By Ted Rosen, MD, FAAD, Editor-in-Chief
“When they met last year, she was the only one with herpes. With the help of her doctor, she’s still the only one.” —Burroughs Wellcome Company advertisement, 1986
Should dermatologists still be experts in sexually transmitted disease? I supervised a night walk-in sexually transmitted disease (STD) clinic for the city of Houston for about 20 years, so this tells you my opinion! Moreover, I am asked to lecture on the subject at conferences and institutional grand rounds worldwide. I answer that rhetorical question in the resounding affirmative. Of course, diagnosing and treating STDs is neither as sexy (pun intended) nor as profitable as, say, administration of fillers and toxins. Still, there are many historical and contemporary reasons why we should strive to be STD authorities. Let’s examine a few.
Probably most importantly, consider this: Where do most STDs occur? STDs occur on the skin of the anogenital region. While many STDs can affect other organ systems (syphilitic hepatitis, gonococcal tenosynovitis, chlamydial salpingitis, and herpetic encephalitis are some examples), the vast majority of STDs initially present with signs or symptoms involving the cutaneous surface or adjacent mucosa. Are dermatologists not the experts in skin, hair, and nails? Who would (or could) be better at recognizing that patchy, non-scarring alopecia might actually represent secondary syphilis? Who would (or could) be better at distinguishing the condyloma lata of secondary lues from external genital warts? Who better than the dermatologist at determining if an oral mucosal lesion is orolabial herpes, Behcet’s disease, or the mucous patch associated with secondary lues? From the perspective of clinical morphology, dermatologists are experts at ascertaining and differentiating genitourinary disease.
What about from a therapeutic standpoint? Again, I maintain that dermatologists are among the most logical practitioners to treat STDs. We know all about imiquimod due to our use of this agent for actinic keratosis; yet, it was originally developed—largely by dermatologists—for the (FDA-approved) treatment of genital warts. We are very familiar with acyclovir and its various analogues because we use them to treat cold sores and shingles; it is not a leap for us to routinely use these agents to manage genital herpes in either an episodic or a suppressive or prophylactic manner. Dermatology providers are also well educated in the use of antibiotics. We are no strangers to doxycycline, the drug of choice for many STDs and the second-tier agent for syphilis.
Historical perspective
There is also the simple historical precedent. A whole series of major dermatological journals signaled, in their various titles, our interest in STDs, especially syphilis. Each of these was once the premier dermatology publication of its time: American Journal of Syphilology and Dermatology, Journal of Cutaneous and Venereal Diseases, Journal of Cutaneous Diseases and Genitourinary Diseases and Archives of Dermatology and Syphilology. From the late 1800s through 1955, few other than dermatology-oriented journals contained high-quality publications regarding STD. Many of the leading dermatologists of the day simultaneously practiced venereology and, in fact, much of the best STD research was performed by dermatologists. For example, it was the director of the Dublin Skin Infirmary, often referred to as the father of Irish dermatology, Dr. William Wallace, who proved conclusively that secondary syphilis was a contagious disease. In Europe, to this day, it is expected that dermatologists will be well versed in the diagnosis and management of STDs. Consider the pre-eminent organization the European Academy of Dermatology and Venereology.
It’s up to us
The clear question in my mind, therefore, is this: If American dermatologists totally abandon sexually transmitted diseases, then who will serve as the keepers of that knowledge and experience? Infectious disease clinicians are busy enough dealing with the COVID-19 pandemic, multiply-drug-resistant and resurgent tuberculosis, endemic fungal infections, rampant urosepsis, and emerging arboviruses. Gynecologists and urologists are, first and foremost, surgically oriented. Which leaves … whom? By default, dermatologists truly comprise that part of the healthcare community best suited to embrace (pun intended) STDs.
Despite prior optimistic predictions of the demise of syphilis and other STDs, these diseases not only persist but also flourish. From 2014 through 2019, the number of US cases and the rates per 100,000 population of syphilis, chlamydia, and gonorrhea increased dramatically due to the inability of public health officials, health care providers of all types, teachers, parents, clergy, and peer groups to meaningfully alter sexual behaviors. No one could have accurately predicted acceptance of casual sexual encounters popularized in television and movies or the ubiquitous use of sexual imagery in advertising. Nor could anyone have predicted the modern phenomena of “booty calls” and “friends with benefits.” Who knew that internet dating sites and cell phone apps would be utilized to almost instantly secure random sexual partners? The paradox is that, while our journals and training programs have steadily de-emphasized STDs, these disorders simply refuse to go away.
During her 2014 HeForShe campaign kick-off presentation, actress Emma Watson famously paraphrased the Jewish scholar Hillel the Elder (110 BC-10 AD) when she asked, “If not me, who? If not now, when?” I would ask the same questions about organized dermatology’s diligent attention to and consistent involvement in the realm of STDs.
