A lot can happen in a year.

In July 2019, Dr Caitríona Ryan and her business partner Dr Nikki Ralph opened the Institute of Dermatologists in the heart of Ballsbridge, the first centre of its kind in the country. Two weeks later, Ryan gave birth to her first born, a baby boy. One year on, the brand has become synonymous with excellence in dermatology and Ryan is due to give birth to her second child. And let’s not forget about the global pandemic that threw the world into flux and forced the Institute to close for three months.

“We’ll be down by at least 25 per cent, but we’re growing if anything. You have to factor in how much more we would have grown in that quarter to have had the domino effect and recruit more patients. The negative impact hasn’t been anything like what it could have been and that’s thanks to our reputation. If we had opened closer to when Covid-19 hit, we wouldn’t have built that and we’d probably be in dire straits right now. 

“Being closed has had an impact on our financials, but business has pretty much bounced back to what it was before, and that happened straight away. I think that’s down to our catchment – most still have their jobs, but they haven’t been able to go on holidays. I know we’re in a recession, but I think people want to treat themselves and spend that money they haven’t spent. We thought that things would be very quiet after we reopened and they’re not.”

Cosmetic and medical dermatology under one roof

Although Ryan and Ralph decided to go into business together only seven months prior to opening, the doctors had a clear vision to bring a world-class dermatology centre to Dublin – combining cosmetic and medical dermatology under one roof, where patients can see the required specialist without further referrals and prolonged waiting times. 

The pair first met in college over 15 years ago and when their building came up for lease unexpectedly, they knew the timing was right to forge ahead with their business idea. “Nikki is the ideal partner. She’s one of the hardest working people I know. We’ve never had an argument. We complement each other very well. I can’t imagine doing it with anyone else.” 

Ryan studied in UCD, specialising in dermatology, and trained in St Vincent’s University Hospital. From there, she went to Dallas, Texas to focus on psoriasis research, but decided to stay and practice. That meant retraining from scratch under the US system and alongside some of the best medical and cosmetic dermatologists in the world for seven years. The result was a comprehensive education and insight into a different healthcare model that would later provide the inspiration for the Institute of Dermatologists. 

“There was a huge gap for private dermatology in Ireland so I modelled the Institute on where I practised in Dallas, which was one of the best dermatology centres in the US.” 

The Institute now has seven dermatologists working together each with sub-speciality interests: psoriasis, skin cancer, cosmetic dermatology and two plastic surgeons, as well as a Mohs surgeon, a very precise type of skin cancer doctor. “It’s always best for a patient to have everything on site because they’re seen by the right person on time. Wait lists are a big issue in medical dermatology in Ireland and this approach optimises patient care. 

“Normally, everyone who works in private dermatology works independently here. As a professional, you grow much more when there’s a collaboration between colleagues. We have a difficult case meeting every month where patients who are either diagnostically challenging  or therapeutically challenging (not responding to treatment) can come in and be seen by all the consultants, so they get seven opinions. We all continue to learn from each other. If you work in isolation for too long, it’s not good for you, or your patients either. It works so efficiently. The consultants are all excellent, but the dynamic and collegiality is fantastic. We share information all the time, not about the specifics of a patient, but we say we learn more from each other than we ever could from our journals.”

The Institute’s interiors are bordering on futuristic, but nothing could be more comforting for a dermatology patient craving the latest treatments. In fact, the architecture and fit out, which cost close to €1.5 million, appear to be a contributing factor in the speedy return of clients post-lockdown. “The architects set it up so that there was a unidirectional flow. We couldn’t have Covid-proofed it better. We employed Henry J Lyons, and while it was expensive, it turns out it was worth its weight in gold. The design was all about efficiency of flow and that also meant we can keep everyone socially distant.”

The stress of the pandemic has proved good for business too, as the impact is playing out on our pores. “I treat a lot of inflammatory dermatology (psoriasis, dermatitis, rosacea, eczema, acne and hives, dermatitis graphism) and see them flaring in people who have been stable for a long time. People are now working from home, and things have dramatically changed in their lives, it shows on their body. People don’t realise the impact it’s had on their stress levels. It’s being shown in a physical way. I’m seeing it in every type of skin condition that can have stress exacerbations, even from people who don’t think they’re stressed. It has definitely impacted more than people realise.”

“When it comes to directorships and tech companies, men need to look young to stay in the game.”

Dr Caitríona Ryan

Irish cosmetic dermatology has largely been female-focused in recent years, but Ryan has witnessed a recent shift. “I’ve seen a huge increase in the numbers of men coming to me for Botox, Intense Pulsed Light (IPL) and body sculpting. I’d say a large proportion of our IPL is on men. We underestimate the amount of pressure that’s put on men to stay looking young. When it comes to directorships and tech companies, etc, men need to look young to stay in the game. They want to be frozen in their 50s for certain jobs like directorships or stockbrokers. There’s immense pressure when it comes to business. I have a lot of men coming for subtle Botox and IPL is huge for that red, ruddy face or flushing or blushing in the middle of a presentation, customer face-to-face or company presentations. Women can wear make-up, men can’t. They’ve no way of disguising it. The red broken vein look has connotations with drinking too, so lots of men are going for IPL to get rid of it. Then they go for Z Lipo to shift beer bellies. You see that in guys who are working out a lot but can’t shift resistant belly fat.”

While injectables like Botox, fillers and Sculptra (invented to counteract the stigmatising sunken cheeks of HIV patients in the 1990s) are becoming more popular in the cosmetic end of things, Ryan believes treatment for skin cancer in both the public and privates sectors will prove the greatest challenge to the dermatology industry in Ireland. 

“The frequency of skin cancer and melanoma is growing exponentially. The predicted values for 10 years from now are huge. That’s our biggest hurdle ahead – how we can cope with the burden of skin cancer, and I think that needs to be done in a much more systematic way. But the public system in particular is under huge pressure and Covid has really impacted that because of the set up with clinics. So waiting lists are only going to grow.” 

These developments are behind the latest hire in the Institute. Specialising in the removal of skin cancer mainly from the head and neck, a Mohs surgeon offers a very precise type of surgery. “If you had a basal cell or squamous cell on your nose, not a melanoma, usually the standard is you get the cancer taken out with four millimetres of healthy skin all the way around that. Imagine that coming off your nose. With Mohs surgery they take the smallest amount of skin and 100 per cent of the perimeter, usually only 10 per cent gets it, but it’s examined and just the positive areas are removed and you end up with tiniest possible scar and 100 per cent cure rate – compared to 90-95 per cent of cure rate with 4mm because that doesn’t examine the perimeter until it’s sent off to the pathologist down the road for examination. 

“So it’s the only way I’d want any cancer taken off my face. It’s the standard of care in the States and UK and there are only four Mohs surgeons in the country, three in Dublin and one in Cork, but the waiting lists are huge. There’s no way you’re going to sit there for a year waiting to be seen with something growing in your nose. Even the psychological impact of that is huge. So that’s something that needs to change and we’re hoping to change it.”

“I think universal healthcare is such an idealistic goal, but already our country can’t provide an efficient health service dealing with the public as is.”

Dr Caitríona Ryan

In terms of Sláintecare, Ryan isn’t convinced, but remains hopeful. “I think universal healthcare is such an idealistic goal, but already our country can’t provide an efficient health service dealing with the public as is. Fifty per cent of our country has private health insurance. If you add that burden to what is already a capsizing system with the enormous waiting list it already has, it’s going to implode completely. 

“In Germany they have universal healthcare, but a private system going alongside it that works in a very cooperative way with it. I think that may be the model to follow. German healthcare is second to none. But again, it’s the bureaucracy that leads to the hurdles and roadblocks along the way. It’ll be a long time coming if it ever comes. I really do think our new minister, Stephen Donnelly, has great vision in lots of ways. Susan Mitchell is his advisor and she’s phenomenal in terms of how she does her research and the insight she has into the healthcare system, so I’m really hoping they can implement change for the better – but they’ll make an excellent team.”