It is the largest organ in the body – taking up 1.85 square meters and weighing some four kilos. Without it, we’d fall apart and be exposed to dangerous bacteria, yeasts and viruses. Yet most people take their skin for granted, unless something goes very wrong.
Some claim that dermatology, the study of the skin, is the easiest medical specialty, as it comes with normal hours and doesn’t require rushing to a hospital to see patients in the middle of the night. Yet diagnosing and treating skin diseases is becoming more complex than ever and requires the skills of a detective and compassion for the suffering patient.
Dr. Robert A. Norman of Tampa, Florida, has written or edited 28 volumes – from medical textbooks to popular, yet scientifically based books – on the skin. A fund-raising co-chairman of the Jewish National Fund’s Doctors for Israel and the 2012 recipient of Hadassah Women’s Zionist Organization of America’s Humanitarian Award, the 58-yearold Norman is not only a physician and author, but also a professional-level tennis player, blues harmonica player, nature photographer, artist, husband and father of five, and faculty member of five medical schools.
Every summer, he also takes medical students to South and Central America, including to Haiti, Argentina, Cuba and Guatemala, to show them unusual dermatology cases in clinics that give them more experience.
The latest of his dermatology books, a 138- page volume called The Blue Man and Other Stories of the Skin published by the University of California Press, explains not only basic and interesting facts on skin, but also contains vignettes of unusual patient cases. He enjoys an ideal world, as he decided when he reached the age of bar mitzva that he would be both a physician and a writer.
SPECIALISTS IN dermatology (a word derived from the Greek for skin and first applied to medicine in 1819) treat not only the skin, but also hair, nails and the scalp. It has been formally taught for more than 300 years, beginning in a school of dermatology in Paris.
“I try to speak for the skin,” writes Norman, “since it cannot speak for itself, and show you how lucky we are to have such an amazing natural covering. Our skin is our partner, nourishing and protecting us, teaching us about the world and serving as a record of our lives… Each day I try to heal the pain, both psychological and physical that illness of the skin causes people, as a physician, I am often required to peel away possibilities to get to the source of my patient’s medical problem and repair what has been disturbed or broken.”
One in every three people suffers from a skin disease at any given time.
Norman, a very empathic doctor, has always tried to look under the surface to discover patient’s personal problems beyond their complaints of itching, swelling or pain. He recalls a man complaining about a growth on his arm that caused pain. He pulled off the man’s home-rigged, ragged dressing and uncovered a profusely bleeding, half-dollar-sized skin cancer. It turned out the patient was so poor he didn’t have the money to get to doctors.
Another case involved an eight-year-old girl who has severe atopic dermatitis and a horrible itch. She had been out of school for three weeks and her mother was unable to work most of the time due to a lack of sleep from trying to care for her daughter. Those who suffer from prolonged skin disease often endure significant impairments of work, school and personal relationships, he writes.
While dermatology used to be considered a low-grade specialty, today it is science- based and rapidly developing, attracting the best medical graduates and requiring a high level of knowledge in psychology, genetics, immunology, biochemistry and many other fields.
Skin, Norman explains, “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 immunological 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 that protects us against bacteria.”
In a piece of skin the size of a US quarter, there are more than three million cells, 100 to 300 sweat glands, 50 nerve endings and a meter of blood vessels at work, the author notes.
“Without ‘normal’ skin, we may find it hard to hold a job, feel self-esteem, make friends or find love.”
THE LIST of skin diseases and conditions is almost endless. Among the most common are atopic dermatitis (eczema, involving a rash that may be a precursor of allergies and asthma); warts (that can be spread to other parts of the body by “auto-innoculation” via the mouth); psoriasis (an autoimmune condition); skin cancer (melanoma is the most deadly) and more. One of the patients who came in had more than 50 different disfiguring skin cancers that he had not bothered to have removed over many years.
Norman is a strong opponent of tanning salons where customers expose themselves to artificially produced ultraviolet-B rays.
He said that in the 1990s, there were almost two million “tanning junkies” who spent money on as many as 100 tanning parlor visits a year.
“No safe tan exists; all tanning is another form of burning,” he declares.
“UV light stimulates the production of melanin in the form of insoluable melanosomes that surround the epidermal cells, which move up to the surface of the skin and result in a tan.”
Although having pale skin used to be considered a sign of having great wealth, because its owner didn’t have to work outdoors, in the 20th and 21st centuries, tan skin was thought to be a sign of beauty and women’s magazines promoted tanning.
Those who claim they get tanned for vitamin D are misguided, says Norman, because this beneficial vitamin can safely and efficiently be obtained with drops and pills. As for those who tan artificially to treat seasonal affective disorder, he advises using “light boxes” that use a healthier broad spectrum light to deal with depression due to darkness.
Even normal skin carries huge numbers of living “things” on it.
“Each of us has about as many bacteria and yeasts on the surface of his or her skin as there are people on Earth.”
In addition, viruses are the smallest live inhabitants of our skin, reproducing by entering a living cell and fooling it into making more of the virus’s own genetic material.
They multiply inside the captive cell until it bursts, releasing more virus to colonize other cells.
Many people also have mites on their body.
“As many as 25 mites have been found hanging on to one human eyelash roof, a density that calls into question their benignity.”
Norman describes patients with delusions who falsely believe that their skin is infected by tiny parasites, causing them to itch endlessly and launch a war against their own skin.
Hospital patients are especially susceptible to infection in operating rooms, especially those undergoing hip replacements. Staphylococcus aureus bacteria flourish in wounds.
Louis Pasteur, who was the first to link bacteria to disease in man, was so fearful of infections that he “avoided shaking hands for fear of contamination.”
Fortunately, the vast majority of living creatures on the skin cause no harm, he assures his readers.
ONE MEMORABLE patient was Anthony, a 14-year-old, brought in by his mother Sophia. She was upset by a growing number of white spots on his face and hands. Performing a skin biopsy, Norman diagnosed vitiligo, caused by the absence or destruction of melanocyte pigments. He prescribed a topical cream and escimer laser treatment to bring the color back while sparing normal skin from harm. The condition affects between 1% and 4% of the world population, and patients since ancient times, he said, have suffered from psychological and social problems. Vitiligo is even grounds for divorce in countries like India.
Albinism, which affects about one in 17,000 in the US, affects people of all races; besides causing their hair to be white, it also weakens their vision and greatly raises their risk of skin cancer. One of Norman’s albino patients who grew up in South Africa had been regarded as “evil” because of the lack of melanocytes.
The “blue man” referred to in the title of the book was a Mr. B., who lived in a convalescent home where Norman consulted. The institution’s nursing director was concerned because he had recently “turned blue,” even through he was breathing normally and suffered no distress, so the problem was not caused by a lack of oxygen. The frail, 76-yearold man worked in an upstate New York post office before retirement. His medical history included a mild stroke, and he had taken minocycline antibiotics for infected bedsores. Norman performed a skin biopsy and a long series of tests. Finally, after ruling out many possible causes for Mr. B’s blue skin, Norman concluded that the antibiotic had caused this rare side effect. When taken off the drug, the poor man’s blue tinge began to fade, and later his normal skin color returned.
The author also discusses tattoos, which have become extremely popular (even in Israel, where it is explicitly regarded as forbidden by the Jewish law because it was a pagan practice to etch images into the skin).
“The electric tattoo machine was patented in 1891,” he says, “but tattoos have existed for thousands of years. Traditional methods included sewing lines into the skin, puncturing the skin with a long sharp point, raking the skin with rows of needles, chiseling he skin by hitting the chisel with a hammer blow to create precise lines and hand-poking it with a tatu needle.
Most of the tattooed patients his had also had piercings in various parts of their bodies.
“The human penchant for decorating the skin is unmatched in the animal world.”
Attending a tattoo competition out of curiosity, Norman confided: “Part of me waned to take a shower, and the other was fascinated by the display of skin and art.”
Tattooing can cause health risks, including infection and allergic reactions, and tattoo removal, requiring laser treatment, is not always entirely successful.
The Florida dermatologist concludes that “healing the psychological and physical pain of my patients are the chief goals of my daily work. Each day I explore and learn more about how the skin and our perception of it influence our social, cultural, spiritual and physical being. I hope that that inquiry, and this book, has helped you to learn and grow in your own skin.”