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Pioneers in Dermatology and Venereology: An interview with Professor Johannes Ring

2023; Wiley; Volume: 37; Issue: 12 Linguagem: Inglês

10.1111/jdv.19579

1468-3083

Johannes Ring,

Dermatology and Skin Diseases

Year of birth: 1945 Inflammatory skin diseases, allergy, eczema, epidemiology, immunology, dermatotherapy Board member and president of many scientific societies, for example, Deutsche Gesellschaft für Allergologie und klinische Immunologie (DGAKI), European Society for Dermatological Research (ESDR), European Dermatology Forum (EDF), European Academy Dermatology and Venereology (EADV), World Allergy Organization (WAO), Collegium Internationale Allergologicum (CIA), International Society of Atopic Dermatitis (ISAD) Honorary member of some dermatological and allergological societies (Finland, Poland, France, Denmark, Switzerland, Hungary, Austria, Japan, ESDR, EAACI) Development of educational programs (eczema school, anaphylaxis school) for patients, primary care physicians, pharmacists and allied health persons. Founding editor of Allergo Journal (now Allergo Journal International) Founding editor of World Allergy Organization Journal (WAO-Journal) Editor-in-Chief Journal of the European Academy of Dermatology and Venereology (JEADV) (2013–2023) I was born after the Second World War in Bad Woerishofen, a spa town where the catholic priest Father Sebastian Kneipp had been treating people with cold water and diets. My family had survived the bombing of Munich. I was born on a Sunday which I always took as a good omen! From 1951 on I have mostly—with some exceptions for United States and Hamburg—been living in Munich. At school, I studied 9 years of Latin, 6 years of Greek and 3 years of modern language where we could choose between English and French. My father said, ‘Don't waste your time learning English at school, you will learn it later anyhow’, and right he was. I also attended a course in classic Hebrew. Growing up I had difficulty accepting my German identity due to the horrific history we had just been through. I hated uniforms and flags, so I reflected my idealism onto Bavaria as my homeland. From Bavaria (and bypassing Germany), I identified myself directly with Europe which I dreamt of as a union of local regions that disregarded the national capitals like Bonn, Paris and Madrid, but instead had a parliament where Bavaria would vote, for instance, with Bretagne and Wales against Catalonia and Tuscany, thus overcoming nationalism. As a matter of fact, it was not until the summer of 2006 that I—like many of my compatriots—waved for the first time the black-red-golden national flag with enthusiasm during the fairy tale of the football FIFA World Cup in Germany. I attended medical school at Ludwig Maximilian University (LMU) in Munich where I started experimental work in immunology for my doctoral thesis, I also studied Bavarian history in parallel. This was possible in those days when universities were not so crowded. During 1968–1969, I was a member of the student parliament when the Medical Faculty was the only one where moderate students were elected while all the other faculties were taken over by the ‘red cells’. This was where some people tragically entered the road to terrorism with the Red Army Faction (RAF). I used the long summer vacation to go for 3 months each to the United States and Japan to work in a hospital (externship). Since then, I cultivated meaningful friendships in America and Japan. The decision to go to dermatology was rather serendipitous and it was not planned from a long-term perspective. During medical school, I did some quite time-consuming experimental work in transplantation immunology. At that time, I wanted to go to Africa in third-world service, but they did not take me. So, I was about to go into general practice in the Bavarian Forest. But in moments of self-reflection, I felt that—despite a successful exam—there were two specialties which I honestly had not really understood, namely psychiatry and dermatology. That is why I pursued half a year of extra training in each of those two disciplines. I respect psychiatry very much, but I felt that it was not my calling. In dermatology, I had the good luck to have ended up in Professor Otto Braun-Falco's private ward where I joined his rounds every day. This experience impressed me very much—it was not so much the discipline in itself but the person Otto Braun-Falco who was the ‘pope’ of dermatology, not only in Germany. After another period in immunological research first with Professor Brendel in Munich, then in Scripps Clinic and Research Foundation in La Jolla, California with Professor Eng Tan, I came back to Germany and decided to go into dermatology and get my training with Professor Braun-Falco. He was not only an excellent dermatologist but also a master for supporting the career of his people: he managed to get 17 of his disciples on chairmanships at German universities. I was his twelfth student when the University of Hamburg called me to take on the position of Director and Chairman. I stayed in Hamburg for 5 years after which I went on to fill the same position for the Department of Dermatology and Allergology Biederstein at Technical University Munich (TUM) in succession of Professor Siegfried Borelli. I never regret my decision. Dermatology is a wonderful specialty. And in Germany where dermatology comes together with allergology, life can never be boring. Every week you see something you have never seen before—if you have open eyes and a critical mind. There are my immediate teachers Walter Brendel (LMU) in transplantation immunology and experimental research, Eng Tan (La Jolla) in Allergology and Otto Braun-Falco in Dermatology, but also associate Professors (‘Oberarzt’ a typical German expression) have influenced me, like Konrad Messmer (LMU). With him, I learned greatly about anaphylaxis. Rudi Pichlmayr (LMU) who was a genial transplant surgeon and immunologist, also Enno Christophers (Kiel), Gerd Plewig (LMU) and Guenther Burg (LMU). I also want to mention predecessors in Hamburg: Dermatology Theodor Nasemann and Allergology Karl-Heinz Schulz, and in Munich Siegfried Borelli (TUM Biederstein). They all shared their knowledge with me not only in clinical medicine and science but also in management skills how to run a University Department and survive in an administrative jungle. I am happy to have found an excellent successor with Tilo Biedermann who will lead the department into the future. A thank you also go to mentors outside my direct universities namely Alain de Weck (Bern) and Erich Fuchs (Wiesbaden). I also learned a lot from colleagues, and I want to especially mention Bernhard Przybilla and Thomas Bieber at LMU, and Reinhard Engst, Ulf Darsow, and Knut Brockow at TUM. Above all, I must thank my wife Professor Heidrun Behrendt-Ring, the founder and director of the new Center of Allergy and Environment (ZAUM) at TUM, who always had the best ideas and has always been a critical companion. Without her, our studies in epidemiology of allergic diseases and eczema as well as allergy and environment would not have been possible. Ring J, Messmer K. Incidence and severity of anaphylactoid reactions to colloid volume substitutes. Lancet 1977;1:466–469. Darsow U, Vieluf D, Ring J. Evaluating the relevance of aeroallergen sensitization in atopic eczema with the atopy patch test: a randomized, double-blind multicenter study. J Am Acad Dermatol 1999; 40:187–193. Ploetz SG, Simon HU, Darsow U, Simon D, Vassina E, Yousefi S et al. Use of an anti-interleukin-5 antibody in the hypereosinophilic syndrome with eosinophilic dermatitis. N Engl J Med 2003; 349:2334–2339. Ring J, Zink A, Arents BWM, Seitz IA, Mensing U, Schielein MC et al. Atopic eczema: burden of disease and individual suffering – results from a large EU study in adults. J Eur Acad Dermatol Venereol 2019; 33:1331–1340. Ring J, Behrendt H. Allergy and civilization. In “Strategies for Sustainability of the Earth System” (Wilderer PA, Grambow M, Molls M, Oexle K eds) p 283–293. TUM edition, Springer Berlin 2022. I might be allowed to add a book: Eyerich K, Ring J. Atopic dermatitis – eczema. Clinics, pathophysiology and therapy. 2nd ed. Springer Nature, Cham Switzerland 2023. This was not given to me in the cradle, if somebody had told me at the end of high school how much I would have to write later on as a medical doctor I would not even have studied medicine. But I liked education and teaching. I also liked to put together newspapers, starting with the local high school newspaper of the humanistic Wilhelms–Gymnasium in Munich. Later I was founding editor of two journals, namely the official journal of the German Allergy Society ‘Allergo Journal’ and the ‘World Allergy Organization (WAO) Journal’ of WAO. Over many years I was the chief editor of a book series ‘Chemical Immunology and Allergy’, published by Karger, Basel. I had not planned to become the Editor of JEADV. But when the EADV president at that time, Jana Hercogova (with whom I did not always share the same opinion) approached me, I applied for the role and was elected as the Editor-in-Chief of the JEADV. This was another big adventure in my life opening a new chapter after the years of being active in immunology, allergy and dermatology as well as education, having served as the Dean of Studies for 10 years in TUM. Only then I could start planning and introducing new things. The breakthrough came with the bidding process for a new publisher and the negotiation of publishing terms with the incumbent publisher Wiley in 2017. We stayed with Wiley, having reached a mutually beneficial agreement both for the publisher and EADV. The first change introduced was a new cover design with the help of medical illustrator Laurence Zulianello. We also changed the contents now arranged according to the types of articles and subjects, and introduced new sections like editorials, commentaries, Editor's Picks, book reviews and historical perspectives. The introduction of the series ‘Pioneers (and Ambassadors) in Dermatology and Venereology’ was a real success and although I do not know whether I deserve to be featured in this series, Asao Sarukawa and the team in Lugano felt adamant about it so I respond to these questions with pleasure. I thank the team for the positive and intense cooperation we had over the last years! I am proud of leading the Journal from Number 11 to Number 4 among all international dermatology journals with an impact factor of now 9.2. We receive feedback from people, old and young that they appreciate our Journal. This gives me a satisfaction. I must say it was also a major achievement for us to publish most of the European guidelines in the past years. Attracting and convincing the guideline development groups has not always been easy. Another big achievement is that we now handle about 4500 new submissions every year quite silently and efficiently without major catastrophes. There were challenges, especially with scientific misconduct. This seems to increase in various ways from faking data (‘forging’), correcting statistics (‘trimming’) or inventing totally new data (‘cooking’), besides ordinary plagiarism. I remember the case of a picture of a foot with a skin-coloured papule on the malleolus treated by photodynamic therapy. It achieved complete healing after 6 weeks. Looking closer at the before and after pictures I realized that this foot was lying on a beautiful Arabian carpet decorated with dark blue and golden ornaments and the foot was placed exactly in the same position after 6 weeks of treatment as was in the original picture. I concluded that this image must have been manipulated with Photoshop and rejected the paper. When I told the story at the council of dermatology editors organized by Larry Parish at the AAD, several other people shouted, ‘I have seen this foot too!’. This was a rather funny episode, but there can be serious events. There is always a danger of someone abusing the reviewer's or editor's power, like in the case when we had rejected a manuscript in accordance with a quite critical review. However, I received an outraged phone call from the author telling me that this was unacceptable and unfair because now the same story had just been published in another journal. It turned out that the reviewer was a co-author of the paper published in the other journal. The reviewer should have declined to review the paper due to a conflict of interest. In these cases, one uses the standard operating procedures stipulated by the ‘Committee on Publication Ethics’ (COPE) involving external statisticians and ethics experts; this could easily take a year and meanwhile, most of the stories are forgotten and the papers are published somewhere else, but it is embarrassing and time-consuming. Also predatory journals continue to increase their presence and make money from the ambition of young researchers who are ready to pay a hefty sum to get their papers published without even checking the credibility of the journal or the names of persons on the editorial board. Among the list of catastrophes for my Journal, the most unpleasant event would be that we are forced to retract a paper because of scientific misconduct. I would rather take the risk of rejecting a paper which later might go on to win the Nobel prize; such things have happened before. Contrary to climate change in the Alps with decreasing glaciers and water coming from the mountains, in science there seems to be an increasing stream of publishable material reaching the dimensions of a flood—we are literally flooded with manuscripts. This has led to the development of many new journals and all of them seem to do quite well. I am also proud that I could convince the EADV executive committee and board of directors to launch a new sister journal JEADV Clinical Practice. The new journal is running very well under the leadership of my friend Dr. Antonio Torrelo. Hopefully, it will receive an impact factor soon. When a paper is rejected from JEADV, we can now offer a referral to our sister journal JEACP where the paper can go through an expedited review process. Another fairly recent phenomenon is the growing number of manuscripts originating from Asia especially China—many of them of quite high quality. There are a lot of very interesting articles and it is difficult to name an absolute highlight or citation classic, except for some guidelines and review articles on acne (Brigitte Dreno) or hidradenitis suppurativa (Christos Zouboulis). Also, the new pathogenic classification of inflammatory skin diseases introduced by Eyerich and Eyerich might develop into a follow up of the well known Types I–IV from Coombs and Gell. Another remarkable work was Jean Hilaire Saurat's papers on ‘Dermatoporosis’, replacing the name of ‘skin ageing’. Unfortunately, we are yet to receive the first original articles of new drug clinical trials. They typically go to the New England Journal of Medicine, the Lancet or to our American friends. We are happy when we get a second or third part of the data on new substances for clinical use. I have several: once, when we still had glass photo slides for projection, we dermatologists often needed to use double projectors because we always have so many slides to show. I went up to the podium with two trays containing 50 slides each, slipped on the steps and the slides fell all over in chaos. It took me half an hour to put them back in order because I had been too lazy to label them with numbers. On another occasion, the connection between the laptop and the projector was lost. The hall was crowded with around 500 people and I was the only plenary speaker at the very special event; there were several ministers from the government and a bishop in the first row. The organizers were desperate but could not fix it. So, I decided to give the lecture without slides. Despite some stress, it did not go so badly. The funny thing was that after the lecture people came up to me saying that this probably was the best lecture they ever heard from me. This makes you reflect on what you are doing wrong every day. Another story: Professor Walter Brendel believed in xenotransplantation as a means to overcome the donor problem. He tried to find a species fitting best to homo sapiens and cross-tested the entire Hellabrunn Zoo in Munich. When an old lion came to death, the veterinarian asked whether we would be interested in a transplant. So the lion was transported into the institute which was in the cellar of the surgery department. The only entrance to this cellar led through a crowded waiting room for the outpatients and to the elevator down to the basement. Two strong men were carrying the lion on a stretcher with some green sheets barely covering him and clearly recognizable as a lion. The kidneys were transplanted to two big shepherd dogs but they were hyperacutely rejected—who would have thought of that? At least Professor Brendel could show a slide labelled with ‘Renal transplant: lion to dog, n = 2’. This led to some uproar in the audience. As a researcher, I regret that we did not manage in Munich to build a large Munich Allergy Research Center even though there had been fantastic opportunities. I also regret that dermatology congresses tend to be less and less exciting due to their sheer size allowing only about 12 cities to be the hosts in Europe. This excludes many other countries that do not have the same capacities. It is so important to have a local character at such an event and a local organizer taking the lead and bringing in specific colours not only to the social events but also to some parts of the scientific program. Fortunately, our spring symposia still have some local character. One of my favorite singers Edith Piaf sang ‘Non, je ne regrette rien’. It may sound a little arrogant but I try to follow this line in my professional life. In Bavaria we have the saying ‘Live and let live’ (‘leben und leben lassen’). Together with the sentence ‘The power is in calmness’ (‘in der Ruhe liegt die Kraft’), this attitude helps me to survive when life becomes hectic. Homer, Dante, Dostoevsky. I also like historical novels by Ken Follett; more and more I enjoy listening to audiobooks while driving over longer distances. My favourite composers are Johann Sebastian Bach and Ludwig van Beethoven, but I also like quiet Bavarian folk music with cimbalon in an alpine cottage. Among artists, I love Monet and Chagall. I am so lucky that my profession always was so exciting that I did not really need a ‘hobby’. One of my interests is to history, as I have a doctorate degree in Bavarian History. And I like the difficult field of ‘Humour in medicine’ because you never can make fun of the patients' suffering but you can make fun of the shortcomings of patients, doctors and researchers. Molière is my role model. I wrote several poems and musicals on the problems of allergy transposing them into the scenery of famous stories like ‘Doctor Faust and Allergy’, ‘King Ludwig's Death and Allergy’, the ‘Odyssey of Allergy’, ‘Parzival and the Grail of Allergy’ and finally Dante's ‘The Comedy of Allergy’. I did not make the music as I am not a composer but I wrote the story and the poems and we produced it with lay people from our department (doctors, nurses, secretaries, technicians and students) and brought it to the stage at international congresses, like the ‘Odyssey of Allergy’ at the 2001 EADV Congress in Munich with 1500 people packed in Löwenbräukeller. It was hard work to put this musical together, but it was also immense fun and had a significant effect on the team building with all my co-workers. Most of all it was great fun! The future will be bright for our Journal—our golden child is growing strong and is now entering early adulthood. Of course, it needs a lot of care and the editor should always keep in mind that the final aim of making a journal is not to get a good impact factor, but to make a good journal that people want to read and learn something from it for their professional life. I would hope that in the future we can have shorter guidelines or maybe just print an executive summary of the guidelines and have the rest published as supplementary material online. I also hope that the Journal remains beautiful and aesthetically pleasing—after all, our specialty is a visual one and we need great pictures. *Note: The Pioneers in Dermatology and Venereology interview series was conceived by Johannes Ring and this interview was conducted by Asao Sarukawa. Open Access funding enabled and organized by Projekt DEAL.