Dermatology in the new millennium

Not heeding the words, "the longer you write, the more you confuse the reader", I will lengthen this presentation to include aspects like turning points in dermatology in the twentieth century, recent achievements, dermatology in the millennium, new thoughts and future ideas. While reading this, one is advised to relax and ponder about all other aspects that one would have chosen oneself.

Turning points in Dermatology in the twentieth century

Turning points must mean genuine and true changes, rather than acceleration along the old line. There have been many during the twentieth century, and some of them are listed below.[1]

General socio-political factors:

Welfare:Public health, vaccines, hygiene, clean water, sewerage

WarCommunications

Books, photography, radio, films, television, computers

Transport

General scientific developments:

GeneticsStructure of DNA

InflammationHistamine, prostaglandins, cytokines, adhesion molecules

ImmunologyCell-mediated and humoral immunity

Tissue culturePathogenic agents Spirochaetes, viruses

TherapiesX-rays, antibacterials, immunosuppressives

Controlled clinical trials Strictly dermatological:

BooksJadassohn, Pillsbury, Rothman, Rook

BiologyKeratinocyte, melanocyte, Langerhan′s cell, basement membrane

DiseasesEpidermolysis bullosa, pemphigus, toxic epidermal necrolysis

PeopleFrom Unna to Katz

TherapiesLocal steroids, griseofulvin, phototherapy, retinoids, Moh′s surgery.

Recent achievements

The important discoveries in the final decades of the last century are mainly related to the detection, characterization, and cloning of various genes responsible for both normal tissue homeostasis and balance between cell survival and death. This balance is maintained by apoptosis, i.e. programmed cell death, which differs from necrosis by distinct morphologic and molecular phenomena. This is a receptor-mediated process, not accompanied by inflammation. Much is known about apoptosis inducers, such as Fas ligand (Fas-L) and tumour necrosis factor (TNF), and their receptors. Recently, other apoptotic ligands and receptors have been identified, but their role in apoptosis is still unclear. Studies on the induction or inhibition of apoptosis are usually performed in vitro, and regulation of the events in vitro is still not fully understood. In dermatology, the role of apoptosis appears to be of crucial importance in autoimmune diseases; apoptosis through the Fas pathway terminates T-cell proliferation, and decreased apoptosis in peripheral lymphocytes is responsible for failure to delete autoreactive T-and B-lymphocyte clones. The mechanism of apoptosis and the role of retroviruses present in a latent state, however, have not been documented. The implications of the present findings for therapy are still limited; however, Fas-L or TNF - may already be envisaged as potential candiates for the destruction of autoreactive cells.

The other great discoveries in autoimmune, inflammatory, and viral skin diseases, as well as in nonmelanoma cutaneous cancers, have not generally led to the establishment of causative therapies. These will be possibly only after the detection of aetiologic factors and a full understanding of the pathogenesis.[2]

Dermatology in the new millennium

Dermatology in the new mellennium will have to focus on the demands, hopes and satisfaction of those who look at themselves as having skin ailments. Governments might modify this by declaring some unperceived needs as important and therefore fundable and others as unimportant.

Hopefully there should be equity, the women will be equal to men, and poor countries equal to the rich. The importance of skin to the individual will not diminish and hopefully will be better recognized by funding agencies. The cost of treating skin diseases will always be an issue, and the case for treating skin disease will have to be made in the competitive world of much life threatening disease.

Dermatologists may themselves opt out of treating conditions which governance deems important. An example would be all breaks in surface continuity of the skin which other professions might wish to take over as leg ulcers, the diabetic foot ulcer, the pressure sore, or burns.[3]

While genetic basis of disease will be increasingly better understood and will give rise to opportunities hardly dreamed of even a decade ago, environmental factors influencing in utero and throughout life will have increasing significance. The complexity of the host in a threatening environment will be acknowledged and the constant search for a single cause of a disease and the magic therapeutic bullet may eventually wane. The climate may become more or less of a threat and migrations due to climate change could be as significant as those due to war.[4]

It is difficult to predict whether management of baldness or skin colour or wrinkles will become a need, which must be met, or something the value of which should be diminished. God and governance may devalue the ′look good′ factor, but many individuals will not. The extent to which pursuit of well-being has to be paid for may determine whether governments want dermatologists. It would be a poor investment for this millennium if our profession pursues the marketing of answers to all skin problems that only dermatologists should provide, often with the most expensive technology, and this at a high cost to patients and to governance. If a compromise is low-cost medications and self or auxiliary help for common skin problems, leaving a few dermatologists to deal with the more difficult problems, then it is a compromise that must be led by dermatologists to make it succeed. These dermatologists should be teachers, researchers and specialists. They must show that the ′look good, feel good′ factor′s contribution to well being is worthy and cost effective.

Elitism is unlikely to fade and nor, for that matter, is poverty. Whether elitism could ever drag the poor up to its standards is doubtful, but hopefully it will make every attempt to distribute knowledge to all levels of society through the significantly improved communication systems that will exist. Whether society will have greater leisure and time to learn all that may become available or whether it will suffer from information fatigue are other unknown possibilities.[5]

Also unpredictable is whether there are other new epidemics like AIDS, or epidemic problems of a different kind like antibiotic resistance or autoimmune diseases, such as diabetes mellitus, or atopic problems such as asthma or eczema. Their development, perhaps as a result of winning the battle against infections, might give dermatological practices an important lesson, encouraging it to look at other paradigms and especially at those which think in terms of balance, or the physical rather than the chemical basis of disease.[6]

The practice of dermatology in the new millennium

At the end of the 20th century dermatologists practiced by seeing one patient at a time; taking a history of variable length; examining the patient to a variable degree; occasionally performing a diagnostic test; but in the end, advising the patient on the nature of the problem with which they present and recommending a therapeutic approach to it. They may have decided to observe the outcome after some time and modify the therapy according to the response. This is what has been happening in dermatology for millennia.

The difference as we go into the new millennium is that science in the 20th century has given us an enormous boost to enchance the art of dermatology when we sit with our patients trying to respond to their request for help. On the other hand, it also has the ability to remove us from that clinical situation by being permitted to replace the art, rather than being merely a tool with which to enhance it. Evidence-based medicine has become a symbol to many people of the correct application of modern scientific knowledge in the clinical practice of our discipline. Therapeutic approaches to disease are recommended on a review of the available scientific studies that have been suitably designed, carefully conducted, scrupulously analyzed and, more importantly, correctly interpreted. This should allow good quality scientific information to contribute to our decision-making in clinical practice.

The struggle in this new millennium, with all the changes that are occurring, will be to maintain a satisfactory balance between "the science" and "the art" in our clinical practice. Although change is a necessary part of our growth and development, there are times when change is sinister, not beneficial. It is up to all of us to maintain our broad view and vigilance, to incorporate change when it is appropriate, but not to be afraid to stand up at times and say "no". If we don′t, we may find that the very hard to define, but very special and some might even say essential part of our practice, the art of medicine, may be swept away before we even realize what has happened. Careful thought will be required lest we rely too much on the modern reductionist approach to defining clinical skills and rely too little on lessons learned from history on the value of the bedside.[7]

New thoughts

We are privileged to have witnessed a historical moment: the end of the twentieth century and the dawn of a new millennium. The twentieth century was a period of striking contrasts during which man walked on the moon, experienced two World Wars, and lived divided by an "iron curtain" under the shadow of a nuclear disaster. Freedom, democracy, and human rights have been ensured for more ethnic and racial groups than ever before, whilst in the Third World, children still die of hunger or of infectious diseases.

Although significant progress has been made, there is a lot to be done. Running through the pages of a contemporary textbook of dermatology, we are disappointed to realize that most skin conditions remain of unknown or obscure, or incompletely understood aetiology and pathogenesis. We have felt embarrassed to admit to our patients that we are almost unaware of what causes common dermatoses, such as psoriasis, vitiligo, alopecia areata, or atopic dermatitis. We must strongly hope that, in the 21st century, emphasis should be placed on revealing and elucidating the aetiopathogenesis of skin disease. This will be the key for definitive treatment and, most importantly, for effective prevention.

The human life span has considerably extended, resulting in a growing proportion of elderly people in the population. Necessary adjustments in dermatological services should be implemented in order to face this new reality. Prevention of skin changes of chronoaging is an issue of increasing concern, and steps in this direction include the recognition of solar radiation as an important inducing factor of aging and the beneficial effect of topical retinoids in both extrinsically and intrinsically aged skin. In addition to aging of the population and currents towards excessive sun exposure, the depletion of the ozone layer is expected to result in an explosive rise in nonmelanoma skin cancer (NMSC) incidence. Efficient preventive education targeted particularly to children and high-risk groups, early diagnosis, and effective management will re-duce the morbidity and mortality of NMSC.[8]

Ideas for tomorrow

In the new millennium, medicine in general and dematology in particular face many challenges, which include:

1. Ever-changing patterns of health care delivery.

2. Discrepancies in the level of care between various countries and within countries.

3. Ease of travel and change in geographic pattern of diseases.

4. Space travel and environmental pollution and changes including ozone depletion and their cutaneous consequences.

5. The HIV epidemic and the role of dermatologists in facing this challenge.

6. Need for effective therapies and vaccines for infections like HIV, leprosy, leishmaniasis, tuberculosis and noninfections like melanoma.

7. Teaching of future dermatologists, and their continued education, especially the use of the computerized and satellite medical facilities, and how to keep up with the new information.

It is time for dematologic societies to examine themselves, and to establish basic philosophies as to their aims, emphasizing the many challenges that face dermatology world wide in this new millennium. Unless societies are geared to meet these challenges, dermatology as a discipline, and dermatologists will suffer. After all, such societies should eventually contribute to the quality care of the patient, and welfare of human kind world over. They are also expected to play a major role in the humanization of dermatology.[9]

Conclusion

Trying to imagine what dermatologists were thinking 100 years ago as they entered the 20th century is a great feeling. They would have been highly excited, possibly more so than we are now about the prospects of the next 100 years. Living in times of ethical crisis, we must redetermine our mission, which is to provide health and welfare to humanity. On the verge of an exciting era, we should pay a tribute to our ancestors and to our teachers and continue to work with devotion, enthusiasm, inspiration, and humanism to make a better world for the generations to come.[10]

Acknowledgement

The author wishes to thank all those whose names are found in the references. Their statements have been reproduced verbatimen this article to give it the seriousness it deserves.