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Cracking autoimmunity’s toughest cases
David Fiorentino’s pursuit of hidden patterns in autoimmune disease is transforming patient care—and may lead to new strategies for cancer prevention. (A little help from his old Stanford pals didn’t hurt.)
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David Fiorentino. Photo: Jess Alvarenga
During his residency, colleagues joked that Stanford dermatologist David Fiorentino carried a personal rain cloud. Whenever he was on call, the hardest cases arrived. Paul Khavari—now chair of Stanford’s Department of Dermatology—was also a resident then. “It wasn’t bad luck. It was because Dave was the best doctor there,” he says.
Fiorentino has spent nearly his entire academic life at Stanford—earning his BA, MD, and PhD, completing his residency, and now serving as a professor of dermatology. From the start, he was drawn to cases where the symptoms didn’t line up and no one knew what to do next. He chose dermatology, he says, because he wanted to “look at people,” not just their test results. Skin, he realized, was a surface covered in clues—a living record of what was happening inside the body.
Within dermatology, Fiorentino gravitated to its most perplexing puzzles: autoimmune diseases, in which the immune system turns on the body.
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David Fiorentino delivering a lecture at Stanford in April 2025, on the promise of cell therapy.
Early in his career, he saw how curiosity and persistence could turn scattered data points into discoveries that change a field. In his first job after college, he was first author of the landmark papers describing interleukin-10, a master regulator protein that transformed scientists’ understanding of the immune system. He was hooked.
“I’m drawn to complicated things that require a bit of intuition and a lot of pattern recognition,” Fiorentino says. A rash on a fingertip, a recurring antibody, even a question patients ask at diagnosis—all could be clues or red herrings.
One question comes up again and again: Am I going to get cancer? For patients with dermatomyositis—an autoimmune disease in which Fiorentino is a leading specialist—the risk is real: Roughly 15 percent will develop malignancy, but predicting who is at risk has long been one of the field’s most elusive problems.
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“I’m drawn to complicated things that require a bit of intuition and a lot of pattern recognition.”David Fiorentino
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David Fiorentino. Photo: Jess Alvarenga
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The case of dermatomyositis and cancer
Dermatomyositis turns the immune system against a person’s own muscles and skin, causing rashes, muscle weakness and pain, fatigue, and even problems breathing or swallowing. So were patients who simultaneously developed dermatomyositis and cancer horribly unlucky, or, as some researchers speculated, was the autoimmune disease causing malignancy? Fiorentino began to see it differently.
Each person’s antibodies form a kind of diary—trillions of molecular entries that record every major immune response. Working with Antony Rosen and Livia Casciola-Rosen of Johns Hopkins University, Fiorentino compared the antibodies of dermatomyositis patients and found a striking pattern: Patients without cancer often had a rich, diverse set of antibodies, as if their immune systems had already fought off a tumor before it could grow. Patients with cancer showed far fewer—a narrower, less effective defense.
Fiorentino hypothesized that fledgling cancer cells may actually trigger dermatomyositis, with two potential outcomes: The immune system eliminates cancer, leaving the patient with only dermatomyositis. Or the cancer persists, leaving the patient with both conditions.
The antibody pattern Fiorentino identified can help doctors pinpoint dermatomyositis patients at highest risk, enabling closer monitoring and earlier intervention. This new insight reframed dermatomyositis as more than a devastating autoimmune disease. “Dermatomyositis,” Fiorentino says, “offers a model for studying cancer at its earliest stages.”
Opportunities to study the immune system independently defeating cancer are vanishingly rare. The implications are tantalizing. If researchers can isolate and understand the antibodies associated with cancer protection in some dermatomyositis patients, they might one day “bottle” that response—designing therapies or even vaccines to help fight off microscopic cancers before they take hold. What began as an attempt to answer patients’ questions could someday inform new strategies for cancer prevention.
Identifying patterns is particularly challenging in autoimmune disease, where evidence is often scattered across specialists. To bring the whole picture into view, Fiorentino co-founded Stanford’s first multidisciplinary rheumatology–dermatology clinic, putting the skin, joints, and lungs into the same conversation. Here, a patient might sit between Fiorentino as he examines skin abnormalities and rheumatologist Lorinda Chung as she reviews lung tests.
The approach has been so successful that Stanford now has three such clinics focused on different autoimmune conditions. Patients travel from across the country to see physicians who work together to connect the dots.
A little help from his friends
Autoimmune diseases are rare and complex, making cohorts difficult to assemble and trials costly. Fortunately, support for Fiorentino’s work is growing across the Stanford community. In April 2025, Fiorentino delivered a lecture on the promise of cell therapy. The event brought together people from all areas of his life, from family to colleagues to patients. Also in the crowd were four of his Stanford classmates: Rich Boyle, ’88, William “Obi” Greenman, ’88, Rob Hull, ’88, and Fred Wang, ’88, MS ’89.
By the end of Fiorentino’s lecture, a switch had been flipped. “I think Dave is on the cusp of something incredible,” says Greenman, who has worked in the biotechnology industry for 35 years. “It takes decades of patience and often lonely perseverance to really make progress in a field like this. The insights that come from Dave’s sustained focus are exactly what’s needed.”
Greenman decided to make a philanthropic gift to Fiorentino’s lab—but he didn’t stop there.
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A night out during undergraduate years at Stanford. Rob Hull, Greenman, Matt Tingler, Fred Wong, and Fiorentino. Photo: courtesy of Fiorentino
A month later, Stanford launched its first Day of Giving—a campaign to support work across the university, with matching funds available to incentivize giving—and Greenman saw an opportunity. He teamed up with Boyle, Hull, and Wang to launch a quiet email campaign to their Class of 1988 peers, urging them to participate in Stanford Day of Giving in support of their classmate’s research. They deliberately left Fiorentino off the email chain, worried he’d wave them off—“Promoting his work doesn’t come naturally to Dave,” Greenman says. By leveraging the matching funds, their campaign raised more than $336,000 for Fiorentino’s lab in 36 hours. They plan to renew the effort for the next Stanford Day of Giving in May 2026.
“Stanford encourages you to think on a grand scale, because you see what other people are able to accomplish,” Greenman says. “One of the greatest joys of my life would be if Dave—after decades dedicated to research and to people suffering from autoimmune disease—could achieve the breakthrough he wants for his patients.”
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(L) Fiorentino and his roommates on the day of graduation. (R) Fiorentino, Greenman, and Greenman’s brother. Photos: courtesy of Fiorentino
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While his classmates’ support doesn’t erase the challenges facing autoimmune research, it gives Fiorentino’s team room to continue asking bold questions. Today, they’re conducting Stanford’s first clinical trials of CAR T-cell therapy for dermatomyositis and systemic sclerosis patients.
CAR T, which has already revolutionized treatment for some blood cancers, re-engineers a patient’s immune cells to eliminate the B cells driving disease. This approach could act as a reset for aggressive autoimmune disorders—not just suppressing the immune system but reprogramming it for lasting remission.
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(L) Mark Griffith, Rodney Murphy, Fiorentino, and Jack Koll. (R) Fiorentino and two Stanford friends including Rob Hull, a donor. Photo was taken in a small Tuscan village, while Fiorentino studied at Stanford in Florence. Photos: courtesy of Fiorentino
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For Fiorentino, CAR T is the next case to crack: working to reveal why some patients respond while others don’t, then refining the therapy until it is safer and more precise. It’s high-risk, high-reward work that takes time and persistence—and a clinician-scientist willing to chase the subtlest clues.
Khavari is also the Carl J. Herzog Professor in Dermatology in the School of Medicine.
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