As a dermatologist, I spend much of my time helping patients understand the myriad bumps, blemishes, and spots on their skin. Patients step out of their lunch break and into my exam room; i.e., a world of strange growths with stranger names, where an eccentric doctor tells them some really gross stuff.
Our most visible organ offers a unique window into our biology, inviting armchair analysis and speculation not afforded by other organs (the liver, kidneys, and heart, for instance, are best examined with blood tests and high-tech imaging). Most patients share my primary diagnostic tools— eyes and fingers—and have years’ worth of experience examining their own skin and judging others’. These commonalities make my specialty feel accessible. Patients breeze into my office after hours of research, confident I’ll agree with their theories and approve of whatever expensive product du jour they purchased online. Entire industries thrive around non-medical skin treatments, and feed a growing trend in misinformed self care. Patients wind up feeling ready to drive NASCAR when they barely have a driver’s license. This accessibility remains stubbornly tied to the ancient role skin plays in our understanding of identity and communication. We use skin to evaluate fitness for mating, to assess risk of danger (scars, for instance, denote associations with past violence), and to identify and categorize “others”. Despite our progress, skin carries real social connotations and consequences, and people understandably want to project an outward image that’s at harmony with their internal sense of identity. Because so many other aspects of our image remain under our control, we feel empowered to modify our skin in ways we don’t dare to modify other organs.
It’s no wonder, then, that a couple bumps on the face can evoke strong emotions and countless hours in the mirror and on the internet. Theories abound in patients’ minds about their imperfections’ source, their implication, and how to eradicate them. I’m often asked how blemishes could have been prevented through diet or other interventions; patients are quick to blame themselves.
I can’t really fault anyone for that; we all know skin elicits unconscious value judgments. It’s easy to dismiss the skin as nothing more than a wrapper, however in reality it’s a living structure that uses reflected photons to communicate with other humans. We control some of that communication (via hairstyles, makeup, skincare routines, facial expressions) while much is unintentional (smokers’ lines, sun damage, scars, rashes) or flat-out uncontrollable (facial features, skin tone, moles, signs of aging).
When we observe our reflection in the mirror, we’re looking at both the external presentation of our genetics and the collective impact of our time spent wandering the Earth. We are beholden to the genetic hands we were dealt and to the fact that we travel linearly through spacetime; the passing days only ever accumulate on our skin. Many experience discomfort as they grapple with dissonance between the images in the mirror and their mind. They parse conflicting expectations to accept and love themselves while being force-fed pressure to conform. This is all made more painful by a social hierarchy built on appearance-based discrimination; it actively encourages and tacitly enforces unattainable ideals.
Meanwhile, the specter of mortality looms in many patient interactions. Is it skin cancer? Will this rash go away? Why am I aging so soon? Am I going to be okay?
Dermatologists often wade into this loaded territory dozens of times every day. Equipped with the same basic diagnostic tools as most of my patients, I try to navigate the underlying fears and social constructs built into the skin and psyche. It is often not enough to offer an accurate diagnosis or treatment regimen. Modern humans have eyes and the internet; we increasingly exist in a culture where expertise is at our fingertips and the pros are out to take advantage of us. Hours of online research result in strong convictions and fluency in marketing terms (fun fact: “combination skin” isn’t actually a thing). So instead of educating patients, I spend much of my time re-educating them on how their skin actually works, trying to outcompete the societal white noise that has already wasted so much of their time, resources, and emotional reserves.
For me, this interplay is eternally fascinating and frustrating. I share society’s obsession with skin. It’s an intricately designed and endlessly interesting barrier comprised of skin cells, pigment-producing cells, blood vessels, nerves, sweat glands, oil glands, scent glands, hair follicles, immune cells, fat, muscle, and connective tissue that allows you to function in a harsh, gaseous environment. Skin’s sheer number of structures and functions make it one of the most pathologically diverse organs in the body. Any part of the system can malfunction, and literally every cell type can overgrow and produce multiple types of tumors on the skin. Throw in a few thousand rashes (typically caused by the immune system and skin infections), as well as depositional, nutritional, genetic, and endocrinological disorders, and you’ve got yourself a cornucopia of potential problems. Layer on top basic notions of identity and culture, and you’ve got yourself a career of endless exploration. Despite such a glut of conditions, dermatologists can frequently make diagnoses after a single glance, and much else can be gathered by learning what they’ve been up to on their journey through spacetime.
I love that through simple and careful observation, I can intuit your hobbies, your vices, how active you are, your age, what medications you take, and your skincare routine with pretty high accuracy. Sometimes a rash can tell me there’s something wrong with your liver, your heart, your hormones, or your immune system. A quick glance at your fingernail-ravaged cuticles can tell me how much stress you have in your life and inform how bluntly I approach our discussion about acne. A one-handed tan and rosacea can tell me you like to spend extra time at the 19th hole and could use some extra teaching around sunscreen and alcohol intake. A brown streak on the dominant wrist tells me you’ve been in the sun with lime juice on your hand, and may prompt me to casually ask whether you like Margaritas. There’s nothing quite so satisfying as the moment a patient looks at you like some kind of wizard for intuiting that they spent the weekend in Cabo. (It’s a different kind of high from the warm-fuzzies consulting derms get when they say to the primary team, “I recommend you check for aortic aneurysm because those purple dots may mean the patient is showering emboli.”)
I suppose this is all to say that the factors that make dermatology so accessible to patients are the same ones that keep me fascinated year after year. With a simple set of tools, a lot of study, and a systematic way of thinking, dermatologists train to become expert observers of the skin and of human behavior. I find satisfaction in making diagnoses in a split second, then helping patients understand and manage the impact of those diagnoses. But I also find pleasure in examining the underlying social factors that cause patients to see me in the first place, and the disparate ways they interpret their bodies and their skin. These factors only add to the breadth and depth of the field, and I am constantly humbled by the diversity of skin, rashes, and humans who walk through my clinic. My professional life is one of endless observation, teaching, and learning, which is probably why I find so much joy in it.*
*Disclaimer: I am aware this somehow morphed into an essay about why I like dermatology, and so I think I’ll end here. I promise not to apply for any more degree programs… in medicine. I however make no guarantees about the burgeoning field of astrobiology.