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Dermatology Practical & Conceptual

ISSN 2160-9381

January 2012 | Volume 2, No. 1

Weedon D. Weedon’s Skin Pathology. 3rd ed. London: Churchill Livingstone Elsevier, 2010

Review by Mark A. Hurt, M.D. and response by David Weedon, M.D.

Citation: Book review: Weedon D. Weedon’s Skin Pathology. 3rd ed. London: Churchill Livingstone Elsevier, 2010. Dermatol Pract Conc. 2012;2(1):15. http://dx.doi.org/10.5826/dpc.0201a15.

Copyright: ©2012 Hurt. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Corresponding Author: Mark A. Hurt, M.D., 2325 Millpark Dr, Maryland Heights, MO, 63043, USA. Tel. 314.991.4470; Email: MarkHurt@aol.com

The cover

Figure 1. Weedon D. Weedon’s Skin Pathology. 3rd ed. London: Churchill Livingstone Elsevier, 2010. Two volumes with index and separate references. ISBN 978-0-70203941-6; $499 MSRP.

Review by Mark A. Hurt, M.D.

Why should one review Weedon’s third edition of Skin Pathology? After all, it has been available for over a year, and most dermatopathologists, surgical pathologists, and dermatologists interested in dermatopathology have a copy of it or have access to it. How will a review of this book help them?

My tripartite answer is simple. It deserves a review because of its near 20-year history; it deserves a hearing because of its author-and it is primarily the work of a single author; and it is grand in scope as it attempts to cover aspects of every major area of dermatopathology.

Dr. Weedon’s preface is a must read. He tells us explicitly that ” . . . this is likely to be the last edition of this book by the current author . . .” and so it is the end of an era no different in magnitude, if not in intellectual outreach, as the passing of Dr. Ackerman in 2008. Fortunately, Dr. Weedon is still alive at this writing, and he will continue, hopefully, to shower us with his integrations of dermatopathologic knowledge for some time to come.

This is an exhaustive text with 1041 pages in the main text and 881 pages of references. Both volumes together weigh 18½ pounds, so this is not a set for any backpack. It resides in my office on a shelf with easy access to my desk.

The cover is a deep blue with pleasing gray lettering; I would have preferred cloth for durability, but the cover supplied is adequate if one does not move the book around too much. On the inside cover are instructions for access to the website that allows Internet access to the full content of the text and references for those who have purchased it.

This is a colorful book made of very nice, sturdy, non-glare paper. All of the photographs are in color, and there is color-coding of the chapters for relatively easy access. There is repeated use of the colors but with enough separation that it is not confusing to find the needed chapter just by matching the colors.

An added bonus in this addition is the presence of uniform, well-photographed examples of lesions-and lots of them!-which is a big plus. In the case of many of the rare conditions he describes, he provides at least one reference-usually a list of key references-so that the reader can find photographs of the rare examples. Another fantastic resource is the presence of tables highlighting the differential diagnosis, histopathological features, and other items related to clinicopathologic correlation.

There are seven sections. The first two address broad issues in the discipline, such as an approach to and the identification of patterns of inflammatory skin diseases. Sections 3 and 4 address specific diseases of the two compartments of the skin: the epidermis and dermis, respectively. Sections 5 and 6 address the skin in systemic disease and infections and infestations, respectively. Finally, section 7 addresses “tumors,” where Dr. Weedon cuts a swath through malformations, hyperplasias, hamartomas, and neoplasms. Dr. Geoffrey Strutton provides the text for the section on “Cutaneous infiltrates-lymphomatous and leukemic.”

Dermatopathologists spend much of their time identifying criteria that they must integrate to formulate a diagnosis. This applies to any diagnosis. I cannot claim to speak for all dermatopathologists, but my practice is similar to many and consists of a wide spectrum of conditions, principally of melanocytic lesions (approximately 30%), other kinds of hamartomas and neoplasms (another 30-40%), with the remainder being composed of inflammatory diseases of the skin and miscellaneous conditions. Although I can produce a differential diagnosis usually from memory today, it was not always so, and often I need help still. It is thus of great importance to find methods that allow one to have an algorithmic window into the diagnostic process. Dr. Ackerman did this famously with his “pattern” method. Dr. Weedon accomplishes this by providing, in his Chapter 1, “An approach to the interpretation of skin biopsies.”

In this approach, he divides inflammatory conditions into “major tissue reaction patterns” and “minor tissue reaction patterns.” The “major patterns” are lichenoid, psoriasiform, spongiotic, vesiculobullous, granulomatous, and vasculopathic. The “minor patterns” are epidermolytic hyperkeratosis, acantholytic dyskeratosis, cornoid lamellation, papillomatosis, acral angiofibromas, eosinophilic cellulitis with “flame figures,” and transepithelial elimination. Finally, the “patterns of inflammation” are similar, in principle, to those of Ackerman’s “pattern method,” albeit somewhat abbreviated and with slightly different emphasis. They are: superficial perivascular inflammation, superficial and deep dermal inflammation, folliculitis and perifolliculitis, and panniculitis. Sections 3-6 are the expansions of these tissue reaction patterns and patterns of inflammation.

Chapter 2, “Diagnostic clues” provides Dr. Weedon’s pearls of wisdom from his many years of experience as a dermatopathologist. Although many of these clues may not enhance readily the diagnostic ability of the novice, those with a few years of practice will recognize immediately how useful they are. In essence, these “clues” are specific findings that allow one to develop a differential diagnosis or a specific diagnosis in some instances. As a rule, these “clues” open the door of one’s mind, but a diagnosis usually requires three to five criteria (sometimes more), all occurring together in a reproducible and repeatable manner, to establish a diagnosis. One should use this chapter as a boilerplate on which to underline and add one’s own experience to that which Dr. Weedon has started.

In the following sections, concerned primarily with inflammatory diseases, the sections follow the basic outline above, exploding the conditions into their minutest detail, including references. I challenge anyone to provide a text with the kind of detail that Dr. Weedon provides, especially from a single-authored text. In fact, I suspect it is because of a single author that everything in it seems so seamless.

Dr. Weedon’s treatment of “tumors” is comprehensive, and despite my disagreement with how he approaches some of the conditions, notably keratoacanthoma and Clark’s (so-called dysplastic or atypical) nevi, he is better than many writers are in that he provides considerable context on all sides of the issues. I, for instance, have come to regard keratoacanthoma as a form of hyperplasia, which is in sharp contrast with Dr. Ackerman’s view of them as malignant neoplasia (squamous cell carcinoma). I also think, somewhat ironically, that keratoacanthoma (as a form of hyperplasia) is uncommon; most lesions that have a pattern similar to keratoacanthomas are neoplastic: squamous cell carcinomas, as Dr. Ackerman advocated. Dr. Weedon is one of few authors who still regard keratoacanthomas as benign squamous cell proliferations. He does not state its nosological position as hyperplasia or neoplasia, but he does state, “Terms such as ‘squamous cell carcinoma’ and ‘squamous cell carcinoma (keratoacanthomatous type)’ are frequently used. Their use cannot be justified on morphological or biological grounds.” This book review is not a forum to settle such matters, but the readers should be aware of Dr. Weedon’s position not only because it runs counter to commonly held views, at least in the United States, but also because he devotes considerable space to it in the text.

As for Clark’s nevus (lentiginous melanocytic nevus), I have a long-standing objection to the continued usage of the terms “dysplastic” and “atypical” to describe such lesions. This is because they are indeed benign, and even its proponents admit it today, even though the admission is couched in unintelligible terminology, such as “lentiginous hyperplasia” and “random cytologic atypia,” implying that these lesions both are and are not malignant at the same time and in the same respect. The proponents of these terms have never laid a proper foundation for such usage, and I do not think they can or will because those terms are undefined and indefinable, especially as concrete findings in specific lesions. That said, Dr. Weedon gives respect to all viewpoints in his text, which is more than I can say for the proponents of those viewpoints. Again, one cannot resolve this problem in a book review except to point out lines of disagreement.

Dr. Weedon is somewhat refreshing in his treatment of melanoma. It is an objective account of the different viewpoints in the literature, including his. There is considerable effort to report on traditional views of classification as well as challenges to those viewpoints. In a general textbook, this is both important and laudable. AJCC reporting of melanoma has recently included a mitotic index for all melanomas with a dermal component 1mm thick or less. The text does not state this explicitly, likely owing to publication timing.

There is, more or less, a traditional approach to adnexal proliferations. Again, Dr. Weedon provides a well-rounded, objective approach to these lesions, and he acknowledges his disagreement with Dr. Ackerman on the nosologic position of most sebaceous neoplasms commonly thought of as adenomas, but which Dr. Ackerman regarded as carcinomas. This is an important and yet not fully resolved controversy that needs more research to settle definitively, in my opinion. At the very least, Dr. Weedon opens the door on the subject so that readers can walk through to consider the problem for themselves.

Finally, I have found it very useful to access the Internet website for this book at www.expertconsult.com. After plugging in the pass code and assigning a name a password, one can access the full text, photographs, and references. This is a real time saver, considering the size of the book and the ability to search on specific words using the search engine.

Who should own this book? – Everyone who makes dermatopathology his or her profession.

In 1992, with the publication of the very first edition of Dr. Weedon’s book under the banner of the Symmers Series of pathology texts, I was relatively young in the field of dermatopathology, then 36 years old, and I still had a lot to learn. When I now compare that seminal text with Dr. Weedon’s 2010 version of it, really a fourth edition, even though it is labeled as the third, I am astounded at how far he has come in his own education, thus enhancing mine, now a student 55 years old. Dr. Weedon reminds me why I became a physician and that I still have a lot to learn about dermatopathology-as do we all who practice it.

It is the end of an era. I cannot speak for my profession, but I can speak for myself, and I hope others will agree with me. Thank you, Dr. Weedon, for an excellent textbook and for your years-long efforts to produce it.

Mark A. Hurt, M.D.

Response and comments by David Weedon

It is not my usual practice to comment on reviews of my book, but as this will be the last edition that I author, I wanted to make a few comments for the younger generation of dermatopathologists and pathologists, particularly on the approach taken to the classification of diseases and the influences that shaped it. I have been privileged to see many interesting cases during my professional career and I should report my millionth patient early next year.

Pathologists who practised dermatopathology in the 1960s and 1970s were heavily influenced by the writings of Walter Lever and to a lesser extent by Hamilton Montgomery (Mayo Clinic), Hermann Pinkus and Amir Mehregan. Lever’s approach was partly clinical with, for example, the “erythemato-squamous” diseases lumped together. This chapter included such histologically disparate entities as psoriasis and lichen planus. Lever was an excellent book if one knew the diagnosis.

In the late 1970s and early 1980s, the approach changed with Ackerman’s landmark “gold” edition in 1978 and the onset of courses at Grossingers, run by Martin Brownstein, with the assistance of a large faculty. Loren E. Golitz was also a director of the courses. It moved to London in 1985, with Martin Black as the course director, along with Martin Brownstein. Independently, Bernard Ackerman ran his own courses, including the famous Sherlockian-inspired course in London in July 1981. As Brownstein and Ackerman both practised in New York, there was a degree of professional rivalry between the two, although Ackerman was on the faculty of Brownstein’s course at Grossingers in August/September, 1981. Ackerman, as the founder of the International Society of Dermatopathology in 1980, also organised/inspired conferences under its auspices with a very enjoyable conference in Liege, Belgium in August 1984. At the Brownstein course at Grossingers, a week later, I spoke on “eczematous dermatitis” (in defiance of Ackerman’s views that it should be “spongiotic dermatitis”-I subsequently saw the “light”), “psoriasiform dermatitis,” and “lichenoid dermatitis.” I had given similar lectures at the Skin Pathology course run by the Victorian Faculty of the Australasian College of Dermatologists in Melbourne in the late 1970s and early 1980s. Similar themes had been expressed at earlier Brownstein courses before I joined the Faculty. This approach differed from the earlier writings of Lever.

As one of the few dermatopathologists on the faculty of both the Brownstein- and Ackerman-inspired courses, I remember, vividly, feeling a little nervous about being in both “camps” simultaneously, but I survived and enjoyed the camaraderie and intellectual exchanges with such people as Martin Black, Edward Wilson Jones, Loren Golitz, Ronald Barr, Amir Mehregan, Ken Hashimoto, John Maize, Neil Smith, Richard Reed, Robert Freeman, Helmut Kerl, Robert Jones, Rona Mackie, Martin Mihm, Geoff Gottlieb, Clay Cockerell, David Elder, Wallace Clark, Jim Graham, and numerous others. I was influenced by them all, and I refined my approach as a consequence of their lectures and discussions with them. It took five years to write the first edition (in the Symmer’s series).

Finally, since the publication of my book, we have published further papers on the abortive variant of keratoacanthoma and the development of squamous cell carcinoma in keratoacanthoma (probably missed in many superficial shaves). I am convinced, beyond a reasonable standard of doubt, that keratoacanthomas and squamous cell carcinomas are as different as “chalk and cheese.” Readers should await an interesting study in the pipeline that will add further weight in supporting my views (the work is not from me, but I am prevented by confidentiality agreements from saying any more).

David Weedon