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Personalized Medicine: Can We Really Achieve This in Dermatology? 1.Introduction

Within dermatology we have the exciting potential for new avenues of growth to add on to our valuable pattern recognition, diagnostic, and treatment skills. Personalized Medicine (PM) is the customization of healthcare using molecular analysis to influence medical decisions, practices, and therapies for the individual patient.

The idea of personalized medicine has old roots. Maimonides, in the 1190s, advocated personalization of medical treatment and that every patient requires individual consideration. The doctor should not say, “his disease is similar to that other case”; rather, he should treat each patient independently according to the patient’s natural constitution, individual psychology, and specific circumstances. The physician should try to cure not a disease but a diseased person. Maimonides cited Galen as saying that in deciding on a treatment the physician needs to observe seven things: “the nature of the sickness, the nature of the patient, his age, his habits, the nature of the town, the season of the year, and the constitution of the surrounding air.”1–3 Now, in addition, we are able to add occupation, genomics and other tests to the diagnostic and treatment mix.

New research data will be based on the use of evolutionary medicine and genomics to highlight how we can become more successful at finding the proper types of antibiotic or therapy and dosage for a particular disease or pathogen and build a competitive edge by prevention and risk management against invasive viruses, bacteria, or wrongly administered drugs.4,5 Certain fields of oncology and reproductive medicine have been utilizing genetic testing for many years. The current effectiveness of the recently created diagnostic tests within dermatology will need to be measured to determine the need to design more and improved tests. If we could combine all factors--past history, current symptoms, allergies, all testing results, and personalized genetic profile—we could have powerful and perhaps more immediate and cost-effective treatments.

What are the factors that provide acceptance or resistance to genetic testing? Key issues include the reliance on the accuracy of data, what action will need to be taken depending on the results, the importance of clear guidelines to improve therapy, the determination and timing of which vaccines will be the most effective for select populations, and concerns about government intervention and “snooping” and inappropriate use of acquired genetic data.

The biocultural investigation of personalized medicine will help us most effectively plan our future. The big question is: with limited resources and funds, how can we get the biggest bang for our healthcare buck? First, we must establish the importance and efficacy of personalized medicine in dermatology and not simply an inevitable outcome of the genetic revolution. The basic economic climate of most Health Maintenance Organisations (HMOs) is to spend as little money as possible to create the most profit for the stockholders. The political and economic climate is always a factor in the acceptance and implementation of any new technique. Redefining the insurance concept of “shared risk” to incorporate the newer concept of “individual risk factors” in personalized medicine in dermatology will require a major paradigm shift, but the use of genetic testing may improve the chance for biological and evolutionary success.

To accomplish the inherent goals of personalized dermatology medicine (PDM), we will increasingly need to factor in the genetic importance of skin disorders as we progress in our profession. In our 2016 book on Personalized, Evolutionary, and Ecological Dermatology (Springer)6 we covered how to enhance the dermatology profession’s valuable pattern recognition, diagnostic, and treatment skills via the evolution of modern medical techniques, including the advent of personalized medicine and genomics. Some of these tools are now readily accessible and enable the customization of healthcare using molecular analysis to influence medical decisions, practices, and therapies for the individual patient.

The evolution of the skin, and the manner in which dermatological conditions are described and managed, reveals the need to consider many aspects on a personal level. In addition, as more is understood about the biology of the skin and how the introduction of new antibiotics, biologics, and other therapies affect our skin’s ecological balance, we need to carry a heightened sense of the importance and offerings of ecological dermatology.

The combination of personalized medicine with a social medicine, evolutionary and ecological perspective, if used carefully and ethically, can assist dermatologists and other physicians in becoming more successful treatment providers. Now that we have about 18 “biologic” therapies for psoriasis and eczema, would it not be much more efficient for everyone to have a genetic ID that would allow the dermatologist to state, “Medication X should work the best of all.” And what about being able to readily detect the most effective antibiotic, anti-inflammatory, anti-pruritic, anti-depressant, or anti-cancer drug for each person? And the best plan to follow for prevention and immune stimulation?

Let’s further explore the provocative and amazingly diversified field of personalized dermatology.

Dr. Robert A. Norman

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