Commentary: changing paradigms in dermatology.

Many medical diagnostic and therapeutic procedures come and go within a few years. Some never make it beyond the realm of basic research. Others have a phenomenal staying power. Initial enthusiasm triggered by isolated reports, or by speculation with apparent scientific basis, often fails to survive the careful statistical scrutiny of evidence-based medicine, cost/effectiveness, related adverse events, competition, or customer (patient, provider, etc.) satisfaction issues. Examples of once promising diagnostic procedures that never made it to every day dermatologic practice include thermochristallography—intended to measure indirectly blood flow through the skin, means to measure skin hydration or oil production, etc. On the other hand, the simplicity, accuracy, and low cost of the potassium hydroxide (KOH) preparation for the diagnosis of dermatophytic infection explains its longevity. Routine histology, not as practical, is definitively an essential diagnostic tool—one that initiated the era of modern dermatology over a century ago. Examples of promising therapeutic procedures that promptly dropped out of the armamentarium of the dermatologist include masoprocol cream—initially thought to replace topical 5-fluorouracil in the treatment of actinic keratosis—succumbed to its unfavorable adverse events profile. Topical steroids have been evolving almost uncontested as a therapeutic necessity despite well recognized side effects. They are still being improved with new vehicles, promising disassociations of their potency vs. atropogenic properties, etc.—this in the face of newer topical immunomodualatory drugs with apparently better safety profiles. My enthusiasm to put together this issue of Clinics in Dermatology developed as a result of my frustration at not seeing in vivo confocal microscopy evolving from the researchers bench to the dermatologist practice with the speed I predicted some 5 years ago when I was first given the opportunity to “play” with this tool, generously lent to me by its developer, Lucid Inc. The revolution in DNA-based science is starting to enter both the diagnostic and the therapeutic arenas; this revolution is moving so fast that we will seemingly skip the so-called pharmacogenomics in favor of pharmacoproteomics. If well, the latter is the immediate consequence of the former. Patch testing has also endured a long and rewarding life; better standardization of allergens, more convenient ways of application, and lots of literature supporting its value are increasing its utilization. The era of information technology is revolutionizing fields as disparate as astrophysics and philosophy; medicine and particularly dermatology are most suitable to progress by leaps and bounds by the better utilization of information and by easing the time consumed by travel to the dermatologist office either from home or from a consultants practice through telemedicine. Psoriasis turned out to be a practical model for the evaluation of drugs intended to treat internal diseases due to a dysregulated immune system. “Biologic” drugs developed out of the understanding of DNA physiology seem poised for practical use as soon as cost, route of administration, and safety limitations are surmounted. Meanwhile, new generations of nuclear hormone receptor ligands are serving to treat this and other skin diseases like acne, where the pathology involving these receptors is known to play a role. Eczema has seen a major change in therapeutic paradigm as epidemiology increased knowledge of immunology and skin metabolism delivers reasons to replace corticosteroid use with lipidizers and calcineurin-inhibiting immune-modulating agents. Finally, antimicrobial, antifungal, antiparasitic, and antiviral agents are being developed at amazing speeds; it seems harder for clinicians to keep up with this knowledge than for bugs to become resistant or for new ones to appear. I was able to bring together some very distinguished dermatologists and put them to the task of presenting the readers of Clinics in Dermatology with a series of articles intended to illustrate what they, and secondarily I, believe are the diagnostic and therapeutic novelties in our field that, like the KOH and topical corticosteroids, are here to stay—for a while. From the Department of Dermatology, Baylor University Medical Center, Texas Dermatology Research Institue, Dallas, Texas. Address correspondence to William Abramovits, MD, Baylor University medical Center, Texas Dermatology Research Institute, 5310 Harvest Hill Road, #260, Dallas, TX 75230. E-mail address: waresearch@texasderm.com