On many days, my primary role is that of a nurturer. I often have to explain that many skin diseases are chronic in nature and only palliative care can be provided. Although there may be a perception that skin conditions only minimally affect patients, those who have protracted and severe conditions often endure serious psychosocial repercussions. All the activities of daily living—including work, sleep, hobbies, and social contact—may be harshly disturbed. Using the Dermatology Life Quality Index, the Beck Depression Inventory, and other quality-of-life measures, researchers have confirmed that those suffering from prolonged skin disease often endure significant impairments of work, school, and personal relationships.
In my stories and in my daily work, the patient is at the center, and the disease is a supporting actor. In the words of one of my heroes, William Carlos Williams, I get to “witness the words being born” while listening to my patients describe what bothers them and why they are seeking help. If I pay close attention and ask the pertinent questions, I can become a part of the birthing process; later, at my writing desk, I am able to record and perhaps better comprehend what has been said and done. In the exam room I’m confronted with themes from the marriage of medicine and literature, reflections on what is happening today in medicine and the world, and questions about how each person lives and interprets personal problems. Although these observations and conversations primarily take place during my exam of a patient, the history that precedes each problem has occurred over years or decades—my job is to take the kernel of a patient’s story that I can glimpse in the exam room and make it come to life in my writing.
On the journey across these pages, I will ask many questions. What can we do to protect our skin and ourselves? How will the skin of the future be different? How does skin color affect social position and how can diseases such as albinism impose real punishment? How do people with skin diseases see themselves and their opportunities in life, and how do their lives change as a result of their conditions? How do people cope with having bodies or diseases that aren’t “normal” in our culture? My overall purpose is to showcase the wonders of the skin, the agony of certain diseases and their attendant social and psychological toll, and provide some insight into how the skin and our perception of it influence our social, cultural, spiritual, and physical being—and how we can learn and grow from our new knowledge.
Why would someone choose dermatology as a career? In his introduction to The Life of the Skin: What It Hides, What It Reveals, and How It Communicates, by Arthur K. Balin and Loretta Pratt Balin, the famous dermatologist Albert Kligman wrote, “When I began, the field of dermatology was a swamp of snakes and nonsense, magic and folklore. The cynical view used to be that people went into dermatology so they didn’t have to be awakened at night to go care for patients.” He continues, “Modern dermatology is rooted in science and developing at an Olympic pace. These days the highest-ranking students apply for dermatology residencies. To become a dermatologist now, a student has to be highly educated and conversant in the fields of psychology, art, immunology, genetics, and biochemistry, to name but a few.”
As the Balins carefully point out in their book, “Dermatologists do far more than treat the skin, for the skin mirrors the health of the entire body.” By means of an eruption, itch, color change, or other sign, the skin can alert us to a problem in the deeper organs. For the visually oriented, the signs and patterns of skin disease signal the diagnosis. But dermatology is also tactile: I often guide the fingertips of medical students to help them touch the sandpaper-like feel of a precancerous skin lesion, the warmth of an area of inflammation, or the blanching of a vascular lesion.
Finally, as Kligman points out, dermatologists also have to know psychology. I see people at their most vulnerable, devastated as many are by their appearance. There is a gratification for both me and my patient from seeing the results of our work, either rapidly, when removing a skin cancer, or over time, when treating psoriasis or cystic acne.
I have divided the book into two parts. I start at the surface, with the enormously dynamic and lifesaving nature of the skin itself. Part 1, “Our Vital Skin,” highlights the skin in its many amazing roles. I’ll investigate how our skin defines us, what we need to do to protect it, what unseen creatures live on it, and how crucial structures within it have determined the course of history.
Part 2, “Living in Our Skins,” goes deeper, into how we deal with skin diseases, the social and psychological issues of skin as social entertainment, and how the skin reveals and communicates our wishes and burdens. The focus here is on how skin color, disease, or irregularity can affect social position, self-esteem, and a person’s opportunities in life. In this section, we’ll see how our skin in all its glory and vagaries—from extra ears to imaginary parasites—manifests itself in our lives and culture.
Throughout, we’ll see that skin has a direct cultural influence on every generation. It is a canopy for each individual and for all of humanity, stretching over us and encompassing the whole range of shape, color, and disturbance, from idiosyncratic, rare diseases to the broad experience of entire societies.
ACKNOWLEDGMENTS
Many thanks to Rachel Berchten and Christopher Lura, and all the editors at the University of California Press. Thanks also to Julie Christianson for her marketing acumen. And I appreciate very much the work of freelance editor Caroline Knapp. Special thanks to editor Naomi Schneider for her patience and for carefully offering great suggestions and helping me through this labor of love.
Great appreciation goes to my brother Howard, who has always helped me in trying to get this writing thing down with the highest quality I can manage and in bringing this book to fruition. Thanks to Dr. David Elpern and others who read earlier drafts of the book and provided useful insight and to those that offered endorsements. As always, I send much love to my family, friends, and patients for all I learn and share with them. Thanks to those that understand my drive for creation that sometimes cuts into the structure of our lives and time, but I hope my work in medicine and writing makes up a little for my absence.
PART ONE
OUR VITAL SKIN
Our skin mediates the most important transactions of our lives. Skin is key to our biology, our sensory experiences, our information gathering, and our rela-tionships with others. Although the many roles it plays are rarely appreciated, it is one of the most remarkable and highly versatile parts of the human body.
—Nina Jablonski, Skin: A Natural History
What is the function of the skin? It is the information source and processor. It is the foundation for sensory reception. It is a barrier between us and our environment. It is an immunologic source of hormones for protective cell differentiation. It protects our underlying organs from radiation and mechanical injury. It serves as a barrier to toxic materials and foreign organisms. It plays a major role in regulating blood pressure and the flow of blood. It performs regenerative repair. It works as a temperature regulator. It is involved in the metabolism and storage of fat, salt, and water. It serves as a reservoir for food and water and as a respiratory organ for the passage of gases. It is a synthesizer of important compounds including vitamin D. It forms an acidic barrier