Global Dermatology: Learning from the Past but Still Learning from the Best?

If we try to draw conclusions about events, analyse data or results (in one or a certain area) and clarify our unknown points in standard or non-standard ways, this leads to the transfer of experience from one area to another. How do we want to follow guidelines, while the most of the obligatory laws are not followed, for example? The aim of prescriptions or recommendations in medicine, for example, (or the laws of a country that do not usually apply to particular classes or castes, as well as business rules) is to give guidance on how it would be appropriate to help people or ourselves (as we have already mentioned) and the people themselves. Unfortunately, this behaviour is also characteristic of developed societies that dictate the rules and try to help … to people, as well. If we come deeper into the system of mutual aid in medicine, it is unfortunate that sometimes the condition of this kind of “ecosystem” (or any of the ecosystems described) is worse than the best tragic-comedy. Unfortunately, the “ecosystem of medicine” is also subordinate and slaves somehow to the stronger “ecosystems” as politics and business and is dependent on them, but for evil or good, these ecosystems have glimpsed at times, no matter what are the motives, which provoke them! And they are most often … once again personal. Although in a number of Eastern European countries, it was unthinkable to even undesirable until recently, that dermasurgery and dermatooncology to be part of modern dermatological societies, the insatiable thirst for growth of young specialists, as well as the impact of Western schools, on their formation as a kind of new hope proved to be stronger in the formation of dermatosurgery, not only all over the world, but also in particular in the Balkans and Bulgaria. These units are gradually being introduced as an indispensable part of any modern clinic, and this part guarantees the best results (in patients with dermatosurgical or dermatooncological needs). The globalisation of dermatology and dermatological science has led to the introduction and involvement of additional auxiliary units, based on a more global concept of the interdisciplinary concept that encompasses psycho-neuroendocrine dermatology which provides a good explanation for some unexplained diseases, such as vitiligo, for example.


Introduction
The advancement of dermatology as a science and introduction of novel surgical treatment techniques as well as the implication of target, noncorticosteroid innovative therapies is due to 1) (similar to the rising of each empire, in historical point of view), the conquest of new territories and the establishment of own habits in the management of patients with certain pathologies (or as in the certain "conquered new territory") and 2) the aggressive behavior or approach of the physicians themselves (analogous to the warriors of the past, even of the present one). This approach undoubtedly helps in conquering of new units or subdivisions of specialities with a close focus of action, as well as in integrating them into the main or "our speciality" -The Dermatology.
Obviously, the phase of initial aggression or short-term aggression is a necessity for the catharsis of every individual, business lobby, politics, innovation, or a military strategy striving for progressive behaviour. Winston Churchill's quotation from 13 May 1940, in front of the Camara of the communities, postulated: "I have nothing to offer but blood, toil, tears and sweat!" [1] Isn't Britain a great state nowadays, I would ask?
The correct application of the relevant rules and the good results in the respective "newly conquered territory" inevitably lead to the strengthening of the positions and the approval of the quality of the services to the others, no matter that someone has been affected or injured during the initial clashes, (I focus not only on the historical equivalent but on the medicine, as well). Or, to put it briefly, there is no success without collateral damage to someone or the destruction of the irrational and old-fashioned statuesque.
Often, those who unwilling to adapt to nature, medicine, science, and politics fall into oblivion, because they have lost their never-presented (false demonstrated) inspiration and have to face the reality for which they are not ready, or they no longer have the strength to fight with. Furthermore, rapid adaptation, rapid reaction, awareness and qualification turn out to be crucial weapons or additional bonuses to expand the zone of influence, even in medicine. This is the basis of the rise of some empires before the beginning of their destruction, which is again due to the loss of control and the loss of selfconsciousness of those, who determine the rules. And this loss of control (certainly, sooner or later) has its explanations, which rather affect the individual human nature or the human effigy, which should not be lost in the name of other ideas and goals-opposite to those of the group and the common goodness. We should ask ourselves -to what extent is philosophy related to medicine and to what extent we are pure and objective to ourselves as people and as clinicians? Because the last two are usually connected. If we try to draw conclusions about events, analyse data or results (in one or a certain area) and clarify our unknown points in standard or non-standard ways, this leads to the transfer of experience from one area to another from philosophy to medicine or politics, for example. Stereotypes of behaviour are repeated and analogous, as well as the predictable behaviour of most individuals. Only in the spheres where the main activities develop are different, in the framework of the so-called "theatre". One great friend once mentioned: "Life is a cabaret!" Namely, the philosophical point of view should not be ignored, because those who do not learn from the past are most often ʺabsorbed in the waves of the present or the futureʺ [2]. That's how it was in politics, business, so it is in medicine. Although the spheres of influence in these "ecosystems" are completely different, the aims of the participants in these "units" or "similar units" should be one -namely, to help people. This also determines the psychological attitude of the participants in the three to say similar "ecosystems": 1) to help people; 2) to want to help people; 3) sometimes to want to help people; 4) to want to help a little to the people and a little to themselves; or 5) more to themselves and less to the people; 6) or to do not want to help people by presumption or ... and so on to the endless. It should be noted that these attitudes are dynamic [3].
The problem is that none of these ecosystems has a presumed mandatory nature, although it is inherently pended. How do we want to follow guidelines, while the most of the obligatory laws are not followed, for example? The aim of prescriptions or recommendations in medicine, for example, (or the laws of a country that do not usually apply to particular classes or castes, as well as business rules) is to give guidance on how it would be appropriate to help people or ourselves (as we have already mentioned) and the people themselves or -how to move on in the right direction? Unfortunately, this behaviour is also characteristic of developed societies that dictate the rules and try to help ... to people, as well. If we come deeper into the system of mutual aid in medicine, it is unfortunate that sometimes the condition of this kind of ʺecosystemʺ (or any of the ecosystems described) is worse than the best tragic-comedy.
And the reason for this is our human nature, our materiality, our indifference, and our bondage to certain models of a non-normative (at some point or permanent) pattern imposed by the society, or excuses me, from the pseudo-community. It is precisely that it leads to a refraction of the vision, the inability to be humanist, the inability to be clean when looking into the mirror, the impossibility to carry out an adequate therapy if you want to? But if we ʺclean up the line of behaviorʺ, if we clear our vision from the "impossible" ... and focus on the "real", then the results would inevitably be presented [4]. Or, in all likelihood, they would be better -both as humans and as healers.
Unfortunately, the "ecosystem of medicine" is also subordinate and slaves somehow to the stronger "ecosystems" as politics and business and is dependent on them, but for evil or good, these ecosystems have glimpsed at times, no matter what are the motives, which provoke them! And they are most often ... once again personal. It means that they support the thesis of the tragic-comedian point of view, which is hidden under the umbrella of many virtues such as humanity and so on [5].
Considering or guiding the slogan that only pure intentions and thoughts would lead to a successful outcome, if we observe the Hippocratic laws or at least: do not harm or, do not harm, above all, or: first of all, do not think only for yourself, or think mainly about the patients, or at least sometimes, think about the patients?! (Something that used to happened to me unfortunately, but at the moment, rarely, ). The person's personality, his decisions, his psychological adjustment itself, or all of them in one -aren't they all the real prerequisite for a successful therapy? Isn't the successful therapy determined by us? I would dare to say bravely -YES! Although these solutions are logical and easy as a spontaneous response, they are usually extremely difficult as a final act. Isn't that... hmpropaganda?
Although in a number of Eastern European countries, it was unthinkable to even undesirable until recently, that dermatosurgery and dermatooncology to be part of modern dermatological societies, the insatiable thirst for growth of young specialists, as well as the impact of Western schools, as The German or, more precisely, the former East German school in Dresden / the Italian School in Rome, Italy / Florence, Italy) on their formation as a kind of new hope proved to be stronger in the formation of dermatosurgery, not only all over the world, but also in particular in the Balkans and Bulgaria. These units are gradually being introduced as an indispensable part of any modern clinic, and this part guarantees the best results (in patients with dermatosurgical or dermatooncological needs) [6,7].
The globalisation of dermatology and dermatological science has led to the introduction and involvement of additional auxiliary units, based on a more global concept of the interdisciplinary concept that encompasses psycho-neuroendocrine dermatology which provides a good explanation for some unexplained diseases, such as vitiligo, for example. For our luck, these therapies were introduced in Bulgaria as one of the first highly selective and promising methods for the treatment of major dermatological diseases due to our proximity and close cooperation with the Italian Dermatological School and Prof. Torello Lotti [8,9].
Despite these irreplaceable and incomparable successes, including also the era of initiation of therapy with biologics for psoriasis and pyoderma gangrenosum, for example, it should be noted that in a number of current diseases, namely in melanoma patients, there are still a number of unclear points and difficulties in terms of which is the best approach in different patients' groups in order to achieve maximum satisfaction for both the physician and the patient [10].
The presence of guidelines in these patients is not always scientifically well-established, and the guidelines themselves are not obligatory, leading to the following problems in the management of these patients: 1) The necessarily of maximum knowledge of dermatologists about the available information on the treatment of skin tumours (this is not always possible due to various factors). This is hampered by the lack of precise guidelines and recommendations. Responsibility couldn't be sought, as a consequence of the variability of the management criteria.
2) The inevitable use of small doors in guidelines to provide the safeness of the physicians themselves but not initially based on maximum patient safety. Doors, used by more refined colleagues, more experienced colleagues.
The idea of creating a special edition of dermatological issue is mainly due to the idea of sharing or accepting good medical practices, which especially in Bulgaria (as well as in many other places in the world) are mediated or provided by two personalities whom I would define first as close friends, and secondly: as our teachers and mentors, as well as world's leaders in dermatology: Prof. Uwe Wollina and Prof. Torello Lotti.
Thanks to the daily and long-standing consultation with the dermatosurgical unit of Prof. Uwe Wollina in Dresden, a great number of Bulgarian patients were and are being assisted daily, and many of them are completely cured of malignant skin tumours.
The introduction of innovative therapies for vitiligo, psoriasis, atopic dermatitis and others cutaneous diseases through low-dose cytokine therapy was facilitated by the contacts and friendly attitude of another prominent person in world's dermatology -Prof. Torello Lotti.
These innovators and I would have dared to say "crusaders" in modern dermatology, are one of the motors or the main reason for: 1. Assistance in creating the special edition of dermatology in the Open Access Macedonian Journal of Medical Science to highlight the progress of good medical practice in Bulgaria, Italy and Germany.
2. The sharing of Bulgarian experience within the framework of the setting of dermatosurgical practices and the immediate results in the long term follows up.

Sharing innovations in some oncological and
non-oncological diseases.
4. They are also the main reason for the good maintenance and work of the ecosystem, leading to satisfied and smiled patients.
I would like to express my sincere thanks, on behalf of all the participants in the specialized dermatologic issue, to another great person and friend, namely -Prof. Mirko Spiroski, who helped and support the specialized edition, despite of the emotional outbursts of some of us which was partly caused by the high summer temperatures, but also partly by the genotypic component with variable penetrance, as well as the lack of regular systemic medication's administration. They say laughter is health, and self-irony is a high degree of awareness or self-consciousness.
Although unconventionally written, I hope that this editorial will make colleagues think about not only the medical but also the human aspects, which, along with the aggressiveness, should be an indispensable part of the progress in medicine. I believe that the formula of success is in balancing between these two "virtues".
It is often mentioned that there is no place in scientific journals for emotional speeches and outbursts, which is or should be correct. But as it was recently found, cytokine levels are those that define our condition such as disease and health. The levels of these small molecules make us react differently in the same situations. Furthermore, they define our emotions and decisions, our human face and nature. And this is the trail that remains behind us, and therefore, it should not be suppressed [11][12][13].
But we still have to ask ourselves whether we live by the rules and are the world a slave to the rules? Are the rules a guarantee for success? I would say rather No! How should we follow the guidelines when they are not mandatory? Should only US recommendations be followed? Isn't it the right time for the creation of Independent European and National Guidelines or strict rules for diagnostic and therapeutic behaviour in melanoma patients, for example? Who defines the rules and boundaries of the correct behaviour? Aren't we? Aren't we winning more when we do not follow them? Why and by who are they created? And to whom do these rules serve?
Many questions with many question marks, but furthermore-questions that we would easily solve if we are friends! Or friends at least for a while... I would add! Because together we are, and will always be stronger! Thanks to all of my friends, especially to Prof. Wollina and Prof. Lotti, who helped me but also help us to become self-aware, self-defined, to be classified as good clinician! I also thank both of them, because I and all of us grew up as people or rather as humans, within our long-term cooperation. We grew up in our relationship with the people around us and the relationship between ourselves! We have understood the right direction to which we should move on, and this ... is not a small one!