A Clinical Atlas of 101 Common Skin Diseases with Histopathologic Correlation

The Second Edition features more than 3,000 color photographs, 200 photomicrographs, and newly revised text. The emphasis of this atlas is clinical diagnosis; importance also is given to relevant laboratory tests, unifying concepts, and therapeutic considerations.

What prompted the undertaking of this pocket atlas of dermatology? The reasons were several and varied, among them the following:

1. Pictures are and always have been an extraordinarily valuable vehicle in the study of clinical dermatology. The first textbook of modern dermatology by Robert Willan, titled Description and Treatment of Cutaneous Diseases and published more than 200 years ago in 1798, was the first to use pictures for purposes of teaching clinical attributes of skin diseases. That Willan understood well the importance of illustrations to the achievement of his purpose is apparent in his words: "In order to convey distinct ideas on the subject, I shall elucidate every genus by coloured engravings representing some of its most striking varieties. This method is new, and will be attended with many advantages.... " In his book, Willan was the first to classify skin diseases systematically, according to different appearances of their individual lesions—such as macules, papules, and pustules—a method that has remained the basis of diagnosis in dermatology to this day. The success of Willan's book, however, was largely attributable to the drawings housed in it.

Willan's use of pictures had an impact on all subsequent texts devoted to clinical dermatology. Hardly any textbook of skin diseases published in the ensuing 200 years was devoid of illustrations. Furthermore, the publication of pictures by Willan gave impetus, beginning in the middle third of the 19th century, to enthusiasm for publication of atlases that sought to portray skin diseases of all kinds as realistically and as beautifully as possible. This objective was achieved remarkably well by startlingly magnificent paintings in volumes like those of Jean-Louis Alibert, Erasmus Wilson, Ferdinand von Hebra, Salomon Ehrmann, Robert Taylor, Prince Morrow, and Radcliffe Crocker, and the riveting lifelike moulages shown in volumes like the ones by Eduard Jacobi and by Leopold Arzt and Karl Zieler. In the 20th century, photographs became the mode of recording diseases morphologically in atlases of dermatology. Some of those atlases, especially the one by Pierre de Graciansky and Stephane Boulle published in 1955, contained photographs of superb quality.

In general, however, the quality of photographs of skin diseases in atlases published in the last third of the 20th century has declined; they have failed to capture the character of skin lesions in a manner comparable to the paintings and moulages of the 19th century. Not only is that statement true of photographs printed in black and white, but also of those in the more recent past that have been exhibited in color. The atlases of the 19th century were art books that enabled students of skin diseases to appreciate lesions in their many hues and surface characteristics, as well as to learn something about the impact of those lesions on the human beings who bore them; the artists rendered facies in a remarkably poignant way that told of the anguish of metastatic carcinoma and conveyed the madness of factitious dermatitis. In this volume we have set out to produce an atlas of dermatology that is a work of art as well as a work of substance.

2. Nearly all contemporary atlases devoted to dermatology have portrayed particular skin diseases in but very few images, often only a single photograph or two or three at most per subject. As Willan acknowledged in the preface to his book, pictures of diseases cannot "extend to every minute circumstance in the course of a disease, being necessarily taken at some fixed period of it." We have sought deliberately to capture as many facets as possible of every disease under consideration here, and to do so by showing as many photographs as we deemed necessary to accomplish that purpose; in one case, no fewer than 88 are requisite for a single disease. We have chosen only images of impeccable quality and of incomparable teaching value; for every one photograph selected, scores were rejected. In short, we have tried diligently to teach clinical dermatology superbly through the pictures printed in the pages that follow.

3. Virtually every atlas of dermatology has depicted lesions in the skin of Caucasians only. We have determined to produce an atlas with universal application, mandating thereby the showing of lesions in the skin of Africans, Asians, and Native Americans, as well as of Caucasians. And that is why the dermatologists who were responsible for selecting photographs for this atlas were recruited from all corners of the world.

4. The teaching of clinical dermatology has declined dramatically in recent years, as dermatology as a specialty has become increasingly a province of surgery and cosmetology and, concurrently, less and less a sovereign state of internal medicine. Coincident with that decline have been the effects on medicine in the United States of managed care, one of the results of which has been that more and more patients with skin diseases are being seen by generalists, and fewer and fewer are being managed by dermatologists. But those physicians in addition to generalists who are actually caring for most patients with skin diseases—for example, pediatricians, gynecologists, and internists—are receiving less and less training in the diagnosis of skin diseases, and the instruction they are being given is of declining worth. We have sought in this atlas to compensate for the deterioration in the teaching of clinical dermatology by producing a volume that would be inordinately educational to those interested seriously in learning about common diseases of the skin, from medical students to residents in dermatology, from generalists to internists, from nurses to physician assistants. We hope that general pathologists and even seasoned dermatologists will profit from this work.

5. All too many atlases of dermatology are not really atlases; they are texts to which a few pictures have been added. We have been committed to preparing instead an authentic atlas in which the pictures do the teaching, and the text, including the legends to photographs, serves to complement them. If any picture in this atlas fails to convey compellingly an important aspect of a disease, we will have fallen short of our purpose.

6. Atlases of dermatology extant do not, for the most part, strive to teach a method for diagnosis and, concurrently, a comprehension of skin diseases. We have endeavored to accomplish both ends by constructing each of the 101 chapters in a methodical way. Each chapter begins with a terse definition of the disease itself, followed by a photograph that portrays typical clinical features of a particular disease. Accompanying it are photomicrographs shot at low and high magnification that capture stereotypical histopathologic findings of the disease and serve as a vehicle to accomplish correlation with the gross findings. Thereafter, in sequence, is a schema just like the one a clinician should employ in examining an actual patient with a skin disease—namely, distribution of lesions, arrangement of lesions, configuration of lesions, and attributes of individual lesions. The sum of those findings, in algorithmic fashion, should lead an examiner to a specific, accurate diagnosis.

Comprehension of each disease is heightened, where appropriate, by showing, pictorially, the life of the lesions that constitute that disease, and the life of the disease in chronological sequence. Unconventional variations in clinical appearance also are shown. A statement about course is followed by a comment that seeks to integrate the morphologic findings, clinically and histopathologically, with the biologic course. Last, a few lines are devoted to practical, effective therapy, the rationale for which is predicated on a grasp of morphologic and biologic aspects of a particular disease.

7. Many texts and atlases of dermatology represent a mere reshuffling of "knowledge"; the information is presented in a less than comprehensible way. Authors tend to copy from one another and to perpetuate clichés. Original ideas are in short supply. A critical perspective based on actual "hands on" experience with patients is missing all too often from those volumes.

We have sought to bring to bear on these pages our own considerable experience with patients and to convey it to those who use this atlas. We have done our best to accomplish that desideratum in a distinctive and instructive way. For example, we have scrupulously avoided the use of trite expressions that abound in dermatology, like "silvery scales" for psoriasis, "footprints in the snow" for lichen planopilaris of the scalp, and "salmon color" for pityriasis rosea. Those banalities are not helpful to an inquisitive, thoughtful student of diseases of the skin. For the most part, we make no reference in legends to photographs to the "stereotypical" color of lesions of diseases because those hues, too, are clichés, being applicable only to skin of lightly pigmented Caucasians; for just one example, pityriasis rosea in darkly pigmented Africans is not salmon colored!

We have also tried diligently to eschew incorrect concepts and to refrain from perpetuating them, such as the myth that three types of acanthosis nigricans exist—benign, pseudo-, and malignant; the typing of melanoma as lentigo maligna, superficial spreading, acral lentiginous, and nodular; and the idea of small-plaque parapsoriasis and large-plaque parapsoriasis as being something other than patches of mycosis fungoides. By avoiding clich�s and erroneous concepts, and by striving to integrate the often many and varied morphologic expressions of a single disease, we have made a conscientious effort to elucidate subjects without oversimplifying them.

8. Ever since individual lesions of the skin were defined and given names, first by the Viennese physician Joseph Jakob Plenck, and then by London dermatologist Robert Willan, dermatologic terminology has suffered from inconsistencies that have hampered communication and, inevitably, have compromised teaching of the subject. Willan, for example, distinguished three major types of papules without making clear their morphologic differences. In textbooks of the last 30 years, the definition of papules has varied considerably; they are defined as solid elevations smaller than 0.5 cm in diameter in the textbook by Braun-Falco et al., as solid elevations smaller than 1.0 cm in diameter in the textbook of Fitzpatrick et al., and as the size of a lentil in the textbook by Korting, notwithstanding the fact that the size of lentils varies greatly. In order to avoid such inconsistencies and to employ a language that is crisp and precise, we have set forth prior to the presentation of individual diseases our definition of individual skin lesions, which are the most important words and phrases we use in this atlas.

9. Simplification of subjects was also meant to be enhanced by our decision to craft succinct legends to photographs. Toward that end, for example, we have made no mention of a particular anatomic site, e.g., the penis, if a glance at a picture makes obvious the site. An exception occurs when the anatomic site is crucial to clinical diagnosis, such as in photodermatitis. In such circumstances, particularly in the section of each chapter given to distribution of lesions, site is mentioned for the purpose of emphasis.

We have also made brief the definition of each of the 101 diseases that constitute the chapters of this volume. It encompasses only those attributes essential to the accurate characterization of each of them. Of course succinctness carries with it the risk of incompleteness, but our goal was not to write a textbook. It was to cut a pictorial swath so wide through common skin diseases that a novice could gain an understanding of those diseases, and an experienced practitioner could conceive of all diseases already well known to him or her in a fresh, novel, and more profound way.

10. Although this atlas emphasizes the clinical aspects of common skin diseases, we have attempted to correlate clinical and histopathologic features and to explain the findings by gross pathology—i.e., the clinical attributes—on the basis of the findings by conventional microscopy. That effort at correlation is exemplified not only at the outset of each chapter, where the clinical picture is joined by photomicrographs, but also near the end of each chapter in the section titled "Integration: Unifying Concept." Our major purpose in that section is to convey the gross pathologic aspects of skin disease in vivo—what clinicians encounter in their daily practice of medicine. Exposure to gross pathology is what practitioners need, not dizzying references to "reticular alteration of the epidermis," "flame figures," and "Miescher's radial granulomas." Nonetheless, histopathologists, e.g., general pathologists, can profit greatly from this atlas because the surfeit of pictures it contains should enable them to begin to achieve what for many of them has been beyond attainment, to wit, clinicopathologic correlation of diseases they usually meet at their microscopes as sections of tissue from punched-out, shaved-off, and curetted specimens. It merits mention that each of the contributors to this atlas is a dermatologist as well as a dermatopathologist.

The organization of the diseases in this atlas is alphabetical (just as it was almost 100 years ago in a textbook titled La Pratique Dermatologique by the French dermatologists, Besnier, Brocq, and Jacquet). All other attempts to classify skin diseases clinically, e.g., "eczematous dermatitis," "disorders of cell kinetics," "benign neoplasms and hyperplasias," and "precancerous lesions and cutaneous carcinomas," have failed because they lack logic and, therefore, consistency.

The names given to the diseases in this work are the ones most dermatologists use. For example, we refer to Darier's disease rather than "keratosis follicularis," Grover's disease instead of "transient acantholytic dermatosis," and Mucha-Habermann disease in lieu of "pityriasis lichenoides et varioliformis acuta" and "pityriasis lichenoides chronica." Some diseases of particular importance, such as melanocytic nevi, melanoma, and mycosis fungoides, have been given more attention than diseases that are also important but less dangerous, such as sebaceous gland hyperplasia, seborrheic dermatitis, and seborrheic keratosis. Parenthetically, the diagnosis of all neoplasms shown, including every melanoma, was verified by histopathologic examination of tissue from a biopsy specimen.

Because we have sought to limit the number of subjects in the atlas to the 101 most common ones, we have had to deviate from our original intention of including in the table of contents discrete specific conditions only, e.g., acne vulgaris, allergic contact dermatitis, and allergic vasculitis. Some subjects incorporated in the contents are more inclusive, to wit, alopecias, cysts and cystic hamartomas, drug eruptions, sclerodermas, viral exanthems, amyloidosis, atypical mycobacterial infections, deep fungal infections, epidermal nevi, connective tissue nevi, epidermolysis bullosa, fibromas, ichthyoses, lymphomas, and porokeratosis. Had we not adopted this system for organization, individual types of alopecia, cysts and cystic hamartomas, and drug eruptions alone would have made up nearly all of the 101 subjects of the book.

In actuality, however, many more than 101 diseases are incorporated in this work. As will become apparent on perusal of the atlas itself, and even the table of contents, more than one disease is covered in various chapters. For example, linear IgA dermatitis is discussed along with dermatitis herpetiformis, herpes gestationis with bullous pemphigoid, and phototoxic dermatitis with photoallergic dermatitis. Furthermore, all kinds of benign proliferations of melanocytes, including so-called blue nevi, are incorporated in the chapter about melanocytic nevi and melanotic macules, all kinds of ichthyoses in the chapter devoted to that subject, and all kinds of sclerodermas in the chapter concerning those conditions, to mention but three examples of the breadth of sweep. Last, wherever a skin lesion—be it a cherry hemangioma, a Miescher's nevus, or a seborrheic keratosis—is encountered as an incidental finding in a photograph, we call it to the reader's attention in the photograph's legend.

Some decisions about classification were arbitrary. For example, we chose to place varicella in a chapter with herpes simplex and zoster, rather than with the other viral exanthems, some of which also are vesicular, e.g., hand, foot, and mouth disease caused by Coxsackie A 5, 10, and 16.

The team that put this atlas together was made up of close colleagues who also are friends. The co-captains were Bernie Ackerman (USA), Helmut Kerl (Austria), and Jorge Sánchez (Puerto Rico). The invaluable players were Ying Guo (Peoples Republic of China/USA), Angelika Hofer (Austria), a resident in the department of dermatology at the University of Graz, who was responsible for managing the team and organizing the material itself—a task that for more than five years she carried out splendidly and with good humor, Paul Kelly (USA), Tetsu Kimura (Japan), Giovanni Borroni (Italy), Charles Crutchfield (USA), Volker Steinkraus (Germany), and Wolfgang Weyers (Germany).

We earnestly hope that those who use our atlas will derive as much benefit and pleasure from it as we have had preparing it!

A. Bernard Ackerman, M.D.
Ackerman Academy of Dermatopathology
New York City
January, 2000