A dermatologist treats disorders of the skin, mouth, hair, nails and external genitalia. This includes malignant and benign growths, contact dermatitis, and sexually transmitted diseases. The dermatologist is trained to recognize external manifestations of systemic diseases. They are trained to perform procedures that include reconstructive flaps/grafts, vein therapy, chemical peeling, acne scaring correction, introducing soft tissue fillers, anti-aging treatments, liposuction, hair transplants, and excisions of growths.
The descriptions of disorders seen by the dermatologist can be graphic in that they are visible to the eye.
The skin is made up of the epidermis, dermis, and subcutis. “Dermis” is Latin for skin, “epi” means above. The deepest layer of the epidermis is the stratum basale which is usually one cell layer thick. It is primarily composed of a population of constantly-dividing keratinocyte (the main cells of the skin) stem cells. When they divide in half, one cell stays in the stratum basale, while the other is pushed upward. As the cells are pushed upward they mature and accumulate the protein keratin. The upper-most layer of the epidermis is the “stratum corneum.” By the time the keratinocytes reach the stratum corneum they are dead packages of keratin 15 to 20 layers deep. This is excellent protection against water loss and infection. The dry and dead cells are not a good place for any parasite to penetrate.
In addition to keratinocyte stem cells, melanocytes are found in the stratum basale. They feed the dark pigment melanin to the stratum corneum. Darker-skinned people have more active melanocytes than lighter-skinned people.
Langerhans cells live in all parts of the epidermis except the stratum corneum; they capture and present pieces of foreign material to the cells of the immune system that will generate a specific response.
The dermis is a white connective tissue composed primarily of an inelastic fiber, called collagen. It also contains blood vessels, lymph vessels, hair follicles, and sweat glands.
The epidermis and dermis combined are the “cutis.” The subcutis or hypodermis is underneath the cutis. It contains many adipocytes, or fat cells. It is estimated that the average person has 30 billion fat cells. When one gains weight the normal response is for the fat cells to just get bigger. Only extreme weight gain can result in the increase of the number of fat cells.
Ancient History and the Middle Ages
The ancient Egyptians devoted significant energy towards the treatment of the skin. They often applied skin ointments while invoking the gods. They did not have a strict separation between medicine and religion.
One issue the Ancient Egyptians had to deal with was scabies; this is an infestation of ten to fifteen mites that burrow into the skin. It can cause a dramatic immune response. It takes about ten minutes to transmit the infestation from one person to another, so it often occurs during sex. It was commonly known as “the seven year itch” because symptoms were thought to last that long. This infestation was often treated with sulfur in Ancient Egypt, and it is still treated with sulfur containing compounds today.
Scabies is one of several conditions that can cause anal itching, or “pruritus ani.” This seems to have been a very common problem in Ancient Egypt. Physicians specialized in treating this ailment. In fact, there was an official title for the Pharaoh’s procto-dermatologist: “The Shepherd of the Royal Anus.” This also was a common problem in ancient Rome, perhaps brought on by the sharing of rinsed-out cleaning sponges at public latrines. Today, this problem is often associated with excessive cleaning.
Ancient people had to deal with small pox and this remained a problem up until 1978, when it was eradicated by vaccination. Three Egyptian mummies have been discovered with signs of small pox. This viral disease caused a distinctive rash with pustules which had a tendency to leave behind scars upon healing. Three out of every ten people infected died from small pox, and as many as 300 million people were killed by this disease in the twentieth century. A handful of samples of the causative virus are preserved in research facilities around the world.
Many people are under the impression that the bible refers to leprosy many times, but in fact the conditions referred to in the bible are several different diseases (or even mildew on one’s clothing), including what we call leprosy (or Hansen’s disease) today. It can cause the deadening of nerves in the periphery, followed by injury or even reabsorption (shrinkage) of the digits. It may be accompanied by the appearance of nodules in the skin.
Hippocrates
One of the earliest examples of purely scientific thinking is the writings of the ancient Greek, Hippocrates, (c. 430 BC) who is traditionally considered the founder of European medicine. Medical students recite a version of the Hippocratic Oath upon graduation from medical school. Referring to a disease, Hippocrates said that its cause was natural or miraculous, because everything is both natural and miraculous.
Hippocrates solidified the theory of the four humors. This theory held that in analogy with the mythical four elements of nature (earth, wind, fire, and water) there were four fluids that controlled the body: blood, phlegm, yellow bile (choler), black bile (melancholer). With the exception of blood, these names may not refer to anything real. “Phlegm” was not what we call phlegm today. Yellow and black bile have never been identified. The idea of four humors may have got its start from observations of sedimenting blood in a vial. Some red blood cells will collect in a dark clot at the bottom of the vial (melancholer?), on top of that will be brighter red blood cells (blood), on top of that will be a cloudy layer of white blood cells (phlegm), and finally the top layer would consist of a cell- free yellowish serum (yellow choler?).
It was thought that one’s disposition was dependent on the balance of these humors. People with a lot of blood were “sanguine.” People with a lot of phlegm lacked energy. Those with an excess of yellow bile, were prone to anger and bilious. Melancholer led to depression.
In addition, diseases arose from short term imbalances in these humors. Disorders of the skin were thought to be manifestations of these imbalances. This started a pattern in which dermatology would not be seen as its own discipline but merely an offshoot of general medicine. This was especially true of the Ancient Greeks, who were prohibited from dissecting cadavers and had very little idea what was going on under the skin.
The Hippocratic school of physicians used poultices (hot, moist, wraps- perhaps with herbs), baths, purgatives (causing bowel movements), emetics (causing vomiting), barley-water, barley-gruel, wine, hydromel (diluted honey drink), and oxymel (honey and vinegar drink). All-in-all it was a pretty subtle approach. It has been criticized as watching someone die with empathy. However, given that physicians of the day did not understand physiology, it was perhaps best that they weren’t aggressive.
Galen
Galen (129 – 217 CE) was an enormously influential Greek who lived in what is now Turkey. His architect father had a dream that he should become a physician, and Galen eventually treated several Roman emperors.
Medieval European scholars developed a reverence for the Greek and Roman works they discovered and translated. Unlike the ancient scholars, they abhorred experimentation and observation. It was enough to read what the ancients thought about an issue. So when Galen made a mistake it went virtually uncorrected for 1300 years.
Galen popularized humorism and emphasized the importance of prognosis.
Barbers and Physicians
If you go to a barbershop today they will cut your hair and may go as far as applying a styptic to a cut. In medieval Europe they also performed medical procedures such as amputating limbs and applying leeches to draw blood. Physicians were university-trained and preferred not to get their hands dirty. However, they might recommend concoctions to relieve symptoms. Dermatology grew out of the university/physician tradition even though they perform minor and major surgical techniques.
The Enlightenment
In the 1770s Joseph Plenck (1738- 1807) of Vienna sought to describe all of the 115 known dermatological diseases. He realized that this would be difficult without a classification system to help organize the information. He developed 14 categories. His work was expanded upon by Robert Willan (1757-1812) of England. After Willan’s death his work was summarized in A Practical Synopsis of Cutaneous Disease prepared by his student, Thomas Bateman (1778-1821). The popularity of this text established Willan as the “Father of Dermatology” in the English-speaking world.
The Nineteenth Century
The microscope started to become important in the understanding of dermatology by the 1840s. Johann Lukas Schönlein (1793-1864) discovered that “favus,” a crusty skin condition, was caused by a fungus, and in 1873 Gerhard Hansen (1841-1912) observed Hansen’s disease is caused by Mycobacterium leprae. This was the first confirmed link between a disease and a specific bacterium. German scientists were especially good at taking the dyes developed for their textile industry and applying them to microscopy. Microscopes became helpful in diagnosing skin pathology even when microorganisms were not involved. That is, they observed the cellular structure of normal and diseased skin.
Before 1850, most physicians strove to master all medicine and rejected specialization. The more discoveries were made, the more difficult it became to be a “jack-of-all-trades.” Dermatology faced especially tough obstacles getting established. The humoral theory led to the tradition that skin conditions were the “badness coming out.” According to this thinking, it was counter-productive to alleviate a skin condition rather than let it run its course. When physicians realized that some conditions were restricted to the skin only, those conditions became less important as they did not reflect a systemic defect.
Syphilis
When dermatology became recognized as a specialty, Dermatologists were the doctor of choice to treat syphilis. This practice continued until the 1940’s. In its early stages syphilis does present with skin sores, although it progresses to cause damage throughout the body. It is sexually transmitted (it can also be transmitted in utero) so it often greeted with embarrassment. According to Tampa and colleagues:
“…each country whose population was affected by the infection blamed the neighboring (and sometimes enemy) countries for the outbreak. So, the inhabitants of today’s Italy, Germany and United Kingdom named syphilis ‘the French disease’, the French named it ‘the Neapolitan disease’, the Russians assigned the name of ‘Polish disease’, the Polish called it ‘the German disease’, The Danish, the Portuguese and the inhabitants of Northern Africa named it ‘the Spanish/Castilian disease’ and the Turks coined the term ‘Christian disease’. Moreover, in Northern India, the Muslims blamed the Hindu for the outbreak of the affliction. However, the Hindu blamed the Muslims and in the end everyone blamed the Europeans.”
Penicillin is effective against syphilis.
The Career of a Dermatologist
A dermatologist undergoes an additional four years of training after medical school. They work about 45 hours per week. They make an average of $283,000.00 a year in the United States. In some regions they make as much as $355,000.00 a year.
Professional Organizations for the Dermatologist
The American Academy of Dermatology is the most influential professional organization for dermatologists. It was founded in 1938.
The American Board of Dermatology administers a voluntary certification. Dermatologists that meet their standards are “board certified.” This establishes standards for training and continued professional development above and beyond the minimum legal standards to practice medicine.
Procedures of the Dermatologist: Liposuction
The first recorded surgical removal of fat from the hypodermis using suction was in the 1920’s by a French physician, Charles Dujarier. Arpad and Giorgio Fischer, an Italian father and son team invented the modern form of liposuction by introducing a blunt-ended suction instrument, called the “cannula” in 1974. This was an improvement over the then-current state of the art in which fat was scraped out using a curette, a kind of metal loop. The old technique led to excessive blood clots and uneven skin.
]The technique was popularized by Parisians Yves-Gerard Illouz and Pierre Fournier. They introduced modifications to the incisions and introduced the “wet technique” in which salt-water saline was injected into the site to make suctioning easier. A great leap forward was made by Jeffrey Klein of California in 1987 when he introduced the “tumescent technique.” This entails injecting as much as three liters (about 100 ounces) of very dilute solution of local anesthetic. The large volume helps in removing the fat while the local anesthetic causes constriction of the blood vessels, decreasing blood loss. With this technique, the procedure can avoid the complications of general anesthesia.
Liposuction does not help in long-term weight loss or with obesity-related issues. However, the adipocytes do not grow back after being removed.
Procedures of the Dermatologist: Skin Peel
Chemical peels are typically acidic solutions that destroy the upper layers of the stratum corneum which is composed of dead cells. The epidermis then works rapidly to produce new cells. The resulting skin may have reduced wrinkles, scars, discoloration, and freckles.
Disorders Treated by the Dermatologist: Psoriasis
As noted above, the stratum basale produces new keratinocytes and pushes them towards the surface. The epidermis normally desquamates, shedding off a few of the upper skin cells on regular basis. Thus, the production of new cells and the loss of old cells are kept roughly in balance. In people suffering from psoriasis, their skin over-produces new cells, leading to swollen, itchy, red patches of skin. In some cases it is associated with arthritis. The cause of psoriasis is not clear, but it seems to be some kind of autoimmune response. Immune cells are attacking skin cells, causing vasodilation, and the over-production of new cells.
Disorders Treated by the Dermatologist: Acne vulgaris
Sebaceous glands excrete an oily substance, sebum, into the hair follicle. Acne vulgaris is typically caused when the bacterium Propionibacterium acnes over-proliferates and blocks the hair follicle. This causes swelling (commonly referred to as pimples) that may or not be inflammatory (involving an immune response that involves vasodilation). Propionibacterium acnes normally lives on sebum and skin proteins. Severe acne can lead to scarring which can be removed by laser-stimulated renewal of collagen that helps to fill in indentations. Alternatively, the patient’s own partially-purified platelets (small blood-clotting blood cells) can be injected into the site. Platelets are thought to promote healing. Yet another method is to inject a suspension of microscopic beads under the scar.
Disorders Treated by the Dermatologist: Skin Cancer
Basal cell carcinoma is the most common skin cancer. It has a five year survival rate of almost 100%. It can destroy large areas of skin, tissue, and even bone. Basal cell carcinoma is usually the result of too much sun exposure or the use of tanning beds.
Dermatofibrosarcoma protuberans is a rare cancer of derived from fibroblast cells of the dermis. The fibroblast is the primary producer of collagen in the skin. The origin of this cancer is fascinating: In the vast majority of cases there is a juxtaposition of the DNA sequences driving the expression of collagen with the gene for a growth factor hormone. Growth factors instruct cells to reproduce and divide. Apparently, this genetic defect causes these cells to instruct themselves to grow and reproduce. Still, these tumors grow slow and rarely kill anyone, but they can be dangerous.
About 87,000 people contract melanoma in the United States each year. It is by far the most serious of the skin cancers, accounting for 1% of all cancer deaths. It has a 92% five year survival rate. If it has spread to nearby lymph nodes, the survival rate is only 62%, and if it has spread further the survival rate is only 18%. This cancer is derived from the melanocyte that produces melanin in the skin.
Merkel cell carcinoma is more aggressive than melanoma but less common. It has an overall five year survival rate of 60%. The Merkell cell reports soft touch sensations to nerve cells and lives in the stratum basale.
The sebaceous carcinoma is also rare and dangerous. It is a tumor derived from the sebaceous gland (that produces the skin oil, sebum). It often presents as a growth on the inside of the eyelid. If it has spread to a lymph node, the survival rate is 50-60%.
There are about 1 million new cases of squamous cell carcinoma a year and almost 9,000 of these people eventually die. The squamous cell (also known as the keratinocyte) is the most common cell in the epidermis- arising from the stratum basale.
Moh’s surgery can be used to remove many skin cancers. This technique uses the microscope to assess the cells being cut out to see if they are cancerous. The physician cuts out progressively wider and deeper sections surrounding the original growth until normal tissue is reached.
Disorders Treated by the Dermatologist: Delayed Contact Hypersensitivity
The rash caused by Poison Ivy is a good example of Delayed Contact Hypersensitivity. It is an allergic response, meaning that it is an inappropriate immune response. It is delayed in the sense that it takes 48- 72 hours to develop. It is believed that Langerhans cells present oils from the poison ivy plant to T-cells (manager cells of the immune system) upon first exposure to the plant as if it was the product of a disease-causing pathogen. This causes there to be a population of T-cells primed to attack the next time this oil is presented. So, the first time one is exposed to poison ivy nothing happens. However, with the second exposure the T-cells order a massive response by macrophage cells that attack everything in and around the second exposure. The oil itself is not dangerous; the only problem is the body’s over-reaction to seeing it again. In general poison ivy rashes get worse with repeated exposure.
Disorders Treated by the Dermatologist: Vitiligo
Vitiligo is a condition in which patches of skin lose pigment. It apparently occurs when melanocytes die. They may be dying as a result of an inappropriate attack by the immune system against healthy cells, called autoimmunity. It can be controlled in some cases by immune suppressing drugs or creams. Tattooing, self-tanning products, and make-up can add artificial color to even-out skin tone. Alternatively, depigmentation might be a choice. Skin grafts, moving pigmented tissue from one part of the body to the other, are sometimes used.
Disorders Treated by the Dermatologist: Wrinkles
Wrinkles develop as we age and our collagen breaks down. The area under the epidermis becomes somewhat deflated and uneven. This trend can be cosmetically ameliorated by several kinds of treatments. Retinoids are lipid hormones related to vitamin A that cause keratinocyte to proliferate and promote the production of collagen, both of these effects inflate the area under the epidermis.
Botulinum toxin is produced by the bacteria Clostridium botulinum, and causes flaccid paralysis in which the muscles can’t contract. This is seen in fatal cases of botulism from food contaminated with Clostridium botulinum when the infected person can’t breathe. Small amounts of botulinum toxin (Botox) can be injected into the skin to relax facial muscles so the skin isn’t pulled tightly over the uneven deposits of collagen. This treatment has to be repeated after several months. There have been very rare cases of injected Botox killing patients.
Disorders Treated by the Dermatologist: Staphylococcus aureus Pathology
Staphylococcus aureus is a bacteria commonly found on the skin, in the respiratory tract, and in the nose. In the case of a wound or abrasion, Staphylococcus aureus can cause boils or scalded skin syndrome (wide swathes of skin look like the patient is suffering from burns).
Staphylococcus aureus contributes to a potentially life-threatening condition called necrotizing fasciitis (also known as “flesh eating disease”) in which large segments of soft tissue are destroyed. The risk of death from this condition after onset is as high as 35%.
Disorders Treated by the Dermatologist: Burns
Burn severity can be categorized into four categories. Third degree burns always lead to scaring and require skin grafts to repair. Fourth degree burns require the surgical removal of damaged tissue and reconstructive surgery.
Widespread burn injury can cause a systemic inflammatory (immune) response, fluid loss, and hypothermia (heat loss). In general there is a hypermetabolic response that burns more calories, increases blood pressure, raises the core temperature, and leads to weight loss. It is important that burn patients be kept warm and provided nutritional support. The control of infection is also important.
Conclusion
A better understanding of human health and medicine has brought dermatology into its rightful place. The ailments of the skin are no longer thought of as merely the reflection of the inner health but are often recognized as manifestations of problems in the skin itself. Therefore dermatology is worthy of special study and is no longer just an offshoot of general medicine.
American Academy of Dermatology, 2017. About the American Academy of Dermatology.. [Online] Available at: https://www.aad.org/about [Accessed 3 July 2017].
Center for Disease Control and Prevention, 2017. Hansen’s disease (leprosy). [Online] Available at: https://www.cdc.gov/leprosy/index.html [Accessed 30 June 2017].
Clayman, G. L. e. a., 2005. Mortality Risk From Squamous Cell Skin Cancer. Journal of Clinical Oncology, 23(4), pp. 759-765.
Fogg, N. P., Harrington, P. E. & Harrington, T. F., 2004. College majors handbook with real career paths and payoffs : the actual jobs, earnings, and trends for graduates of 60 college majors. Indianapolis, IN: JIST Works.
Hippocrates, 1868. Hippocrates Collected Works I. Digital Hippocrates ed. Cambridge: Cambridge Harvard University Press .
KRISHNAMURTHY, A. & MAJHI, U., 2014. Fibrosarcomatous Dermatofibrosarcoma Protuberans: An Unusual Tumor in the Facial Skin.. Indian Journal of Dermatology., 59(1), pp. 1-2.
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