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It must be evident to the patient and to the non-dermatologist clinician! Or: how I learned to stop worrying and no longer spurn the word 'eczema'.


Robledo F. Rocha

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When I still was a medical student, I undertook a practical training program in Internal Medicine at Allgemeines Krankenhaus der Stadt Wien, the legendary AKH, in Vienna. One of the admitted patients suddenly developed pruritic clear vesicles along the sides of his fingers, and Prof. K. wanted to know a diagnostic hypothesis from me. Trying to demonstrate some confidence, I quickly answered: “It’s a kind of eczema.” But he gave me back this reply: “You’re right and you're wrong. You’re right because the patient is likely to take from you the correct orientation about his illness and to receive a successful treatment. And you’re wrong because this disease is expected to be called dyshidrotic dermatitis. The word ‘eczema’ should be banished from medical vocabulary. Von Hebra and Kaposi, two of the greatest ever dermatologists, worked here at AKH, and both used to say that the most suitable definition of eczema is that which looks like eczema!”

I thought about it afterwards. What hell is the problem in using a word that stood the test of time?

I got a response few years later, when I was resident in Pathology. Dr. A. Bernard Ackerman came to Vitória, the city where I was living in those days, in order to conduct a very intensive five-day course of Dermatopathology. It wasn’t difficult for him persuading me to avoid the word ‘eczema’. Dr. Ackerman told that it is merely a descriptive diagnosis shared by a variety of cutaneous conditions with widely diverse etiologies, some of which are completely unrelated. Furthermore, he said, even the supposed microscopic hallmark of ‘eczema’, the spongiosis, is unreliable, since this feature is usually minimal, if so, in chronic lesions with superimposed lichenification that the original spongiotic process is no more prone to be identified. Dr. Ackerman rounded the issue off by arguing that some skin diseases, like psoriasis, dermatophytosis, pigmented purpuric dermatosis, and mycosis fungoides, may present variable spongiosis, although nobody hasn’t demonstrated any effort of include them into the group of the eczematous dermatitis.

Henceforward I started to spurn the word ‘eczema’ in my reports, professional talks and classes.

This radical attitude brought me some problems. My reports became less understandable that patients started to demand a consultation just to ask me questions like this: “I googled ‘seborrheic dermatitis’ and I found that it’s a kind of eczema. Is this a truthful information?” Once, a non-dermatologist clinician phoned me to ask about ‘nummular dermatitis’ and then she criticized my explanation: “You were expected to made clear in your report that it is nothing but a kind of eczema!” And medical students disapproved my academic polemicism: “Dear professor, all these renowned books use the word ‘eczema’ without any firmly rejection. You mean that all of them are mistaken? What is your problem in using a word that stood the test of time?”

Oh, yeah, I did recognize the last question! It’s the same that I made myself years before in Vienna, when I still was a medical student. I had a strong sense of déjà-vu, but in a reverse way, that invited me to a reflection.

Nowadays my reports are fairly different on the use of the word ‘eczema’. “It must be evident to the patient and to the non-dermatologist clinician!”, I think as I begin to draw it up. And my reputation grew within medical students.

Oh, yeah, I learned to stop worrying and no longer spurn the word ‘eczema’!

Nevertheless, a familiar feeling of inaccuracy remains in me every time I write or say the word ‘eczema’. Perhaps this residual contempt shall pass one day.

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Dr. Phillip McKee

Posted

A lovely blog which covers the issue very well. I do think that we spend too much time playing around with terminology which often confuses the dermatologist and sometimes us. For example I have never seen the point of changing Reed-Sternberg cells into Sternberg-Reed cells or Jacob-Creutzfeldt disease into Creutzfeldt-Jacob disease. Who cares? I have always felt that folk who nitpick over such issues don't have enough to do!!! If such an issue applied to myself long after my death, I don't think I would be very interested in it. I would hope that by then I would be in Heaven with my wife and family eating 24 oz ribeye steaks daily and driving extremely fast on narrow (one way) roads in my Ferrari!!!!!!
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Guest Jim Davie MD

Posted

I've also gone through the same cycle of love-hate-love for eczema in my career.

For the benefit of clarity, and depending on clinician, I now often add 'eczematous' or 'eczematous pattern" as an adjective to the diagnosis line so that it provides a much more easily digested and recognizable signpost to both dermatologists or non-dermatologists who may receive it better than an arguably more precise diagnosis, e.g. "Spongiotic microvesicular perivascular dermatitis with eosinophils." (Such longer, descriptive phrases I frequently move to a Diagnosis Comment paragraph, sometimes within the context of a differential diagnosis and/or clinical correlation discussion, so that it is available for those clinicians who have interest in the finer details of what it actually represents).

In a similar vein, I find it sometimes convenient to add synonyms to diagnoses so that clinicians can "lock on" to their old, favorite, well-recognized synonym...and not be unnecessarily confused by an unfamiliar one. (But that's a separate discussion).
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Dr. Richard Carr

Posted

Jim - love your comments but you might want to just omit the description and write.
"Acute/subacute/chronic spongiotic (eczematous) dermatitis confirmed without/with occasional/with moderately/numerous/numerous eosinophils. +/- Fungi (PAS) - delete as appropriate.

I rarely if ever write enough to justify another summary/diagnostic line!

Spongiotic and eczematous are used interchangeably in my reports and merely indicate a reaction pattern. I frequently ask a quesion in my report when appropriate e.g. Could this be discoid eczema? Could this be pompholyx etc. (numular for numb skulls, dishidrotic likewise! - whow wants unnecessary phone calls). I sometimes can make a more specific diagnosis and then I obviouly give it. Phillip's comments are priceless!
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