Indian Journal of Dermatology, Venereology and Leprology Medknow Publications on behalf of The Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) ISSN: 0378-6323 EISSN: 0973-3922 Vol. 70, Num. 3, 2004, pp. 149-151

Indian Journal of Dermatology, Venereology, Leprology, Vol. 70, No. 3, May-June, 2004, pp. 149-151

View Point

Dermatopathology in India

Mysore Venkataram

Venkat Charmalaya - Centre for Advanced Dermatology, Bangalore
Correspondence Address:Venkat Charmalaya - Centre for Advanced Dermatology, 3437, 1G cross, 7th Main, Subanna Garden, Vijay Nagar, Bangalore - 560040 anikethvenkat@vsnl.net

Code Number: dv04048

Dermatology and pathology have traditionally had very close interactions and clinical dermatologists have always been in the forefront of dermatopathology. The reasons for this are not difficult to seek:

1. Both are visually oriented specialties needing similar learning skills.
2. A clinical dermatologist is also the gross pathologist in case of skin biopsies.
3. The skin is the easiest organ to biopsy.
4. General pathologists have always shown, with certain exceptions, a lack of interest in dermatopathology.

This has meant that a dermatology postgraduate has to study pathology deeply. It has also meant that most dermatopathologists are clinicians, as is the case with the author of this article. More than 50% of the entrants for Royal College Diploma in Dermatopathology are clinicians!

In India, dermatopathology has been somewhat slow to develop as a separate subspecialty. In fact, the stimulus for writing this commentary was the recent pre-conference dermatopathology workshop held in Mumbai at the Annual IADVL Conference, 2004. Despite a very interesting academic programme and an impressive array of speakers, both national and international, it was somewhat depressing to note that the total number of attendants did not exceed 40 - a paltry figure when compared to the sellout crowd at the neighboring Cosmetic Dermatology workshop or the Dermatosurgery workshop. A contrast was provided by the first hands-on dermatopathology workshop at St John's Medical College, Bangalore held in February 2004. An impressive crowd of 250 participants, turned up and the workshop was a resounding success. However there was one jarring note. Out of the 250 participants, 110 were dermatology postgraduates, 120 were pathology postgraduates and the rest, organizing committee members and the faculty. However, very few practicing dermatologist-either teaching or nonteaching-participated.

These two events prompted me to ask and answer some difficult questions about the state of dermatopathology in India. The objectives are to stimulate fresh thinking, invite comments and thereby contribute to establish programmes and schemes to enhance the position of dermatopathology in India.

FIRSTLY, WHAT IS THE CURRENT STATUS OF DERMATOPATHOLOGY IN INDIA?

In most colleges dermatopathology is still being taught by clinicians. There are very few trained or qualified dermatopathologists. In most places dermatopathology still depends totally on coordination between the departments of pathology and dermatology. Often such coordination may be unsatisfactory or non-existent. Very few dermatology departments have a dermatopathology division. This means that dermatologists are dependent on the facilities provided by the general pathologist. The apathy of general pathologists with reference to dermatopathology is well established the world over. Hence, unless the general pathologist is deeply committed to dermatopathology (which is quite rare), the quality of reports is not always satisfactory. General pathologists are usually not interested in dermatopathology for the following reasons:

1. They are not familiar with dermatology; exposure to dermatology in undergraduate education is a meager two weeks and what is learnt is very soon forgotten. Very few postgraduate programmes in MD (Pathology) include any formal study of dermatology.
2. The plethora of terms in dermatopathology confuses them.
3. The gross examination of a biopsy specimen, which is so important, is done by the clinician in case of a skin biopsy, unlike most other specialties.
4. Pathologists are more comfortable with the large three dimensional specimens of other organs, than with skin biopsy specimens, which tend to be small.
5. Skin biopsies are performed mostly for inflammatory disorders which are regarded as trivial by general pathologists.

Specialized services such as direct immunofluorescence are not available in most places as general pathologists consider them too cumbersome to perform. Immunohistochemistry is also rarely performed as it is expensive and skin cancer is not common in India.

While the dermatology curriculum lays emphasis on the teaching of dermatopathology, only a small amount of time is actually spent on it. Very few questions appear in examination papers. Only a handful of slides are kept for interpretation in examinations.

If this is the situation in the colleges, the scene is dismal in the private practice sector. A practicing dermatologist only infrequently performs a biopsy. This is partly because he has no trust in the general pathologist who usually reports such specimens, and partly because doing a biopsy is not considered viable financially. This is also in part due to the fact that dermatosurgery has been slow to develop in India and still does not include the surgery of skin cancers (which are uncommon anyway and are handled still by plastic or general surgeons). Dermatopathologists have always developed well in areas where skin cancers are common. Consequently, a practicing dermatologist is rarely interested in any teaching activity related to dermatopathology.

THIS IS THE PRESENT SCENARIO. WHAT OF THE FUTURE?

Not very bright I am afraid. The lure of cosmetic dermatology and dermatosurgery is too strong to resist for the young dermatologist, who sees quick financial rewards in these subspecialties. Skin cancer being uncommon in India, dermatopathology may never attain the pre-eminent position it has in the West, with the result that most young postgraduates may never learn dermatopathology properly. Also, dermatopathology may never be financially self sustaining. Most specialized investigations such as immunofluorescence will only be viable as part of a set up which also does investigations for nephropathology and rheumatology. Again, the earning from reporting specimens can never match the earnings from clinical work.

How can we change this?
Despite this rather depressive scenario that I have painted, perhaps not all is lost. There are a number of pointers suggesting that the situation can be improved. For the first time, we have a number of fully trained dermatopathologists in the major metros. The number is small, but a beginning has been made. The advent of dermatosurgery and the consequent improvement in the surgical skills of dermatologists may lead to an increasing number of biopsies and cancer surgeries. The advent of corporate hospitals and corporate laboratories may also lead to the establishment of better dermatopathology facilities. Increasing awareness among the public, increasing medicolegal problems and insurance coverage may require the biopsy confirmation of diagnoses. This may lead to dermatologists performing more biopsies. Awareness of the importance of dermatopathology among the teaching faculty is very high. So it should not be difficult to harness this goodwill and enforce better teaching programmes.

So what can be done?
There should be a regular programme to teach and practice dermatopathology. It should be mandatory for a dermatology postgraduate to spend at least two sessions of two hours each every week in studying dermatopathology. Dermatopathology workshops should be conducted in each zone at least once a year. This can be done with the help of local dermatology associations. Each association should have a dermatopathology wing and a coordinator who would organize such workshops with the help of the central pool of trained dermatopathologists available in the country. The Dermatopathology Society of India has a vital role to play in this respect. One dedicated dermatopathology session can be made mandatory in all state and zonal conferences. Special awards can be declared for the best paper in such sessions. There should be more fellowships in dermatopathology under dermatopathologists, each fellowship to last 6 months. Establishment of computer aided teaching facilities in dermatopathology and using the internet for online learning and to create image banks would help dermatologists in remote places. Establishment of teledermatopathology facilities would avoid the physical transfer of slides. Lastly and importantly, close interactions with pathologists, pathology associations and departments of pathology are needed to further improve facilities.

Obviously both the Dermatopathology Society of India and the IADVL have significant roles to play. The new breed of dermatopathologists have a huge respon-sibility in organizing such programmes to attract talent, to educate post-graduate students and to enhance the prestige of the subject. It is hoped that this article will provide stimulus for thought in these directions.

Copyright 2004 - Indian Journal of Dermatology, Venereology, Leprology