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Autumn 2015, Vol. 23 No. 3

Hong Kong J. Dermatol. Venereol. (2015) 23, 103-104


Editorial

Recalling dermatology

Stephen Lee 李啟焱

What's in a name? To some extent, it depends on the context and purpose of the naming process. In the commercial world, naming rights are all important. Advertising gurus spend tremendous resources on branding. Similarly, in political messaging themes, colours and music go a long way to package the pitch. Another enduring example of the power of persuasion is journalism.

In medicine, accurate and meaningful nomenclature is vital and it needs to be revisited periodically by clinicians and researchers, even if at times the exercise is on an intellectual level only. Moreover, with new knowledge gained through research, medical rethinking is a healthy evolution which should be supported. This said, on a pragmatic level, misleading or inappropriate nomenclature can result in serious health outcomes!

"Hutchinson's melanotic freckle" (HMF) is a classic example of inappropriate naming in dermatology and cancer medicine. HMF is not a freckle as such and this nomenclature anomaly should be discontinued. Bona fide freckles are benign skin lesions which are of cosmetic significance only. By contrast, lentigo maligna and lentigo maligna melanoma must be taken seriously by both doctors and patients. Furthermore, if a patient is informed that his or her pigmented lesion is a "melanotic freckle" the patient may not proceed to proper and adequate management. Worse still, for vanity reasons, the patient may simply resort to lasering without any histological evidence. The above should ring medico-legal alarm bells clearly and unapologetically.

"Atypical fibroxanthoma" (AF) could also be considered for a name change. Like HMF, an AF usually develops in sun exposed areas of older fair skinned people. Whether AF is a true cutaneous malignancy is a question still awaiting a definitive answer. That aside, even if we chose to abide by convention, it would be awkward and clumsy to describe a lesion of this type presenting with unusual clinical features: an atypical atypical fibroxanthoma? Perhaps not. An alternative name for this dermatological wonder could be a "reactive fibroxanthoma", which after all has arisen as a result of chronic sun and immunological damage to the skin.

"Pseudo" and "Para" are often encountered prefixes in dermatology. Pseudolymphoma and parapsoriasis are examples that come to mind readily. To be sure, a number of authors have tried to make sense of this bag of names in a learned and scholarly manner. For the sake of our concerned and confused patients, we should try to reach a meaningful consensus. The sun could then set peacefully and reflectively with the knowledge that future scholars of dermatology will treasure the efforts of their forebears. The unthinkable consequence of indulging in an era of inaction is that our beloved profession could degenerate into pseudo and para dermatology.

Border control has emerged to be a hot geopolitical topic internationally. In surgical dermatology and dermatopathology much attention has been paid to margins. In the wider context of dermatology, surgical oncology and procedural general practice obtaining clear margins is an all important margin call. Accepting that achieving clear margins in the removal of a skin cancer should be an intended goal, we should nonetheless be prudent in our interpretation of a histopathological report which concludes with "excision is complete." This is not just a pedantic issue. There is a critical difference between clear margins and complete removal. If a patient is informed that the skin tumour has been completely removed he or she may understandably decide to cancel follow-up appointments. Adequate management of lentigo maligna and lentigo maligna melanoma, which are probably best considered field defects, illustrates this aptly.

To err is human, and clinicians and pathologists are not immune. Even the proudest doctor may recognise that medicine is a humbling vocation and there is room for improvement for all of us.

Stephen Lee
李啟焱