2

A short version of the long history of dermatology

98. A Red face with Pustules

99. A young Gentlewoman cured of Freckles by an Accident

100. A red Nose cured

101. A Palsy and Death ensuing the Cure of a red Face

102. An illustrious Lady cured of Flushings and a red Face

103. The cure of a red Face by Bleeding in the Nose

104. A Person kill’d by a Leech

105. Another in like Manner

106. A Gentlewoman cured of a Gutta Rosacea

Selected case studies from Daniel Turner’s 1736
De Morbis Cutaneis: A treatise of diseases incident to the skin

‘I saw an Upper West Side dermatologist – tall, blond, with intimidatingly great skin – who prescribed me another round of Retin-A.’¹ There’s a lot to parse here, but I homed in on the description of the dermatologist, more like a snippet of dialogue from Sex and the City than Grey’s Anatomy. Prospective patients don’t ask whether a nephrologist has good kidneys or insist that their cardiologist’s heart be exemplary before booking a consultation. We don’t judge ophthalmologists by their beautiful eyes. But is flawless skin a prerequisite for a dermatologist?

Professor Pablo Fernández-Peñas commented in a dermatology webinar that ‘Skin is our calling card.’ He wasn’t talking about himself but rather advocating for patients whose skin concerns are often dismissed as trivial. His point was that dermatology matters, and that fixing skin disorders is about health and wellbeing, not aesthetics, even if skin repair brings bonus cosmetic and psychological benefits. After years of talking to dermatologists for reasons both personal and writerly, I realised his description of skin as calling card had lodged in my brain.

I knew I was misconstruing the statement’s original intent, but I nevertheless fixated on the exteriors of skin specialists themselves, their own calling cards. What was dermatologists’ skin like? Not only those celebrity dermatologists who give plastic-surgeons-to-the-stars a run for their money. All dermatologists. Those more likely to publish in JAMA Dermatology, or to at least read it, than to appear in Vanity Fair, or on Botched.

I wondered about the workaday dermatologists in hospitals and clinics, peering for long shifts at eczema, psoriasis, pigmentation disorders, eruptions of acne, the symptoms of autoimmune diseases and rare but devastating inherited conditions such as epidermolysis bullosa, where the skin blisters with even mild friction. Those dermatologists devoted to hunting down and excising skin cancers. Those who spend their days treating distressed patients ashamed of their itchy, inflamed, flaking, allergic, suppurating skin. Board-certified dermatologists, dermatologists admitted to the Australasian College of Dermatologists or the American Academy of Dermatology. Members of the Royal College of Physicians in the United Kingdom who undertake years of further dermatology training to get onto the specialist register. All those people studying the science of skin, its physiology and pathology. Supervisors and lecturers in medical faculties, researchers and clinicians – the accredited, authoritative, dependable. Is their skin of the same (mainly) high standard as the work they do?

There is a joke that the collective noun for dermatologists is ‘a rash’. They do see a lot of rashes, it’s true, but I think that when two or more are gathered, a ‘complexion of dermatologists’ makes a better descriptor. For, once I began paying attention, the evidence for dermatologists having good skin snowballed. I watched a story about Australia’s first Aboriginal dermatologist, Dana Slape, on television. The profile was glowing and so was she. Dr Slape’s personal story and the work she does are inspirational – one of her patients with a chronic condition told me she was the best dermatologist she had ever seen – but I have no doubt other viewers, like me, were thinking as they watched, ‘She has great skin.’²

I watched TikTok videos of dermatologists giving advice about hormonal acne to their millions of followers. I assumed, wrongly, that they were models with perfect skin rather than highly qualified practitioners. Sitting in the waiting area of the busy dermatology practice I go to, I studied the doctors’ faces. Here is my attempt at field notes, words I jotted down each time a dermatologist appeared to call for their next patient: ‘alabaster’, ‘normal’ (I have no idea what I meant by that) and ‘looks young for her age’. Their headgear may have distracted me from my task. Dermatologists often wear magnifying visors with inbuilt lights strapped around their heads. They pull the visor up to their hairline and turn off the light between appointments, like weary coalminers but with better skin.

Listening hard and peering closely at the on-screen faces in dermatology Zoom webinars, I decided that poor lighting and occasional pixelation made adequate skin assessments impossible. So, I studied dermatologists’ author photos, prominent on the back covers – and sometimes on the front – of their skincare books. Professional photos lie, and makeup works miracles, but when I looked at dermatologists’ websites, even when they were wearing unflattering scrubs, I always reached the same conclusion: they have amazing skin. Smooth, evenly toned, flawless and often unwrinkled.

Are they a self-selecting group? Do they weed out the blotchy and blemished from their ranks? Of course, academic grades and aptitude matter to selection panels charged with deciding who to admit to dermatology training programs, but maybe being smooth-faced counts too. Perhaps some are plumped, smoothed and lasered by their own hand, with their own products. I could find no visible cysts, scars, premature wrinkles or pigmentation loss anywhere in sight. Some dermatologists, particularly those who do cosmetic work, speak publicly about the pressure to look good. Dr Terri P. Morris, a board-certified dermatologist from Virginia, said in a career profile, ‘I really feel that in cosmetics dermatology, I have to try to look the best I can. Because if I don’t, how are patients going to believe that I can make them look better?’³

Sydney dermatologist Dr Michelle Hunt said to me, ‘It’s nice to be able to reassure patients that even though I have had cosmetic treatments myself, I still look natural but hopefully a little younger than my age!’ She was good-humoured enough to remind me of the Seinfeld episode where George heaps scorn on the dermatologist Jerry is dating who claims she is saving lives: ‘She’s one step above working at the Clinique counter.’⁴

Dermatologists probably grapple with these misperceptions more than most other medical specialists. There are tensions between the cosmetic side of the profession and more ‘traditional’ dermatology, but I decided not to allow my glib question about dermatologists’ perfect skin derail the story of skin I wanted to tell – to trap me in generalisations and undermine my quest to take seriously what is often seen as superficial. And, anyway, the global pandemic stopped me from doing fieldwork, so I never saw dermatologists gathered en masse, up close at their annual meetings.

One wag suggested that other doctors see skin as a ‘flesh bag’ into which all the other ‘serious’ organs are stuffed. @DrGlaucomflecken, an ophthalmologist who spoofs medical specialisations in comedic TikTok videos, joked about dermatologists: ‘Just because we have a great schedule and we have these beautiful faces, people don’t take us seriously.’ But the more I learnt about dermatologists – and dermatology’s history – the more I admired them.

‘When I started in dermatology back in 1972, in Australia at least, it was a bit of a backwater. I couldn’t tell my teachers after I graduated – I worked at The Alfred Hospital in Melbourne – that I was interested in dermatology. I did general medicine first and trained as a physician. It was like doing psychiatry in those days. All the dropouts wanted to do it. If you fast-forward, now the top medical students in the country try to do dermatology.’ Professor Robin Marks, retired after an eminent career as a clinical dermatologist and researcher, is talking to me over the phone. He welcomes the chance to revisit how dermatology was perceived and to consider its shifting place within medicine.

While relatively small compared to other specialties, dermatology has also become one of the most popular medical specialisations in the United States, where it has a reputation among med-school grads for being a residency nearly impossible to ‘match’ into (meaning to be accepted into a residency program). It’s competitive elsewhere too. A British study showed that a sample group of medical undergraduates saw dermatology as niche, but a few rotations changed their minds. After that, more agreed that it was full of variety, which is a verifiable fact when you consider that dermatology deals with thousands of conditions.⁵ Its approach is also different. Pablo Fernández-Peñas points out, ‘Dermatology is one of the few specialties that still uses a lot of clinical skills for diagnosis.’⁶ It relies on visual and tactile recognition, listening skills, even smell.

I met Sydney dermatologist Dr Samuel Zagarella in his suburban rooms early one morning before his patients started arriving. He told me, ‘The beauty of dermatology, why I love it so much, is that just by looking at the skin you have insight into disease process that other doctors don’t have unless they do a CT scan or a laparoscopy, sticking holes into people so you can see inside them.’ Dermatologists don’t have to choose between medicine and surgery because they do both. I can see why Robin Marks claimed, ‘It’s the classical art of medicine.’

Yet dermatology has a reputation for not being ‘real’ medicine. For being all surface, somehow superficial, as if our skin doesn’t interface with the rest of us. Another reason for this might be that the field is no longer prominent in hospitals. Dr Michelle Hunt described an international phenomenon: ‘The almost complete disappearance of inpatient hospital beds available to our patients. The traditional twenty-bed dermatology ward that existed when I was a trainee is extinct.’ Cynics argue that patients rarely die on a dermatologist’s watch because by the time their condition becomes life-threatening they have already been referred elsewhere, to oncology for example. That they have chronic conditions that are treated – often by topical creams – but never cured. Dermatologists see their patients during standard office hours. Code red, middle-of-the-night callouts are rare. Zagarella jokes about the attitude of those saving lives in non-stop, adrenalised emergencies: ‘If you didn’t end up alcoholic and divorced you weren’t a real doctor.’

Perhaps I was developing Stockholm syndrome after all my time enmeshed in the world of dermatology. I see the unfairness of the medical system’s hierarchies of access and staffing as much as anyone but I started to feel annoyed on dermatologists’ behalf by the smug superiority other specialties direct their way. As if skin afflictions are inconsequential, don’t cause depression and anxiety, don’t reflect systemic health issues and don’t fill the top positions in lists of the most common cancers. As if skin conditions don’t account for one-third of all childhood disease.⁷ Dermatology is serious.

Dr Pascale Guitera, a dermatologist who works in academic and clinical settings in Sydney, chatted to me about the beginnings of her medical career in Paris. We talked on speakerphone while she was driving. She was stuck in traffic, which meant – happily for me – that we had a long conversation. Guitera confessed, ‘I didn’t want to be a dermatologist at all when I began in medical school. I was thinking it was a dusty and smelly specialty. But when you’re twenty you think a little bit differently than when you’re older.’ She was studying cardiology and told me that her male colleagues were ‘Very predatory . . . It was very macho, not very nice or welcoming to females. I found dermatology more welcoming. It was a young specialty with lots of opportunity.’

She says that working with confocal microscopy – optical biopsies of the skin, with no cutting involved – on melanomas ended up changing her life. Australia seemed like the place to be. She said, ‘Things were moving faster in Australia, with so much skin cancer and melanoma. I fell in love with the country – the people, and the generosity of the patients.’ She is now director of the Sydney Melanoma Diagnostic Centre and a faculty member of the Melanoma Institute Australia, as well as associate professor in dermatology at the University of Sydney.

Examining dermatologists under a glare like that of their Wood’s lamps, lasers and dermatoscopes set me wondering about the profession’s history. Dermatology lends itself to figurative language, skin as metaphor a rich seam to mine, although I would argue some writers should consider taking the scalpel or liquid nitrogen to their puns. I stopped counting the number of times I read the phrase ‘a rash decision’, or indeed ‘skin deep’. In that spirit, I’m sure you’re itching to know how dermatology started. What is skin’s role in the history of medicine? And how do centuries of colonisation and migration influence how skin conditions are treated today?

One of the bibles of dermatology, as we’ve seen, is Rook’s Textbook of Dermatology. First published in 1968 and referred to by everyone in the know as ‘the Rook Book’, it is now in its ninth edition. Dermatology textbooks appear impressively comprehensive (Rook’s has 160 chapters across four volumes) but the perception that they encompass everything within their many pages can be dangerous. Many trainee doctors, and their professors, don’t recognise common conditions on black or brown skin because their textbooks only present pink or red lesions on white skin. Primary care physicians, dermatologists and their patients have all called for more images of darker skin in medical textbooks.

In 2020, Malone Mukwende, a student at St George’s Medical School in London, helped produce a handbook called Mind the Gap to assist with clinical diagnoses in darker skin.⁸ His efforts went viral. The perils of training focused only on white skin don’t apply only to dermatology. Mind the Gap’s most unforgettable photo, in part because we can see the patient’s face, is of an intubated woman who is experiencing hypoxaemia. Lack of oxygen turns you blue or grey, a condition called cyanosis (cyan meaning blue). If a White doctor has a Bougainvillean or Sudanese patient with dark skin, for example, will they recognise blueness?

Sydney dermatologist Dr Monisha Gupta shared a vivid example of this skin-colour issue from her own training in India in the 1990s. She said the Rook textbook, which then had black-and-white images, described psoriasis as ‘Skin plaques with salmon-pink colour. I trained in the landlocked state of Punjab and had never seen a salmon. I didn’t have access to the internet either. So, I didn’t understand the description. Today, if I had to describe psoriasis in a darker-skinned individual I would say they are “violaceous, boysenberry-purple plaques”.’ Gupta’s fellow dermatologist, Melbourne-based Dr Michelle Rodrigues, whose background is also Indian, said when she was training in Australia in the 1990s and 2000s, ‘There was nothing relating to skin of colour.’⁹ She went on to found Australia’s only dedicated dermatology centre for those with skin of colour, and she continues to advocate for better education for medical practitioners.

This wall of Whiteness also obstructs the view back in time for anyone seeking to learn about the origins of human skin, or the history of dermatology. Most historians of dermatology – more likely to be retired practitioners than academic historians – embrace the idea that ‘the genius of great men’ drives history. A mechanism for understanding the cause, diagnosis and treatment of every malady bides its time before its discovery, when it becomes the next step in the trajectory of knowledge propelled ever onwards by the eminent men of medicine.

The authors of many histories of medicine deign to stand in the shoes of the doctors of Antiquity, the Renaissance or the Enlightenment, but their backwards gaze is suffused with arrogant hindsight. From our modern standpoint of evidence and reason, we watch those fledgling dermatologists of yore wrestle with the pathology of disease, equipped with nothing but flawed assumptions, rudimentary instruments and shifting nomenclature. How can you build case knowledge when it isn’t clear to you, let alone your fellow physicians, what you’re describing?

I balance my laptop, a recording device and a deep well of empathy as I stand on the fault lines where science and culture meet, shifting my weight from one side to the other, keeping my gaze steady.

Case histories, textbooks, general histories and memoirs written by physicians of skin plot breakthroughs scattered across the centuries. Ancient texts on papyrus or vellum that identify a recognisable dermal eruption may prompt a sense of affinity with those who came before. What do you know, Ancient Egyptians had psoriasis too. Yet medico-historians seem to assume we can’t really learn from skin’s case histories, the actual ills of our ancestors. It’s true that our medical knowledge is superior, stratospherically so, but our complacency deserves a corrective. The late historian of medicine Roy Porter rejected the idea that ‘the story of health and medicine is a pageant of progress’.¹⁰ Any twenty-first-century person who has an autoimmune disease such as skin lupus, or one of so many other conditions still without a cure, might only agree.

Histories of dermatology, while compelling and heroic, are also insular, focused on a European slice of the world.¹¹ They pay little attention to the influence of prevailing social and cultural values, to class, race and gender, to power imbalances and dispossession. Some writers gesture to the deep knowledge and long history of traditional Chinese medicine and mention the principles of Indian Ayurvedic medicine, but they leave serious consideration of shamans, folk-healers and indigenous peoples to others. You are more likely to read the phrase ‘ancient organic remedies’ on the label of a bottle of expensive moisturiser or on a website opposed to Western medicine than in any mainstream history of dermatology, although the Rook Book has a new section on aesthetics, including a chapter on cosmeceuticals that interrogates the efficacy of peptides, vitamins, antioxidants and anti-inflammatories, from aloe to turmeric.¹²

Contemplating skin’s prehistory catapulted me far back in time, by way of the literature of evolutionary biology, to the first Homo sapiens. Faster than you can utter the words ‘cradle of civilisation’ or ‘White privilege’, discussion of prehistoric skin leaps to the evolution of skin colour. Everything defaults, it seems, to the pervasive language of race, which is frustrating to a novice like me seeking out the first principles of human skin. While our species might never have evolved without our big brains and opposable thumbs, I relished and shared Monty Lyman’s sense of wonder at the evolution of the skin that got us to where we are today and clothes us still. ‘The human story could never have happened without our skin’s unique, if unromantic, qualities of nakedness and sweatiness,’ he writes, ‘the highly intelligent, but heat-sensitive, human brain could never have spread across the globe without a body capable of carrying it long distances in hot climates.’¹³

I am no evolutionary biologist, but if I had my amateurish way, we would add Homo dermis to Homo erectus or Homo ergaster and other members of the early Homo line-up that are ‘siblings’ to Homo sapiens. If someone were to denigrate a fellow human by calling them ‘a big hairy ape’, you could break the insult down into three parts: first, an apparent lack of intelligence; second, an evident hirsutism; and third, the alleged big hairy ape’s lumbering tendencies. Humans are more upright and – not to put too fine a point on it – smarter, but our relative lack of hair is indeed another difference between us and our non-human ancestors. Charles Darwin himself referred to the ‘nakedness of our skin’ in The Descent of Man. I’m taking liberties in paraphrasing the founder of evolutionary theory, but Darwin thought our relative hairlessness evolved to make us sexier to potential mates.

Darwin’s theory may hold some truth – eye of the beholder and all – but more recent research by evolutionary biologists and primatologists shows that skin played a key role in evolution, one quite different to Darwin’s theory of attractiveness. A brief but exciting foray into primate biology showed me that because we evolved to be relatively hairless creatures, human skin developed ‘adaptive structural changes’ that gave our skin greater strength, resilience and increased sensibility. Call it species vanity, but I was surprised to learn from scholar William Montagna that ‘Our skin is thicker than that of most other primates, tougher, more taut and more elastic.’¹⁴

Skin plays a role in our bipedal abilities too. It takes energy to remain upright, move about on two legs and hone skills of cognition and coordination: all this heat-generating energy must dissipate somehow, lest we overheat and perish. Having a body that is not covered in thick hair helps to regulate our internal temperatures. Montagna was a prolific Italian-born American biologist and primatologist who specialised in skin. He explained, in what Nina Jablonski describes as landmark work¹⁵ that ‘Dissipation of heat is the function that most conspicuously distinguishes human skin from that of all other mammals.’¹⁶ But because our hairlessness leaves us exposed to the environment, we developed an acute cutaneous sensory system, ‘a superlative tactile sensibility that would keep [humans] constantly informed of external conditions’.¹⁷

The process for ‘heat dissipation through skin’ is, of course, sweating. A 2018 study in the Journal of Human Evolution compared the density of sweat glands in three kinds of primates: macaques, chimpanzees and humans. Humans came out on top, with ten times as many sweat glands as the other primates, leading researchers to conclude that the density of eccrine sweat glands is a unique part of human lineage.¹⁸

When we want to shame and insult someone for their excessive sweating, the animal metaphor of choice is not the hairy ape but the sweaty pig. Porcine sweating lies beyond anything I’m seeking to learn, so I can’t confirm if ‘sweating like a pig’ is biologically accurate. But I do know that we have no grounds for accusing someone of sweating like an ape, because humans are the Earth’s sweatiest primates. Jablonski says, ‘The humble sweat gland thus must assume pride of place in human evolution.’¹⁹

If you think of sweaty bodies pounding the pavement during a lunchtime jog in Hyde Park, or a mass of people running in the Boston Marathon, you have landed on one evolutionary milestone made possible by our skin: we can run, even in hot temperatures, and our skin will act as a thermostat to maintain an internal temperature between 36 and 38 degrees Celsius. Running is central to the modern pursuit of personal fitness; in a time prior to recorded history it was no doubt useful for catching dinner, or fleeing from becoming it, as humans moved across the savannah and beyond.

These prehistorical considerations don’t feature in most histories of modern dermatology, however, to which we return. Immersed in the more recent history of the past millennium or so, I imagine myself, gowned and masked, observing a clinical encounter through the steam of a Roman bath, or from the corner of a medieval monastery, a herbalist’s cupboard, a shambolic eighteenth-century alleyway leading to a physician’s rooms. Or in my own times, sitting on a moulded-plastic chair in an air-conditioned hospital. A silent observer, I consider the forces, the discourses and the hierarchies that make this practitioner the expert for this patient with this condition.

What are the connections between a system of scientific knowledge and a system of belief? Might we find a junction between scientific method and the art of healing in any of these spaces? Also, how much do these doctors charge?²⁰

Dermatology is the ‘oldest of all the branches of medicine’, proclaimed a correspondent of the British Medical Journal in 1933.²¹ His proposition might be disputed, not least as he himself would have known that skin had only recently come to be considered an organ in its own right. Nevertheless, his boosterish case for dermatology’s long history solidifies when you factor in the rashes, scabs and parasites rife on bodies across human history. Skin also happens to be the most visible site to track the history of medicine – from the blistering, cupping, leeching, smoking and bloodletting used over centuries to remove the ‘evils of sickness’, to being a conduit for the life-saving drugs conveyed by epidermal syringe. This unnamed BMJ dermatologist, writing between the world wars, welcomes with great enthusiasm a just-published short volume about his specialty by the ‘famous American dermatologist William Pusey’.

The History of Dermatology may be close to a century old but it makes an excellent portal into dermatology’s progress as a medical specialty, from antiquity to the dawn of the twentieth century.²² Writing from Chicago, William Allen Pusey, renowned dermatologist and pioneer in the use of roentgen (radiation) therapy for treating skin disease, bares his own skin at the start of the book with this epigraph: ‘Creative intelligence is combined to the very few.’²³ Including himself in this exalted group perhaps appears arrogant, but I suspect Pusey had in mind those historians – particularly the many German historians of medicine – and physicians who make up the collective biography that is his book. He stands on their shoulders.²⁴

Staking a claim to his specialty’s longevity, Pusey informs his readers that the world’s oldest surviving medical book, the Ebers Papyrus, from Ancient Egypt, is devoted in part to surgery and skin. It describes alopecia, psoriasis, leprosy, scabies, furuncles and carbuncles. (The difference between the latter two is surely a starting point for a grotesque limerick about someone’s uncle: carbuncles are clusters of furuncles.) Sections of this influential papyrus list herbal remedies for bites inflicted by wasps, tarantulas, lice and fleas, even crocodiles. Pusey observes in an enticing way, too scant on detail for this reader, that the Egyptians were fixated on cosmetic dermatology. Everyone knows they used kohl as eyeliner, but perhaps he has Cleopatra and her famous milk baths in mind? Tracing anxieties about hair loss back through millennia, he mentions that the Egyptians made invocations to the sun hoping to reduce baldness.

Pusey makes perfunctory nods to the ancients including, of course, Hippocrates of Kos, described without fail in encyclopaedias and PowerPoint presentations around the world as ‘the father of medicine’. Hippocrates’ list of skin ailments recites like a visceral poetry of affliction: leprosy, lichen, scrofula, herpes, acne, loss of hair and disturbances of the nails. Pusey lists the achievements of Pliny the Elder, and Galen of Pergamon, the prolific physician of the Roman Empire, who historian Roy Porter described in his history of Western medicine as a man of vast erudition with a matching ego.²⁵

Aristotle wrote much of what we know about Hippocrates. In his quest to cover all bases of human knowledge, Aristotle wrote about skin, which he saw as an unflattering by-product not wholly of the body. He wrote that the skin is formed ‘by the drying of the flesh, like the scum upon boiled substances; it is so formed not only because it is on the outside, but also because what is glutinous, being unable to evaporate, remains on the surface’. This left skin – for centuries – in a paradoxical purgatory, revered yet dishonoured, celebrated yet ignored, bodies flayed solely to show what lay underneath. As University of Cambridge scholar Steven Connor writes, ‘For the classical and medieval worlds, the skin was everything and nothing . . . invisible like a screen.’²⁶

During the Byzantine empire, from Baghdad to Córdoba medical specialists were known as ‘physician-philosophers’. They contributed to knowledge of smallpox, studied and preserved Greek and Roman medical knowledge before it was transmitted, hundreds of years later, back to Renaissance Spain and Italy, translated from Greek to Arabic to Latin.²⁷ Like many books of its ilk, Pusey’s History of Dermatology treats the Middle Ages as a placeholder while we check our watches and wait for the Age of Reason to dawn. Yet the medieval period contains dermatological riches too arresting, and disgusting, to ignore.

The swollen and inflamed buboes of bubonic plague, the Black Death of the fourteenth century, for one. Another horror was known as St Anthony’s Fire. Caused by eating rye infected with a fungus – and poor people ate more rye bread than the wealthy, who preferred wheat bread – sufferers became horrifyingly ill with ergotism. Toxins in the rye caused hallucinations and, almost unimaginably, an actual blackening of the limbs, as if they had been ablaze. Calling it hellfire seems apt; the illness was so bad that many assumed it was divine retribution. St Anthony’s Fire was treated with cooling verbena and sage, which may have offered some relief, but when limbs turned gangrenous the only option was amputation. Medieval amputation was as bad as it sounds.²⁸

What might twenty-first-century students of medicine’s ‘placebo effect’ make of the healing touch of the king? The ‘Royal Touch’, as it was known, was appropriated by French royals and English monarchs from the time of Edward the Confessor in the eleventh century up until the end of Queen Anne’s reign in 1714.²⁹ Desperate wretches cursed with scrofula, their lymph nodes inflamed by tuberculosis, gathered in the hopes of receiving a miracle cure transmitted from the heavens by way of touch from a consecrated royal. Recovery rates of the scrofulous are not documented, but even if the cure were rumoured rather than actual, the ritual surely reinforced the divine right of kings. Regal insurance, should their military or political power falter. Reaping a national benefit was possible too: this ‘ceremonial laying on of hands was believed to cure the lesions, and further, to cleanse the nation of collective transgressions against God’.³⁰

In Shakespeare’s Macbeth, Prince Malcolm – soon to become king himself – offers a brief account of the Royal Touch to Macduff: ‘How he solicits heaven Himself best knows.’ He describes desperate pilgrims as ‘All swoll’n and ulcerous, pitiful to the eye’, as they seek the ‘healing benediction’.³¹ One critic has suggested that as well as praising indirectly his royal patron, King James I, who carried out the practice, Shakespeare perhaps had in mind royal benediction as a godly counterpoint to the demonic magic and dire prophecies of the witches. Not to mention Lady Macbeth’s obsessive hand-scrubbing.³²

Written long before any exhortation to decolonise dermatology, the pace of Pusey’s History of Dermatology quickens as the globe is colonised by European powers. He refers to the remedies of ‘primitive peoples’, by which he means non-Europeans, although he might have classed women in this group too. Women were excluded from the universities and hospitals that began to flourish during the Renaissance, which made it easier to ignore their folk remedies. Men ran the apothecaries, and historians debate the medical role that was played by women outside the domestic sphere. German mystic, abbess and polymath Hildegard von Bingen’s accomplishments include (possibly) being the first woman to write about skin diseases, including rosacea, and how to treat them.³³ Without question, women harvested herbs, made ointments, unguents and tinctures, and bandaged and applied salves to the skin over centuries. ‘Wise women’ – midwives, nurses and herbalists probably among them – were burnt at the stake during the Middle Ages for their efforts, accused of witchcraft.³⁴

Amid this horror, I was drawn to the wonderful names of botanicals. Pusey can’t resist including evocative lists of herbs, seeds and potions that were used as household remedies through the ages. Nor can I: aloes, dill, juniper, fennel, mint, turpentine, castor oil, linseed, beer, yeast, milk, hartshorn, iron, soda, saltpetre, caraway, coriander and poppy. He lists ingredients related specifically to dermatology, with the caveats that these treatments were not ‘rational’, that they were ‘more magic than intelligent’: antimony, calamine, sulphur, red lead, wax, balsam, myrrh, oil, goose-grease, honey and sea salt. As therapeutic as they sound, such remedies were overwhelmed by the great scourges of humankind: leprosy, syphilis, scabies and smallpox. Once ‘rational’ dermatology is set on its path, it becomes possible to associate the names of particular physicians with the diseases they identified and treated.

Leprosy, an ancient disease that is still prevalent in some parts of the world, drives exclusion and evokes horror to this day. It is now known as Hansen’s disease, and is curable with multi-drug, year-long treatment. Being the archetypical disease of stigma, however, means that its old moniker, shrouded in superstition and prejudice, has barely shifted. Leviticus (13:45–46) in the Old Testament includes the instruction that those defiled wretches with leprous skin must cry out ‘Unclean, Unclean’ as a warning to anyone who might come close.

Leprosy is less contagious than the shame and forced exile traditionally associated with it would suggest. Furthermore, some dermatologists have concluded that biblical leprosy is as likely to have been psoriasis or vitiligo. The disease affects the skin, the nervous system, by causing numbness, and the respiratory tract. Its origins are contested, but leprosy is one of humanity’s oldest diseases. Scholars have identified ancient references to leprosy in India and East Africa and, while it was present during the period of the Roman Empire, it most likely spread across Europe after the Crusades. Slave traders carried the disease to West Africa and across the Atlantic to the Americas.

Concerted investigation of leprosy by individual physicians powered dermatology’s progress.³⁵ Pusey describes French surgeon Henri de Mondeville’s fourteenth-century account of the effects of leprosy as being ‘as sharp a description of cutaneous symptoms as can be found, and has not been improved upon’.³⁶ It is indeed vivid. Norwegian doctor Gerhard Henrik Armauer Hansen, after whom the disease is now named, identified the bacteria Mycobacterium leprae in 1873. Not only was it the first disease-causing bacteria to be identified in humans, Hansen’s discovery proved that leprosy was no curse or punishment for sin. Yet leprosy remains a paradox because it has not been eradicated; there are an estimated 200,000 people with this disease in India and Africa, and, shamefully, still a handful of cases in wealthy Australia.³⁷ Ninety-five per cent of all humans have immunity to it, but it remains the one communicable disease that is also a major cause of physical disability.

Syphilis, another stigmatising disease that is today curable with antibiotics, manifests on the skin in its second stage, a harbinger of worse symptoms if left untreated. It is spread mainly through skin-to-skin contact, usually sexual, via a small ulcer called a chancre. Again, this disease spurred dermatological investigation and consolidation of knowledge. No wonder, given that every nation liked to think of it as coming from somewhere else: the Italians called it ‘the French disease’, the French ‘the Italian disease’, the Russians ‘the Polish disease’, the Poles ‘the Russian disease’, the Turks ‘the Christian disease’, and so on.³⁸ The research of Jean Astruc, a prolific writer and physician at the French royal court (who died twenty years before the French Revolution), became the compendium and treatise De Morbis Venereis, the first major work devoted to syphilis. Astruc commissioned the Jesuit mission in Beijing to obtain and label the herbs that the Chinese used to treat syphilis, and ship them to him in Paris for classification and study. The Journal of Ethnopharmacology, where I discovered this unexpected story, reminds us that disease is global and that not all dermatological knowledge stems from Europe.³⁹

After listing various medical scholars from across Europe who studied and wrote about syphilis, Pusey observes that, ‘In the three hundred years before 1800 the whole clinical story of syphilis was worked out’⁴⁰ – if not its treatment. The publication of his history of dermatology in 1933 coincided with the discovery of penicillin. Pusey’s career in dermatology came to an end at the dawn of the antibiotic revolution that would transform how infections of all kinds, including syphilis and leprosy, were treated.

The denouement of the biggest success story in the history of medicine, the eradication of smallpox through mass vaccination, was decades away. The appearance and later destruction of this deadly virus played out on the skin of humans across centuries. Its end began, famously, with pus from a milkmaid’s cowpox sore. Gloucestershire physician Edward Jenner is cast as this story’s hero, but as one historian writes, ‘For centuries, the Chinese had been blowing dried, ground-up smallpox material up the nose, and Arabs had been introducing pus under the skin. Inoculation had long been widespread in North and sub-Saharan Africa.’⁴¹

Dermatology has many progenitors, each a putative father of the specialty, but many bestow that honour upon Robert Willan. His Description and Treatment of Cutaneous Diseases, printed with graphic colour plates and published in parts between 1798 and 1808, was disseminated widely across Europe. Thanks to Willan, skin began to be understood on its own terms and was now conceived as a membrane, its purpose principally considered the elimination of wastes. A Quaker, born in Yorkshire and trained in Edinburgh, although he practised in London, Willan spotted the difference between chickenpox and smallpox. He is responsible for the modern conception of eczema. Eyewitness to the industrial revolution, he demonstrated the links between mechanisation and skin disease in factory workers. He was praised for ‘preaching the language of cleanliness’ but this did not stop Willan from contracting tuberculosis. He died on the island of Madeira in 1812, where he had moved for the benefit of the warmer climate.⁴²

Clinical dermatology made tremendous strides in the nineteenth century, notably with the establishment of the Hôpital Saint-Louis in Paris. A dedicated skin hospital, still functioning today in the tenth arrondissement, it happens to be where Pascale Guitera did her dermatology training two and a half centuries later. Five thousand disfigured figures in glass cabinets will never become one of Paris’s top tourist attractions, but you can visit its Musée des Moulages, a wax museum that displays the nineteenth-century gamut of skin disease.

Disease was documented in another curious form in the detailed drawings found in skin atlases. These volumes became nineteenth-century collectables, housed in the libraries of the upper classes. Dramatically different to the disembodied colour photographs of modern dermatology textbooks, and graphic as they may be, these drawings are works of art. One image from Thomas Bateman’s 1828 Delineations of Cutaneous Disease shows a lounging woman from behind. We see her aquiline nose in profile. Her bare back is draped with cloth, evoking an Ancient Roman who has just removed her tunic to get comfortable, letting her stole drop to her waist. Her back is covered with tentacled curlicues, her neck with neatly aligned red pustules. Were it not for the caption Psoriosis Gyrata, the viewer might assume her back was hennaed and she was wearing a necklace the wrong way round. Medical historian Jonathan Reinarz says these lavish atlases ‘Really set a new pattern for a medical text’.⁴³

The 1800s marked the era of laboratory study into the anatomy and pathology of skin. Ferdinand von Hebra, a renowned clinical dermatologist who worked at the Allgemeines Krankenhaus in Vienna, published a paper called Über die Krätze. This can be translated as About the Scratch, that irresistible urge that is the beginning, middle and end of so much skin disease. May krätze be a German word you never need to know because, specifically, it means scabies. Hebra, following the Italian physician Giovanni Cosimo Bonomo who prescribed antiseptic baths back in the seventeenth century, concluded that scabies was a local disease produced by the dastardly itch mite, rather than a systemic one caused by imbalances in the body as had previously been thought.

It is valid to ask whether scabies is better understood as a biological or a social phenomenon, given its association with poverty. As someone who has had it and can still recall the off-the-scale itchiness (or pruritus) I endured until it was treated, I wasn’t surprised to learn that scabies comes from the Latin word scabere, meaning ‘to scratch’. Caused by a tiny burrowing mite, scabies is highly contagious but treatable with a scabicide lotion (permethrin or the more recent ivermectin, which won its developers a Nobel Prize in medicine in 2015 and which does not cure COVID-19). Scabies patients must also wash their clothing in hot water and, as a precaution, all the clothes and bedding of others in their household. Which is why, in deprived and overcrowded communities, scabies can become endemic.

Scabies affects more than 100 million people across the globe, often because of reinfection. Maintaining distance and cleanliness is difficult if you’re in a refugee camp, a remote Australian Indigenous community with inadequate housing, or in many islands across the Pacific, where scabies is often rife.⁴⁴ One extreme seventeenth-century treatment for scabies was a mercury-coated girdle. London surgeon Daniel Turner, who lived between 1667 and 1740, worked in the blurred space between surgeon and physician, wanting very much to be accepted as the latter. In his book-length list of every skin disease he had come across (items 98 to 106 appear as this chapter’s opening), which manages to be comic, insightful and exhausting, he admitted that resorting to such a drastic remedy was rare. All the same, he promised that ‘we seldom meet with an Itch (however obstinate) that stands out against a Mercurial salivation’. Given a choice between the spirit-crushing itch of scabies or the devastating effects of mercury poisoning, some patients chose the latter to ease their suffering.⁴⁵

Overconfident, Dr William Pusey writes, ‘Before 1900, all the essential features in the anatomy and pathology of the skin had been worked out.’⁴⁶ Were he to reappear in 2022, Pusey might be surprised to learn that the dermatology curriculum of the UK Joint Royal Colleges of Physicians Training Board lists four thousand separate skin diseases and systemic ailments with ‘cutaneous manifestations’. As a champion of the eternal trajectory of medical progress, he would be unsurprised by emerging twenty-first-century immunotherapies, molecular medicine and gene therapies. Nor would the steroids and biologics that suppress the immune inflammatory responses of eczema and psoriasis surprise him. He would, however, be astonished that not all dermatologists are White men.

Women are now the majority of dermatology trainees in the United States. In the 1970s, less than 10 per cent of all dermatologists there were women. The numbers are comparable in Australia, where 45 per cent of working dermatologists are women.⁴⁷ Within the wider world of work, dermatology may not be the best exemplar of gender equality, but it scores better than many fields within the world of medicine. Orthopaedic surgery, for example, is more than 80 per cent male. Yet, most senior academics in dermatology are men and, as in most professions, female dermatologists earn less money than their male counterparts.⁴⁸

Dermatology is one of medicine’s least-diverse specialties in another way. Young American dermatologists Robert J. Smith and Brittany U. Oliver, who met during their residency at the Hospital of the University of Pennsylvania, felt compelled by the Black Lives Matter movement to write an editorial about dermatology and race.⁴⁹ (The piece notes that Smith is White, Oliver is Black.) What they produced for JAMA Dermatology is notably eloquent for a medical journal, so I wasn’t surprised when they described their collaboration to me ‘as a wonderful writing partnership’. Their opening line shows that history and politics are never left behind in the waiting room: ‘As trainees in dermatology, we feel a great disconnect between our professional approach to skin color and the reality of the racially charged world around us.’

The editorial is programmatic too. Never denying the currents of history nor partitioning science and culture, Smith and Oliver propose a formal curriculum on racial inequality, ‘to teach how historical perceptions of Black skin have led to the racial inequities that persist today’. They call for increased ethnic and racial diversity within dermatology and better advocacy for Black patients by the dermatologists caring for them. Disproportionately high COVID mortality rates among people of colour have been widely reported and discussed in recent years. Less known, perhaps, is that Black patients’ survival outcomes are worse with specific skin diseases, notably melanoma. Patients of colour, note Smith and Oliver, are less likely to be offered more expensive biologic therapies for treatment of psoriasis.

Their final, rhetorically charged words deserve to resonate: ‘Within the house of medicine, dermatologists are the designated caretakers of the skin. As a specialty, we must now embrace a greater calling. We must address the racial inequities and racial health disparities that exist because of systemic marginalization of people based on their skin color. Black patients’ lives are drastically affected by society’s perceptions of their skin color. It is time for us to acknowledge that our patients’ ailments neither begin nor end at the clinic door. We call on all dermatologists to join the fight in dismantling systemic racism.’