Commentary

Clinicians have to deal with patients, not just with their diseases. In some instances, it may be difficult to differentiate benign from premalignant parapsoriasis, as clear-cut criteria for early diagnosis are lacking. In such situations, the patient may be faced with a normal life expectancy or the risk of disease progression with tumor

Table 1 Most Useful Criteria for Distinguishing Between Benign and Premalignant Forms of Parapsoriasis en Plaques

Benign form (small patch type)

Premalignant form (large patch type) with or without poikiloderma

Age distribution Sex incidence

(male:female) Clinical features

Preferential localizations Histological features

Prognosis

Adults 5:1

All ages 2:1

Small (2-6 cm in diameter), mostly Few large patches pityriasiform oval, or finger-like patches, slightly scaling with or without erythematous (pseudoatrophy) and telangiectases and wrinkled surface uniformly pinkish or netlike pigmentation yellowish with pityriasiform scaling Trunk and upper extremities

Patchy parakeratosis, slight perivascular patchy infiltrate, no edema, no epidermotropism

Life expectancy normal; no progress to mycosis fungoides

Breast and buttocks

Slight epidermal atrophy with loss of rete ridges, significant bandlike dermal lymphocytic infiltrate sparing the subepidermal zone, no epidermotropism, no edema; telangiectases either prominent (poikilodermatous variant) or absent Life expectancy normal in most cases; progress to mycosis fungoides may occur

Figure 2 Biologic behavior of the benign and the premalignant forms of parapsoriasis en plaques. The latter have the potential of evolving into mycosis fungoides.

spread and death, even though the clinician cannot adequately assess the risk. Only the dynamic evolution of the disease allows a retrospective diagnosis.

Malignant melanoma, squamous cell carcinoma, mycosis fungoides, or other cutaneous T-cell lymphomas are malignant neoplastic diseases. Lentigo maligna (Hutchinson's freckle, Dubreuilh's disease) and parapsoriasis en plaques are prema-lignant conditions, just as some adenomas may progress to colon cancer or angioim-munoblastic lymphadenopathy may evolve into lymphoma (5,6). Progress into frank neoplasia usually requires a period of time in these conditions. Changes in the clinical presentation and—more importantly—in the histological, phenotypical or geno-typical features indicate this progression. The new molecular technologies such as gene profiling, genomics, and proteomics may allow an even more precise tracking of the disease status. This progression is coupled with a change in prognosis from normal or almost normal life expectancy to reduced survival time.

Those diseases that clearly have clinical and histological changes and cannot be regarded as normal, but also do not fulfill criteria of malignancy, deserve to be labeled with a term, which reflects this intermediate situation and as distinct nosologic entities. This term since the days of Brocq has been "parapsoriasis," and there is no reason for changing it (7). Otherwise, there will be a bias in epidemiologic data on frequencies, mortality rates, and other parameters.

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