Dermatology: Practical and Conceptual Book Review | Dermatol Pract Concept 2014;4(3):18 85 DERMATOLOGY PRACTICAL & CONCEPTUAL www.derm101.com Review by François Milette I heartily recommend this book to pathologists and derma- tologists looking for a practical and easy to consult guide to differential diagnosis in dermatopathology. This book fulfills all the promises stated in its preface. This is rare! Without any pretention, this guide is presented as a “supplement to existing textbooks of dermatopathology.” It does not pretend to cover every entity, it acknowledges its limitations to “classic” examples of each disease, and it stresses the fact that there is no substitute for experience in dealing with unusual cases and for a close collaboration between clinicians and pathologists in order to establish a reliable diagnosis. These may be statements of the obvious but they nevertheless are easy to forget, as any experienced dermatopathologist knows. Indeed this practical guide is certainly not sufficient to acquire thorough practicing skill in dermatopathology. As the “supplement to existing textbooks” it intends to be, it certainly needs to be supplemented in return. Nevertheless, from the very first pages to the last chapters, the reader senses that the author is an experienced practitioner effectively shar- ing his practical approach to skin biopsies. The book is constructed around its Chapter 1C captioned “Differential diagnosis lists.” In this chapter, the reader finds a list of various characteristics, some clinical (skin lesions with and without pruritus, the colors—white, red, green, yel- low—of lesions, etc.); some physio-pathological (“Kidney and the skin,” “Gastrointestinal tract and the skin,” “Pregnancy rashes,” “Arthritis and skin diseases,” etc.); some topological (e.g., axilla, groin, head, elbow,. lesions); some histological Review of Practical Dermatopathology, 2nd edition by Ronald P. Rapini François Milette1 1 Centre Hospitalier Pierre-Boucher, Longueuil, Canada Citation: Milette F. Review of Practical Dermatopathology, 2nd edition by Ronald P. Rapini. Dermatol Pract Concept. 2014;4(3):18. http:// dx.doi.org/10.5826/dpc.0403a18 Published: July 31, 2014 Copyright: ©2014 Milette. 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: François Milette M.D., Centre Hospitalier Pierre-Boucher, Longueuil, Canada. Email: francois.milette@cssspb.qc.ca Figure  1. Rapini RP. Practical Dermatopathology. 2nd ed. Ed- inburgh  : Elsevier, 2012. ISBN: 978-0-323-06658-7. 460 pages. $189.00. (e.g., hemosiderin, horn cyst, interstitial inflammation, acan- tholysis), etc. For each of these nonspecific and rather arbi- trary characteristics, a list of entities/diseases is given—151 lists! The most frequent entities on these lists are italicized identifying a first indication toward the final diagnosis. Most entities listed are cross-referenced to one of the other chapters (Chapters 2 to 29) of the book, on the first page of which they are included in a new differential diagnosis list. Each element of this new list is then shortly discussed in a concise and very practical format, including a short definition with clinical and/ or physiopathological discussion, enumerations of histopatho- logical characteristics and clinical variations and a new, more restricted list of differential diagnosis that can be the starting point of a new cycle of exploration through the book in the same or another chapter. High quality microphotographs are also presented of the classical aspect of most entities discussed. The whole book is thus structured around its Chapter 1, which is, in fact, something like a crossroad in the labyrinth of dermatopathologic diagnoses, the book as a whole appearing therefore as a huge informal algorithm. 86 Book Review | Dermatol Pract Concept 2014;4(3):18 Certainly using this book/algorithm optimally requires experience and clinical knowledge, and this is admitted by the author in his preface. Because of these need for experience and clinical knowledge, the book may not be a first choice for the beginner pathologist or dermatologist. Or may it? For a beginner the problem would be where to start in his exploration of a given lesion. For example, is it to be approached as a violaceous lesion, a nodule, a knee lesion, a vasculitis? This may be of no consequence to the dermatolo- gist who, in any case, will perform a biopsy, but the patholo- gist will have to select an entrance into the labyrinth. At first sight, therefore, this work may not be a good introductory book. On the other hand, though, one soon realizes that there is more than one way to exit the labyrinth and that gaining experience is precisely that: through repeated failures and successes, one finds the shortest way in various situations. If this book were considered a traveler’s guide in the world of dermatopathology, it may well be a very good introductory work after all! In any event, as this lengthy description suggests, this is not the kind of book to be read from cover to cover. It, rather, is a work through which to wander in search of the best- fitting diagnosis. And since this kind of wandering is precisely what the dematopathologist’s brain does all day long, going through it is like following in real-time the thought process of a practitioner. This is a remarkable achievement for the author and a very pleasurable experience for the reader, inducing reflection on the intellectual process called “making a diagnosis.” Of course, this single author’s work, the synopsis of the thought process of an individual, is subjective, and the reader will here and there find some details he might have wished added, deleted or presented otherwise. But the approach adopted by Dr. Rapini is most pedagogical and everyone will be enriched by it. Being a perpetual work in progress, this approach can never be definitive but continuously adapting it to one’s own thinking is a great source of professional growth. Another very remarkable aspect of this Arbeit that I would like to stress is that even if the author has tried to “distill [only] the most important facts into the text,” con- troversies are not overlooked and are stated in a remarkably concise and clear way, a powerful stimulus for looking farther into them. Controversies are indeed “most important facts” never to be forgotten. Consider, for example, how one of the most important controversies in dermatopathology—dysplasia in melanocytic lesions—is evoked: “The National Institutes of Health consensus confer- ence published in the Journal of the American Medi- cal Associationin 1992 recommended that clinicians use the term “atypical mole” and that pathologists abandon the term dysplastic nevus in favor of the term nevus with architectural disorder, because these lesions usually have more architectural atypia (bridg- ing, single melanocytes, shouldering, fibroplasia, lym- phocytes, described below) than cytologic atypia. The consensus conference recommended grading the cyto- logic atypia (see below) as mild, moderate, or severe. Because the architectural disorder is often more sig- nificant, some authorities grade both the architecture and the cytology. Other pathologists refuse to grade these at all, citing papers showing irreproducibil- ity. Some pathologists use the term dysplastic nevus when the cytologic atypia is mainly within the epi- dermal melanocytes, using the term atypical nevus when it is in the dermis. Others use the two terms as synonyms. Unlike in gynecologic pathology, there is no uniform agreed-upon terminology for mela- nocytic neoplasms, and this is a big problem. Since melanocytic terminology is more like the Wild West, the clinician must know how a particular pathologist uses these terms. Some authorities have complained that dysplastic nevus is overdiagnosed when there are only minimal architectural changes; Ackerman sar- castically called it “the most common nevus in man”. The term Clark nevus arose out of the aversion for calling these lesions truly ‘dysplastic.’” How could a beginner not question seriously the notion of dysplasia (and atypia) after its having been presented to him in such a way? The same is true concerning parapsoriasis: “Parapsoriasis  is very  controversial. Dermatologists use different terminology for various forms (many terms have historical significance only). Some con- sider all examples of parapsoriasis to be mycosis fun- goides, while others consider the small plaque type as benign and the large plaque (parapsoriasis en plaque) and variegate (retiform) types as representing early mycosis fungoides.” This admission of controversy is very appropriate, although I would have appreciated if Dr. Rapini had stated his practitioner’s point of view on these important subjects. In summary, this book is remarkable. It fulfills all its promises. It indeed is a valuable supplement to dermato- pathology textbooks, serving as a guide into them, toward deeper knowledge on various entities. The book is particularly “user friendly” in its ebook ver- sion which is supplemented with online ressources, including a collection of clinical images and a pretest of 69 multiple choice questions. Last and not least, the quality of the photomicropaphs included is outstanding, and if there is one suggestion I might dare make to the author, it would be to add more of them, perhaps as a new section of multimedia resources.