (author’s transl)”, Dtsch Med Wochensch, n° 105, 1980, p. 373-377. 10. Lukes RJ and Collins RD, “Immunologic characterization of human malignant lymphomas”, Cance, n° 34, 1974 p. 1488-1503. 11. Beltraminelli H, et al, “Primary cutaneous CD4+ small-/medium-sized pleomorphic T-cell lymphoma: a cutaneous nodular proliferation of pleomorphic T lymphocytes of undetermined significance? A study of 136 cases”, Am J Dermatopathol, n° 31, 2009, p. 317-322. 12. French LE, et al, “Regression of multifocal, skin-restricted, CD30- positive large T-cell lymphoma with interferon alfa and bexarotene therapy”, J Am Acad Dermatol, n° 45, 2001 p. 914-918. 13. Contassot E, et al, “Resistance to FasL and tumor necrosis factor- related apoptosis-inducing ligand-mediated apoptosis in Sezary syndrome T-cells associated with impaired death receptor and FLICE- inhibitory protein expression”, Blood, n° 111, 2008, p. 4780-4787.

468 Dermatologic Oncology

Dermatooncology

Cutaneous malignancies are an urgent problem in dermatology as well as in general medicine. Today, we estimate that every third Swiss person will develop a cutaneous malignancy once in a lifetime. The lifetime risk of melanoma, which accounts for most deaths caused by skin cancers, is 1 out of 70 for newborns of the new millennium. Based on these drastic epidemiological features, cutaneous oncology must be in the focus of the Swiss Dermatology Society. In fact, cutaneous oncology has been one focus of its clinical activities for a long time.

For decades, surgery and radiotherapy have been primarily used as standard treatment approaches for cancer. There are several highly specialised centres that offer most advanced surgical techniques combined with specific histopathological approaches, such as Mohs-surgery. These techniques allow for ultimate control over the complete resection of cutaneous malignancies. Switzerland has always been one of the leading countries in the field of dermatological radiotherapy. This established practice was started by Professor Bruno Bloch (Zurich) and recently has been continued by Professor Renato Panizzon (Zurich and later Lausanne). A chapter of this book has been dedicated to radiotherapy in dermatology. University hospitals in Switzerland offer specialised outpatient clinics for skin cancer patients. Today, these outpatient clinics offer special techniques for early detection, including digital follow-up

469 Spirit and Soul of Swiss Dermatology and Venereology of pigmented lesions and confocal microscopy. Professor Ralph Braun has established new techniques for total body imaging in Geneva and Zurich that allow close monitoring of all pigmented lesions on the body surface. In addition to these techniques that are used in a subgroup of high risk patients, the Swiss Society of Dermatology and Venereology (SSDV) has always been engaged in prevention campaigns. From the early 1990s until 2010, there was a very close and productive cooperation between the SSDV and the Swiss Cancer League. This cooperation was supported extensively by the Swiss dermatologists. Moreover, Swiss dermatologists agreed to close down their offices for one day per year to offer free skin cancer prevention screening. These activities have been summarised in annual reports and a publication by Heinzerling et al [1]. Despite the fact that secondary prevention is the strength of dermatologists, unfortunately it is not a priority of the Swiss Cancer League and therefore, the cooperation between them and the SSDV ended in 2011. Since 2012 the prevention campaigns in Switzerland have been organised by the SSDV alone under the guidance of Professor Ralph Braun from Zurich. There are several exciting examples of how Swiss dermatologists contribute to first class research in the field of cutaneous oncology. The group of Professor Büchner in Basel has studied the mechanism of the regression of basal cell carcinomas by intralesional interferon alpha. They were able to show that the up regulation of CD95 is crucial for the anti-tumour effect of alpha interferon. The results of this study had a great impact on the registration of interferon as intralesional therapy for basal cell carcinoma (BCC) [2, 3]. Another very important development for the treatment of actinic keratosis and superficial BCC was the clinical development of photodynamic therapy (PDT). Professor Lasse Braathen from the University Hospital in Bern is one of the pioneers in this field. His research contributions led to the registration of methyl- aminolevulinic acid together with a special red light irradiation device. His activities are reflected in the current European guidelines for photodynamic therapy [4]. Intensive basic and clinical research activities for cutaneous lymphomas are conducted in Geneva and Zurich. Professor Günther Burg always had an active role in the European Organisation for the

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Research and Treatment of Cancer (EORTC) cutaneous lymphoma group. Furthermore, he is one of the main authors of the EORTC classification of cutaneous lymphomas [5]. Professor Burg is also the founder of the International Society for Cutaneous Lymphomas (ISCL) (see chapter on cutaneous lymphomas by A. Cozzio et al.). Guidelines for the treatment of cutaneous melanomas have existed for more than a decade [6] [7] but the treatment of advanced melanoma remains a challenge. In Switzerland, the Dermatology Society has agreed that low risk melanomas can be managed in private dermatology offices. Patients that qualify for sentinel lymph node biopsy should be referred to regional centers such as the university hospitals. The SSDV does not recommend performing sentinel node biopsy in smaller hospitals because the procedure requires a multidisciplinary group that involves: dermatologists, plastic surgeons, nuclear medicine experts and pathologist. Just 20 years ago, most patients with a primary melanoma underwent prophylactic dissection of the locoregional lymph nodes. Currently, the initial treatment of primary melanoma is driven by biomarkers, particularly tumour thickness and the node stage. For thin tumours, their severity may be upgraded when ulceration is present and the mitotic rate is high, particularly if tumour thickness is higher than 0.75 mm. From a surgical viewpoint, tumour thickness dictates the size of the surgical margin at resection. Sentinel node biopsy should be performed for patients with non- palpable diseases; A positive sentinel node raises the possibility of lymph node dissection. A key challenge for the research community is to investigate the interrelated roles of surgery and adjuvant therapy as the risk associated with the nature and stage of the disease increases. Today only patients with a confirmed micro-node metastases should undergo lymph node dissection. After a long dispute regarding the use of adjuvant interferon therapy in melanomas with node involvement (stage N1A and higher) should be treated with interferon-alpha. Interferon-α is a pleiotropic cytokine, with a number of fundamental roles in human biochemistry. For example, it inhibits viral replication via Mx proteins. This mechanism is essential to our resistance to viral infection. Interferon-α is also a

471 Spirit and Soul of Swiss Dermatology and Venereology very potent immune regulator, and has anti-proliferative properties. These immune regulatory and growth inhibitory functions make it a very promising anti-cancer drug; researchers have worked for decades to find applications for this molecule in oncology. Interferon has a relatively short half-life; when it is injected, it rapidly undergoes proteolysis. This makes it difficult to produce an area under the curve of sufficient magnitude to ensure biological efficacy. This limitation has been overcome by the addition of one or more polyethylene glycol (PEG) polymer chains to the interferon molecule, a process known as pegylation, which impedes the ability of the immune system to recognise the molecule, and therefore slows the rate of its catabolism. The half-life of pegylated interferon is thus several times greater than that of the unpegylated molecule. Since pegylated interferon-alpha (PegIFN-α) is suitable for long- term therapy, the EORTC initiated a large prospective randomised trial to investigate the protective effect of PegIFNα-2b in the adjuvant setting [8]. 1256 patients with resected stage III melanoma were randomised for observation, or to receive PegIFNα-2b therapy [8]. Randomisation was stratified for microscopic (N1) vs. macroscopic (N2) nodal involvement, number of positive nodes, ulceration and tumour thickness. The interferon group received an induction interferon dose of a weekly dose of 6 μg/kg for the first 8 weeks and then the dose was reduced to 3 μg/kg per week for 5 years Relapse-free survival (RFS) (primary endpoint), distant- metastases-free survival (DMFS) and OS were analysed for the intent-to-treat population [8]. At 3.8 years of median follow-up, RFS was significantly improved by 18% in the PegIFNα-2b arm compared with observation; the 4-year RFS rate was 45.6% vs 38.9%. OS was unchanged in the two groups. In stage III-N1a (micro metastases detected in the sentinel node) both RFS (HR 0.72, 57.7% vs 45.4%, P=0.01) and DMFS (HR 0.73, 60.5% vs 52.6%, P=0.01) were prolonged in the PegIFNα-2b arm, whereas in stage III- N1b (macroscopic metastases) there was no benefit 8[ ]. This trial showed that a prolonged adjuvant treatment with IFN-α improved the RFS period and DMFS in a subgroup of patients with low tumour burden [8].

The Department of Dermatology has pioneered the use of cytokines for melanoma therapy. Reinhard Dummer and

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Günter Burg have introduced the treatment with interleukin-2 in Switzerland [9]. There was always a very strong interest in vaccination strategies. Therefore, in cooperation with the German Cancer Centre, the Department has also performed clinical trials using dendritic cells [10]. There was also intensive work on gene therapy. Actually more than 100 patients have been treated with different types of gene transfer in the Department of Dermatology. The department has used gene modified cells [11], adenoviruses [12] and other approaches in human beings. There was also intensive research on the mode of action of the toll-like receptor 7 agonist imiquimod [13]. In addition, immune modifying antibodies such as ipilimumab and anti PD1 antibodies were used first in the Zürich Department of Dermatology in Switzerland. Ipilimumab is the first molecule with an positive impact on overall survival in metastatic stage IV melanomas [14]. Ipilimumab (previously known as MDX-010; Bristol-Myers Squibb/Medarex, Princeton, NJ) has been subject to several clinical studies in the past. Ipilimumab is an IgG1 antibody and binds to CTLA-4 (cytotoxic T-lymphocyte-associated antigen-4), which, is an inducible receptor expressed by activated T-cells. It ligates the B7-family of molecules on antigen-presenting cells and has an immunoregulatory effect. Once triggered, it inhibits T-cell proliferation and function. Blocking CTLA-4 consequently leads to an enhancement of antitumour immunity.

Currently, there are a number of patients being treated in the context of the EORTC study investigating adjuvant therapy with ipilimumab for high risk melanoma patients. The results of this trial are expected in 2014. The Department of Dermatology in Zurich is one of the reference centere in Switzerland for the use of this sophisticated treatment approach [15].

Molecular dissection of melanoma and impact on therapeutic strategy In the last decade melanomas were divided into several molecular subgroups based on genomic alterations including mutations, deletions and amplifications in addition to clinical features. Up to 50% of melanomas derived from skin without chronic sun

473 Spirit and Soul of Swiss Dermatology and Venereology damage (intermittently exposed to UV) contain mutations in the gene encoding the serine-threonine protein kinase BRAF. BRAF, together with ARAF and CRAF activate a second protein known as mitogen-activated protein kinase (MEK), which in turn activates extracellular signal-regulated kinase (ERK). Additionally, 20% of melanomas present RAS mutations. Finally, a minor percentages have activating mutations in the KIT gene, most common in mucosal melanomas derived from the genital regions [16, 17], or mutations in GNA11/or GNAQ genes in uveal melanomas [18, 19]. Some of the targetable mutations in the KIT gene are also found in acral and other mucosal melanomas but with lower frequency. The KIT receptor protein tyrosine kinase is a transmembrane protein consisting of extracellular and intracellular domains. Most KIT mutations are localised to exon 11, which codes for the juxtamembrane domain and exon 13, which codes for a kinase domain. Today, there are number of new kinase inhibitors that have promising efficacy such as vermurafenib [20]. Tramatenib is a MEK inhibitor that has also been shown to increase overall survival in this patient population [20]. Vemurafenbib and dabrafenib are relatively selective for their intended target, V600E BRAF, with little cross-reactivity for wildtype BRAF and CRAF [21, 22]. Few other kinases are inhibited with 10- to 100-fold concentration needed to inhibit V600E BRAF. These agents inhibit selectively the growth of cells that harbour a V600E BRAF mutation. In several clinical trials, vemurafenib and dabrafenib have both demonstrated impressive clinical efficacy with a response rate in the range of 50% in V600E mutated advanced melanomas [22-24]. Unfortunately, response duration is highly variable, as shown by phase 2 and phase 3 trials. In a phase 2 trial, vemurafenib produced objective responses in 53% of 132 patients with metastatic melanoma harbouring a V600E or V600K mutation [25]. The median duration of response was 6.7 months. In a phase 3 trial, with dacarbazine monotherapy as the control arm, overall survival was significantly improved amongst the 337 patients with V600E mutant metastatic melanoma compared to the 338 patients who received dacarbazine (hazard ratio 0.37; 95% CI, 0.26 to 0.55; p value < 0.001) [20], as was the progression free survival. In addition, the response rate was much better in the vemurafenib arm

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(48% objective response rate vs 5%; p value < 0.001). This data led to the approval of vemurafenib in the US, the European Union and Switzerland. If a patient suffers from symptomatic metastases from a BRAF V600 mutated melanoma, a selective inhibitor such as vemurafenib is a good option, because it has a high chance for a rapid response including improvement of quality of life. Selective BRAF inhibitors can be safely used in patients with brain metastases and show significant efficacy in this compartment. The Department of Dermatology, University Hospital, Zürich, has been actively participating in the most important clinical trials worldwide. Additionally, there is an intensive basic research program investigating in vitro aspects of melanoma biology [26]. The Skin Cancer Research Society “Verein für Hautkrebsforschung” is an important institution in Switzerland supported by the Skin Cancer Research Foundation (www.skincancer.ch). All dermatologists in Switzerland are encouraged to actively participate in the work of the foundation and the public is encouraged to donate.

Reinhard Dummer1, Robert Hunger2, Günter Burg3

1 Department of Dermatology, University Hospital Zurich, Gloriastrasse 31, 8091 Zurich. 2 Department of Dermatology, University Hospital Bern, Inselspital, 3012 Bern. 3 Haldenstrasse 14, 8124 Maur.

475 Spirit and Soul of Swiss Dermatology and Venereology

References 1. Heinzerling LM, Dummer R, Panizzon RG, Bloch PH, Barbezat R, Burg G, “Prevention Campaign against Skin Cancer”, Dermatology, n° 205, 2002, p. 229-233. 2. Buechner SA, Wernli M, Harr T, Hahn S, Itin P, Erb P, “Regression of basal cell carcinoma by intralesional interferon-alpha treatment is mediated by CD95 (Apo-1/Fas)-CD95 ligand-induced suicide”, J Clin Invest, n° 100, 1997, p. 2691-2696. 3. Urosevic M, Dummer R, “Immunotherapy for nonmelanoma skin cancer: does it have a future?”, Cancer, n° 94, 2002, p. 477-485. 4. Morton CA, Szeimies RM, Sidoroff A, Braathen LR, “European guidelines for topical photodynamic therapy part 1: treatment delivery and current indications – actinic keratoses, Bowen’s disease, basal cell carcinoma”, J Eur Acad Dermatol Venereol, 2012 Nov 26. 5. Willemze R, Jaffe ES, Burg G, Cerroni L, Berti E, Swerdlow SH, et al, “WHO-EORTC classification for cutaneous lymphomas”, Blood, n° 105, 2005, p. 3768-3785. 6. Dummer R, Bosch U, Panizzon R, Bloch PH, Burg G, “Swiss guidelines for the treatment and follow-up of cutaneous melanoma”, Dermatology, n° 203, 2001, p. 75-80. 7. Dummer R, Guggenheim M, Arnold AW, Braun R, von Moos R, “Updated Swiss guidelines for the treatment and follow-up of cutaneous melanoma”, Swiss Med Wkly, n° 14, 2001, p. 13320. 8. Eggermont AM, Suciu S, Testori A, Santinami M, Kruit WH, Marsden J, et al, “Long-term results of the randomized phase III trial EORTC 18991 of adjuvant therapy with pegylated interferon alfa-2b versus observation in resected stage III melanoma”, J Clin Oncol, n° 30, 2012, p. 3810-3818. 9. Dummer R, Gore M, Hancock B, Guillou P, Grobben H, Becker J, et al, “A multicenter phase II clinical trial using dacarbazine and continuous infusion of interleukin-2 in metastatic melanoma: clinical data and immunomonitoring”, Cancer, n° 75, 1995, p. 1038-1044. 10. Nestle FO, Alijagic S, Gilliet M, Sun Y, Grabbe S, Dummer R, et al, “Vaccination of melanoma patients with peptide- or tumor lysate- pulsed dendritic cells”, Nat Med, n° 4, 1998, p. 328-332. 11. Rochlitz C, Dreno B, Jantscheff P, Cavalli F, Squiban P, Acres B, et al, “Immunotherapy of metastatic melanoma by intratumoral injections of Vero cells producing human IL-2: phase II randomized

476 Dermatologic Oncology

study comparing two dose levels”, Cancer Gene Ther, n° 9, 2002, p. 289-295. 12. Dummer R, Hassel JC, Fellenberg F, Eichmuller S, Maier T, Slos P, et al, “Adenovirus-mediated intralesional interferon-gamma gene transfer induces tumor regressions in cutaneous lymphomas”, Blood, n° 104, 2004, p. 1631-1638. 13. Urosevic M, Dummer R, Conrad C, Beyeler M, Laine E, Burg G, et al, “Disease-independent skin recruitment and activation of plasmacytoid predendritic cells following imiquimod treatment”, J Natl Cancer Inst, n° 97, 2005, p. 1143-1153. 14. Hodi FS, O’Day SJ, McDermott DF, Weber RW, Sosman JA, Haanen JB, et al, “Improved survival with ipilimumab in patients with metastatic melanoma”, N Engl J Med, n° 363, 2010, p. 711-723. 15. Goldinger S, Romano E, Michielin O, Dummer R, “Management und Beurteilung des Ansprechens von Ipilimumab bei Patienten mit Melanom”, Swiss Medical Forum, n° 44, 2012, p. 851-855. 16. Omholt K, Grafstrom E, Kanter-Lewensohn L, Hansson J, Ragnarsson- Olding BK, “KIT pathway alterations in mucosal melanomas of the vulva and other sites”, Clin Cancer Res, n° 17, 2011, p. 3933-3942. 17. Schoenewolf NL, Bull C, Belloni B, Holzmann D, Tonolla S, Lang R, et al, “Sinonasal, genital and acrolentiginous melanomas show distinct characteristics of KIT expression and mutations”, Eur J Cancer, n° 48, 2012, p. 1842-1852. 18. Van Raamsdonk CD, Bezrookove V, Green G, Bauer J, Gaugler L, O’Brien JM, et al, “Frequent somatic mutations of GNAQ in uveal melanoma and blue naevi”, Nature, n° 457, 2009, p. 599-602. 19. Van Raamsdonk CD, Griewank KG, Crosby MB, Garrido MC, Vemula S, Wiesner T, et al, “Mutations in GNA11 in uveal melanoma”, N Engl J Med, n° 363, 2010, p. 2191-2199. 20. Chapman PB, Hauschild A, Robert C, Haanen JB, Ascierto P, Larkin J, et al, “Improved survival with vemurafenib in melanoma with BRAF V600E mutation”, N Engl J Med, n° 364, 2011, p. 2507-2516. 21. Bollag G, Hirth P, Tsai J, Zhang J, Ibrahim PN, Cho H, et al, “Clinical efficacy of a RAF inhibitor needs broad target blockade in BRAF- mutant melanoma”, Nature, n° 467, 2010, p. 596-599. 22. Kefford RA, Arkenaua H, Brown MP, Millward M, Infante JR, Long G, et al, “Phase I/II study of GSK2118436, a selective inhibitor of oncogenic mutant BRAF kinase, in patients with metastatic melanoma

477 Spirit and Soul of Swiss Dermatology and Venereology

and other solid tumors”, J Clin Oncol, n° 28 (Supplement), 2010, Abstract p. 8503. 23. Long GV, Kefford RF, Carr PJ, Brown MP, Curtis M, Lebowitz PF, et al, “Phase 1/2 study of GSK2118436, a selective inhibitor of V600 mutant (mut) BRAF kinase: evidence of activity in melanoma brain metastases (mets)”, Ann Oncol, n° 21, 2010, p. 8-12. 24. Flaherty KT, Puzanov I, Kim KB, Ribas A, McArthur GA, Sosman JA, et al, “Inhibition of mutated, activated BRAF in metastatic melanoma”, N Engl J Med, n° 363, 2010, p. 809-819. 25. Dummer R, Rinderknecht J, Goldinger SM, “Ultraviolet A and photosensitivity during vemurafenib therapy”, N Engl J Med, n° 366, 2012, p. 480-481. 26. Widmer DS, Cheng PF, Eichhoff OM, Belloni BC, Zipser MC, Schlegel NC, et al, “Systematic classification of melanoma cells by phenotype-specific gene expression mapping”, Pigment Cell Melanoma Res, n° 25, 2012, p. 343-353.

478 Radiotherapy

Working group “Radiotherapy SSDV”

According to the historical documents of our society, the first “SSDV Course in Radiotherapy” was organised by Professor Guido Miescher in Zurich in 1945, although it is possible that he held a course earlier. From then on it was compulsory for all residents specialising in dermatology to take it. In 1949 there was a committee discussion about this course, and Professor Miescher suggested that it should take place alternately in another department (this kind of discussion existed already at that time!), so the course took place in Bern. In 1951 the Society proposed the introduction of compulsory 3-month radiotherapy training for all residents as part of the 4-year specialist training programme, during 6 months in a radio-oncology department. At the Society’s spring meeting in Neuchâtel in 1953 Professor Miescher gave a talk on “New developments in dermatologic radiotherapy.” He demonstrated the possibilities of Grenz- and soft-x-ray machines, and that this kind of treatment should remain in the hands of dermatologists. He also suggested that a book on dermatologic radiotherapy be published! In addition, the practising dermatologists asked that the x-ray machines be annually inspected by independent experts. The inspection of the radiotherapy equipment by external firms was also discussed at the radiotherapy course in Zurich in 1955. It was suggested that the firms check the machines in a couple of private practices in a row in order to

479 Spirit and Soul of Swiss Dermatology and Venereology save on costs for individual visits. In 1958 Professor R. Schuppli pointed out that patients should be adequately protected during radiotherapy sessions. A first book on “Physical Modalities in Dermatology,” edited by H. Goldschmidt, Philadelphia, came out in 1978 [1]. The book dealt mainly with radiotherapy. The radiotherapy courses SSDV were held every two years in the Zurich department with a second exception in Bern in 1983. In the nineteen-eighties, radiation treatment, which had been seen as an excellent treatment modality for malignant and benign skin diseases since the detection of x-rays, began to lose favour. This was due to the fear of x-rays in the general population because of atomic bombs and to the availability of new drugs such as corticosteroids and antibiotics. Also, investment and liability costs deterred dermatologists from investigating radiotherapy equipment. Finally, training possibilities for residents diminished, and in that way the new generation almost forgot about the possibilities of this well-established treatment modality. This was the reason why a second book “Modern Dermatologic Radiation Therapy” was edited by H. Goldschmidt and R.G. Panizzon [2] in 1991. In addition, different publications were released, especially in Europe, about the excellent possibilities of treating skin tumours with radiotherapy. In the meantime x-ray machines were no longer available and it was difficult to get replacement parts for the old machines. The “Working group Radiotherapy SSDV” held its first session under the presidency of Renato G. Panizzon at the annual meeting of our Society in the year 2000. From then until 2010 the radiotherapy courses were held alternately every two years in Lausanne and Zurich. The compulsory course, now named “Course of Radiotherapy/ Radioprotection SSDV,” was recognised by the Swiss Health Authority in 2002 after years of discussion guided by Reinhard Dummer and Renato G. Panizzon. Completion of the course allows board-certified dermatologists to use soft x-ray machines in their practice as well as in university hospitals. This is quite a unique possibility in Europe, and the young dermatologists should recognise this chance!

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Figure 1. Radiotherapy Workshop AAD Atlanta 1990. From left: Profs. R.G. Panizzon, M. Caccialanza, Milan, and R. Pujol, Barcelona.

Figure 2. Prof. R. Baer, New York adressing a few words of encouragement at the Radiotherapy Workshop, AAD, Dallas 1991. To the right: Drs Ted Kingery and Coleman Jacobson.

481 Spirit and Soul of Swiss Dermatology and Venereology

Figure 3. Prof. R.G. Panizzon sitting on the “Röntgen bench” called “Röntgenplatz” in Pontresina, Switzerland, bench on which used to sit W.C.. Röntgen when he used to come for a holiday.

Before new superficial x-ray machines came onto the market the Zurich University department published several important papers on topics such as: i) The use of Grenz rays for Lentigo maligna, where the long- term, disease-free survival rate for patients is more than 90% [3]. ii) The use of soft x-ray for basal cell carcinomas, where this treatment is most promising for nodular subtypes [4]. iii) Recently large and difficult to treat squamous cell carcinomas of the eye region which show best responses and long term control [5].

During this period the need for a new monograph was recognised, and “Radiation Treatment and Radiation Reactions in Dermatology” was issued by Renato G. Panizzon and Jay S. Cooper in 2004 [6]. Prof. St. Lautenschlager, Zurich is the president of the “Working group Radiotherapy SSDV” since 2008.

482 Radiotherapy

After repeated interventions by Renato G. Panizzon involving different potential manufacturers, new superficial x-ray machines are (or are planned to be) on the market, produced in the UK or Germany. Such machines are installed in the Dept. of Dermatology of the University Hospital Zurich (R. Dummer), in the Outpatient Clinic of the City Hospital Triemli Zurich (St. Lautenschlager), and in the Dept. of Radio-oncology of the University Hospital in Lausanne. We have seen a renaissance of dermatologic radiotherapy in Europe and the US since these new machines became available. To bolster these efforts, a second extended edition of the book “Radiation Treatment and Radiation Reactions in Dermatology,” edited by Renato G. Panizzon and W. Heinrich Seegenschmiedt, will be published in 2013.

Renato Panizzon, Reinhard Dummer, Stephan Lautenschlager

483 Spirit and Soul of Swiss Dermatology and Venereology

References 1. Goldschmidt H, Physical Modalities in Dermatologic Therapy, Springer: New York, 1978. 2. Goldschmidt H, Panizzon RG, Modern Dermatologic Radiation Therapy, Springer: New York, 1991 3. Farshad A, Burg G, Panizzon R, Dummer R, « A retrospective study of 150 patients with lentigo maligna and lentigo maligna melanoma and the efficacy of radiotherapy using Grenz or soft X-rays », Br J Dermatol, n° 146, 2002, p. 1042-1046. 4. Zagrodnik B, Kempf W, Seifert B, Muller B, Burg G, Urosevic M, et al, « Superficial radiotherapy for patients with basal cell carcinoma: recurrence rates, histologic subtypes, and expression of p53 and Bcl-2 », Cancer, n° 98, 2003, p. 2708-2714. 5. Barysch MJ, Eggmann N, Beyeler M, Panizzon RG, Seifert B, Dummer R, « Long-Term Recurrence Rate of Large and Difficult to Treat Cutaneous Squamous Cell Carcinomas after Superficial Radiotherapy », Dermatology, 2012 Mar 20. 6. Panizzon RG, Cooper JS, Radiation Treatment and Radiation Reactions Dermatology, Springer: Berlin, 2004. 7. Panizzon RG, Seegenschmiedt WH, Radiation Treatment and Radiation Reactions in Dermatology, 2nd ed, Springer: Berlin, 2013 (in print).

484 Dermatopathology

The Swiss Group of Dermatopathology (SGDP) and dermatopathology in Switzerland – historical and contemporary aspects

Dermatopathology is an essential part of dermatology and has a long tradition in the Swiss Society of Dermatology and Venereology. The contributions by Karl Gustav Theodor Simon; „die Hautkrankheiten durch anatomische Studien erläutert,“ (Skin disorders explained by anatomic studies) in 1848 and by Felix von Baerensprung; „Beiträge zur Anatomie und Pathologie der menschlichen Haut,“ (Contributions on anatomy and pathology of the human skin) also in 1848, were the base for dermatopathology in German speaking countries and initiated the clinico-pathologic correlation, as well as classifications of skin diseases based on histopathologic findings. Technical innovations such as the introduction of binoculars, apochromatic objectives, new histological dyes to stain various structures of tissues and cells, as well as the modern type of microtoms in the second half of the 19th century led to the increasing impact of pathology and dermatopathology. The publication of „Die Histopathologie der Hautkrankheiten,“ (The histopathology of skin disorders) by Paul Gerson Unna in 1894 and „die Histologie der Hautkrankheiten,“ (The histology of skin diseases) by Oscar Gans in 1925 represent milestones for dermatopathology. Since the beginning of the 20th century the histological examination of skin biopsies became an integral part of dermatologic diagnosis.

485 Spirit and Soul of Swiss Dermatology and Venereology

In Switherland at that time skin biopsies were analysed for diagnostic and research purposes in the departments of dermatology of Swiss university hospitals. In the first half of the 20th century histological findings were reported at the annual meetings of the SGDV/SSDV and in publications. At the first SGDV/SSDV meetings in 1913 and 1914 Max Winkler presented histologic aspects of chondrodermatitis nodularis and Joseph Jadassohn on nevi with depigmentation, as well as mast cells in urticaria pigmentosa. Felix Lewandowsky and Wilhelm Lutz in Basel published their seminal work on epidermodysplasia verruciformis in 1922. Incontinentia pigmenti was presented by Marion B. Sulzberger at the annual SGDV/SSDV meeting in 1925 in Zürich and published in Archiv für Dermatologie und Syphilis in 1928. Later, contributions by Guido Miescher in Zürich followed about cheilitis granulomatosa (1945) (Figure 1) and the „Radiärknötchen“ in erythema nodosum (1951). The two volume book „Histopathologie der Haut“ (Histopathology of the skin) by U.W. Schnyder in 1973 as part of the book series „Spezielle pathologische Anatomie“ (Special pathological anatomy; (eds) Doerr, Seifert, Ühlinger, Springer) was one of the most important books on dermatopathology in the German language for several decades. A correlate in the French-speaking part of Switzerland are the histology sections by P. Chavaz and coworkers in the dermatology textbook edited by J.H. Saurat (Masson). The tradition of books on dermatopathology was continued by the book „Dermatopathologie“ by W. Kempf and coauthors (W. Kempf, M. Hantschke, W. Burgdorf, H. Kutzner, Steinkopff, 2007) which was translated into the French language by R. Panizzon, Lausanne, and into the English language. The increasing number of skin biopsies and their technical progress (electron microscopy, immunohistochemistry) resulted in an increasing importance of dermatopathology in dermatology and pathology, but also of the dermatopathology laboratories at the university clinics. Since the beginning of the nineteen eighties, staff members with specialised expertise in dermatopathology have led these dermatopathology units (St. Büchner, Basel; L. Zala, Bern; P. Chavaz, Genf, D. Hohl, Lausanne; R. Panizzon, Zürich). The contributions of the dermatopathology units at the university clinic in Basel focused on lymphoproliferative disorders, especially T-cell lymphomas and leukemias (St. Büchner, R. Schuppli),

486 Dermatopathology on histological, immunophenotypic and electron microscopic aspects of borrelia skin infection (St. Büchner) and basal cell carcinoma (St. Büchner), Rosacea and demodex folliculorum (T. Rufli), oral hairy leukoplakia and genodermatoses (P. Itin), and graft-vs-host disease (P. Häusermann). The main dermatopathologic topics at the Department of Dermatology at the university clinic in Bern include autoimmunbullous disorders (L. Borradori, H. Beltraminelli), cutaneous lymphomas in collaboration with the Group Français pour l’Étude des Lymphomes Cutanées (H. Beltraminelli, R. Hunger, C. Schlapbach), paraneoplastic disorders, drug eruptions, psoriasis, eosinophilic disorders and lichen planus (N. Yawalkar, D. Simon, H. Beltraminelli). In the past, dermatopathologic publications focused on mastocytoses (T. Hunziker, M. Brönnimann) and skin carcinomas (I. Hegyi). There is a collaboration by H. Beltraminelli with the Stellenbosch University in Cape Town, South Africa and the Regional Dermatology Training Centre in Moshi, Tanzania, where since 2009 H. Beltraminelli has acted as coordinator for the development of dermatopathology. The publications from the Dermatopathology Unit in Geneva comprised ultrastructural studies of porokeratosis Mibelli (P. Chavaz), angioma serpiginosum, graft-vs-host disease, Merkel cells (P. Chavaz), amyloidosis and bullous pemphigoid (I. Masouyé), as well as CD44 and hyaluronate (G. Kaya). Important and seminal studies on genodermatoses, especially disorders of cornification were published by D. Hohl from the department of Dermatology in Lausanne, and case reports with clinico-pathologic correlation by R. Panizzon and coworkers. Histological and electron microscopic studies in genodermatoses (U.W. Schnyder, D. Hohl), malignant melanoma, pityriasis rosea, eosinophilic cellulitis, keratosis lichenoides chronica and lichenoid benign keratosis (R. Panizzon) represented main topics of the publications from the Dermatopathology Unit at the university hospital in Zürich during the period from 1960 to 1990. In subsequent years the focus shifted towards dermatooncological aspects with histology of cutaneous lymphomas (G. Burg, W. Kempf, J. Kamarashev, R. Dummer) and malignant melanoma (R. Dummer, J. Kamarashev, K. Kerl, G. Burg,). The book „Skin Tumours Pathology and Genetics“ in the WHO book series (WHO Classification Pathology and Genetics; IARC

487 Spirit and Soul of Swiss Dermatology and Venereology

Press) edited by P. LeBoit, G. Burg, D. Weedon, and A. Sarasin (2006) was a milestone and included the achievements of the WHO/EORTC classification on cutaneous lymphomas, which in part was elaborated at meetings organised by G. Burg in 2004 in Zürich. In 2005, G. Burg and W. Kempf published the book „Cutaneous lymphomas“ with a comprehensive view on the classification, clinico-pathological and therapeutic aspects of these skin neoplasms and related disorders (Taylor and Francis, Dekker, 2005). Other dermatopathology topics in Zürich included histologic aspects of skin disorders in organ transplant recipients (G. Hofbauer, W. Kempf), virus-induced neoplasias and molecular diagnosis of skin infections (W. Kempf), as well as the histology of cutaneous drug reactions (K. Kerl). More than 30 articles are published every year in peer-reveiwed journals by the members of the Swiss Group of Dermatopathology (SGDP). After the American Society of Dermatopathology (ASDP) and the International Society of Dermatopathology (ISDP) had been founded in 1962 and 1979, respectively, dermatopathology working groups (Arbeitsgruppen Dermatohistopathologie) were also founded in the German-speaking countries. In Switzerland, the dermatologists St. Büchner, P. Chavaz, D. Hohl, W. Kuhn, R. Panizzon, B. Schönberg, Ch. Sigg and G. Zala (in alphabetical order) founded the Arbeitsgruppe Dermatohistopathologie (ADH) of the SGDV/SSDV in 1992. T. Hardmeier was the representative member of the Swiss Society of Pathology (SGPath) in this group. The activities of the working group included the organisation of self-assessment courses in the context of the annual SGDV/SSDV meeting and the construction of slide libraries for teaching purposes at the dermatology clinics. The histologic case presentations became a well-known and important part of the annual SGDV/SSDV meetings and are appreciated by the clinicians. The Rencontres de dermatopathologie organised by P. Chavaz and coworkers are very well attended. The Arbeitsgruppe Dermatohistopathologie (ADH) was renamed the Swiss Group of Dermatopathology (SGDP) in 2006. Since 2008 the SGDP has its own website (www.sgdp.net), on which the cases of the self-assessment courses can be accessed by virtual microscopy. G. Zala (1993-1996), P. Chavaz (1996-1999), St. Büchner (1999-2006), G. Kaya (2006-2011) und W. Kempf (since 2011) acted as Presidents of the SGDP. As highlights of the

488 Dermatopathology

SGDP history, G. Burg during his term as President of the ISDP organised in 1996 the annual meeting of the ISDP in Zürich. Five years later, in 2011, the ISDP meeting organised by G. Kaya and W. Kempf was held in Geneva as a joint meeting in conjunction with the SGDV/SSDV meeting. The idea of the European Society of Dermatopathology (ESDP) was originally born in Zürich, and the society is going to be officially founded in Geneva in the near future. Skin biopsies are examined not only in the dermatopathology units of the university clinics, but also in private dermatopathology laboratories in Switzerland. The Institut für Dermatopathologie Zürich (IDPZ) was the first private dermatopathology laboratory founded in 1989 by C. Sigg and W. Kuhn. Since then several other laboratories dedicated to dermatopathology have followed. Two members of the SGDP (B. Paredes, L. Schärer) are partners in the Dermatopathologie Bodensee Friedrichshafen in Germany. A survey in 2006 revealed that more than 200,000 skin biopsies had been examined by 23 dermatopathologists working in academic and private dermatopathology units in Switzerland. In 5 of these laboratories molecular tests are performed on skin biopsies. Residents get their training in dermatopathology with an emphasis on clinico-pathologic correlation in 6 institutions in Switzerland. A milestone for dermatopathological activites in Switzerland was the introduction of the subspecialty title dermatopathology (Schwerpunkttitel Dermatopathologie) in January 2009, which was created after extensive negotiations with the Swiss Society of Pathology. The financial aspects of TARMED positions for dermatopathology are the main issue in ongoing activities. The acceptance of a minimal set of TARMED positions by the health system in March 2012 was an important step for the future of dermatopathology in Switzerland and as an integral part of dermatopathology in dermatology. The requirements for the subspecialty title include one year training in surgical pathology, the signing-out of at least 6,000 skin biopsies under supervision including employment of special techniques (immunohistochemistry, in situ hybridization) in dermatopathology and clinico-pathologic correlation, as well as the exam of the International Committee for Dermatopathology (ICDP; http:// icdermpath.org).

489 Spirit and Soul of Swiss Dermatology and Venereology

The SGDP is an active group of professional dermatopathologists, which campaigns for the preservation of the high quality and tradition of dermatopathology, but also for the future development of dermatopathology in Switzerland and in the SGDV/SSDV.

Figure 1. G. Miescher: Chelitis granulomatosa, 1945.

Werner Kempf, Peter Häusermann, Jivko Kamarachev, Helmut Kerl, Helmut Beltraminelli, Stan Büchner, Renato Panizzon, Günter Burg

490 Dermatopathology

Figure 2. Epidermodysplasia verruciformis by F. Lewandowsky and W. Lutz, presented at the annual SGDV/SSDV meeting 1920.

Figure 3. Workshop on the classification of cutaneous B-cell lymphomas (WHO-EORTC classification) in Zürich in February 2004.

491

Pediatric Dermatology

Paediatric Dermatology in Switzerland

Skin diseases in children are very common and account for 20% of all visits to paediatric offices and clinics. They present with a very broad spectrum, ranging from developmental abnormalities and genetic syndromes to tumours, infections and inflammatory dermatoses, with atopic dermatitis being the most common diagnosis. Compared to adult dermatology, skin diseases in children are very different in many respects: the spectrum of skin disorders has a different emphasis and the approach to managing the child and the family is often challenging. This difference is best highlighted in respect to neonatal skin conditions, developmental disorders of the skin and genetic diseases, which include the practical and ethical aspects of prenatal diagnosis. A multidisciplinary setting is essential for the management of many patients. Unlike in other disciplines, the focus of paediatric dermatology is very much on specific dermatoses and less on aesthetic issues and procedures. It is crucial to recognise early signs of potential severe skin disease or a lifelong genetic disorder promptly. The first textbook devoted to paediatric dermatology was Cutaneous Diseases Incidental to Childhood by Walter C. Dendy (a surgeon), published in London in 1827. It was not until 1972 that paediatric dermatology was officially born at the first International Symposium of Paediatric Dermatology in Mexico City. Following that historic meeting, interest in this discipline has grown dramatically the world over and it now plays an integral role

493 Spirit and Soul of Swiss Dermatology and Venereology at all major dermatological and paediatric meetings. Since then, 10 world congresses of paediatric dermatology have been held, and there are several academic journals specifically dedicated to this subject. The Society for Pediatric Dermatology (SPD) in the USA was founded in 1975, and the European Society for Pediatric Dermatology (ESPD) in 1983. Mexico has led the way in training with a programme for both paediatricians and dermatologists, founded in 1973. In the USA paediatric dermatology became an independent board-certified subspecialty as recently as 2004. Elsewhere in the world, training remains ad hoc and includes paediatricians with a special interest in dermatology, dermatologists with a special interest in children, and a select handful who have full training in both specialties. Paediatric dermatology has a long history in Switzerland and is well-documented thanks to the original descriptions of many genetic diseases by Joseph Jadassohn and Oskar Nägeli in Bern, Bruno Bloch, Guido Miescher and Urs Schnyder in Zürich or Felix Lewandowsky in Basel. Jean-Hilaire Saurat imported the seminal idea of paediatric dermatology as a subspecialty from France in 1982 when he was appointed Professor of Dermatology in Geneva. Whilst in Paris, he had developed a special interest in paediatric dermatology in the newly created paediatric unit at Necker Hospital. He became co-founder of the European Society for Paediatric Dermatology (ESPD), functioned as its treasurer for more than two decades and organised clinical meetings of the Swiss Society for Dermatology and Venereology devoted to this novel topic. He gathered an inspired group of young clinicians in Geneva, such as Anne-Marie Calza (dermatologist) and Marc Lacour (paediatrician), who can now be considered the deans of Swiss paediatric dermatology. Gradually, paediatric dermatologists were trained in Switzerland, most of them initially being dermatologists who had completed a specialist fellowship abroad. To date, there are two specialists in Switzerland with an FMH board-certification for both dermatology and paediatrics: Marc Pleimes and Lisa Weibel in Zurich. There are well-established paediatric dermatology services in all five University Hospitals today with highly frequented clinics and multidisciplinary teams. This led to the foundation of the Swiss Group for Pediatric Dermatology (SGPD) in 2003, under the Presidency of Daniel Hohl, as part of the Swiss Society for

494 Pediatric Dermatology

Dermatology and Venereology (SSDV). The objectives of the SGPD are listed in Table 1.

In 2010 Daniel Hohl, Stéphanie Christen-Zäch, Marc Lacour and the SGPD were appointed to host the 10th European Congress of Pediatric Dermatology (ESPD) in Lausanne with 771 participants. The current President of the SGPD is Stéphanie Christen-Zäch and Lisa Weibel functions as secretary. Paediatric dermatology is an actively developing subspecialty in Switzerland and is now one of the mandatory prerequisites of the Swiss dermatology FMH training programme. The SGDP provides standardised training courses for dermatologists and paediatricians every two years and additional conferences throughout the year. These meetings are very well received with high numbers of participants. Workshops for paediatric dermatology are usually the first ones to be booked out at many dermatology events. This well reflects the high levels of need and interest of dermatologists, paediatricians and general practitioners in this field. Two studies published by board members of the SGPD provide important epidemiologic data on the significance of paediatric dermatology in Switzerland (Table 2).

Wenk et al. evaluated 1100 patient visits of children < 16 years referred to their dermatology clinic in Aarau over a 3-year period. Atopic dermatitis was the most common diagnosis (26%),

Table 1. Objectives of the Swiss Group for Pediatric Dermatology (SGPD)

To further establish the subspecialty of paediatric dermatology in Switzerland. To guarantee a high standard of dermatological care for children. To support progress in paediatric dermatology by research and scientific work. To substantially integrate paediatric dermatology in the FMH training curricula for dermatology and paediatrics. To encourage a close collaboration between dermatologists and paediatricians. To cultivate an active collaboration with international experts in paediatric dermatology.

495 Spirit and Soul of Swiss Dermatology and Venereology

Table 2. Swiss publications on the epidemiology of paediatric dermatology in Switzerland

Wenk C, Itin P, “Epidemiology of paediatric dermatology and allergology in the region of Aargau, Switzerland”, Pediatr Dermatol, n° 20, 2003, p. 482-487. Landolt B, Staubli G, Lips U, Weibel L, “Skin disorders encountered in a Swiss pediatric emergency department”, Swiss Med Wkly, n° 4, 2013, p. 143. followed by melanocytic nevi (9%), and viral warts (5%). As this was a dermatology subspecialty clinic, higher frequencies of chronic and uncommon dermatoses such as genetic and autoimmune diseases were seen, whereas frequent diagnoses such as diaper rash, scabies, pediculosis, impetigo contagiosa, warts and molluscum contagiosum were expected to be higher, compared with the figures in the literature. Wenk et al. concluded that these dermatoses were underreported, as most children are first treated by general practitioners and paediatricians. They emphasised that the dermatological education of medical students, primary care physicians, and paediatricians should focus on allergic skin diseases, skin infections, pigmentation disorders, and vascular lesions. A more recent study by Landolt et al. reports skin disorders encountered in the emergency unit of the University Children’s Hospital Zurich during a 1-year period. A questionnaire assessed the need for dermatological support. Skin findings were recorded in 1572 patients, representing 17.4% of all attendances. The skin problem was the primary cause of the emergency unit visit or related to the primary complaint in 853 (54.3%) and 335 (21.3%) cases respectively. In 373 patients (23.8%) a diagnosis was only suspected or remained unknown. Inflammatory and allergic disorders were most commonly encountered, followed by skin infections, physically induced skin lesions and congenital disorders (Figure 1). Viral and parainfectious exanthem was the most common diagnosis (17.6%), followed by anogenital dermatitis (7.7%), gingivostomatitis (7.1%), petechiae (6.4%), burns (6.0%), urticaria (5.0%) and insect bite reactions (5.0%). 5.2% of the patients with skin conditions were hospitalised. The emergency doctors expressed the wish for a dermatological opinion in 25%

496 Pediatric Dermatology of all patients with skin findings. Thus the high frequency, broad spectrum and diagnostic difficulties of paediatric skin conditions were identified. The authors highlight the need for educational measures and close collaboration between the two specialities to improve the management of these children.

Figure 1. Clinical examples of skin disorders which are commonly encountered in a Paediatric Emergency Department. 1A. Hand-foot-mouth disease. 1B. Perianal streptococcal infection. 1C. Anular urticaria of childhood. 1D. Periocular herpes simplex virus infection. From: Landolt B, Staubli G, Lips U, Weibel L, “Skin disorders encountered in a Swiss paediatric emergency department”, Swiss Med Wkly, n° 4, 2013, p. 143.

An additional aspect which underlines the importance of prompt and correct diagnosis of congenital skin disorders applies to the Swiss insurance system for disability (Invalidenversicherung, IV). A number of dermatological conditions such as haemangioma, congenital nevus, ichthyosis, epidermolysis bullosa, ectodermal dysplasia and others are listed as congenital disorders. It is compulsory that the IV covers the costs for medical care once the diagnosis has been established and reported by the treating physician (before the age of 20).

497 Spirit and Soul of Swiss Dermatology and Venereology

Figure 2. Photographic documentation of 8 infants with problematic infantile haemangiomas during treatment with propranolol. From : Schiestl C, Neuhaus K, Zoller S et al, “Efficacy and safety of propranolol as first-line treatment for infantile haemangiomas”, Eur J Pediatr, n° 170, 2011, p. 493-501.

In recent years there has been a significant advance in the knowledge and understanding of basic skin biology and the pathogenesis of many paediatric dermatology conditions, in particular the molecular

498 Pediatric Dermatology genetics of a large number of inherited skin diseases. Massively parallel (next-generation) sequencing technologies have created paradigm shifts in how these conditions are investigated. These new technologies are rapidly accelerating the rate of the discovery of genetic skin diseases, such as epidermolysis bullosa, ichthyosis and autoinflammatory syndromes. Identification of the causative gene is the first step towards defining potential translational therapies. Somatic mosaicism for mutations in genes of the PI3-AKT pathway explain a variety of overgrowth syndromes. Somatic mosaicism for mutations in the genes of the RAS pathway leads to some forms of epidermal nevi suggesting these may be “mosaic RASopathies.” The incidental discovery of the effectiveness of propranolol for the treatment of infantile haemangiomas by Léauté-Labrèze et al in 2008 represents a historic milestone, not only in paediatric dermatology, but in medicine in general. The initial report published in the New England Journal of Medicine was met with great interest, and physicians all over the world began using propranolol for this indication. Today propranolol is the first- line treatment of choice for problematic haemangiomas and is by far superior to all previous treatment modalities with respect to efficacy and tolerance. Figure 2 illustrates the treatment response to oral propranolol in a Swiss cohort of infants, as published by Schiestl et al. in 2011. Inspired by the vision of an expanding international community, the Swiss representatives of paediatric dermatology aim to further establish this outstanding subspecialty. The arrangement of a training programme may be a future project, such as those implemented in Mexico and the USA. To quote Sidney Hurwitz, in Pediatric Dermatology in 1988: “Those of us who have committed ourselves to this discipline are proud of the accomplishments of the past, appreciate the rapidly growing interest in this field in the present and look forward to the challenges of the future with continued optimism and enthusiasm.”

Lisa Weibel, Peter Itin, Christen-Zäch, Daniel Hohl

499

Dermatologic Surgery

One century later – a look at Dermatosurgery

Surgery has always been part of dermatology in Switzerland, a certain amount having always been practised in all clinics. In 1992 I had the opportunity to start my internship in the department of Professor Saurat at the University of Geneva. Each university has icons related to some subspecialty and at this time there were four names which were strongly associated with the history of Genevan dermatosurgery. The consultants at the University at this time were, Dr. Bezzola and Dr. Tapernoux. Dr. Schaer was also a consultant and the former head of assistants, while Dr. Harms supervised and taught basic and advanced minor surgery. Whereas Dr. Schaer was known to practise delicate surgery for all small lesions, her masculine counterparts were known for their perfect, extended tumour surgery. Dr. Bezzola was a co-founder and extremely involved member of the Board of the ISDS (International Society of Dermatologic Surgery). He had spent a year in the Department of Plastic Surgery at the Walter Reed Hospital in the United States in 1973. With Dr. Tapernoux – who had had the chance to spend the same year (1973) with Perry Robins in the States – they attempted to be the first to introduce Mohs surgery into Switzerland in 1974. First with the zinc chloride technique at the University of Lausanne, followed by the zinc chloride and fresh frozen technique at the University of Geneva. Although very much involved, they did not – for various technical and circumstantial reasons – succeed in introducing Mohs micrographic surgery. This success was conferred to their successors at a later date.

501 Spirit and Soul of Swiss Dermatology and Venereology

In 1978 Professor Saurat became Head of the Department of Dermatology in Geneva. Although Professor Saurat had only a minor respect for dermatosurgeons and reduced them somehow to their cerebellar functions, he was and still is a visionary in several ways. There are several basic reflections which were decisive for dermatology in general but one in particular was decisive for Swiss dermatosurgery which will be explained later. I am unable to list all of his contributions to dermatology but I was directly concerned with at least two of them. The first – before anybody else was speaking about dermoscopy, he had already invested and engaged himself in a videomicroscopy project. The second – convinced that dermatology was a medical specialty, he let himself be persuaded – by two very complementary individuals – that dermatosurgery needed to change. They were Denis Salomon, head of assistants and Maurice Adatto (at that time an assistant), a rising star in dermatosurgery in Geneva. Denis Salomon was an excellent clinician and had sufficient scientific background to argue with Professor Saurat; Maurice Adatto had the surgical background – he did two years of plastic surgery before starting dermatology – which Professor Saurat respected, combined with his well-known perseverance to accomplish what he wants. Full of determination, Maurice Adatto went to America, at his own expense to learn the Mohs technique and laser from Tim Rosio in Wisconsin, for three subsequent years. With his last visit to Tim Rosio, he was accompanied by Denis Salomon. They began in 1992 to practise Mohs micrographic surgery with the help of Tim Rosio at the University of Geneva. In close teamwork with pathologists, Denis Salomon’s scientific spirit and Maurice Adatto’s surgical skills led to Mohs surgery becoming a real success and they were able to present their first study on Mohs surgery at the SGDV Congress in Bern as early as autumn 1992. Apart from this challenge in oncologic dermatosurgery, Maurice Adatto introduced phlebologic surgery and performed ambulant crossectomies under local anaesthesia and initiated the laser platform at the University of Geneva. Sometimes life decides for you, so in 1992 I joined the team performing Mohs micrographic surgery in Geneva as an assistant. I worked with Maurice and Denis and finally, in order to polish my knowledge on Mohs surgery, I visited Ramsey Mellete at the University of Colorado in Denver and Dan Siegel – the current President of the American Academy of Dermatology and

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Venereology – at Stony Brook University, New York in 1996 and 1997. In consequence we practiced Mohs and Mohs surgery in Geneva since 1992. In Zurich things went differently. Professor Urs Schnyder (Chair of the Department from 1978-1991), Alfred Eichmann and Armin Blank established a strong dermatology surgery encompassing dermato-oncological surgery, dermabrasion, cutaneous laser surgery and phlebology. Erich Küng took over from Armin Blank, and passed the torch soon after to Jürg Hafner, who at that time was undertaking the first attempts to establish Mohs’ micrographic surgery under the supervision of his boss and pioneer in micrographic surgery, Günter Burg. The Zurich histology laboratory staff, however, did not like the frozen section technique and the classical “fresh tissue technique” never really took off. Actually, Professor Günter Burg was among the first trainees of Perry Robins in NY, and introduced the zinc chloride in vivo fixation technique in Munich under the chair of Otto Braun- Falco in 1971. Including Birger Konz in his Mohs group, they soon switched to the fresh frozen technique, which proved to be much better tolerated by the patients. Burg published his first Munich series in the very first issue of the Journal of Dermatologic and Oncologic Surgery in 1974 (one year after Tromovich’s publication on the “fresh frozen technique” in Cancer). In 1994 Jürg Hafner left for Geneva to do his residency training in vascular medicine (angiology). He took out this opportunity to glance at Mohs surgery in Geneva. Before returning to his former employment in Zurich he took three months off to visit three of the most prominent dermatologic surgery clinics in Germany: LMU Munich (Birger Konz, Chair Gerd Plewig), Kassel (Johannes Petres) and Tübingen (Helmut Breuninger, Chair Gernot Rassner). From 1996 he established the “Slow Mohs” version of micrographic surgery (using formalin fixation and paraffin embedded sections), as promoted by the Department of Dermatology at Tübingen University (“Tübinger Torte”). In 2005/06 Severin Läuchli took part on several occasions in preceptorships in classical Mohs micrographic surgery in the US. The laboratory team at home had meanwhile shown interest in introducing frozen sections as part of their routine. Today, the Department of Dermatology of the University of Zurich performs both classical Mohs MGS (small to intermediate-sized specimens for the “facial H-zone”) and the

503 Spirit and Soul of Swiss Dermatology and Venereology

Tübinger Torte technique (for large specimens and most locations outside the “facial H-zone”). Dermatosurgery in Switzerland took an important step when Erich Küng, Alain Bezzola, Jean-Pierre Grillet and Walty Bayard founded the Swiss Working Group of Dermatologic Surgery (ADC/ GDC). Until then, dermatosurgery was somehow “subcutaneous” – everybody knew it existed but nobody spoke about it. Now, it suddenly became visible thanks to the strong commitment of Erich Küng and his colleagues. With the introduction of “Tarmed” in 2002, the Swiss tarification system was profoundly changed, and dermatology almost lost access to surgery. The old generation of dermatologists perceived themselves to be more oriented towards internal medicine and almost totally missed out on entries in the surgical chapters when the new tarification catalogue was created. The big cake of “surgery” was at risk of being shared out behind the curtain, excluding dermatology. It was only relatively late that the younger generation of dermatologists recognised this threat and began fighting for dermatosurgery – dermatology is basically both conservative and surgical! Through a series of tough sessions, Denis Salomon, Maurice Adatto, Jean-Pierre Grillet and myself managed to convince our discussion partners from all the other surgical specialties that dermatologists are competent surgeons. ENT was the most generous specialty, supporting our vision on skin surgery, and more particularly skin cancer surgery. Probably due to my strong engagement during the “Tarmed- struggle,” I was elected to follow Erich Küng as President of the Working Group of Dermatologic Surgery. On accepting this task I had two clear projects in mind: to defend the survival of dermatologic surgery nationwide and to achieve the goal that all universities will practise micrographic surgery one day. The endless discussions about the existence of dermatosurgery ceased with the foundation of the FMCH in 2004. The FMCH unites all surgical subspecialties of medicine, to defend the specific interests of this subgroup against the internists who are more represented by the FMH. As this new governing organisation of surgical specialties was looking for new members, they were keen for the dermatologists, a very large specialty, to join the club. In function as President of the Swiss Working group of Dermatologic

504 Dermatologic Surgery surgery together with M. Adatto, JP Grillet and D. Salomon I could convince the board that we should join this organisation. After difficult discussions we were able to convince the Board of the Swiss Society of Dermatology to join this organisation. Professor Saurat and Professor Itin – although non-surgeons – and Professor Burg were visionary enough to give us the necessary back-up to get this idea accepted by the board of the Swiss Society of Dermatology. That is why Switzerland is the only country in Europe where dermatology is recognised as a surgical specialty today. Time has shown that this was the correct decision; from then on the entity of dematosurgery was no longer questioned by other surgical specialties and our surgical activity was guaranteed. In 2007 the new Head of Dermatology at the University of Bern was Professor Luca Borradori, who was a pupil of Professor Saurat and accustomed to micrographic surgery. Although he did not consider himself a surgeon he had no doubt that the introduction of micrographic surgery to the Inselspital in Bern was a strong priority. Since the departure of Walty Bayard – an excellent dermatosurgeon and phlebologist – from the University in Bern, surgery was more or less in the hands of the plastic surgeons. In 2008 I had the honour of helping introduce micrographic surgery to the University of Bern as lecturer, initially with Dr. Parmentier, and in the last two years with two of my best collaborators and skilled surgeons, Dr. Della Torre and Dr. Marco Stieger. In the same year I was able to help organise the introduction of Mohs surgery to the regional hospital of Bellinzona in Tessin with one of my former assistants from Geneva, Dr. Gionata Marazza. Gionata Marazza was an excellent collaborator in Geneva and he evolved to become a very experienced surgeon. His commitment and modesty made him destined to be the future President of the Swiss Working Group of Dermatosurgery. It was also in this year that the new Head of Dermatology in Zurich, Professor French – a pupil of Professor Saurat who worked with us in Geneva as an assistant – favoured PD Dr. Läuchli’s (a pupil of Professor Hafner) idea of introducing the frozen technique of micrographic surgery to the University of Zurich. Slowly, over the next 3 years, every university introduced this technique, with the help of other universities, so that finally in 2011 all the departments of dermatology in Switzerland offered micrographic surgery either as a fresh frozen or slow Mohs technique.

505 Spirit and Soul of Swiss Dermatology and Venereology

When we look at the last few decades we see that Swiss dermatosurgery has widely benefited from two situations. Firstly, that all young dermatologists had to go abroad to learn about dermatosurgery because there was no one to teach them. Secondly, on returning there was no one to back up and/or restrict their activity in the clinic. This made us prudent and allowed us to be creative and to practise surgery free from empiric dogmas (which are rarely evidence-based). Each of us had to learn from the patient and find our own way, but this is probably also the reason that most of this generation has learned to remain humble. Times have changed: whereas in 1895 Dubreuilh calculated that dermatosurgery constituted 2.5 % of his activity, we cannot deny that it constitutes nearly 50% of our activity today. This is the reason the American Academy of Dermatology was putting up the question whether Dermatologic Surgery should be added to the society’s name in 2013, and I am wondering whether we should do the same. In 2012 the Swiss Society of Mohs Surgery was established, and 100 years after the foundation of the Swiss Society of Dermatology and Venereology we are the first and only country in Europe where dermatology is recognised as a surgical specialty, and we are also the first and only country in Europe which offers micrographic surgery at all the university departments of dermatology. This is undeniably a success story for dermatosurgery, and I can only hope that it will continue for another 100 years.

André Skaria

I want to thank the following colleagues for their valuable collaboration and helpful information: Dr. M. Adatto Dr. A, Bezzola Prof. G. Burg Prof. J. Hafner Dr. B. Tapernoux and Mrs. Robyn Neilson for editing the English text.

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Figure 1. Maurice Adatto, Denis Salomon, André Skaria and the chair Professor JH. Saurat. This was the first group in Switzerland which performed Mohs surgery on a regular base in 1992.

Figure 2. A known face in the swiss Society of dermatology and dermatologic surgery; Prof. J. Hafner.

507 Spirit and Soul of Swiss Dermatology and Venereology

Figure 3. Dr. A. M. Skaria, Professor J. Hafner and Professor J. Alcalay past president of the ISDS, ISDS Meeting in Lucern.

Figure 4. Prof. G. Burg, Prof. J. Hafner, Prof. R. Kaufmann, Prof. D. Siegel (President AAD), Prof J. Alcalay (Past President ISDS) at the ISDS Meeting in Lucern.

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Figure 5. DR. A. M. Skaria, Dr. M. Stieger, Dr. R. Della Torre the actual Mohs surgery team at the Inselspital Bern in 2013.

509

Trichology

Trichology in Switzerland

“Insanity: Doing the same thing over and over again and expecting different results.” Albert Einstein

Dermatologic conditions are gratifying for diagnosis. One has but to look and recognise, since everything to be named is in full view. Looking would seem to be the simplest of diagnostic skills, and yet its simplicity lures one into neglect. To reach the level of artistry, looking must be a skilful active undertaking. The skill comes in making sense out of what is seen, and it comes within the quest for the underlying cause, once the disorder has been named. The diagnostic process may be one of instantaneous recognition. The informed look is the one most practised by the knowledgeable dermatologist; it comes from understanding, experience and visual memory. Where the diagnosis doesn’t come from a glance, the diagnostic tests come in, i.e. the dermatological techniques of examination, and the laboratory evaluation. The dermatologic patient expects more than just standing there and looking. These principles apply particularly to problems related to the condition of the hair. Few dermatologic problems carry as many emotional overtones as the complaint of hair loss. In general, the best way to alleviate

511 Spirit and Soul of Swiss Dermatology and Venereology the emotional distress related to hair loss is to effectively treat it. In fact, one of the oldest medical professions, according to Greek historian Herodotus, was the Egyptian “Physician of the Head” who specialised in disorders of the scalp. From the 4,000 year-old medical papyri of the ancient Egyptians down to modern times, human hair has been the object of cosmetic and medical interest, but more so of superstition and mystery. For prevention or treatment of hair loss, countless herbal solutions, oils, lotions, magic pills, and even spiritual invocations have been advocated, and with the advance of medical technologies, ultraviolet light-emitting lamps, electrical scalp simulators, and vacuum-cap machines have been alleged to help stimulate the follicles to grow hair. Most lack scientifically measurable efficacy in preventing hair loss or promoting hair growth. With the same tenacity as these questionable hair remedies have dominated the markets, age-old myths regarding hair growth and loss continue to exist up to this day. It is only with the emergence of topical minoxidil and oral finasteride that the standards have been set for the scientific evidence for safety and efficacy of hair growth promoting agents. Topical minoxidil was introduced early onto the Swiss market for the treatment of pattern hair loss, and the Department of Dermatology at the University Hospital in Zurich was one of the centres participating in a multicentre study on using oral finasteride for the treatment of male pattern hair loss. It is the introduction of these drugs into the treatment of hair loss that has heralded the emancipation of the treatment of hair loss from its age-old tradition of quackery. And it was the advertisement of oral finasteride on the Swiss market that triggered a small group of Swiss dermatologists with common interests to gather and promote clinical trichology as a science. The Swiss Trichology Study Group was launched in 1999. The founding members (in alphabetical order) were: Anita Bon, Pierre de Viragh, Stefano Gilardi, Peter Itin, Ralph M. Trüeb (founding President), and Myriam Wyss. The objectives of the Swiss Trichology Study Group are listed in Table 1.

Anita Bon had “introduced topical immunotherapy with diphenylcyclopropenon (DCP) of alopecia areata early on in the Department of Dermatology, at the University Hospital in Zurich; Pierre de Viragh had co-authored with Bernard Ackerman a seminal textbook on neoplasms with follicular differentiation;

512 Trichology

Table 1. Objectives of the Swiss Trichology Study Group • To understand the hair patient on an emotional level and his/her medical problem on a technical level. • To deliver sound patient education and effective trichologic therapy. • To represent trichology as a discipline based on evidence (EBM) from science, engineering, and statistics. • To set standards of good medical practice (GMP) in trichology. • To support progress in trichology through continuous medical education (CME). • To abolish quackery in trichology.

Stefano Gilardi was the representative for southern Switzerland (Tessin); Peter Itin had contributed to the genetics of hair diseases, and particularly to a deeper understanding of trichothiodystrophy; and Myriam Wyss had supervised the Hair Clinic at the University Hospital in Zurich ad interim during Ralph M. Trüeb’s research fellowship at the University of Texas South Western Medical School in Dallas in 1994/95. The first joint publications of the study group are listed in Table 2.

Since then, the Swiss Trichology Study Group has not only annually organised cutting-edge trichology workshops for Swiss dermatologists with an interest in hair on the occasion of the annual meetings of the Swiss Society of Dermatology and Venereology (SGDV), but some of its members have joined the European Hair Research Society (EHRS) and advanced into the arena of international trichology, with active participation at major international meetings, and the publication of a significant number of peer-reviewed papers relevant to hair. Not that the contribution of Swiss dermatology to the advance of trichology was something new, no, in as early as 1915 Lassueur from Lausanne sent the indicator case of lichen planopilaris to Graham Little in London, who has the merit of being the original describer of the (Lassueur-) Graham Little syndrome, but since then Swiss

513 Spirit and Soul of Swiss Dermatology and Venereology

Table 2. Joint publications of the Swiss Trichology Study Group (2001-4)

“Status of scalp hair and therapy of alopecia in men in Switzerland”, Praxis, n° 90, 2001, p. 241-248. “Photographic documentation of the effectiveness of 1 mg oral finasteride in treatment of androgenic alopecia in the man in routine general practice in Switzerland”, Praxis, n° 90, 2001, p. 2087-2093. “The value of hair cosmetics and pharmaceuticals”, Dermatology, n° 202, 2001, p. 275-282. “Finasteride treatment of patterned hair loss in normoandrogenic postmenopausal women”, Dermatology, n° 209, 2004, p. 202-207.

Table 3. Textbooks on hair of Swiss origin or with Swiss contribution (in German and English language)

Trüeb RM, Lier D, Hauptsache Haar. Das Haar im Spiegel von Medizin und Psychologie. Rüffer & Rub Verlag, Zürich, 2003. Trüeb RM, Haare. Praxis der Trichologie. Steinkopff, Darmstadt, 2004. Blume-Peytavi U, Tosti A, Whiting D, Trüeb RM (eds.), Hair Growth and Disorders, Berlin Heidelberg : Springer, 2008. Trüeb RM, Tobin DJ (eds.), Aging Hair, Berlin, Heidelberg: Springer, 2010. Trüeb RM, Guide to Successful Management, Berlin Heidelberg: Springer, 2013 (in press). trichology has made its appearance on the international stage more recognisable. Ralph M. Trüeb was President of the EHRS from 2008 to 11, and since then he has remained an internationally invited lecturer on hair. Ultimately, he is author and editor or co-editor of a number of textbooks on hair, both in German and English (Table 3). A characteristic of Swiss trichology is its more critical approach to age-old claims repeated over and over again, and at the same time a very practical and open-minded approach to the hair patient and his/her concern.

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Among the most prevalent physician’s misconceptions that have been recognised as standing in the way of the successful management of hair loss are the seven listed in Table 4. Through continuous observation and study these have been refuted as myths. Finally, while mainstream scientists are working on gene polymorphisms diagnostics for the prediction of risk, prevention, diagnosis, and targeted treatment development on stem cell technology, and on bioengeneering for the reconstruction of the hair follicles, we have become aware that a multitude of causal relationships underlie hair loss, and that there is a need for a more holostic approach for the successful management of the problem. New insights have focused on the role of internal and external factors such as: nutrition (proteins, energy, vitamins, and trace metals), hormones, aging, seasonality of hair growth and shedding, cigarette smoking, UV radiation, and hair care. A number of publications, partly of studies conducted by young and astute Swiss scientists, have addressed exactly these questions, and more. Among these, some have been inaugural dissertations at the University of Zurich (Table 5).

Table 4. Physician’s myths on hair (from: Trüeb RM, Female Alopecia. Guide to Successful Management, Springer 2013) • The majority of women complaining of hair loss are suffering from imaginary hair loss. • Losing 100 strands of hair per day is normal. • The most frequent disorder associated with hair loss in women is iron deficiency. • The first line therapy for androgenetic alopecia in women are antiandrogens. • Nutritional supplements have no significant effect on hair growth and shedding. • Aging of hair and androgenetic alopecia are basically the same. • Androgenetic alopecia is an exclusively non-inflammatory and non-fibrosing alopecia.

515 Spirit and Soul of Swiss Dermatology and Venereology

Table 5. Studies and inaugural dissertations (University of Zurich) conducted by Swiss scientists on clinical trichology (publications in order of chronology) Trachsler S, Trueb RM, “Value of direct immunofluorescence for differential diagnosis of cicatricial alopecia”, Dermatology, n° 211, 2005, p. 98-102. Lengg N, Heidecker B, Seifert B, Trüeb RM, “Dietary supplement increases anagen hair rate in women with telogen effluvium: results of a double-blind, placebo-controlled trial”, Therapy, n° 4, 2007, p. 59-65 Bregy A, Trueb RM, “No association between serum ferritin levels >10 microg/l and hair loss activity in women”, Dermatology, n° 217, 2008, p. 1-6. Kunz M, Seifert B, Trüeb RM, “Seasonality of hair shedding in healthy women complaining of hair loss”, Dermatology., n° 219, 2009, p. 105-110. Galliker NA, Trüeb RM, “Value of trichoscopy versus trichogram for diagnosis of female androgenetic alopecia”, Int J Trichology, n° 4, 2012, p. 19-22. Hotzenköcherle Trüeb B, Burkhardt S, Trüeb RS, Impact of seasonality of hair growth and shedding on clinical trials with hair growth promoting agents, Inaugural Dissertation, University of Zurich (submitted).

The future of Swiss trichology remains bright. Despite globalisation with substantial shifts occurring also within international hair research societies, and the option of joining in with rivalry between the continents, Switzerland does not remain a small island within the remoteness of Alpine Europe, but is making an effort to partake in the global changes through continuous presence and active participation (Figures 1, 2).

Ralph Trüeb

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Figure 1. Ralph M. Trüeb (center) and international faculty on the occasion of Hair India 2012, in Chennai, India.

Figure 2. Ralph M. Trüeb presenting his latest textbook on Female Alopecia. Guide to Successful Management, in Abu Dhabi, United Arab Emirates, December 2012.

517

Tropical Dermatology

History of Dermatology in Switzerland – Tropical Dermatology

Tropical dermatological diseases are rarely encountered in the Swiss environment. However, some Swiss colleagues have contributed a lot to this field in the past, or are still very active and highly interested in this challenging field of dermatology. In 2009, European countries received more than 3 million immigrants from non-European countries; this trend will continue for the foreseeable future. As a result, dermatologists practising in Switzerland routinely encounter unfamiliar presentations of common skin diseases. Furthermore, in order to care adequately for patients from around the globe, it is very useful if Swiss dermatologists are familiar with particular cultural and social behaviour which may impact on health. Three-quarters of the 17 neglected tropical diseases (NTD) listed by the World Health Organization (WHO) present with skin lesions. This fact has continuously motivated Swiss dermatologists to work in tropical areas or to focus their research on tropical skin diseases. The area can be divided into: – tropical dermatology, i.e. treating and managing skin diseases in tropical areas with limited resources; – imported dermatoses in returning travelers and immigrants, an area of increasing importance due to the current high mobility.

519 Spirit and Soul of Swiss Dermatology and Venereology

Contributions of Swiss dermatology to the field of tropical skin diseases Important contributions have been made with regard to one of the diseases which still challenges most tropical areas: leprosy. In 1873 Hansen discovered Mycobacterium leprae at Bergen in Norway, and in 1897 the First International Leprosy Congress was held in Berlin. As early as 1889 Josef Jadassohn (1863-1936), who was the Director of the Dermatological Clinic in Bern from 1896 until 1910, used the term “tuberculoid” to describe a special form of leprosy. This form resembles the histopathological features of noncaseous tuberculosis and is still used for the paucibacillary or “tuberculoid” form of leprosy. Later, a very important contribution was made to the treatment of leprosy: the drug Lamprene® was introduced by JR Geigy Ltd., from Basel in Switzerland in 1978. This is still one of the key drugs in the treatment of leprosy, and plays a substantial role worldwide in the well-established, multi-drug, long-term leprosy treatment. Prof. Dr. Shantaram J. Yawalkar, an Indian scientist and dermatologist who moved to Switzerland, was very active in the field of leprosy and contributed a great deal of research. His booklet “Leprosy for medical practitioners and paramedical workers” [Figure 1], first published in 1986 and republished many times since then, most recently in 2002, is still a milestone in the field of leprosy. It offers abundant, very detailed and practical information for all people treating this disease. He was also the first to formulate a combined therapy using rifampicin and dapsone, intended to mitigate bacterial resistance (Lancet, Ref 2). Professor Yawalkar, therefore, “has played an important role in ensuring that all healthcare providers have the knowledge and the skill to diagnose leprosy and its management,” as stated by Maria Neira, Director of the Department of Control, Prevention and Eradication of Communicable Diseases of the World Health Organization (WHO), Geneva, in the foreword of the 7th edition of this very useful booklet. The goal formulated by the WHO in 1999 of eradicating leprosy by the year 2005 has still not been fulfilled. Although drugs to cure leprosy are widely available, this disease continues to be a serious problem in many areas of the world such as Brazil, India and sub-Saharan Africa due to lack of healthcare access and/or delayed diagnosis.

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Although leprosy is no longer a strong focus of Swiss research, another mycobacterium-related disease – Buruli ulcer, caused by Mycobacterium ulcerans – is still being researched by the Swiss Tropical Institute (nowadays the Swiss Tropical and Public Health Institute) in Basel. Gert Pluscke and his team have contributed many substantial insights into this devastating disease, which still causes mutilating lesions in large areas of the southern hemisphere such as sub-Saharan Africa and in the aboriginal population of Australia [3-5].

Arthropod-related skin diseases Important contributions related to tropical diseases have also been made in the field of arthropod- related skin diseases. The former head of the Department of Dermatology in Basel, Professor Theo Rufli, had a strong research focus on arthropods and their relationship to skin problems. He edited an outstanding and very comprehensive textbook on the subject of arthropod-related skin problems with Professor Yani Mumcuoglu. Although first published in 1983, this book on “Dermatological Entomology” is still one of the most relevant reference books in the field [6]. Professor Yani Mumcuoglou is a highly regarded entomologist and closely collaborates with the Department of Dermatology in Basel. He later moved to Israel and is now Associate Professor of the Parasitology Association of Turkey. Hexapodes such as flies, lice, bedbugs, mosquitos, hymenoptera, and mites are systematically well-described and well-illustrated, with abundant information on related skin problems and allergies. Unfortunately the book is no longer available as it has been sold out. A sound knowledge of arthropods is crucial in order to know how to defend against them. Mosquitos and lice are carriers of many infectious diseases – most notably malaria. Efficient repellents are therefore mandatory for disease prevention. Several dermato- pharmaceutical components of highly efficient repellents, which provide excellent protection against, for example, the Anopheles mosquito, which transmits malaria, have been developed by Swiss pharmaceutical companies, often in very close collaboration with the Swiss Tropical Institute. Mosquito nets treated with repellent have also been developed, and have been demonstrated to reduce the risk of malaria [7].

521 Spirit and Soul of Swiss Dermatology and Venereology

Various Swiss dermatologists working and collaborating in tropical areas

In recent years, several members of the Swiss Society of Dermatology and Venereology have shown a strong interest and activity in tropical areas. Professor Alfred Eichmann, former Head of the Dermatological Outpatient Clinic at the Stadtspital Triemli, has regularly participated in exchanges with many centres in tropical areas, especially Bangkok, Thailand, where he learned and later also taught about sexually transmitted infections (STIs). His successor, Professor Stephan Lautenschlager, has also continued this tradition, maintaining a close and continuous exchange with East Asian centres. This allows him to maintain and develop a dense network of global experts on the universal problem of sexually transmitted infections.

In 1995, Professor Günther Burg supported a fellowship for Dr. Emma Moshi, a pathologist from Tanzania, with the International Foundation of Dermatology. She trained for 6 months in the Department of Dermatopathology at the University Hospital of Zurich. On her return to her original hospital, the Kilimanjaro Christian Medial College in Moshi, Tanzania, she initiated a programme allowing a series of Swiss dermatologists to volunteer as consultant dermatologists at the affiliated Regional Dermatology Training Centre (RDTC). In 1997 Peter Schmid-Grendelmeier and his family went to Moshi to work and teach for 1 ½ years [8-13]. He was followed in: – 1999 by Dr. Luzi Gilli, dermatologist at the Praxis Rheinacherhof, Rheinach BL, – 2003 by Dr. Beatrice Simona-Huber, Locarno [14], – 2008 by Dr. Tanja Graf, Praxis Bäumleingasse Basel, – and in 2009 by Dr. Helmut Beltraminelli, Head of the Dermatopathology Unit at the Inselspital Bern, These colleagues all spent 6 to 12 months or more working as consultant dermatologists and teachers at the RDTC.

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PD Dr. Alex Navarini, from the Department of Dermatology in Zürich, who is currently working on a research project on genetic aspects of inflammatory skin disorders in the UK, has spent several months in Ifakara, Tanzania, working with the Swiss Institute for Tropical Medicine and Public Health [15].

The Regional Dermatology Training Centre (RDTC)

In 1992, an international taskforce decided to build the RDTC at the local university hospital, the Kilimanjaro Christian Medical Centre (KCMC). Although the RDTC was first conceived as a regional hospital, it has become a pan-African reference centre for the management of dermatological diseases and dermatological training. This has been possible thanks to the support of the International Foundation for Dermatology (IFD), the International Society of Dermatology (ISD), the International League of Dermatological Societies (ILDS), KCMC, the Tanzanian Ministry of Health, other national/international dermatology societies and the WHO (from the WHO-designed “Collaborative Centre for Dermatology, Leprosy and Sexually Transmitted Diseases”). The RDTC takes care of more than 13,000 patients with skin diseases and performs about 500 skin biopsies annually. The latter are often performed by “community dermatologists” during their training. Since 1992 more than 200 Medical Officers (10-15 attendants yearly) from 16 subsidiary African countries have completed their education at the RDTC and returned to their country of origin (mostly East Africa) to work in the community. Important duties of the RDTC are: a) Education of medical officers – so-called “community dermatologists.” b) Education of residents in dermatology (10 trained and 10 in training). c) Instruction of medical students from the local Tumaini University College in Moshi. d) Organisation of an annual dermatological conference held in January, which has provided CME for all trained specialists since 1992. This is a major tropical dermatology conference

523 Spirit and Soul of Swiss Dermatology and Venereology

with specialists from several African countries and from many other countries around the world.

The contribution of all these Swiss colleagues consisted mainly of teaching and training the African physicians and medical officers and providing patient care. In addition, tele-medical and dermatopatholgical links have been built up linking the RDTC with contacts all over the world. Numerous Swiss pharmaceutical companies have generously supported these physicians and the RDTC by donating drugs, IT equipment or grants. The Swiss Society of Dermatology and Venereology has also repeatedly supported African participants of this programme.

The 3 aspects which have been especially developed by our Swiss colleagues: 1) Tele-dermatology and web-based learning techniques have been introduced to the RDTC. Using dermaNet, a tele- dermatological link was established in 1997 thanks to the strong support of the SSDV and the Roche Company (Dr. Laura Milesi) and HIN page (Dr. L. Kühnis). The first teleconference with Swiss colleagues took place in October 1997 [16, 17] when email and Internet access was still very limited, difficult and expensive in sub-Saharan Africa. Since then, electronic communication has rapidly improved, and today fibre optic technology allows rapid online communication in the main cities of Tanzania (and East Africa). In addition, mobile telephone and common Internet access are available in large areas of the country and in lower socio-economic parts of the population. Therefore tele-dermatological discussion, case exchange and training programmes are rapidly gaining importance and have also been a part of work on an almost daily basis in Africa. In particular, Helmut Beltraminelli and Peter Schmid- Grendelmeier are still closely engaged in a variety of teledermatological programmes which focus on tropical dermatology such as www.piel.telederm.org or www.African. Dermatology.org or www.telederm.org or http://telepath. patho.unibas.ch/ipath/. A consulting system for doctors

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working for Médecins Sans Frontieres, who often work under extreme conditions, with very limited resources and limited expertise in skin diseases has also been established by Professor Rod Hay (UK) and Peter Schmid-Grendelmeier with colleagues from all over the world under the auspices of the International Foundation of Dermatology. 2) Dermatopathology at the RDTC has been strongly developed and supported by Helmut Beltraminelli, who spent 6 months at the RDTC in 2009. He assessed all the histopathological cases submitted and reviewed all the slides prepared for teaching purposes during the 4 previous years. Since then he returns once a year, to review all the dermatopathology slides from that year and to teach dermatopathology to dermatologists and community dermatologists. He also regularly participates as a speaker at the dermatology conference mentioned above. In collaboration with a group of other motivated experts and with limited financial support (provided by Dermlink Grant, the International Foundation of Dermatology [Professor R. Hay], the Swiss-South-African Cooperation Grant from the University of Basel, the Switzerland and Private Foundation of Professor B. Naafs in the Netherlands, and a private donation from Dr. J. Cuevas in Spain), he started a project focusing on the promotion of exchanges and fellowships in collaboration with the RDTC, the University Hospital in Nairobi (Dr. D. Zuriel, Dr. S. Kiprono), the University Hospital in Bern (Dr. H. Beltraminelli), the Dermatopathology Clinic in Graz, Austria (Professor L. Cerroni), and the Pathology department at Stellenbosh University in Cape Town, South Africa (Professor J. Schneider). This project has given selected African physicians the opportunity to increase their knowledge and expertise in dermatopathology outside Africa. These elective periods have enabled one African colleague to successfully pass the international board examination in dermatopathology. The dermatopathology unit at the Dermatology Clinic in the Inselspital in Bern University Hospital has been officially recognised by the International Committee for

525 Spirit and Soul of Swiss Dermatology and Venereology

Dermatopathology (www.icdermpath.org) as an accredited dermatopathology training centre. Young fellows from several African and Asian countries have already spent some months in Bern learning dermatopathology. 3) Practical workshops on allergology in the tropics, and research on atopic dermatitis have been implemented at the RDTC by Peter Schmid-Grendelmeier on a regular basis for RDTC medical officers and residents during the annual CME meeting. The workshops are co-organised by Georg Klein and Rosmaria Moser from Austria and Johannes Ring from Munich, Germany. Johannes Ring, the current and past principals of the RDTC, Elisante John Masenga, Henning Grossman and Peter Schmid-Grendelmeier also organised the 7th Rajka Symposium, a research meeting focused on atopic dermatitis, gathering more than 120 experts from 5 continents in Moshi, Tanzania in 2012. This was the first time that such a meeting had taken place in Africa and the mutual exchange between “Africans” and those from “Out of Africa” was highly rewarding and stimulating. The meeting was possible due to the generous support of the EAACI (www.eaaci.org), CK- Care (www.ck-care.org), and was also attended by several Swiss colleagues. Research collaborations in the field of atopic dermatitis have been undertaken by the Allergy Unit of the Department of Dermatology in Zurich with centres in Cape Town, South Africa, Moshi, Tanzania and recently also Gaborone, Botswana and Harare, Zimbabwe.

Activities in tropical dermatology outside Africa by Swiss dermatologists Professor Paul Bigliardi has been Associate Professor and Senior Consultant for Dermatology at the Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore since 2011, so the SSDV even has a member in a permanent academic position in a tropical area. Before he left for Singapore, he was Associate Professor and Head of the Dermatology Outpatient Clinic at the University of Lausanne. In addition to providing clinical services for dermatology and allergology, he is creating

526 Tropical Dermatology a research unit in Singapore. His focus and main interests are dermatoallergology, atopic dermatitis, pruritis and wounds. Günter Burg, former Head of the Department of Dermatology in Zürich, his wife Doris Burg, and the IT specialist Vahid Djamei have established a strong tele-dermatological and dermatopathological collaboration with Kathmandu in Nepal. He has spent several weeks there since 2006, where he and local colleagues have created a very strong dermatopathology unit, which includes a slide collection. For his ongoing activities Professor Burg was nominated Visiting Professor of the Nepal Medical College Teaching Hospital, University of Kathmandu, also in 2006. Andreas Bircher, Professor and Head of the Allergy Unit and Vice Chair of the Department of Dermatology at the University of Basel has already spent two teaching and training periods in Phnom Penh, Cambodia. He works with the dermatology training programme which Professor Christoph Benedick (originally from Germany) has very successfully created over the last few years. Many other colleagues have spent months or years in tropical areas, not all known to the authors. Dr. Andrea Cadotsch (now in Zürich) worked in Latin America (Peru) for several years, where he was involved in clinical areas and even research on cutaneous leishmaniasis. Since then he has qualified and trained in public health areas and epidemiology, using all this former knowledge, and translating it into current dermatological problems here in Switzerland. Dr. Armin Blank in Zürich, has repeatedly worked in tropical areas for the ICRC. In conclusion, tropical dermatology has had its position in the SSDV throughout its history, beginning with Professor J. Jadassohn through to Professor S. Yawalkar and the numerous colleagues working in such areas in the last few decades.

Peter Schmid-Grendelmeier1, Helmut Beltraminelli2

1 Dept. of Dermatology, Inselspital Bern. 2 Allergy Unit, Dept. of Dermatology, University Hospital Zurich.

527 Spirit and Soul of Swiss Dermatology and Venereology

Figure 1. Cover of the booklet written by Professor S. Yawalkar.

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Figure 2. The 7th Rajka Meeting on Atopic Dermatitis, which took place in Moshi, Tanzania.

529 Spirit and Soul of Swiss Dermatology and Venereology

Figure 3. Peter Schmid-Grendelmeier teaching in Tanzania.

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Figure 4. Dr. Helmut Beltraminelli at the microscope at the RDTC in Moshi.

Figure 5. Tropical skin problems encountered in sub-Saharan Africa.

2a) Onchocerciasis 2b) Elephantiasis due to Filariasis

531 Spirit and Soul of Swiss Dermatology and Venereology

2c) Eumycetoma pedis 2d) Chromoblastomycosis

2e) Kaposi-Sarcoma

2b) Medina worm (Dracunculosis)

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Figure 6. Typical Skin problems in returiing travellers.

2a) Ecthyma due to mixed bacterial 2h) Vitiligo infection

2a) Ecthyma due to mixed bacterial 2b) Scabies infection

533 Spirit and Soul of Swiss Dermatology and Venereology

2c) Cutaneous larva migrans

2d) Tungiasis

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References 1. Yawalkar SJ, Lamprene (Clofazimine) in leprosy. Basic information, fourth revised edition 1993 (First published in 1978). 2. Yawalkar SJ, McDougall AC, Languillon J, Ghosh S, Hajra SK, Opromolla DV, Tonello CJ, “Once-monthly rifampicin plus daily dapsone in initial treatment of lepromatous leprosy”, Lancet, n° 8283, 1982, p. 1199–1202. 3. Peduzzi E, Groeper C, Schütte D, Zajac P, Rondini S, Mensah-Quainoo E, Spagnoli GC, Pluschke G, Daubenberger CA, “Local activation of the innate immune system in Buruli ulcer lesions”, J Invest Dermatol, n° 127, 2007, p. 638-645. 4. Schütte D, Umboock A, Pluschke G, “Phagocytosis of Mycobacterium ulcerans in the course of rifampicin and streptomycin chemotherapy in Buruli ulcer lesions”, Br J Dermatol, n° 160, 2009, p. 273-283 5. Röltgen K, Assan-Ampah K, Danso E, Yeboah-Manu D, Pluschke G, “Development of a temperature-switch PCR-based SNP typing method for Mycobacterium ulcerans”, PLoS Negl Trop Dsi, n° 6, 2012, p. 1904. 6. Rufli R, Muncuoglou Y, Dermatologische Entomologie (Beiträge zur Dermatologie Band 9), Perimed Fachbuch Gesellschaft, 1983. 7. Keiser J, Singer BH, Uztinger J, “Reducing the burden of malaria in different eco-epidemiological settings with environmental management: a systematic review”, Lancet Infect Dis, n° 5, 2005, p. 695-708. 8. Schmid-Grendelmeier P, Mahé A, Pönnighaus JM, Welsh O, Stingl P, Leppard BJ, “Tropical dermatology. Part I”, Am Acad Dermatol, n° 46, 2002, p. 571-583. 9. Welsh O, Schmid-Grendelmeier P, Stingl P, Hafner J, Leppard B, Mahé A, “Tropical dermatology. Part II”, J Am Acad Dermatol, n° 46, 2002, p. 748-763. 10. Dinkela A, Ferié J, Mbata M, Schmid-Grendelmeier M, Hatz C, “Efficacy of triclosan soap against superficial dermatomycoses: a double-blind clinical trial in 224 primary school-children in Kilombero District, Morogoro Region, Tanzania.”, Int J Dermatol, n° 46, 2007, p. 23-28. 11. Wamburu G, Masenga EJ, Moshi EZ, Schmid-Grendelmeier P, Kempf W, Orfanos CE, “HIV – associated and non – HIV associated types of Kaposi’s sarcoma in an African population in Tanzania. Status of

535 Spirit and Soul of Swiss Dermatology and Venereology

immune suppression and HHV-8 seroprevalence.”, Eur J Dermatol, n° 16, 2006, p. 677-682. 12. Ferié J, Dinkela A, Mbata M, Idindili B, Schmid-Grendelmeier P, Hatz C, “Skin disorders among school children in rural Tanzania and an assessment of therapeutic needs”, Trop Doct, n° 36, 2006, p. 219-221. 13. Haug S, (1st edition), Glatz M (2nd edition) and Schmid-Grendelmeier P, Beetle dermatitis. In: Imported skin diseases, (eds) Faber W, Hay RJ, Naafs B, Wiley Blackwell, 2012. 14. Torello L, “International activities. The Regional Dermatology Training Centre”, International Journal of Dermatology, n° 43, 2004, p. 618–621. 15. Navarini AA, Stoeckle M, Navarini S, Mossdorf E, Jullu BS, Mchomvu R, Mbata M, Kibatala P, Tanner M, Hatz C, Schmid- Grendelmeier P, “Antihistamines are superior to topical steroids in managing human immunodeficiency virus (HIV)-associated papular pruritic eruption”, Int J Dermatol, n° 49, 2010, p. 83-86. 16. Ferié J, Dinkela A, Mbata M, Idindili B, Schmid-Grendelmeier P, Hatz C, “Skin disorders among school children in rural Tanzania and an assessment of therapeutic needs”, Trop Doct, n° 36, 2006, p. 219-221. 17. Schmid-Grendelmeier P, Masenga EJ, Haeffner A, Burg G, “Teledermatology as a new tool in sub-saharan Africa: an experience from Tanzania”, J Am Acad Dermatol, n° 42, 2000, p. 833-835. 18. Schmid-Grendelmeier P, Doe P, Pakenham-Walsh N, “Teledermatology in sub-Saharan Africa”, Curr Probl Dermatol, n° 32, 2003, p. 233-426. 19. Bigliardi PL, Tobin DJ, Gaveriaux-Ruff C, Bigliardi-Qi M. Opioids and the skin--where do we stand?”, Exp Dermatol, n° 18, 2011, p. 424-30. 20. Kiprono SK, Chaula BM, Beltraminelli H, Histological Review of Skin Cancers in African Albinos: A 10-year Retrospective Review, Article submitted for publication. 21. Beltraminelli. H, Focus on dermatopathology in developing countries in Capacity to benefit: A CD of the story of Community Dermatology, International Society of Dermatology, Task force Skin Care for All: Community Dermatology, 2011. www.intsocderm.org

536 Venereal Diseases (Sexually Transmitted Infections)

From syphilography to sexual health

Dermatology is an independent specialty thanks largely to sexually transmitted diseases, and in particular to the incidence of syphilis and the variety of its clinical pictures. This fact was taken into account in the naming of the newly founded Society with the name “Société Suisse de Dermatologie et de Syphiligraphie” or “Schweizerische Gesellschaft für Dermatologie und Syphilidologie” [sic] [1] (Swiss Society of Dermatology and Syphilography). The academic part of the founding meeting in 1913 was in fact devoted to the treatment of syphilis with Salvarsan 606. Research into the treatment of venereal diseases was research focus for the speaker, Hughes Oltramare (Geneva), and also for Emile Dind (Lausanne), Joseph Jadassohn (Bern) und Max Tièche (Zurich) [1, 2, 3, 4, 5]. In the case of Dind, his interest in venereal diseases and public health issues may well have been the deciding factor for his appointment as head of dermatology in Lausanne [3]. The foundation of the SSDV occurred at a time of rapid development from the discovery of the syphilis pathogen, to the first diagnostic tests and treatment possibilities (see Table 1). A Switzerland-wide epidemiological study evaluated and published by Hubert Jäger, later head of dermatology in Lausanne, gives a clear picture of the extent of the problem at that time [6]. Out of a population of 3,880,320, a total of 15,607 patients were registered in the period from the 1st of October 1920 to the 30th September 1921. That is, one in 250 Swiss citizens had venereal disease. Gonorrhoea was the most common (6,965),

537 Spirit and Soul of Swiss Dermatology and Venereology

Table 1. “Milestones” in venereology 1793 Distinction between syphilis and gonorrhoea 1879 Discovery of gonococcus (Neisser) 1889 Discovery of Haemophilus (Ducrey) 1905 Discovery of Treponema pallidum (Schaudinn and Hoffmann) 1906 Wassermann reaction 1907 Discovery of Chlamydia trachomatis (Halberstaedter and von Prowazek) 1910 Salvarsan 606 for the treatment of syphilis (Ehrlich and Hata) 1943 Penicillin for the treatment of syphilis and gonorrhoea 1980s HIV/AIDS 1981 Aciclovir (1988 Nobel Prize for Gertrude B. Elion and George H. Hitchings in part for this discovery) 1981 Introduction of the hepatitis B vaccination 2006 Introduction of the HPV vaccination (types 6, 11, 16, 18) followed by syphilis (5,615). Up to one third of patients came to dermatological polyclinics because of venereal disease. As a result of improved treatment options – penicillin from the 1940s – the incidence of syphilis decreased continually up to 1957. The rate of venereal diseases was correspondingly classified as “unalarming” by Walter Burckhardt – Head of the Städtische Poliklinik für Haut- und Geschlechtskrankheiten (Municipal Polyclinic for Skin and Venereal Diseases) in Zurich – in 1971 [7]. At the same time, he pointed out the wave-like course of syphilis infections in a 14-year rhythm, peaking after each World War [8]. In 1962/1963 a further peak occurred, affecting primarily homosexual men. Thereafter only 20 – 40 cases a year were registered nationally by the six Swiss polyclinics for Skin and Venereal Diseases. Rising incidence has been registered again in the Western World since 1995 and in Switzerland since 2002. This led to the reintroduction in 2006 by the Ministry of Health of the laboratory reporting requirement, which had been abolished in 1997 in the naïve belief that the disease had been conquered. The trend continues and the incidence of both syphilis and gonorrhoea increased in 2012 [11]. Switzerland has hereby taken on a leading position in the incidence of syphilis in Europe [12]. Syphilography – the description of syphilis – has regained importance as a result of the increase in syphilis diagnoses, as can

538 Venereal Diseases (Sexually Transmitted Infections) be seen from publications reminding about forgotten manifestations of syphilis or describing new ones [13-17]. The HIV infection, which has been an epidemic since the 1980s, did not become part of dermatology’s domain in Switzerland, but led to the expansion of infectiology in internal medicine. This was due to the severity of the disease, and in part to political reasons, but largely because the dermatological manifestations all but disappeared as a result of the anti-retroviral therapy. Nevertheless, in the early phases of the HIV epidemic the cutaneous manifestations were described by dermatologists [18-20]. To this, surely the most important sexually transmitted infection, further infections have since been added, however. 12 new pathogens have been discovered since 1975 alone, so that it is currently assumed that there are more than 30 sexually transmitted pathogens [21]. This broadening of the spectrum of pathogens has also led to adaptation of the terminology. Syphilography became venereology, as illustrated by the current name of our Society. Later, one spoke of sexually transmitted diseases (STDs), then of sexually transmitted infections (STIs), as asymptomatic infections are also possible, not just clinically manifest diseases. A further, extended concept is that of sexual health, whereby not only aspects of sexually transmitted diseases, but also a generally positive approach to sexuality are considered important [22]. This is in line with the WHO definition of health as “… a state of complete physical, mental and social well-being, not merely the absence of disease…” The limits of the physician’s possibilities will soon be reached with such a broadening of definition. In the aim of a non-judgmental approach to patients the terms for risk groups have also changed, so that today we refer to FSW (female sex workers) or MSM (men who have sex with men). It is only a question of time, however, before these impersonal acronyms are considered discriminating and no longer “politically correct”. A possible answer to the concept of sexual health is the creation of new centres, such as, for example, the centres for sexual health or GUM (genitourinary medicine) centres in England. In addition to the already existing low-threshold counselling and treatment on offer in Switzerland, for example in the dermatological outpatient clinic of Stadtspital Triemli Zürich, the critical factor in the identification of patients at risk would be the sexual history taking in daily (general) practice. Although over 90% of patients would welcome this, it is only

539 Spirit and Soul of Swiss Dermatology and Venereology done in less than half [23]. Intensive information of all physicians in training or continued education in this respect is necessary. After a century of advances, new difficulties in the treatment of venereal diseases are arising. While important advances have been made concerning viruses thanks to antiviral drugs (genital herpes) and vaccinations (hepatitis B, human papillomavirus), the balance, particularly regarding bacterial infections, is not so positive. After initially helping 85% of syphilis patients in the first years, the arsenic compound (Salvarsan 606) became less effective in the following years [24]. In addition, the side-effects were not insignificant. The introduction of penicillin for the treatment of syphilis in the 1940s was therefore a further advance. Benzathine penicillin is still the first-line drug today. The active ingredient is, however, despite being listed as first-line therapy in all guidelines, currently not an approved drug in Switzerland and therefore not available, but must be purchased abroad. In the pre-antibiotic era, gonorrhoea was treated with an antiseptic instillation in the urethra, which caused a chemically- induced urethritis and discharge for weeks or months [25]. Sulfonamide drugs (cibazol) were therefore a significant therapeutic improvement. Guido Miescher – who succeeded Bruno Bloch as professor in Zurich – introduced the first corresponding therapies in Switzerland. Miescher also discovered the first gonococcal resistance to cibazol and began penicillin treatment of gonorrhoea [25]. The subsequent increase of penicillin-resistance led initially to dosage increase, later to the switch to cephalosporins. The work of Alfred Eichmann [26-28] is particularly of note regarding the description and characterisation of gonorrhoeal resistance to antibiotics. Resistance has increased in recent years, so that the oral forms of third generation cephalosporins are now no longer recommended. This leaves intramuscular ceftriaxone as the only antibiotic available for the treatment of gonorrhoea. The possibility of an untreatable gonorrhoea is already being discussed in high- ranking medical journals [29]. American, British and German guidelines therefore recommend combination therapy with azithromycin or doxycycline. Thus, venereal diseases remain an ongoing issue 100 years after the founding of the SSDV.

Siegfried Borelli, Stephan Lautenschlager

540 Venereal Diseases (Sexually Transmitted Infections)

References 1. Frenk E. La Société Suisse De Dermatologie Et De Vénéréologie. Schweizerische Gesellschaft für Dermatologie und Venerologie. in Dermatologie und Venerologie in der Schweiz. Ein historischer Rückblick. Frenk E (Hrsg.) Editions Alphil Neuchatel 2004. 2. Laugier P, Hunziker N, Harms M. La Clinique De Dermatologie De Genève. in Dermatologie und Venerologie in der Schweiz. Ein historischer Rückblick. Frenk E (Hrsg.) Editions Alphil Neuchatel, 2004. 3. Frenk E. Le Service De Dermatologie Et De Vénéréologie Du centre Hospitalier Universitaire Vaudois Lausanne. in Dermatologie und Venerologie in der Schweiz. Ein historischer Rückblick. Frenk E (Hrsg.) Editions Alphil Neuchatel 2004. 4. Boschung U, Yawalkar N, Braathen L. Die Dermatologische Universitätsklinik und -Poliklinik Bern. in Dermatologie und Venerologie in der Schweiz. Ein historischer Rückblick. Frenk E (Hrsg.) Editions Alphil Neuchatel 2004. 5. Lautenschlager S, Eichmann A. Die Städtische Poliklinik Zürich für Haut- und Geschlechtskrankheiten. in Dermatologie und Venerologie in der Schweiz. Ein historischer Rückblick. Frenk E (Hrsg.) Editions Alphil Neuchatel 2004. 6. Haustein H. Statistik der Geschlechtskrankheiten. Die Länder mit Sondererhebungen 1. Die Schweiz. in Handbuch der Haut- und Geschlechtskrankheiten Band XXII Soziale Bedeutung. Bekämpfung. Statistik der Geschlechtskrankheiten herausgegeben von J. Jadassohn. Verlag von Julius Springer 1927 pp 601-647. 7. Burckhardt W. Die Geschlechtskrankheiten heute. Schweiz Rundsch Med Prax. 1971; 60: 408-11. 8. Burckhardt W, Bohnenblust A. Die Lueskurve in der Schweiz seit dem 1.Weltkrieg. Dermatologica. 1967; 135: 341-4. 9. Lautenschlager S. Sexually transmitted infections in Switzerland: return of the classics. Dermatology. 2005; 210: 134-42. 10. Abraham S, Toutous-Trellu L, Pechère M, Hugonnet S, Liassine N, Yerly S, Rohner P, Ninet B, Hirschel B, Piguet V. Increased incidence of sexually transmitted infections in Geneva, Switzerland. Dermatology. 2006; 212: 41-6. 11. HIV-und STIs 2012: Trend weiterhin steigend. BAG-Bulletin 48 26. November 2012. pp 910-13.

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12. Lautenschlager S. Sexuell übertragene Infektionen: die Schweiz und ihr unrühmlicher Spitzenplatz in Europa. Schweiz Med Forum 2012; 12: 4-5. 13. Friedli A, Chavaz P, Harms M. Alopecia syphilitica: report of two cases in Geneva. Dermatology. 2001; 202:376-7. 14. Pournaras CC, Masouye I, Piletta P, Piguet V, Saurat JH, French LE. Extensive annular verrucous late secondary syphilis. Br J Dermatol. 2005; 152: 1343-5. 15. Lautenschlager S, Schwarzkopf S, Borelli S. Presternal indurated ulceration: primary syphilis. Dermatology. 2006; 212: 200-2. 16. Meyer Sauteur PM, Trück J, Bosshard PP, Tomaske M, Morán Cadenas F, Lautenschlager S, Goetschel P. Congenital syphilis in Switzerland: gone, forgotten, on the return. Swiss Med Wkly. 2012 Jan 11; 141: w13325. doi: 10.4414/smw.2011.13325. 17. Yayli S, Della Torre R, Hegyi I, Schneiter T, Beltraminelli H, Borradori L, Fux C. Late secondary syphilis with nodular lesions mimicking Kaposi sarcoma in a patient with human immunodeficiency virus. Int J Dermatol. 2013 [Epub ahead of print]. 18. Rüdlinger R, Grob R, Buchmann P, Christen D, Steiner R. Anogenital warts of the condyloma acuminatum type in HIV-positive patients. Dermatologica. 1988; 176: 277-81. 19. Rufli T. Syphilis and HIV infection.Dermatologica . 1989; 179: 113-7. 20. Itin PH, Lautenschlager S, Flückiger R, Rufli T. Oral manifestations in HIV-infected patients: diagnosis and management. J Am Acad Dermatol. 1993; 29: 749-60. 21. Lautenschlager S. Sexuell übertragene Infektionen: update 2013. Praxis 2013; 102: 273-8. 22. Positionspapier Sexuelle Gesundheit – Definition und Positionierung. der Deutschen STI-Gesellschaft (DSTIG). www.dstig.de. 23. Meystre-Agustoni G, Jeannin A, de Heller K, Pécoud A, Bodenmann P, Dubois-Arber F. Talking about sexuality with the physician: are patients receiving what they wish? Swiss Med Wkly. 2011; 141: w13178. 24. Lautenschlager S. Ubi Venus, ibi syphilis. Praxis 2011; 100:1019-1023. 25. Eichmann A. Sexuell übertragene Krankheiten. Gestern – heute – morgen. Swiss MED 1985; 7: 43-53.

542 Venereal Diseases (Sexually Transmitted Infections)

26. Eichmann F, Stieger M, Schwarz K, Konzelmann M. Beta-lactamase -produzierende Gonokokken in der Region Zürich. Epidemiologie und Empfindlichkeit gegenüber verschiedenen Antibiotika. Schweiz Med Wochenschr. 1982; 112: 713-8. 27. Eichmann AR, Piffaretti JC. Penicillinase producing Neisseria gonorrhoeae in Zurich, Switzerland. Br J Vener Dis. 1984; 60: 147-50. 28. Schläpfer G, Eichmann A. Penicillinaseproduzierende Stämme von N.gonorrhoeae (PPNG) im Raume Zürich, 1981-1988: Häufigkeit, antibiotische Empfindlichkeit und Plasmidprofil (3.Mitteilung). Schweiz Med Wochenschr. 1990; 120: 92-7. 29. Duncan S, Duncan CJ. The emerging threat of untreatable gonococcal infection. N Engl J Med 2012; 366: 2136.

543

Wound Healing

Chronic wounds are an important problem in Switzerland, occurring in more than 1% of the population and probably more than 3% of octogenarians. Wound healing is a sub-specialty of dermatology that has made tremendous advances over the past few years. It is a typical interdisciplinary field in medicine: general surgeons, vascular surgeons, plastic surgeons, orthopedic surgeons, angiologists, endocrinologists, dermatologists and many more have made important contributions to wound care. In the past few years it has also become a model for a successful inter-professional collaboration with many nurses trained as wound care experts. At the beginning of the last century, wounds were dressed with cloths and gauze to prevent external contamination, and kept dry in order to prevent the much-feared wound infections. In the 1960s, several groundbreaking publications led to a completely different approach. Winter et al. showed in 1963 that wounds epithelialise faster when left under an intact blister as opposed to when they desiccate. This led to a paradigm shift: henceforth, wounds were kept moist. A whole new industry developed, producing a vast array of modern wound dressings. Great hope was placed on semi-occlusive dressings that stimulate healing through maintaining a moist, warm environment and increasing the local CO2-concentration whilst protecting the wound from outside contamination. However, as the use of occlusive dressings is limited in wounds that are already infected, in oncological wounds, or in patients with special risks

545 Spirit and Soul of Swiss Dermatology and Venereology such as diabetes or arterial disease, many other dressings were developed that allow a moisture balance by absorbing excess wound fluid whilst keeping the wound surface moist. Furthermore, means were developed to keep wounds free from bacteria or other microbiological contamination. It was found that silver compounds can be added to many different types of dressing, thus efficiently reducing the bacterial load in critically colonised wounds. Many antiseptic substances that were used in wound treatment were found to be toxic and impairing to the wound healing process. They were replaced with modern antiseptics, which are suitable for chronic wounds. However, initial hopes that these antimicrobial strategies would speed up wound healing could not be proven in controlled trials. Therefore, these rather expensive measures should only be used during phases of wound healing when there are actual clinical signs of wound infection or critical contamination. Today, there is a wide consensus that modern wound care should involve the four principles of tissue removal, infection control, moisture balance and promotion of epithelialisation. This involves good debridement, the use of antiseptic substances when required, and the choice of a suitable dressing to maintain a moist wound surface while absorbing excess exudate and different measures such as artificial skin substitutes or skin transplants to speed up epithelialisation. With all of this progress in the local treatment of wounds, it is too often forgotten that the most important aspect in the treatment of chronic wounds is to correct the underlying pathology. In vascular ulcers, the venous hypertension must be corrected with compression therapy or surgical measures; arterial pathologies must be addressed with transluminal angioplasty or vascular surgery. Decubitus and neuropathic wounds cannot heal without pressure relief. Ulcerating tumours must be surgically removed. In this interdisciplinary field, dermatologists make a particularly important contribution with their expertise in the diagnosis of vascular and non-vascular chronic wounds. Dermatologists are familiar with many skin diseases that can ulcerate, as well as the diagnosis of a vasculitic ulcer, a pyoderma grosum, a necrobiosis lipoidica, or many other infectious ulcerations which belong to their routine repertoire. It is not a rare occurrence that an exulcerating basal cell carcinoma is treated as a chronic ulcer with different

546 Wound Healing wound healing agents until a dermatologist makes the correct diagnosis and initiates surgical removal. An important contribution of dermatologists in the field of wound care was the development of different artificial skin substitutes. While skin transplants, mainly in the form of split thickness skin grafts, have always been widely practised by dermatologists and surgeons in order to cover chronic and post-operative wounds, for many elderly patients the need for bed rest and hospitalisation caused by such treatment is not very practical. For such patients, artificially cultivated skin substitutes are an excellent alternative. Many labs have developed different approaches for cultivating skin cells. In Switzerland two products are currently commercially marketed for use in chronic wounds. One product cultivates autologous cells from the patient’s outer root sheath cells from plucked anagen hair, whereby a skin equivalent is grown within 4-6 weeks. This approach has been developed with important contributions from several Swiss scientists. The other product uses allogenic cells from neonatal foreskins to construct a by- layered skin equivalent. Switzerland is the only country in Europe where these two products are reimbursed by health insurance if certain conditions are met regarding the duration of treatment and previous treatment of the wound, as well as the Centre using such skin equivalents. The SSDV established guidelines for the use of these products together with the Swiss Association for Wound Care (SAfW), which regulate the conditions for the reimbursement of these products. In order to promote modern wound care in Switzerland, the Swiss Association for Wound Care (SAfW) was founded in 1996 by a vascular surgeon (Professor Urs Brunner † 2007), but has always been supported by many dermatologists. Professor Jürg Hafner (Zürich) was a co-founder and longtime vice-president of the organisation. The 2nd President of the organisation was Professor Thomas Hunziker (Bern), and since 2005 Dr. Severin Läuchli (Zürich) has been President of this organisation. Dr. Markus Streit (Aarau) has chaired the Scientific Committee of the SAfW since its formation in 2009. One of the main goals of the SAfW is to provide a solid education in the field of wound care. The annual wound care symposium held by the Association is one of the ways in which this goal is achieved. A separate French-speaking section of the SAfW was founded in 2006 in order to promote the

547 Spirit and Soul of Swiss Dermatology and Venereology

SAfW’s goals in all of Switzerland, and in this context, an Italian- speaking working group has been active in the Ticino since 2010. To take into consideration not only the interdisciplinary, but also the inter-professional aspect of wound care, a training course for wound care experts has been created by SAfW in cooperation with H+, the Association of Swiss hospitals, in Aarau. For the many aspects of local treatment of chronic wounds, it is not possible for the dermatologist or the generalist to keep abreast of all the rapid developments. This is classically the domain of nurses with a particular interest in wound care. The training of wound care experts, which is mainly undertaken by experienced nurses, therefore fills an important gap in the treatment of patients with chronic wounds by providing nursing staff with expert knowledge in local treatment so as to complement the guidance of the treating physician who is mainly focusing on treating the underlying pathologies. In this way, wound care has become a field with a truly successful inter-professional collaboration much to the benefit of patients burdened with chronic disease.

Severin Läuchli, Markus Streit, Christa Prins

548 Wound Healing

549

Educating Physicians

Undergraduate

The Undergraduate’s View – from a Zurich perspective From Acanthosis nigricans to Zoster generalisatus Before the first dermatology lecture in the first year of medical studies (Master of Medicine, M. Med.), some students are sure to wonder how the 30 hours allocated to the study block on skin will be filled when, as one has gathered from various sides, the treatment of all dermatological diseases supposedly lies in the prescription of a cortisone cream. However, it becomes clear during the first lecture that one will need to invest some time in order to learn the proper pronunciation of the Latin names of the basic dermatological and venereological diseases, not to mention to have a solid command of their diagnosis, clinical presentation, therapy and prognosis. First things first, however.

Structure of the study of medicine in Zurich Only those students who – having passed their Matura or school- leaving exams – pass the aptitude test (numerus clausus) held by the Rectors’ Conference of the Swiss Universities (CRUS) in 9 test locales each year, are entitled to study medicine. 4,419 had registered for this test for the study year 2013/2014 by 15.2.2013. This year the limit for the number of first year students in all of Switzerland was only 1,468.

553 Spirit and Soul of Swiss Dermatology and Venereology

Since the Bologna Process – since 2007 in Zürich – the study of medicine has consisted of a Bachelor degree (B. Med.) in the first and second year of studies as medicine for beginners, and in the third year as advanced medicine, followed by a Master study programme (M. Med.) from the fourth (first year of M. Med. studies) to the sixth (third year of M. Med. studies). Two semesters of the M. Med. programme take the form of an elective intern year in hospitals (at the University of Zurich this occurs in the fifth year of studies). In addition to the compulsory modules of the core studies, medical students are given the opportunity to deepen their knowledge of individually chosen subjects in the elective modules, which comprise a half-day each week. It is thus possible to enrol in biomedical sciences, clinical medicine, general practice medicine, surgery and many more, whereby one has to be quick to enrol in the most popular subjects. The Master’s thesis is also a condition for registration for the federal board certification examination. This should enable students to gain scientific access to projects and the ability to create an independent report on the research performed. The Master’s thesis can, for example, consist of an original research project, a clinical case study, an essay or a media report. Diverse other formats are also accepted. The curriculum and all further information for students can be found on the virtual training platform Medicine (www.vam.uzh.ch).

Dermatology in the study of medicine Dermatological and allergological knowledge is primarily imparted in the study block on skin in the first year of the M. Med. programme. However, dermatological lectures have already been held in other areas, such as in the subject blocks on “Immunity and Infection,” “Respiration,” “Digestion” and “Medicine and Age.” An appealing introduction to the specialty is made as early as the third year of studies in the clinical introduction to dermatology, with a fascinating visit to the Moulage collection of the university. What for some remains a visit to a “gallery of horrors,” piques an interest in dermatology for others. For most students, however, the interest in this specialty is first awakened in the elective year.

554 Undergraduate

Figure 1. Large auditorium east (Hörsaal Ost), University Hospital Zurich.

The study block “Dermatology” provides the core information. It consists of a total of 30 lessons in which a basic knowledge of pathophysiology, pathology, clinical presentation, diagnosis and therapy of skin diseases, sexually transmitted diseases and allergic conditions in adults and children is imparted. Regardless of their later field of specialty, all students should have a basic command of the important and common dermatological diseases such as eczema, acne, psoriasis, skin tumours, venereal diseases, ulcus cruris, autoimmune dermatoses, intolerance reactions to medication and contact allergies. In the sixth year of studies (or third year of M. Med. studies), eight further dermatological group lessons of 1½ hours each take place. These courses are presented on four corresponding afternoons in the Dermatological Clinic and Policlinic USZ, and the Dermatology Outpatients of the Stadtspital Triemli. Being so closely practice- related they are very popular with students. The most important points are also covered in-depth once again in a total of ten hours of dermatological, and six hours of allergological revision. The lecturers adhere to the national learning objectives catalogue of the Swiss Medical Interfaculty Conference in order that the most

555 Spirit and Soul of Swiss Dermatology and Venereology important aspects examined in the federal board certification exam are covered, and the lectures are not too focused on certain “popular” disciplines of the different universities (such as dermatological oncology, allergology and several others). This lists the knowledge, skills and practical abilities which a medical student should have acquired on completion of their studies (http:/sclo.smifk.ch/Swiss Catalogue of Learning Objectives for Undergraduate Medical Training).

The elective year Students gain practical skills and an insight into clinical routine in their elective year, which consists of a ten-month internship in hospitals and practices. One of these ten months from the elective year can be used for the Master’s thesis. However, many students take longer than nine months to complete their internship; some even extend their elective year to four semesters and consequently sit their federal exam a year later. It is also possible to spend three months of the elective year in foreign hospitals. Many are drawn, for example, to Africa and India, but America and England are also very popular. Some participate in an exchange programme organised by the medical faculty. An internship in dermatology is often organised so that the most important dermatological basics for the federal exam (which may have escaped some students in their third and fourth year) can be learnt. Interest in dermatology often grows rapidly, however, on noticing how diverse and challenging this field is in the clinic. A highlight for interns is the performance of punch, shave or excision biopsies. It is quickly recognised that in addition to inspection and palpation, comprehensive further diagnosis is required, such as dermatopathology, primary immunofluorescence, immunohistochemistry, molecular biology and many others. This is how the enthusiasm of both the first and last authors of this chapter for the fascinating field of dermatology was won over during their elective years! Topical steroid therapy – initially thought to be the only treatment possibility – is also complemented by ointment dressings, photo-, radio- or cryotherapy and a broad spectrum of systemic treatment applications, from antibiotics over biologics to cytostatics.

556 Undergraduate

Figure 2. Moulage museum.

Those diseases which also touch on other disciplines, requiring a knowledge of gynaecological, infectiological, rheumatological, oncological, immunological, surgical, and in particular also internal medicine, demonstrate the reach and versatility of dermatology.

DOIT (Dermatology Online with Interactive Technology) Platform (www.cyberderm.net) DOIT is a multi-award- winning (e.g. Medida-Prix 2009) multilingual, interactive, systematic and case-based electronic learning platform which complements the classical lectures and courses of third to sixth year medicine, and can be accessed regardless of time or location. As a method of “blended Figure 3. learning,” DOIT supplements the Psoriasis. lectures in an interactive way and its

557 Spirit and Soul of Swiss Dermatology and Venereology diverse modules make it particularly useful for exam preparation and also in clinical routine. The modular construction of the platform follows a physiological 5-step learning process, from (1) systematic learning, (2) training with cases and MC questions, (3) tests with entertaining learning games, (4) feedback and (5) repetition with audiovisual podcasts which are also compatible with mobile devices. The contents are based on the Swiss learning catalogue. The European Dermatology Forum, an association of all dermatological clinics in Europe, has adopted the platform as the standard learning platform for dermatology. Access is via www.swisdom.org or www.cyberderm.net.

Exams

From one to five exams are planned after each semester in the current medical studies programme. In the second partial exam in the first M. Med. study year the study block skin comprises 12% of the questions. In addition to the written multiple-choice exams, more and more OSCE (objective structural clinical examinations) are being included in the exam plan. A federal board certification examination takes place at the conclusion of the studies. 10-20 questions from the field of dermatology make up ca. 2-5% of the total point score of the written part (multiple choice questions). For the CSE (clinical skills evaluation), a “clinical relay” is organised simultaneously at all five medical faculties in Switzerland with actors as patients. The students have 13 minutes per case for history-taking and examination, with a break after six cases. In all, 12 cases must be covered. Of these, it is possible that none, or at most two could be from the dermatological field. This examination method, based on the principles of OSCE, is mainly in order to make oral exams more objective, as the test is whether all students examine and discuss the most important points of the standardised cases. At the same time, their bedside manner and interaction with the patients are evaluated, and this is included in the assessment.

558 Undergraduate

The thesis and start in dermatology If one has become infected by the dermatology virus in the elective year, it is advisable to take this into account when choosing a thesis topic. In view of the possibility that one may later choose to specialise in this field, it is helpful not to distance oneself completely from dermatology, which is why some, including the first author, also choose to work on their dissertation at a dermatological clinic. In this way one can hope, after two years in a clinical basic specialty (surgery, or in the first author’s case, internal medicine), to gain a further education placement in one of the five university clinics, or to begin at a second grade teaching and training centre (‘B-Stelle’), such as the Dermatological Outpatients of the Triemli Hospital, the Dermatological Department of the Canton Hospital Aarau or the Ospedale San Giovanni in Bellinzona. Suzanne Erne1, Günter Burg, Peter Schmid-Grendelmeier2

Figure 4. The 5 physiological learning process-steps of DOIT.

1 University of Zürich. 2 Allergy Unit, Dept. of Dermatology, University Hospital, Zürich.

559 Spirit and Soul of Swiss Dermatology and Venereology

Figure 5. Screenshot from www.cyberderm.net

Figure 6. Further screenshot from www.cyberderm.net

560 The Residents’ View

Specialist training in dermatology and venereology – the resident’s point of view

The specialty area of dermatology and venereology has been extremely popular for doctors in training for decades. There are many reasons for young doctors to choose to specialise in dermatology and venereology, but the main motivation is the diversity and depth of the field. Residency positions are rare, however, as only 5 Swiss university clinics and a few other large hospitals offer specialty residency training places. As a result, the waiting lists for residency training are long, and those who do get a place consider themselves lucky. The training centres (the dermatological clinics and departments) must go to great lengths to ensure that the colleagues in training are really taught in all aspects of this broad specialty. Due to the enormous expansion of the knowledge base in all of medicine, and in particular in dermatology, the curriculum has recently been extended to cover five, rather than the previous four years, of residency in dermatology. Previously four years plus an “extra” year in a different specialty were required. The extra year is no longer officially required, but the fact is that young doctors are expected to have a clinical foundation, usually in internal medicine and surgery. All in all, most dermatologists have undergone 8 to 10 years of training before they take their board exams. In view of the close ties between specialist dermatological knowledge and all other areas of internal medicine this seems sensible.

561 Spirit and Soul of Swiss Dermatology and Venereology

Dermatology is generally seen as a “small” specialty. This term is actually inappropriate and confusing. The field has a broad interface with all internal specialist areas, in particular with immunology, oncology, and angiology, but also with plastic surgery, maxillofacial surgery and ophthalmology/eyelid surgery. Patients of both sexes and all ages – beginning with the paediatric and ending with the geriatric population – are seen in dermatology and venereology. Resident dermatologists must learn an impressive range of treatments, both in theory and in practice. In addition to the common and frequent internal medications, immune suppression and modern biologics play a central role. Local treatments are specifically dermatological, beginning with simple procedures and tricks, and continuing as far as complicated extemporaneous preparations, which are unfortunately seldom used today. Other specifically dermatological applications are the use of different sources of UV-light for the treatment of skin diseases, photodynamic therapy, dermatological laser therapy and radiation therapy. All residents undergo surgical training focusing on the treatment of malignant skin tumours. A knowledge of dermato-histopathology, which all young dermatologists must learn from the bottom up, can be invaluable for the operator checking excision margins. This form of surgery, involving intraoperative margin control, and in which the doctor is operator and histopathologist combined, is known as micrographic surgery. The performance of many procedures in local anaesthesia allows low-risk and uncomplicated treatment, even of very elderly patients. Today dermatologists treat over half of the skin cancer patients in Switzerland. Dermatooncology focuses on the treatment of advanced stages of melanoma, cutaneous lymphomas and the now very common basal cell carcinoma and spinocellular carcinomas. A series of effective medications in the treatment of advanced, metastasised melanoma has been introduced. Today it is very important that young dermatologists are familiar with this new generation of targeted therapies. Palliative care and the accompaniment of those affected have also made great advances and enjoy an increasingly important role in a holistic therapy concept.

562 The Residents’ View

With the exponential increase of possibilities in immunological and microbiological research in the last 20 years, dermatological research has shot up to a worldwide peak. In general, residents in the clinic are expected to participate in research projects – be it clinical or translational research – in addition to their clinical work. In Switzerland, every specialist society sets the training curriculum. The Swiss Institute for Medical Education (SIME) coordinates the programme and monitors quality, which also includes visiting the training centres. The contents of the residency training programme have already been described. In addition, 9 in- depth courses in the various sub-specialties, as well as proof of operative experience and twice-yearly “mini clinical exercises” (Mini CEX) and two “direct observation of procedures and skills” (DOPS) are required. The first monitor in particular the interaction with patients, the clinical evaluation and assessment of the respective situation and the ability to make a diagnosis and develop a differentiated treatment plan. In the latter, practical ability, beginning with the performance and evaluation of a mycological direct preparation and ending with demanding skin cancer operations, are supervised and documented. All of these events are documented by each resident in a logbook, which is checked and validated once a year by the head of the training centre. In the last year of training the candidates usually sit a one-day board certification exam, which is run by a standing committee of the SSDV according to modern international standards. The candidates are handed the resulting certification along with the usual obligatory documents, most importantly the certificate of attendance of the mandatory courses and the Mini CEX and DOPS credits in to the SIME, which then issues the federal diploma in dermatology and venereology. The Federal Department of Home Affairs (FDHA; Eidgenössisches Departement des Innern) accredits all 44 Swiss specialist titles every 7 years. Swiss specialist medical qualifications are recognised within the EU, whereby in reality freedom of movement remains severely limited. The university departments are under enormous pressure today, not only clinically, but also economically and scientifically. Ten years after the introduction of the DRG system, the university

563 Spirit and Soul of Swiss Dermatology and Venereology clinics in Germany have removed the simple reviews and procedures previously offered and concentrate on financially interesting diagnoses. Inevitably, residents’ training suffers as a result. Such precarious conditions have not yet taken over our academic institutions. However, the medical profession in this country is also under the obligation to carry out a heavy clinical workload at the same time as performing research, with the automatic result that less time remains for teaching and training residents. From the residents’ point of view, it is very much to be hoped that the clinically orientated training in Switzerland remains an important focus of the university clinics. Since Hippocrates, the thorough training of the following generation of doctors has been a central element of our profession. It is indispensable for the long- term survival of a specialty. Currently, the prospects for a freshly trained dermatologist are generally still good. Most find a position in a practice relatively easily, although from a political perspective regulations have been issued and restrictions on the number of specialists in free practice are under discussion. In line with the constantly increasing healthcare costs there was a freeze on new practices in all of Switzerland from 2002 to 2012. This meant that dermatologists and other specialists who had completed their training were unable (with a few exceptions) to open their own practice. The fact that the demand for dermatologists is currently greater than the supply is demonstrated by the fact that waiting times for an appointment in a dermatological practice are often several months, and that a newly opened practice usually has a large number of patients within a short time. The recent political discussions about restricting the number of specialists are heavily criticised by us residents. The Federal Parliament is currently considering making it a condition that physicians have worked in a Swiss hospital for 3 years before being allowed to set up their own practice. This would be a sensible restriction. All of those keen to set up their own practice who have worked longer in a Swiss clinic will be well familiar with all of the organisational rules of the Swiss healthcare system. In summary, most of the dermatology residents consider themselves lucky to have received one of the rare training places. What is special about this specialty is its incredible diversity, and the possibility of practising it without too many restrictions on an outpatient basis. It is not quite self-evident that the clinics can

564 The Residents’ View offer the complete spectrum of the training programme, and it is a lot of work on all sides – the training centres, the dermatology residents, and the SSDV – to keep the training standards high. One of the great Swiss pedagogues, Heinrich Pestalozzi, stated that in primary school a child must learn with its “head, heart and hands.” This is particularly relevant for our diverse specialty. The central issue for us young dermatologists is that we must comprehend the specialty in its whole complexity in order to later be able to advise and treat our patients in all areas. In this sense, it is also one of the best moments in the medical profession when we are later – in Hippocrates’ sense – able to pass our knowledge and abilities on to following generations.

Martin Theiler

565

The Research Fellow’s View

The skin is not only the largest organ but also an extremely fascinating site for research. Its unique structure and localisation allow the study of almost any aspect of the human organism including epithelial barrier function, immunological mechanisms, tissue regeneration, tumorigenesis, vascularisation, metabolic and endocrinological processes, genetic diseases, as well as interactions with commensals and pathogens, and responses to chemical and physical stimuli. Due to its ready availability and its accessibility, skin specimens may be obtained relatively easily, and biological processes and treatment outcomes in skin can often be visualised and monitored with little to no invasiveness. It is therefore not surprising that many dermatologists are interested in conducting research and that many researchers from other fields choose the skin as their favourite research organ. Switzerland has a long tradition of dermatological research, and the SGDV has fostered many young researchers. The current Swiss dermatology curriculum for residents requires at least 5 years of specific training, and most – if not all – of this training takes place at Swiss university clinics. Besides learning excellent clinical dermatology, this is a great opportunity for residents to be exposed to research early by participating in ongoing projects, local scientific meetings, or by pursuing their own research ideas in independent projects. In clinical research, implementation of high GCP (Good Clinical Practice) standards has recently led to

567 Spirit and Soul of Swiss Dermatology and Venereology the formation of many clinical trial centres. Working in a clinical study group can be another fascinating research experience for young MDs and may – besides facilitating entry into dermatology residency – significantly shape future research careers. The Swiss dermatology training curriculum values research and offers MD/ PhD candidates a faster track to becoming dermatologists (4 years instead of 5). Time and money are important key factors for scientific success. Over the last years, the ever-increasing complexity and quality standards in all aspects of research, ranging from grant writing to how the actual experiments are performed to finally writing the paper, have made science much more time-intensive and expensive. Aware of this, many clinics have started to give residents with a strong scientific interest time off for research and in addition to provide better financial support. The SGDV also provides funding for dermatological research: poster prizes for clinical and experimental research projects are awarded at the annual SGDV meetings. Moreover, funding for courses, travel expenses or research projects is available through foundations which the SGDV has established in collaboration with industry. This has allowed many researchers to attend international scientific conferences to present their research and exchange ideas. More funding for research career development or project-related funding can be obtained from the Swiss National Science Foundation and other foundations in Switzerland and abroad. Even though funding is a condition for research, there are also several other important factors for successful and enjoyable research which money cannot buy. First of all, good mentorship is often crucial. A mentor is a person that oversees one’s development and gives advice and support at critical points in a project or in a career. Mentors may be the PI of the study, the chairman of a clinic or an independent advanced researcher from a different institution. Nowadays, all Swiss universities also offer specific mentorship programs for young researchers, and participation in these is highly encouraged. Another important issue in research is finding a good scientific niche – a field of research that is fun and at the same time promising. Last but not least, research is never performed by one individual alone. Therefore, finding the right collaborators and – for those who are in a position to

568 The Research Fellow’s View employ – good employees are other important milestones in a scientific career. For all these reasons (and several more), active participation in a local collegial professional organisation like the SGDV is highly recommended.

Beda Mühleisen

569

Hospital Careers for Women

Academic and Hospital Careers for Women

The daughter of a priest, Marie Heim Vögtlin was on the right track to a good Swiss woman’s career in the mid-eighteenth century. She trained as a housekeeper in Zurich and became engaged to her cousin, Fritz Eismann. When he left her for a Russian medical student, the heartache drove the priest’s daughter to rethink her idea of women. Marie Heim Vögtlin was accepted to study at the University of Zürich, which was the first European university to allow women students, and went down in the annals of history as the first Swiss female doctor. This energetic woman did not only manage a career, but as a mother of two children she also managed to integrate family and sports activities (she was an experienced mountain hiker), making her a role model for the modern female doctor. The Swiss National Science Foundation (SNSF) named the Marie Heim Vögtlin Scholarship after her. This stipend supports female researchers whose professional career has been interrupted for family reasons. Looking back, an excellent dermatologist and researcher of note is Nicole Hunziker, who worked under professors Jadassohn, Laugier and Saurat. 117 of her articles are to be found in PubMed. Of particular note is the article “Essential lenticular melanic pigmentation of the lip and cheek mucosa”, published in 1970 in Arch. Belg. Dermatol. Syphiligr., and this disease is known worldwide as Laugier-Hunziker syndrome. Monika Harms, who devoted her clinical and scientific career to research on acne and the

571 Spirit and Soul of Swiss Dermatology and Venereology use of retinoids, was also in Geneva. In addition, she was the first to describe “gloves and socks syndrome,” an infection primarily caused by Parvovirus B19. Where do we stand with regards to women and medicine today? How well are women represented in the academic sector or in the framework of a hospital career in the field of dermatology and allergology? 11,962 women doctors practise in all of Switzerland (FMH statistics, 2012), thus constituting 37.5% of all doctors. The percentage of women residents is higher (56%) than that of men. Women are well-represented in dermatology, making up 219 (47%) of the 466 practising dermatologists, whereas with 50 out of 119 in allergology their representation is average. Women are thus well-represented in dermatological-allergological primary care. However, the same is true here: the higher the hierarchy level, the lower the percentage of women. A mere 9% of all head consultant positions in Switzerland are occupied by women. Although combining career and family is easier now than it was in the 19th century, current statistics show that at the time of writing this article, only 3 women in Romandy (Dr. Christa Prins PD, Dr. Laurence Toutous-Tréllu and Dr. Isabelle Masouyé at the University Hospital in Geneva), and three women in German- speaking Switzerland (Dr. Marianne Lerch, Kantonsspital Winterthur, Professor Dagmar Simon, Inselspital Bern, and Professor Barbara Ballmer-Weber, Universitätsspital Zürich) held executive positions in the area of dermatology/allergology. Dr. Lisa Weibel is Head of the Department of Dermatology at the Kinderspital Zürich. Professor Mirjana Maiwald, Zürich, Dr. Katrin Scherer, Basel, and PD Dr. Stephanie Christen, Lausanne, qualified as professors in recent years. In German-speaking Switzerland there are 3 female senior consultants, as opposed to 18 male senior consultants and heads of departments in university and cantonal hospitals. Why are women reluctant to take this as ever tough and demanding route? Why is it still harder for women to follow an academic or hospital career in a specialty in which women and men are equally represented today? An obvious obstacle is the fact that child-rearing in Switzerland is still largely the responsibility of the mother. Additional factors are the lack of part-time positions and daycare places, non-existent models for a more substantial involvement of fathers in the raising of and caring for children, as well as the

572 Hospital Careers for Women persistence of the critical attitude towards professional women with children which still pervades Swiss society today. Added to these are the limited possibilities for personal or project funding in university institutions dominated by men, and the corresponding greater attraction of private practice which offers more flexibility in terms of time. Our society also lacks the understanding that men and women are equally capable of fulfilling executive roles. The gender ratio of medical students is progressively skewed towards an increasing numbers of female students. If we do not take the opportunity to reinforce the numbers of women in senior positions and academia in the field of medicine there will bea vacuum of well-trained leaders in our specialty in the future. Similar discussions are currently being held in the Swiss economy. For example, the percentage of women on the administrative boards of listed companies in Switzerland is conspicuously below the European average, which leads to the question of a quota system, such as has already been introduced in Norway, France, Spain, or Italy. The equal status of men and women stipulated by law is not even approximately reached with regard to women in senior (executive) positions. In the long run, our society cannot afford not to use the potential of well-trained and qualified women in medicine – and not only in this field. A balanced quota of women in executive positions has been shown by a number of studies to have a positive influence on the work environment. Equally, a direct positive link appears to exist between the percentage of women in executive positions and the performance of a company. Teams with a gender-mix are more successful in the long term than male-only (and probably also women-only) executive committees. The insights which have been gained from economics can be transferred to the situation in medicine. In order to ensure a successful healthcare system in which women are correspondingly represented on all hierarchical levels, it is vital to take measures which make it easier to combine family and career and to remove negative incentives. These include flexible work conditions for parents, daycare facilities, discrimination-free promotion systems with transparent qualification criteria and a subsequent objective basis for decision-making. Working in academia and in senior hospital positions provides access to an extremely diverse field of practice. Specialisation in an area, and the national and international exchange this brings

573 Spirit and Soul of Swiss Dermatology and Venereology with it, not only invigorates everyday practice, but also leads to a permanent personal learning process, which can in turn lead to creative research and a continuous improvement in the quality of clinical practice. Passing on one’s own knowledge to students through courses and lectures, or to residents on the basis of patient- oriented teaching, plays a major and meaningful role in the positive evaluation of one’s own practice. Bearing all of this in mind, we are keen to motivate younger colleagues to follow their desire for a hospital career if they have it, and not let themselves be dissuaded by the above-mentioned hurdles, but instead to allow themselves to be enthusiastic about the diversity of a hospital or academic career.

Barbara Ballmer et al.

574 Postgraduate, and the UEMS

Educating Physicians. Postgraduate Medical Education/Dermatology Residency Training (on the occasion of the Centennial of the Swiss Society of Dermatology and Venereology)

At present we are running a highly specified Residency Training Program (RTP). The requirement is a 5-year residency in a dermatology department, 3 years of which have to be undertaken in a university department. During these 5 years our 9 subspecialties (i.e. allergology and clinical immunology, angiology, dermatosurgery, dermatopathology and immunopathology, mycology, photobiology and phototherapy, proctology, dermatooncology and prevention and rehabilitation) are taught over a period of 3 to 6 months each. Every dermatology department with residents is expected to present a Residency Training Concept and is regularly supervised by a so-called Visitation Team. Also, we have a sophisticated web-based e-Logbook for every resident of our specialty, which needs to be continuously updated by the participants. The documentation comprises diagnostic and therapeutic interventions and skills, surgical interventions, workplace-based assessments, i.e. MiniCEX (Clinical Evaluation Exercise) and DOPS (Directly Observed Procedural Skills), attended courses, scientific work, teaching activities, attestations and certificates. The candidates’ progress is monitored in regular performance evaluation discussions. In print, the entire dossier with the accompanying documents might fill an A4 booklet of

575 Spirit and Soul of Swiss Dermatology and Venereology about 50 pages. The Swiss Dermatologists were the first to have such a Logbook. Finally a mandatory examination with a practical-oral test and a written test ensures a further standardisation of the level of the examination for the respective candidates. An optional Subspecialty Certification in Dermatopathology guarantees that this discipline remains in the hands of dermatologists, and emphasises the importance of the clinicopathological correlation. 12 months of general pathology (after a previous 3-year period of general dermatology), and 12 months of dermatopathology (in an accredited training centre) are required. During this time 6000 biopsies need to be evaluated and the ‘International Board Certifying Examination in Dermatopathology” has to be successfully undertaken. This examination is annually organised by the European Union of Medical Specialists (UEMS), the Section of Dermato-Venereology and the Section of Pathology under the auspices of the International Committee for Dermatopathology. The Swiss Medical Association is a private non-profit organisation. Since 2005 our RTPs are accredited every 5 years on the basis of self-evaluation reports of the corresponding medical specialist societies, at their own expense. This accreditation is mandatory under the Federal Law of University Medical Professions (MedBG). The accreditation process of medical education falls under the competence of an independent accreditation authority (the Swiss Accreditation Council) and the Swiss University Conference; but it is the responsibility of the Federal Department of Home Affairs (DHA) to accredit the postgraduate medical education. In fact, a typical resident takes about 7 to 9 years before taking his final dermatological examination, because it is not easy to find employment in a dermatology department. The heads are looking for doctors with previous experience who can fulfill the needs of their departments. The most wanted qualifications are internal medicine, angiology, surgery and pathology. Our RTP already fulfills the requirements for the specialty of dermatology and venereology, as established in 2001 by the Specialist Section and the European Board of Dermato- Venereology of the UEMS (European Union of Medical Specialists). In the good old days life was very different…

576 Postgraduate, and the UEMS

In the old days the endorsement of a university dermatology department or the famous name of a great Professor of Dermatology guaranteed the quality of the resident training and entitled the resident, after a certain period of time, to become a board-certified specialist in dermatology and venereology. A brief attestation of attendance in the department was sufficient. In June 1931, the Swiss Medical Association first accepted the existence of 14 different medical specialties, as distinguished from the field of the General Practitioner, with dermatology and venereology being 2 different specialties. Minimum requirements were 2 years of dermatological training in a hospital qualified to provide the required standard for such resident training together with 1 year in another medical discipline. We shared this 3-year cycle with the disciplines of psychiatry, ophthalmology, otorhinolaryngology, pediatrics, radiology and urology. The holding of two different titles, e.g. dermatology and venereology, was already possible, but needed the approval of the Executive Committee of the Swiss Medical Association. Eight years later, in July 1939 (less than 2 months before the Second World War), the Swiss Chamber of Medicine (the Board of the Swiss Medical Association) tightened the requirements for the now united disciplines of dermatology and venereology. Four years of residency were required, 1 year of which had to be practised in another medical discipline. A minimum of two years had to be spent in a university department of dermatology. 1 year of residency training abroad would be taken into account. Another obligation was 3 to 6 months training in dermatological x-ray therapy with a corresponding technical course. Simultaneously the use of the three letters F. M. H. (Foederatio Medicorum Helveticorum) as a sign of quality were allowed. In March 1953 the Swiss Chamber of Medicine decided on the procedural rules for obtaining specialist titles. Future candidates had to present a doctor’s degree from a Swiss university or from a foreign university of equal standard. Also the Executive Committee of the Swiss Medical Association had to create a list of the officially recognised training centres, i.e. dermatology departments. At that time a maximum period of 2 years of residency training abroad was allowed. As usual in modern society forms were created: Application forms for the specialist title and official certification

577 Spirit and Soul of Swiss Dermatology and Venereology forms to be completed at least every 2 years by the heads of departments. In June 1963 the length of residency training was again extended to 5 years including 1 year in another medical discipline. Still the specialist societies, i.e. the Swiss Society of Dermatology and Venereology (SSDV), and even more the Cantonal Medical Societies were consulted before awarding the title “Specialist of Dermatology and Venereology FMH,” and of course further regulation was ongoing: holidays, military service, absences etc. had to be declared. The procedural rules for obtaining specialist titles comprised all medical disciplines or specialties in one paper. In May 1979 the Swiss Chamber of Medicine decided to form a Committee for Training of Medical Specialists and Continuing Medical Education (called KWFB). In April 2009 this Committee was morphed into the independent Swiss Institute of Medical Education (SIWF), making it responsible for all the 44 different RTPs and the corresponding Continuing Medical Education (CME- CPD). The legal basis is the so-called Federal Law of University Medical Professions (MedBG), which entered into force in September 2007. Effectively, the private Swiss Institute of Medical Education, with its professional know-how, took over governmental functions. The privatisation of governmental functions represents a win-win-situation for all interested parties. It guarantees certain liberties to Swiss medical doctors and a substantial financial relief to the government. In 1987, after almost 25 years of no change, A. A. Ramelet, the newly elected President of the SSDV, was charged with the formation of a structured RTP by the Swiss Medical Association (or rather by the above mentioned new Committee). That was not an easy mission at all, because, for the first time the frontiers of our discipline had to be defined and defended against the opposition of the other disciplines, and in particular against the interests of surgeons and plastic surgeons. A small working group with U.W. Schnyder (University of Zurich), T. Rufli (University of Basel), F. Favre (private practice and past President of the SSDV), and A. A. Ramelet met several times in Biel to develop this program. On the one hand it was important to preserve all the subspecialties of dermatology, and on the other to respect the different traditions in German and French-speaking Switzerland, as well as the fact that not all subspecialties could be taught in all university departments.

578 Postgraduate, and the UEMS

The above-described 9 subspecialties were at that time slightly different, dermato-oncology and prevention and rehabilitation having in the meantime replaced andrology and kryosurgery. To acquire the title of dermatology and venereology, it was sufficient to have practised 6 of the 9 subspecialties. Minimum requirements for surgical interventions were formulated. The technical course in dermatological x-ray therapy was changed into a course on dermatological radiation biology and therapy, also including the old x-ray therapy. The attendance at 3 scientific meetings of the SSDV was requested and a private practice assistance of 3 months as a part of the residency training was allowed. Simultaneously the Working Group made a categorisation of the dermatology departments: The 5 university departments were category A (with 4 years of residency training). The Municipal Dermatology and Venereology Health care Centre of Zurich (today the Dermatological Ambulatory of the Triemli Hospital) was categorised as B (with 2 years of chargeable training) and the smaller departments of Bellinzona (Ospedale San Giovanni) and Davos (Dermatology and Allergy Clinic) category C (with 1 year of training). A minimum attendance of 2 years at an A Clinic was required. The first structured RTP came into force in January 1990. It fitted on just 3 A4 pages. 6 years later, in July 1996, under the presidency of Henri Perroud, a new RTP required for the first time an examination for future dermatologists. There was a practical-written test in the form of a medical report after the referral of a patient (lasting 1 hour) and an oral test with questions on the whole field of dermatology and venereology (lasting 30 minutes). The examiners were a representative from a university department and a representative from a private practice. In addition the 9 subspecialties were more deeply characterised and the creditable Private Practice Assistance was extended to 6 months (category D). Moreover the criteria of the different residency training departments were further refined. A mini revision of the RTP, under the presidency of Jean-Paul Gabbud, introducing dermoscopy and laser treatments came into force in January 1998. Later on Jean-Paul Gabbud continued for many years to further develop our RTP. As a member of the European Board of Dermato-Venereology of the UEMS (the European Union of Medical Specialists) Jean-Paul was able to respect the European trends and tendencies in our RTP.

579 Spirit and Soul of Swiss Dermatology and Venereology

In January 2000, under the presidency of Renato Panizzon, in a new version of the RTP, as per the de facto evolution, andrology was removed and cryosurgery integrated into the field of dermatosurgery. In July 2007, under the presidency of Peter Itin, in the current version of the RTP, the total length of the residency was preserved, but was merely limited to dermatology and venereology training. General principles were formulated for the specialist and the specialty of dermatology and venereology. The growing fields of dermato-oncology and prevention and rehabilitation became new subspecialties. According to the international trend of patient protection and standardisation of tests the examination for future dermatologists was changed into a session without patients being present. The primary initiator was Luca Borradori, Head of the Bern University Department, who has been in charge of the examination for many years. In a practical-oral test the candidates are interrogated by 3 different groups of examiners on the whole field of dermatology and venereology, for a period of 20 to 25 minutes each. In a written test the candidates have to interpret 2 different dermatopathology slides, within 30 minutes. In the medium-term, the SSDV intends to integrate the examination of the European Board of Dermato-Venereology into the national exam. In May 2008, the Swiss Chamber of Medicine accepted an optional subspecialty certification in dermatopathology. That was a successful ending to a long quarrel and tedious negotiations with the pathologists. In July 2009, under the presidency of Tom Hofer, the Logbook for Residents was implemented, the dermatologists being the first to use this new tool. The latest version of our RTP dates from November 2009. A mini revision slightly raised the standards for the different residency training departments. This RTP now fits onto 14 A4 pages. Currently there is a big discussion in Switzerland about whether medical doctors coming from abroad have the same standards as Swiss doctors. However, according to the bilateral agreements between the European Union and Switzerland, including the Agreement on the Free Movement of Persons (i.e. medical doctors), which came into force in June 2002, the right of free movement is complemented by the mutual recognition of professional

580 Postgraduate, and the UEMS qualifications (diplomas, certificates and other formal qualifications). Therefore the only way to improve the standards of European medical doctors in Switzerland is to try to influence the quality of medical training in European countries by means of the European Union of Medical Specialists (UEMS). Like all other European Countries Switzerland is allowed 2 representatives on the European Board of Dermato-Venereology. In fact, the economic situation, the health care systems and the dermatological traditions in European countries are so different that the harmonisation of specialist training will take time. We will always have good quality doctors and less good quality doctors, but our highly specified Residency Training Program, the sophisticated e-Logbook and the final mandatory examination of our candidates guarantee at least a good standard of the less talented and less hard-working future dermatovenereologists. educatingphysiciansfinalversion.doc

Peter Bloch

581

Swiss Institute for Medical Education (SIME)

The Swiss Institute for Medical Education (SIME; das Schweizerische Institut für ärztliche Weiter- und Fortbildung, SIWF/ ISFM) regulates the postgraduate training for Swiss physicians towards a specialist title and also lifelong learning (continuing medical education). The institute combines both regulatory and financial competence and is completely independent and separate from professional politics of the FMH. The SIME was established in its current form in 2009. As with other free academic professions, the medical profession regulates its own further education. The Swiss Medical Association (FMH) was responsible for all aspects of further education for physicians for the complete 20th Century and into the early 21st Century. This professional and regulatory sovereignty which, with “minimal” administrative effort, lasted over a century, only recently came under criticism. An expert report of the Swiss Science and Technology Council (Schweizerischer Wissenschafts- und Technologierat, SWTR) recommended that further education for physicians be regulated by an institute which was independent of professional politics. At the same time, but independently, the Commission for Continuing Education (Kommission für Weiter- und Fortbildung, KWFB) of the FMH also received pressure from the political side. National councillor Bea Heim, of the Canton of Solothurn, had looked closely at the education of young Swiss physicians, which led her to question the fairness of the system (national council motion from 15.2.2007). As a result, those responsible in the FMH and

583 Spirit and Soul of Swiss Dermatology and Venereology

KWFB decided to act on the problem and provide a solution which would be supported by the majority. This was to separate the issues concerning continuing education (KWFB) from those concerning professional politics (FMH). In retrospect, the attempt to work out a sustainable solution a few years ago was genuinely successful, and all participants profit from it; the young physicians in training, the FMH, Swiss healthcare politics and last but not least, the patients. The former KWFB was transferred to the Swiss Institute for Medical Education (SIME). The SIME regulates continuing medical education as a completely independent institute on two levels. The training system (Weiterbildungs-Ordnung und Fortbildungs-Ordnung) describes the general foundations of all medical postgraduate titles and the 45 training programmes (45 Weiterbildungsprogramme) the details of each individual specialist title. The Federal Department of Home Affairs (FDHA; Eidgenössisches Departement des Innern, EDI) reviews the 45 training programmes and approves them, occasionally providing suggestions or requiring changes. The government thus has the highest control over the quality of medical training without having to stoop to getting involved in the detailed management of the specialist training programmes. It can rely completely on the expert competence of the medical profession. The SIME is financially self-supporting and doesn’t cost the state or the taxpayer anything. The 9,000 Swiss residents complete their specialist training at a total of 1,200 further education institutions and 650 practices. Management and board review all new applications and amendment applications for training programmes towards specialist titles, and the “focalised training modules” (Schwerpunkte und Fähigkeitsausweise). The Committee for Continuing Education Institutions (Weiterbildungsstättenkommission) is in charge of recognition of educational institutions and organises 80 – 100 visits to further education institutions, whereby a review is compulsory every time the director changes. The Title Committee (Titelkommission) judges the applications for the specialist title and the Appeals Committee (Einsprachekommission) deals with the around 100 appeals each year. The sharing of professional knowledge is considered one of the finest tasks in many professions. In particular, the pioneers

584 Swiss Institute for Medical Education (SIME) of modern medicine have made many fitting statements on the subject, for example William Osler: “The work of an institution in which there is no teaching is rarely first class.” For a large number of physicians who hold a senior position in a public hospital, the possibility of training the next generation is one of the most important motivating factors in their professional work. Representatives of all of the medical specialist titles and the most important public partners involved in medical training and continuing education meet at the annual SIME plenary assembly to learn about the newest trends and to discuss and vote on controversial issues and changes to training programmes. The board of the SIME is recruited from the members of the plenary assembly, and meets four times a year in Bern. The majority of the tasks which arise are carried out autonomously by the professionalised SIME management. Management and board work together very efficiently. Resolutions passed by the board do not need to be presented to the plenary assembly. The plenary assembly is only concerned with the most important issues and individual matters for which a majority resolution could not be achieved in the board.

Figure 1. Left: Christoph Hänggeli, Secretary General of the SIME Right: Werner Bauer, President of the SIME

585 Lifelong medical education is still not monitored by the authorities today; instead the specialist societies are responsible. In order to make monitoring of continuing education easier, the SIME continuing education platform was introduced in 2011 and is being developed and becoming available in stages. Online monitoring of further education is thus possible, which significantly simplifies the administrative work from all sides. The SSDV has been able to depend on the friendly and informative support of the SIME in the past. In addition, it has a position on the board and thus insight into the workings of the SIME. It is impressive to see how competent and smoothly this institute works and the number of experienced physicians committed to the provision of an exemplary professional, modern and humane education for young physicians. In this regard, the cooperation with the SIME is really “contagious”. The SSDV would like to take this opportunity to thank the SIME for its excellent work.

Jürg Hafner, Peter Bloch, Christoph Hänggeli, Hans-Rudolf Koelz, Werner Bauer Swiss Institute for Medical Education (SIME)

SIWF FMH

Einsprachekommis- Präsident SIWF Generalsekretariat Präsident FMH Standeskommission sion WB-Titel (3 MG) FMH Geschäfts- Präsidium Geschäftsleitung stelle SIWF Einsprachekommis- Geschäftsprüfungs- SIWF (5 MG) sion WB-Stätten (3 MG) kommission

Vorstand SIWF Zentralvorstand WB-Stätten- (19 MG + 9 stG) Delegiertenver- kommission (78 MG) sammlung Generalsekretär Geschäftsführer

Titelkommission Plenum SIWF Ärztekammer (84 MG) (56 MG + 35 stG) Rechenschaftspflicht

Öffentliche Inst. Med. Fakultäten Fachgesell- VSAO (Basis- VLSS (Basis- Dachverbände Kant. Ärztege- BAG, GDK, etc. (5) schaften (45) organisation) organisation) (7) sellschaften (24)

Ärztinnen und Ärzte / Mitglieder FMH / Urabstimmung

Geschäftsleitung SIWF

Präsident Vizepräsident Vizepräsident Vizepräsident Geschäftsführer W. Bauer J. P. Keller H. R. Koelz R. Stolz Ch. Hänggeli

Repräsentation des SIWF, Weiterbildungsstätten Weiterbildungsprogramme, e-Projekte Operative Leitung, Koordination der Projekte Fortbildung Personal, Recht

Vorstand SIWF Ex-officio-Mitglieder : Ständige Gäste :

SGAM SGC SGGG SGIM SGP BAG BAG Th. Rosemann B. Muff P. Hohlfeld J. Pfisterer Ch. Rudin C. Gasser O. Glardon

Collège GDK SGPP VLSS VSAO VSAO des Doyens E. Mariéthoz D. Georgescu H.-U Würsten M.-C. Desax R. Tandjung K. Grätz

Medizinische Fakultäten : H+ IML R. Ziegler Ch. Beyeler Basel Bern Genf Lausanne Zürich R. Bingisser I. Baumgartner J.-F. Balavoine Th. Bischoff R. Wüthrich MEBEKO MEBEKO Ch. Kuhn H. Hoppeler Vom Plenum gewählte Vorstandsmitglieder : SGKPT SGAR SGDV SGPath SGPath MEBEKO M. Kondo T. Cassina J. Hafner G. Cathomas S. Stöhr Oestreicher V. Schreiber

WB Weiterbildung SGGG Schweiz. Gesellschaft für SGAR Schweizerische Gesellschaft für MG, stG Mitglieder, ständige Gäste Gynäkologie und Geburtshilfe Anästhesiologie und Reanimation BAGB Bundesamt für Gesundheit SGIM Schweiz. Gesellschaft für SGDV Schweiz. Gesellschaft für GDKB Gesundheitsdirektorenkonferenz Allgemeine Innere Medizin Dermatologie und Venerologie VSAO Verband der Schweizer Assistenz- SGP Schweiz. Gesellschaft für Pädiatrie SGPath Schweiz. Gesellschaft für und Oberärztinnen und -ärzte SGPneu Schweiz. Gesellschaft für Pathologie VLSSB Verein der Leitenden Spitalärzte Pneumologie H+ H+ Die Spitäler der Schweiz der Schweiz SGPP Schweiz. Gesellschaft für Psychiatrie IML Institut für medizinische Lehre SGAMB Schweiz. Gesellschaft für und Psychotherapie der Universität Bern Allgemeinmedizin SGKPT Schweiz. Gesellschaft für Klinische MEBEKO Medizinalberufekommission SGCB Schweiz. Gesellschaft für Chirurgie Pharmakologie und Toxikologie

GESCHÄFTSBERICHT 2012

Figure 2a. Organigram of the SIME (in German)

587 Spirit and Soul of Swiss Dermatology and Venereology

ISFM FMH

Secrétariat général Comm. opp. pour Président ISFM Président FMH Commission les titres de FP (3 m) FMH de déontologie Secrétariat Présidence Direction ISFM ISFM Comm. opp. pour Commission (5 m) les établ. FP (3 m) de gestion

Comité ISFM Comm. des établ. de Comité central Assemblée

(19 m + 9 ip) Directeur

formation postgr. (78 m) Secrétaire général des délégués

Comm. des titres Plénum ISFM Chambre médicale (84 m) (56 m + 35 ip) Obligation de rendre compte

Inst. publiques Facultés de Sociétés de ASMAC AMDHS Org. faîtières Sociétés cant. de OFSP, CDS, etc. médecine (5) discipline méd. (45) (organisation (organisation (7) médecine (24) de base) de base)

Corps médical / Membres de la FMH / Votation générale

Direction de l’ISFM

Président Vice-président Vice-président Vice-président Directeur W. Bauer J. P. Keller H. R. Koelz R. Stolz Ch. Hänggeli

Représentation de l’ISFM Etablissements de formation Programmes de formation e-projets Responsable opérationnel, Coordination des projets postgraduée postgraduée, form. continue personnel, droit

Comité de l’ISFM Membres ex-officio : Invités permanents :

SSMG SSC SSGO SSMI SGP OFSP OFSP Th. Rosemann B. Muff P. Hohlfeld J. Pfisterer Ch. Rudin C. Gasser O. Glardon

Collège SGPP VLSS VSAO VSAO CDS des Doyens E. Mariéthoz D. Georgescu H.-U Würsten M.-C. Desax R. Tandjung K. Grätz

Facultés de medicine : H+ IML R. Ziegler Ch. Beyeler Bâle Berne Genève Lausanne Zurich R. Bingisser I. Baumgartner J.-F. Balavoine Th. Bischoff R. Wüthrich MEBEKO MEBEKO Ch. Kuhn H. Hoppeler Membres du comité élus par le plénum : SSPTC SSAR SSDV SSPath SSPneu MEBEKO M. Kondo T. Cassina J. Hafner G. Cathomas S. Stöhr Oestreicher V. Schreiber

FP formation postgraduée SSC Soc. suisse de chirurgie SSPTC Soc. suisse de pharmacologie m, ip membre, invité permanent SSGO Soc. suisse de gynécologie et de toxicologie cliniques OFSP Office fédéral de la santé publique et d’obstétrique SSAR Soc. suisse d’anesth. et de réanim. CDS Conférence suisse des directrices SSMI Soc. suisse de médecine interne SSDV Soc. suisse de dermat. et vénéréol. et directeurs cantonaux de la santé générale SSPath Soc. suisse de pathologie ASMAC Assoc. suisse des médecins- SSP Soc. suisse de pédiatrie H+ H+ Les hôpitaux de Suisse assistant(e)s et chef(fe)s de clinique SSPneu Soc. suisse de pneumologie IML Institut d’enseignement médical AMDHS Assoc. des médecins dirigeants SSPP Soc. suisse de psychiatrie de l’Université de Berne d’hôpitaux de Suisse et de psychothérapie MEBEKO Commission fédérale des professions SSMG Soc. suisse de médecine générale médicales

RAPPORT DE GESTION 2012 Figure 2b. Organigram of the SIME (in French)

588 9

Health politics in Switzerland

The Swiss healthcare system is held in high regard, both domestically and internationally. Historically, this view is based on the high concentration of excellent scientists and clinicians relative to the size of our country. In surveys of the last few years, the Swiss population has been satisfied or very satisfied with their healthcare system. The main criticism is the high cost of health insurance and out-of-pocket expenses (deductibles) burdening private households. Currently one third of all Swiss households receive financial support in order to be able to pay for health insurance. In this way, primarily single mothers and low-income families with a large number of children are relieved of the premiums which they would otherwise be unable to pay. The Swiss people have retained their right to free choice of physician. A landmark referendum was held on this issue as recently as 17.06.2012, and the parliamentary bill was rejected with a significant majority of 76%. Free choice of physician, diagnosis and treatment remain defining factors in Swiss healthcare today. Neither patients nor physicians want to change anything about the system, which has proven its worth outstandingly over decades (Figure 1).

Healthcare benefits and healthcare costs Our healthcare politicians generally consider the Swiss healthcare system to be too expensive. Data from the OECD relativise this finding, however. Within the OECD, Swiss healthcare costs are mid-range in relation to gross domestic product (Figure 2). Efficiency as measured by neonatal mortality or life expectancy, however, is in the upper norm (Figure 3). Only Japan has an even higher average life expectancy.

591 Spirit and Soul of Swiss Dermatology and Venereology

Figure 1. Swiss health politics and health care system (Courtesy of A.-G. Bütikofer, modified J. Hafner).

7.2.1 Total health expenditure as a share of GDP, 2009 (or nearest year) Public Private % of GDP 20 18

16 14

12 10 8 6 4 2

Italy Spain Brazil Chilie Israel Korea China India France Austria Iceland OECDIreland Japan Poland MexicoTurkey Canada Belgium PortugalSweden GreeceNorway Finland Hungary Estonia GermanyDenmark Slovenia Australia Indonesia Switzerland United StatesNetherlands New Zealand South Africa Luxembourg United Kingdom Slovak Republic Czech Republic Russian Federation

Figure 2. Health expenditures in relation to gross domestic product (DMP).

Each generation of healthcare politicians makes a renewed attempt to increase the out-of-pocket expenses of physician invoices. This measure should reduce costs, as everyone has to pay

592 Health politics in Switzerland

the first 400 Swiss francs per year and 10% of the total cost from his/her own pocket. In terms of direct co-payments, the Swiss are already at the forefront internationally. The out-of-the pocket health expenditures per capita for medical services in Switzerland is the highest of all OECD countries (Figure 4). All Swiss politicians who have anything to do with healthcare politics should take this fact to heart. The current health insurance law was introduced in 1996 by Federal Councillor Ruth Dreifuss (social democratic party). In short, its defining characteristic is that health insurance is compulsory for all residents of this country, and that a very broad catalogue of benefits is available to all residents. The private tariff for outpatients was abolished at that time. Today, many are of the opinion that a prioritisation of the basic healthcare benefits is necessary, with a differentiation between necessary and desirable benefits.

1.1.1 Life expectancy at birth, 2009 (or nearest year), and years gained since 1960 Life expectancy at birth, 2009 Years gained, 1960-2009 83.0 Japan 15.2 82.3 Switzerland 10.8 81.8 Italy 12.0 81.8 Spain 12.0 81.6 Australia 10.7 81.6 Israel 9.9 81.5 Iceland 8.6 81.4 Sweden 8.3 81.0 France 10.7 81.0 Norway 7.2 80.8 New Zealand 9.7 80.7 Canada 9.4 80.7 Luxembourg 11.3 80.6 Netherlands 7.1 80.4 Austria 11.7 80.4 United Kingdom 9.6 80.3 Germany 11.3 80.3 Greece 10.4 80.3 Korean 27.9 80.0 Belgium 10.2 80.0 Finland 11.0 80.0 Ireland 10.0 79.6 Portugal 16.6 79.5 OECD 11.7 79.0 Denmark 6.6 79.0 Slovenia 10.5 78.4 Chilie 21.4 78.2 United States 8.3 77.3 Czech Republic 6.7 75.8 Poland 8.0 75.3 Mexico 17.0 75.0 Estonia 6.5 75.0 Slovak Republic 4.4 74.0 Hungary 6.0 73.8 Turkey 26.5 73.3 China 27.7 72.8 Brazil 71.7 Indonesia 30.0 68.7 Russian Federation 0.0 64.1 India 21.5 52.7 South Africa 2.6 90 80 70 60 50 40 0 5 10 15 20 25 30 Years Years

Source : OECD Health Data 2011 : World Bank and national sources for non-OECD countries.

Figure 3. Life expectancy at birth.

593 Spirit and Soul of Swiss Dermatology and Venereology

6.3.1 Out-of-pocket expenditure as a share of nal household consumption, 2009 (or nearest year)

% 7

6.2

6 5.4

5 4.7 4.6

4.3 4.2 4.2 4.1 3.9

3.5 4 3.4 3.4 3.4 3.3 3.3 3.2 3.1 3.1 3.1 3.0 2.9 2.9 2.8 2.8 2.7 2.5 3 2.4 2.4 2.4 2.4 2.2

1.6 1.6 1.5 1.5 2

Italy Chile Greece Korea Israel Spain OECD Austria Japan France Turkey Mexico Sweden NorwayFinlandIceland Canada Estonia PolandIreland BelgiumPortugal Hungary Denmark Australia Germany Slovenia Switzerland Luxembourg New Zealand Netherlands United States Czech Republic Slovak Republic United Kingdom

1. Private sector total. Source: OECD Health Data 2011. Figure 4. Burden of out-of-pocket health expenditure.

Outpatient tariff After a long preparatory phase, the outpatient invoicing system Tarmed was actively introduced in 2003. The Tarmed Tariff System is based on a combined calculation of time and technical services. Tarmed originally had two good goals: the time tariff (“Minutage”) was to improve the situation of the “less technically orientated” general practitioners and the very exact diagnostic and interventional tariff was to establish a flexible system which could be rapidly adaptable to technical innovations. So far, neither of these main goals has been achieved. Financially, general practitioners are still slightly worse off than “specialists”. This relative underappreciation is one of the reasons why the number of medical graduates who choose general practice continues to decrease. A number of partners are involved in the Tarmed Tariff System: the Swiss Medical Association (FMH), H+ (Association of Swiss Hospitals), Medicinal Tariff Committee (Medizinaltarif- Kommission, MTK), Disability Insurance (Invalidenversicherung, IV), Military Insurance (Militärversicherung, MV), santé suisse (Association of Swiss Health Insurers), and the Swiss Conference of the Cantonal Ministers of Public Health (Konferenz der kantonalen Gesundheitsdirektoren, GDK) as observers. When Tarmed was introduced it was agreed that changes could only be

594 Health politics in Switzerland implemented if accepted unanimously by all tariff partners. As a result of this situation the Tarmed system has only been minimally adapted since its introduction. The desired improvement for GPs has also not been forthcoming. Currently, the FMH and individual cantons have decided upon a series of measures designed to improve the position of GPs and thus make this profession more attractive. At time of writing, the Tarmed System is being adapted chapter-by-chapter to the current situation by Swiss physicians. A new, specific tariff chapter for general practitioners is to assist in financially improving their position.

Inpatient tariff After several years of preparation, per case flat rates for inpatients were introduced under the name of SwissDRG in January 2012. The system is closely based on the German DRG system (G-DRG). It is not yet possible to clearly determine the effects of this change.

“Exploding” healthcare costs Is a rapidly stark growing healthcare system a blessing or a curse? Rapid biological and medical advances have led to genuine, measurable improvements in care and quality of life for a large number of previously chronic and disabling diseases. Life expectancy in good health is greatly increased. The people don’t want to give up this improvement in standard of living which is so central to personal wellbeing: “There is no price on health” (but costs). Two arguments are commonly brought up as to why the over- inflated development of the medical sector does not have tobe a disadvantage for the national economy. On the one hand, this sector generates a high proportion of jobs and prosperity. In the industrial sector it generates innovation and export. On the other hand, prevention of disability and rapidly restored health also mean increased productivity of people who would otherwise be sick. As it is still not possible to measure or objectify these effects they can only be brought into the discussion hypothetically. In addition, when discussing the costs, it must not be forgotten that 10% of the population use 70% of the healthcare systems in the industrialised countries. In other words, there are particularly expensive aspects of medical care where a considerable savings

595 Spirit and Soul of Swiss Dermatology and Venereology potential may be possible. This discussion unavoidably becomes rapidly very sensitive from an ethical point of view. Should the western nations reach the financial limit of their healthcare systems however, they won’t be able to avoid an ethical and transparent discussion about prioritisation. The same issues arise regarding the rapidly increasing therapeutic possibilities with the most expensive medications. The objective data on the “cost explosion” in the Swiss healthcare system read as follows: the actual healthcare costs pro person and year increased by 2% from 2000-2009, lying significantly below the OECD average (Figure 5). Have all Swiss politicians really seen this chart? Luxembourg 01 Portugal 02 Israel 02 Italy 02 Iceland 02 Switzerland 02 Germany 02 France 02 Austria 02 Norway 02 Japan 02 Hungary 03 Australia 03 Mexico 03 United States 03 Denmark 03 Sweden 03 Canada 04 Slovenia 04 OECD 04 Spain 04 Finland 04 Belgium 04 Netherlands 04 United Kingdom 05 New Zealand 05 Chile 05 Czech Republic 06 Ireland 06 Turkey 06 Greece 07 Poland 07 Estonia 08 Korea 09 Slovak Republic 11

0 4 8 Annual average growth rate (%)

Figure 5. 12 Annual increase in health expenditure per capita (over the last 10 years).

596 Health politics in Switzerland

Medication shortages and medication prices The chemical and pharmaceutical industries have belonged to the most important and innovative economic sectors in Switzerland since the pioneer period at the beginning of the 20th Century. However, a number of medications which we would like or even need to use regularly, on the basis of scientific evidence, in dermatology are often not available via the regular channels. These medications include benzathine penicillin (for treatment of syphilis: approved for this indication in CH but not available, must be imported), Ivermectin (for treatment of scabies: not approved for this indication in Switzerland, unlicensed use), and fumaric acid (for treatment of psoriasis: not approved for this indication in Switzerland, unlicensed use), dapsone or colchicine (for treatment of a number of inflammatory skin disorders, approved in other countries for certain indications, not however in CH, leading to unlicensed or sometimes off-label use). These problems arise because the approval of medications according to modern laws is very strictly regulated in western countries, and clinical studies following strict scientific and ethical guidelines are required for every single indication. In most cases, only the pharmaceutical industry is in a position to do so, and from an economical point of view, the effort is simply too great for a number of important but less common indications. In addition, the market in small countries like Switzerland (8 million inhabitants) is simply too small and economically unattractive for the pharmaceutical industry. Regulatory approval is required for every clinical application of these medications, at considerable administrative cost. A task force of SSDV board members is currently looking at how these problems could be proactively tackled and solved. The high medication costs of the “high price” island of Switzerland are a further major topic for discussion in which some room to manoeuvre probably exists. The pharmaceutical industry invests significantly in innovation and development. This should and must be respected and rewarded in the future. The research industry needs an environment in which research is rewarded. Politics in particular is called upon here. Good conditions need to be established for the research industry, and at the same time action must be taken when medication prices are too high – no easy undertaking.

597 Spirit and Soul of Swiss Dermatology and Venereology

Health insurance companies Next year there is to be a vote in Switzerland on whether the currently competing private health insurance companies should be replaced by a single “unified” health insurance company. As explained above, health insurance has been compulsory for all Swiss residents since 1996. Each individual chooses an insurance product from the innumerable private companies, everybody has at least basic healthcare and can supplement it with additional insurance according to their requirements and finances. With the paradigm shift of a single national health insurance scheme, all Swiss residents would need to have basic insurance with the single public health insurance company. The advantage of this would be that it would put a stop to the current courting of low-risk people (young, healthy, preferably male rather than female, and those without chronic illnesses). The “unified” health insurance would create a state monopoly in basic insurance, which economically liberal thinking circles criticise. The “economic liberal” circles are considering loosening the contractual obligation which currently forces the health insurance companies to enter into a contract with every licensed physician. If the contractual obligation is “loosened”, the health insurance companies would be free to enter into a contract with only those physicians who suit their concept. Economic factors would significantly influence the current freedom of treatment. In the model of the “unified health insurance”, the state protects the freedom of treatment of the physician and thereby the practice of his/her profession. The current flexible relationship between physician and patient is deliberately being specially protected. Thus this apparently “unliberal” system is paradoxically the best guarantee for a libertarian organised medicine in Switzerland. Should the Swiss people accept the “unified” health insurance scheme, the opportunity should be taken to consider reintroducing the private outpatient tariff. As mentioned earlier, this was completely abolished on introduction of the health insurance law in 1996, which in retrospect was probably a mistake. On the other hand, many medical experts agree that the current generous benefit catalogue of the services in the basic insurance needs to be streamlined, and that the “nice-to-have” benefits should be removed. The medical profession would need to cooperate for this painful process, and each specialist society to consider where necessity ends in their field and indulgence, best paid for by the individual, begins.

598 Health politics in Switzerland

Training in the healthcare professions The number of positions available for medical students and for training in other healthcare professions in Switzerland needs to be significantly increased in the coming years. In the case of physicians, the fact that 40% of those working in Swiss hospitals are colleagues from other countries is due on the one hand to the regulation of hospital working hours, and on the other to the increase in the number of young part-time physicians with families. This is not a long-term solution as it transfers the costs of medical studies to other countries, and it is not right that a prosperous industrialised nation is not capable of training enough junior physicians from its own country. There are sufficient numbers of high school graduates interested. Only about 800 of the around 3,000 applicants who sit the aptitude test each year can be accepted. This number is to increase in the coming years to 1100. A large handicap in the other healthcare professions is the federalism of the Swiss training system. Each canton is authorised to develop and run its own education programme. After decades of discussion, harmonisation of the primary school curriculum is due to take place in the coming years. Such a development is necessary in the medical professions.

The Foederatio Medicorum Helveticorum (FMH, Swiss Medical Association) Reflecting Switzerland itself, the Swiss Medical Association (FMH) is democratically and federally organised. The Chamber of Physicians (Ärztekammer; n= 200) takes on the legislative role and its board (Vorstand; n = 9) the executive. Each Swiss physician is represented in the Chamber of Physicians on the one hand by his/her specialist association (e.g. the SSDV), and on the other by the basic organisation (e.g. the cantonal medical board or the Swiss Association of Residents and Senior Physicians; Verband Schweizerischer Assistenz- und Oberärztinnen und -ärzte, VSAO). They are thus represented both by “experts” and “unions” in the parliament of Swiss physicians (Figure 6a, b). The board is divided organically into focus areas, which permit it to prepare solutions and act quickly in the everyday business of healthcare politics (president and secretary general of the FMH: Figure 7, 8).

599 Spirit and Soul of Swiss Dermatology and Venereology

Mitglieder

VSAO VLSS KG FG Dachverbände

ÄK

ZV GPK SK SIWF DV*

Wahl ..... Bestätigung

Figure 6a (in German) Organigram of the Swiss Medical Association (FMH)

ÄK: Ärztekammer DV: Delegiertenversammlung FG: Fachgesellschaften GPK: Geschäftsprüfungskommission KG: Kantonale Ärztegesellschaften SIWF: Schweizerisches Institut für ärztliche Weiter- und Fortbildung SK: Standeskommission VSAO: Verband Schweizerischer Assistenz- und Oberärztinnen und -ärzte VLSS: Verein der Leitenden Spitalärzte der Schweiz ZV: Zentralvorstand

*: Wahlberechtigt sind: Dachverbände, VSAO, VLSS und Ärztinnen Schweiz (MWS). (Courtesy of FMH)

The Chamber of Physicians meets twice yearly in Biel, and is the highest organisation of the medical profession. Healthcare politics has changed more rapidly in the last few years than in earlier decades, which has made it necessary for the medical profession to make decisions faster. For this reason, the delegates’ assembly (Delegiertenversammlung, DV), a core parliament of 33 members of the Chamber of Physicians representing the umbrella organisations and the regions in equal measure, meets six to eight times a year. Over the last 5 years the FMH has made a name for itself in Swiss healthcare politics as a partner to be taken seriously. The FMH was able to win two major referendums with its votes

600 Health politics in Switzerland

Membres

ASMAC AMDHS SCM SDM Org. faîtières

ChM

CC CdG CdD ISFM AD*

Nomination ..... Confirmation

Figure 6b (in French) Organigram of the Swiss Medical Association (FMH)

AD: Assemblée des délégués AMDHS: Association des médecins dirigeants d’hôpitaux de Suisse ASMAC: Association suisse des médecins-assistant(e)s et chef(fe)s de clinique CC: Comité central CdD: Commission de déontologie CdG: Commission de gestion ChM: Chambre médicale ISFM: Institut suisse pour la formation médicale postgraduée et continue SCM: Sociétés cantonales de médecine SDM: Sociétés de discipline médicale

*: Sont éligibles: les organisations faîtières, l’ASMAC, l’AMDHS et les Femmes médecins Suisse (MWS). (Courtesy of FMH)

(the “monism” draft bill – “Monismus Vorlage” – from 1.6.2006, and the Managed Care draft bill from 17.6.2012). With the full force of their convictions, Swiss physicians have made relevant contributions to sustainable and practical solutions on important subjects such as the “Zulassungsstopp” or registration stop (regulation of certification of new practices) or the practical application of “e-Health”. Doctors who have worked as a resident or senior physician in a Swiss clinic for at least three years and have a Swiss or European consultant’s diploma are permitted to open a practice. On the subject of e-Health, the protection of professional secrecy (Berufsgeheimnis) was given the highest priority.

601 Spirit and Soul of Swiss Dermatology and Venereology

Figure 7. Jürg Schlup (Dr. med., President of the FMH).

Figure 8. Anne-Geneviève Bütikofer (lic. iur., Secretary General of the FMH).

602 Health politics in Switzerland

The Foederatio Medicorum Chirurgicorum Helveticorum (the Swiss College of Surgeons, fmCh) The fmCh is the umbrella organisation of 16 surgical and interventional specialist societies in Switzerland, including dermatology and venereology. In the FMH the general practitioners and paediatricians dominate the votes because 100 of the 200 seats are distributed amongst the cantonal physician associations, which are influenced by the general practitioners. The fmCh therefore provides a counterpoint, and ensures that the specialists are heard in the Chamber of Physicians and national healthcare politics. The fmCh is vital for specialist fields such as dermatology and venereology. Many important subjects, including and at the forefront the campaign against the Managed Care draft bill, have been extremely successfully supported by the general secretariat of the fmCh. We would like to take this opportunity to personally thank the president Urban Laffer (Figure 9) and general secretary Markus Trutmann (Figure 10) for their untiring efforts.

Outlook Crucial decisions will be made in healthcare politics over the next decade and it is vital that the medical profession is actively involved in their making. It is not good when the physicians politely step aside and let the politicians make all of the decisions. Politicians have plausible convictions and arguments, and these are to be respected and considered in discussion. In general, however, they lack the expert insight into the complex matter of healthcare, and they are influenced by lobbyists from all possible directions. Many of our parliamentarians have seats on the administrative boards of health insurance or pharmaceutical companies (at once). Both chambers, the national (Nationalrat) and the state or upper (Ständerat), have a health commission, made up of parliamentary experts involved in all healthcare issues and the preparation of health policies and their elections. The majority of politicians in both national and state health commissions are on the administrative board of a health insurance company. We physicians must participate in the creation of the healthcare system of the future because no one knows the subject as well

603 Spirit and Soul of Swiss Dermatology and Venereology as we do. We must fight with honest arguments and uphold our convictions in order to create our children’s healthcare system and that in which the following generations of physicians will be working.

Jürg Hafner, Jean-Pierre Grillet, Thomas Hofer

Figure 9. Urban Laffer (Prof. Dr. med., President of the Swiss College of Surgeons, fmCh).

Figure 10. Markus Trutmann (Dr. med., Secretary General of the Swiss College of Surgeons, fmCh).

604 List of authors

Anliker Mark, Dr. med., Head of Division, Bereich Dermatologie und Allergologie, Haus 31, Kantonsspital St. Gallen, 9007 St.Gallen, e-mail: [email protected]

Ballmer Barbara, Prof. Dr. med., Allergiestation, Dermatologische Klinik, Universitätsspital Zürich, Gloriastrasse 31, 8091 Zürich, e-mail: [email protected]

Bigliardi Paul, Dr. med., Untere Rheingasse 3, 8245 Feuerthalen e-mail: [email protected]

Bircher Andreas, Prof. Dr. med., Allergiestation, Dermatologische Klinik, Universitätsspital Basel, Petersgraben 4, 4031 Basel, e-mail: [email protected]

Bloch Peter, Dr. med., Archstrasse 7, 8800 Thalwil, e-mail: [email protected]

Boehncke Wolf-Henning, Prof. Dr. med., Head of Department, Service de Dermatologie HCUG, Rue Micheli-du-Crest 24, 1211 Genève 14, e-mail: [email protected]

Borelli Siegfried, Dr. med., Dermatologisches Ambulatorium des Stadtspitals Triemli, Herman Greulich-Strasse 70, 8004 Zürich, e-mail: [email protected]

Borradori Luca, Prof., Director and Chairman Dept. of Dermatology, University Hospital of Berne-Inselspital, 3010 Bern, e-mail: [email protected]

605 Spirit and Soul of Swiss Dermatology and Venereology

Brand Christoph, Prof. Dr. med., Head of Division, Zentrum für Dermatologie und Allergologie, Kantonsspital Luzern, 6004 Luzern, e-mail: [email protected]

Burgdorf Walter, MD, Traubinger Str 45A, 82327 Tutzing, Germany, e-mail: [email protected]

Cozzio Antonio, PD Dr. Dr., Dermatologische Klinik, Universitätsspital Zürich, Gloriastrasse 31, 8091 Zürich, e-mail: [email protected]

Donghi Davide, Italian translator, Via Frasca 10, 6900 Lugano, e-mail: [email protected]

Dubertret Louis, Prof., Chairman emeritus, Hôpital Saint-Louis, 1 av Claude Vellefaux, 75475 Paris, e-mail: [email protected]

Dummer Reinhard, Prof. Dr. med., Dermatologische Klinik, Universitätsspital Zürich, Gloriastrasse 31, 8091 Zürich, e-mail: [email protected]

Erne Susanne, Dermatologische Klinik, UniversitätsSpital Zürich, Gloriastrasse 31, 8091 Zürich, e-mail: [email protected]

French Lars E., Prof. Dr. med., Head of Department Dermatologische Klinik, Universitätsspital Zürich, Gloriastrasse 31, 8091 Zürich, e-mail: [email protected]

Gabbud Jean-Paul A., Dr. med., Gurtenweg 27, 3074 Muri, e-mail: [email protected]

Geiges Michael, Dr. med., Marktgasse 3, 8302 Kloten, e-mail: [email protected]

Gilliet Michel, Prof., Service de Dermatologie, Head of Department, Hôpital de Beaumont 04/CHUV, 1011 Lausanne, e-mail: [email protected]

606 List of authors

Girolomoni Giampiero, Dermatologia, Head of Department, Università di Verona, Piazzale A. Stefani 1, 37126 Verona, Italy, e-mail: [email protected]

Glatz Martin, Dr. med., Dermatology Branch/NCI/NIH, Bldg 10/12N260, 10 Center Drive, Bethesda, MD 20892, USA, e-mail: [email protected]

Grillet Jean-Pierre, Dr. med., Chemin Beau-Soleil 12, 1206 Genève, e-mail: [email protected]

Gueissaz Felix, Dr. med., Av du 1er mars 33, 2000 Neuchâtel, e-mail: [email protected]

Hafner Jürg, Prof. Dr. med., Dermatologische Klinik, 8091 Universitätsspital Zürich, e-mail: [email protected]

Harms Monika, PD Dr. med., Ch de la Réserve 11, 1222 Vesenaz, e-mail: [email protected]

Hofbauer Günther, Prof. Dr. med., Dermatologische Klinik, Universitätsspital Zürich, Gloriastrasse 31, 8091 Zürich, e-mail: [email protected]

Hofer Thomas, Dr. med., Winkelriedstrasse 10, 5430 Wettingen, e-mail: [email protected]

Itin Peter, Prof. Dr. med., Head of Department, Dermatologische Universitätsklinik, Petersgraben 4, 4031 Basel, e-mail: [email protected]

Kaufmann Roland, Prof. Dr. med., Direktor der Klinik für Dermatologie, Venerologie und Allergologie, Klinikum der J.W.Goethe-Universität, Theodor-Stern-Kai 7, D-60590 Frankfurt am Main, e-mail: [email protected]

607 Spirit and Soul of Swiss Dermatology and Venereology

Kempf Werner, Prof. Dr. med., Schaffhauserplatz 3, 8006 Zürich, e-mail: [email protected]

Kerl Helmut, MD Professor & Chairman emerit, Department of Dermatology, Medical University of Graz, Auenbruggerplatz 8, A-8036 Graz, e-mail: [email protected]

Kreyden Oliver, Dr. med., Methininserhof, Baselstrasse 9, 4132 Muttenz, e-mail: [email protected]

Krischer Joachim, Dr., Cabinet et Centre Laser Dermatologique, 1bis, JD Maillard, 1217 Meyrin, e-mail: [email protected]

Kündig Thomas, PD. Dr. med., Dermatologische Klinik, Universitätsspital Zürich, Gloriastrasse 31, 8091 Zürich, e-mail: [email protected]

Laffitte Emmanuel, Dr. med., Service de Dermatologie HCUG, Rue Micheli-du-Crest 24, 1211 Genève 14, e-mail: [email protected]

Läuchli Severin, Dr. med., Dermatologische Klinik, Universitätsspital Zürich, Gloriastrasse 31, 8091 Zürich, e-mail: [email protected]

Lautenschlager Stephan, Prof. Dr. med., Head of Outpatient Clinic Dermatologisches Ambulatorium des Stadtspitals Triemli, Herman Greulich-Strasse 70, 8004 Zürich, e-mail. [email protected]

Mainetti Carlo, Dr. med., Head of Division, Clinica di Dermatologia, Ospedale San Giovanni EOC, 6500 Bellinzona, e-mail: [email protected]

Mazzi Rodolfo, Dr. med., Piazza Grande 22, 6600 Locarno, e-mail: [email protected]

608 List of authors

Monod Michel, Prof. Dr., Service de Dermatologie, Hôpital Beaumont, Bâtiment 04, CHUV, 1010 Lausanne, e-mail: [email protected]

Mühleisen Beda, Dr. med., Dermatologische Klinik, Universitätsspital Zürich, Gloriastrasse 31, 8091 Zürich, e-mail: [email protected]

Nobbe Stephan, Dr. med., Abteilung für Dermatologie, Kantonsspital Frauenfeld, 8500 Frauenfeld, e-mail: [email protected]

Panizzon Renato, Prof. Dr. med., Chairman emeritus Ruelle du Croset 5, 1009 Pully, e-mail: [email protected]

Perroud Henri-Max, Dr. med., Grand-Places 14, 1700 Fribourg, e-mail: [email protected]

Pongratz Monica, Rue des Messeillers 12, 2000 Neuchâtel, e-mail: [email protected]

Prince Pierre, French translator, Les Cernayes 8, 2400 Le Locle, e-mail: [email protected]

Ramelet Albert-Adrien, Dr. med. Dr. h. c., Place Benjamin-Constant 2, 1003 Lausanne, e-mail: [email protected]

Schmid-Grendelmeier Peter, Prof. Dr. med., Allergiestation, Dermatologische Klinik, Universitätsspital Zürich, 8091 Zürich, e-mail: [email protected]

Sigg Christian, Dr. med., Regensbergstrasse 91, 8050 Zürich, e-mail: [email protected]

Skaria Andreas, Dr. med., Rue de Lausanne 15, 1800 Vevey, e-mail: [email protected]

Streit Markus, Dr. med., Abteilung für Dermatologie, Kantonsspital Aarau, 5000 Aarau, e-mail: [email protected]

609 Spirit and Soul of Swiss Dermatology and Venereology

Theiler Martin, Dr. med., Dermatologische Klinik, Universitätsspital Zürich, Gloriastrasse 31, 8091 Zürich, e-mail: [email protected]

Toutous-Tréllu Laurence, PD Dr. med., Service de Dermatologie HCUG, Rue Micheli-du-Crest 24, 1211 Genève 14, e-mail: [email protected]

Travis Susan, English translator and proofreader, Mittenwalder Str 10, 10961 Berlin, website: www.translategerman.de, e-mail: [email protected]

Trüeb Ralph M., Prof. Dr. med., Bahnhofplatz 1A, 8304 Wallisellen, e-mail: [email protected]

Tscharner Gion, Romansh translator, Runatsch 146, 7530 Zernez, e-mail: [email protected]

Weibel Lisa, Dr. med., Dermatologische Klinik, Universitätsspital Zürich, Gloriastrasse 31, 8091 Zürich, e-mail: [email protected]

610 Editors

Editors

 Jürg Hafner Prof. Dr. med., Senior Staff Physician at the Department of Dermatology, University Hospital of Zurich. Medical Training in Surgery, Dermatology and Venereology, Vascular Medicine (Angiology) and Dermatologic Surgery in Muri, Zurich, Geneva, and several Dermatologic Surgery Divisions in Germany. President of the Swiss Society of Dermatology and Venereology, Secretary of the Swiss Society of Phlebology, Board of the Swiss College of Surgeons, Board of the Swiss Institute of Medical Education.

Michael Geiges  Dr. med. Dermatologist in private practice in Kloten (Zurich); Senior Physician at the Department of Dermatology, University Hospital of Zurich; Scientific coworker at the Institute and Museum of Medical History of the University of Zurich; Curator of the Museum of Wax Moulages, University and University Hospital Zurich. Medical Training in Psychiatry, Surgery, Internal Medicine, Dermatology and Venereology and Medical History in Zurich, Affoltern a.A. and Wald. Archivist of the SSDV, President of the European Society for the History of Dermatology and Venereology, President of the German Working Group for the History of Dermatology and Venereology.

 Michel Gilliet Prof. Dr. med., Professor and Chairman at the Department of Dermatology, University Hospital of Lausanne. Medical Training in Dermatology and Venereology in Zurich and Houston. Research Fellow at DNAX Research Institute, Palo Alto (CA), Assistant Professor and Co-Director at the MD Anderson Cancer Center, University of Texas. Board of the Swiss Society of Dermatology and Venereology.

613 Achevé d’imprimer en septembre 2013 aux Éditions Alphil

Responsable de production : Inês Marques SSDV Committee 1913 1 – Vnorovsky 9 – Merian 2 – Tièche 10 – Lennhof 3 – Narbel 11 – Guth 4 – Dind 12 – Antonietti 5 – Oltramare 13 – Winkler 6 – Jadassohn 14 – Lassueur 7 – Bloch 15 – Dösseker 8 – Helg 16 – Du Bois

SSDV Committee 2013 1 – Wolf-Henning Boehncke 9 – Michel Gilliet 2 – Konstantine Buxtorf 10 – Carlo Mainetti 3 – Monica Pongratz 11 – Gionata Marazza 4 – Jürg Hafner 12 – Stephan Lautenschlager 5 – Peter Bloch 13 – Daniel Hohl 6 – Enrica Bianchi 14 – André Skaria 7 – Luca Borradori 15 – Jean-Pierre Grillet 8 – Christian Schuster 16 – Gion Tscharner

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