12

Skin irony

People are like planets, you need a thick skin.

Harper in Angels in America: Millennium Approaches, Act I, Scene 3¹

Tony Kushner’s dramatic tour de force Angels in America has its grand historical and political themes jostle – by way of sex, death and poetry – with messy emotions and a few cheap laughs. In an early scene that takes place in New York City, two men sit on a bench near an Upper West Side funeral home. They are Prior Walter and Louis Ironson. Louis’s grandmother’s funeral service has just finished. His lover, Prior, rolls up his sleeve and shows him ‘a dark purple spot on the underside of his arm near his shoulder’.

PRIOR: See.

LOUIS: That’s just a burst blood vessel.

PRIOR: Not according to the best medical authorities.

LOUIS: What?

(Pause)

Tell me.

PRIOR: K.S., baby. Lesion number one. Lookit. The wine-dark kiss of the angel of death.

LOUIS: (Very softly, holding Prior’s arm): Oh please . . .

PRIOR: I’m a lesionnaire. The Foreign Lesion. The American Lesion. Lesionnaire’s disease.

LOUIS: Stop.

PRIOR: My troubles are lesion.

LOUIS: Will you stop.

PRIOR: Don’t you think I’m handling this well? I’m going to die.²

‘K.S.’ is Kaposi’s sarcoma, a disease that can appear on the skin, mucous membranes or lymph nodes. Its vivid red-purple lesions were associated with HIV/AIDS, particularly in the early years of the virus; marks of disclosure shouting a deadly diagnosis to a hostile world, a sign that something within was going badly wrong. Dermatologist Dr Pascale Guitera said to me, ‘Suddenly, with HIV, we were seeing cancers like Kaposi’s sarcoma that we had rarely seen before. We realised that Kaposi was related to the immune system and, in time, found new pathways – particularly with T cells that were regulating more than destroying – that we were not aware of. Dermatology reminds us we are a big body interacting each time with everything.’ Identifying the mechanisms that destroyed the immune system and caused opportunistic skin infections, and symptoms much worse, gave rise to the immunotherapies used to manage HIV, and cancers such as melanoma.

When Guitera says that the body’s skin – the shape of us – interacts with everything, she means the skin and the liver, the skin and the blood, the skin and the immune system. But she might also mean the skin and the self. The cosmetic can be cosmic, as Michael Taussig says. We’re mostly unaware of our skin. It’s just there, in the way that gravity is just there, or in the way that time just keeps passing. Unless we’ve made a Faustian bargain and have a secret portrait in the attic keeping us young, like fictional Dorian Gray, regardless of cosmetic interventions most of us have – or will have – faces that match our years. Ageing brings decreased skin elasticity and increased friability that can make it more difficult for a wound to heal. If something is friable it is easily crumbled; aged skin is not usually that fragile, but a lot can go wrong with skin.

Dermatology recognises four thousand or so skin conditions. When one of them appears on our surface, mysterious or chronic, our anxiety surges and our mood sinks. Watching a rash spread can be like watching flood waters rising, except that you can’t evacuate. Monty Lyman writes, ‘I was captivated by the idea of “reading” the skin, communicating with messengers who told stories of distant and unseen internal organs.’³ Skin can act as a barometer of much else.

What is the skin trying to say? The conditions we’ve looked at in this book – the challenging but non-life-threatening vitiligo, acne, psoriasis and eczema – are often systemic. They can affect the whole body, but skin is the stage where the action plays out. Rashes, itches and inflammation can also be by-products of disease, one symptom among many rather than the main concern. Darkened, thickened skin patches, for example, can denote diabetes. The rare genetic skin disorder ichthyosis makes skin red and scaly, prone to itchiness, dryness and infection, and can be painful. Ichthyosis, I learnt, can appear in adults who have lymphoma or multiple myeloma. Australian writer Carly Findlay talks about living with ichthyosis since childhood in her defiant memoir, Say Hello.⁴ As well as it being painful and physically very obvious, Findlay says that the biggest obstacle she faces is not the ichthyosis itself, but the discrimination and ableism it provokes in others.

Our linguistic skills struggle to do justice to the splotches across our bodies. It is confounding that liver spots, which I assumed represented a direct connection between our biggest organ and a crucial internal one, have nothing to do with the liver and everything to do with the sun. ‘Liver spot’ is simply another word for age spots, or solar lentigines. For clinicians, especially non-dermatologists, distinguishing between the permutations of rash, lesion, pustule, blister, hyperpigmentation, hypopigmentation, ulceration or crusting on skins of varying pigments must be like attempting a one-thousand-piece Jackson Pollock jigsaw puzzle, one with splatters from the colour spectrum across red-purple-magenta-puce-pink-aubergine-brown, an occasional yellow, blue-grey or white splash indicating jaundice or pallor. Harvard Medical School dermatologist Dr Steven Chen is active on #DermTwitter as a clinician and educator and joked in a tweet that after choosing paint colours for interior redecoration, his skin exams were about to get more interesting: ‘The ulcer is surrounded by a “balboa mist” border and has a “camellia pink” base with some “man on the moon” crust.’⁵

For most of us, most of the time, whatever its colour, whatever its markings, skin just is. We check in on ourselves unconsciously, running a finger along a strand of hair, touching the skin on our nose as if to make sure it’s still there. We unthinkingly scratch an itch. The health and safety guidelines that emerged around COVID-19 made us realise how hard it is not to touch your face. Other times, what we do or have done to our skin – tattooing, passionate caresses, exposing bare legs to springtime air – can make us feel confident without and peaceful within, at one with the universe. But so much of what our skin does – and does to us – is out of our control. It might not reflect how we see ourselves or how we want to be seen. It might be a perfect reflection of our self but carry dubious status in the eyes of others. Skin’s imperfections and betrayals can bring us crashing back to Earth.

Imagine the psychic impact of K.S. lesions on a young body. An entry stamp for a club you have dreaded joining appears on your skin, as stark as a ‘We regret to inform you . . .’ telegram delivered during war. Your skin as the bearer of bad news. David (a pseudonym) volunteered with the Community Support Network, a group that offered home care for people with AIDS, in Sydney in the mid-1980s. He recalled a confronting scene. ‘When I first started caring, it was horrific. People’s average lifespan was under twelve months. Kaposi’s sarcoma was rampant. Going to the clinic at St Vincent’s was just a horror story. They would have certain days where people with HIV would present and there would be twenty or thirty people there with various forms of Kaposi’s sitting in wheelchairs.’⁶ Few of the young men who made up this hellish scene survived to tell their stories, felled too soon by a devastating virus transmitted primarily through sex, one cruel enough to stain the skin. A horror of biblical proportions.

In Angels in America, Prior delays exposing the lesion on his arm to Louis because he fears Louis will abandon him when he gets sick. He is right to worry; Louis does leave him. Kaposi’s sarcoma was a harbinger of death for most people with AIDS in the early years of the disease. Yet though Prior grows frail and walks with a stick, is hospitalised, brutalised by experimental drugs, prayed for by a pious homophobic Mormon lady, hallucinates, and is visited by a fierce angel, he doesn’t die. He is the play’s hero and delivers its final speech, one difficult to hear without weeping as you remember all those young men. We won’t die secret deaths anymore. I imagine Prior Walter living on, fabulous, a long-term survivor thanks to antiretroviral drugs and because he cannot help wanting more life.

AIDS became known as ‘the gay plague’, and those diagnosed with the disease were often ridiculed. AIDS was rampant until new classes of drugs ensured it was no longer a death sentence, and then it seemed strangely forgotten. Until another plague arrived in 2020. With COVID-19, the tragedy of isolated deaths in hospitals played out across the globe once more, the dying surrounded by masked and gowned medical teams hypercautious about infection. Families of the sick were again distant, though this time by force, not choice. We lived through another frenzied search for origins and means of contagion, therapeutic drugs, vaccines, botched public health responses, public hysteria and all kinds of misinformation. Quarantine was resurrected. And, once again, the skin could mark the presence of a virus. COVID-19’s main symptoms are respiratory, but it affects the skin too.

Dermatologist Hélène du P. Menagé told me that at the start of 2021 she saw something unexpected in her practice. ‘A whole cohort of people were coming in with unusual chilblains. I had no idea what it was at first, but it’s COVID. These people now test negative but have been in a COVID environment. This perniosis [the medical term for chilblains] is probably inflammatory rather than thrombotic.’ For some, the only clinical sign of COVID infection was on the skin. The British Association of Dermatologists divided COVID-related skin conditions into three categories: COVID digits, what Menagé saw, can appear on (mainly) young people’s toes and fingers, long after the original infection. Second is eczema, which can develop on people who have never had eczema before. The third group is a range of rashes – purpuric, rosacea, urticarial – that researchers said were more common to COVID and made up a more diverse set than those of other rash-producing viruses.⁷ Fearful people, recovered or not, bearing unusual rashes or COVID toe – chilblains in summer! – were signs of a world turned upside down. Those stricken with long COVID no doubt wonder what ‘normal’ will look like when they can expose themselves to the world again.

Imperfection, as Lee Kofman describes it in her book Imperfect, casts her and many of her subjects as perpetual outliers – self-conscious and wary, carrying traumas visible from the outside. Kofman writes about her lifelong compulsion to conceal her scars. Born in the former Soviet Union with a congenital heart condition, surgery in Moscow when she was a child left her with scars on her wrist, under her armpits, on each side of her groin and, most prominently, on her chest, beginning at her collarbone and ending somewhere below her breasts. With wry irony she writes, ‘If I’d been operated upon in the West, this scar would have looked more presentable, but in the Soviet hospitals no surgeon wasted their precious time on such trivia as aesthetic skin suturing.’ Worse was to come. Aged ten, she was run over by a bus in Odessa and the lower part of one of her legs was badly damaged. Her mother, waiting in the hospital afterwards, overheard a senior surgeon utter words no parent wants to hear when their child is in the operating theatre: ‘What kind of idiots are these? They might have been sewing up a dog, not a person!’

After living for many years in Tel Aviv, Kofman moved to Melbourne, where she realised her scars were embedded into her psyche as much as into her body. In her candid book, rooted in experience, scholarship and empathy, she interviews many people who are ‘different’. I found her story profound because, as she notes, being able-bodied does not free her from what is for her a burden. She writes, ‘Women’s selfhood has always been tied closely to their appearance; women have been, and are, their bodies.’⁸ After years of wearing clothing that hides her scars – for Kofman, the beach is not a place of liberation – and engaging in surreptitious tactics to ensure they remain unseen, she writes, ‘I began suspecting that it wasn’t just me always trying to manipulate my body and minimise its offences. Since then, I’ve been wondering: is it possible that the relationship between body and self goes both ways? That our bodies turn tricks on us too, smiling their fleshy smiles at our dreams of mastery? Is it possible my body has something to do with the person that I am?’ She ponders whether beauty and its supposed opposite, imperfection, go deeper than the skin to enter our core.⁹

In her conclusion, Kofman uses an evocative phrase, writing that our ‘Body Surface’, as she calls it, ‘doesn’t determine us, but creates the weather of our lives’.¹⁰ I was not at all surprised by her retelling of a conversation with another writer she describes as beautiful, ‘lipsticked and slim’.¹¹ This woman, decades older than Kofman, assumes she must be writing about scars as metaphors of survival. She is dismissive when Kofman corrects her and explains she is writing about actual scars, about what it’s like to live inside a scarred body. The other writer responds by saying, ‘Oh, body image’, with blithe derision. I felt affronted myself; I mean, who among us has never looked in the mirror and wished for something a little different to look back – thinner, smoother, younger? Perhaps inadequacy, exclusion or stigma are not existential torments this woman has had to grapple with. Lucky her.

People who fit a certain mould can assert its irrelevance. You’re perfect to me, they patronise, when someone with, say, an obvious port-wine stain knows all too well that their birthmark is what everyone sees first and may not get beyond. A man told me, gut-wrenchingly, about the severe acne he experienced as an adolescent: ‘I felt as if my appearance was a burden on people – and I still haven’t shaken that, even without the acne.’ If we were truthful, we would acknowledge that, seeing as we can be distracted by something as trivial as parsley in someone’s teeth, facial or bodily differences must be more unsettling. The challenge is to move beyond these and see the whole person. If we deny their scars are relevant or even noticeable, we can’t achieve that.

Naomi Wolf’s bestselling book The Beauty Myth, about the poisonous, exploitative nature of beauty as currency, made a big impact when it was published in 1990. (It has lived on my bookshelves ever since, but I chose not to revisit it in this book because its author seems to have turned into a conspiracy theorist.¹²) Were we to give Wolf’s book a makeover – Now with social media! Free Botox voucher inside! – its thesis would be bolstered by a Grand Canyon’s worth of new evidence. I might propose a companion volume: The Beauty-From-Within Myth. We seem not to insist that beautiful people be beautiful on the inside too. Attractive people who rail against oppressive beauty standards rarely forget that beauty is gendered. But, especially if they are not people of colour, they often seem to forget that beauty is intersectional: its norms are racialised, and exclude trans and queer people, and the disabled. They might assume everyone has the accoutrements of stable employment and secure housing. Exceptions to the default are possible but remain just that, exceptions.

American scholar and writer Tressie McMillan Cottom, in her powerful, discomforting essay ‘In the Name of Beauty’, from the collection Thick, makes clear that the beauty myth is White, it is Western and it is a specific kind of capital. She writes, ‘When white feminists catalogue how beauty standards over time have changed, from the “curvier” Marilyn Monroe to the skeletal Twiggy to the synthetic-athletic Pamela Anderson, their archetypes belie beauty’s true function: whiteness.’¹³ That she describes herself as ‘not beautiful’ made her essay controversial and deeply transgressive. White feminists decried her self-assessment, responding, as she puts it, with ‘neoliberal self-help’, wanting to fix her rather than fix the world.¹⁴ Some Black women accused her of being self-hating, of not loving herself for who she is.

But her self-categorisation does not rest on the aesthetic. She writes about beauty as an instrument of capitalism, one designed to coerce and exclude, which is of course what politics does too. It is about power. What beauty is changes as our collective values change, but its economic potency remains. Countless magazine articles and psychological studies tell us that humans have an innate preference for symmetrical faces. But there is no reason we should default to some ‘natural’ innate preference for White, blonde women as the archetype of attractiveness and desirability. McMillan Cottom stated this bluntly in an interview: ‘Turn on Fox News, right? And you tell me what the visual comportment of power looks like.’¹⁵ Her brilliant essay argues that ‘Because it is an idea and a good and a body, beauty serves many useful functions for our economic system.’

I reproduce the essay’s powerful final words, which are even more impactful when you’ve read those that precede them:

When beauty is white and I am dark, it means that I am more likely to be punished in school, to receive higher sentences for crimes, less likely to marry, and less likely to marry someone with higher economic status. Denying these empirical realities is its own kind of violence, even when our intentions are good.

They say that beauty is in the eye of the beholder and that ugly is as ugly does. Both are lies. Ugly is everything done to you in the name of beauty.

Knowing the difference is part of getting free.¹⁶

The title of this chapter comes from words I saw painted on a shopfront window. SKIN IRONY stopped me in my tracks. If my neurotransmitters hadn’t fired up with the concept’s possibilities, I might have paid more attention to what was behind the words before I photographed them with my phone. I assumed SKIN IRONY would brand a cosmetics store or beauty salon, perhaps a laser clinic, but the unintentional irony was that Skin Irony is a kind of wristwatch. (Which makes no sense to me, although my face is a literal reminder of skin as a marker of time.) SKIN IRONY made me picture other cynical generation X-ers applying their skincare products ironically, hyperaware of the incongruities between expectation and reality. Or perhaps skin irony promised revolution: earnest skincare proselytisers pivoting to self-criticism and smashing the oppressive structures of cleansing and moisturising. The queen is dead, long live the queen!

Skin is real, it’s a fact, we can’t live without it. Skin’s irony is that appearances are never what they seem. The pay-off that may or may not result from the exertions and expense of grooming. The smoke and mirrors of filters and muscle relaxants, the camouflage of makeup. A country proud of its Whiteness with many of its citizens desperately wanting a year-round tan. The way a tan on a body sipping an Aperol spritz by the pool means something completely different to the brown skin on a body labouring on a farm. The faux truth and verbal irony of beauty is in the eye of the beholder; that aphorism conveying a generosity and inclusiveness the speaker doesn’t believe themselves, because the person in question is not beautiful by all the standard, culturally dictated measures. Is it situational irony that McMillan Cottom, who writes about not being beautiful, received a 2020 Macarthur ‘Genius Grant’? I would call that poetic justice. One reason I love her work lies in its sociology: it scrutinises the social structures that form the self as much as it examines the individual self.

Lee Kofman doesn’t feel that she or the other ‘imperfect’ people she writes about, including her own son, who has albinism, have the luxury of being detached and ironic about their appearance. The contradictions and dualities of skin are never distant. Our skin structures who we are in a social and a psychic sense. Skin might be read as our authentic self, but we won’t always feel comfortable in our skin. Skin colour is no guarantee of belonging, as we have seen. We can feel proud of our skin and how it got us to where we are, and commit to loving ourselves. Until it makes us invisible, or until someone else’s words or gaze diminishes or judges us, makes us feel captive in our own skin. Or pushes us into self-abnegation. Few skin-related insults will be as visceral as King Lear’s to his daughter Goneril when he sees her for what she is. He tells her that she is like a disease that has infected him: ‘Thou art a boil, A plague-sore or embossèd carbuncle, In my corrupted blood.’¹⁷

Skin can become a weapon used against us by others. Sometimes, our own emotions make our skin turn on us in ungovernable ways. We can only take it personally.

During the terrible months after our son died in 2001, a painful rash splayed across my husband’s torso. Shingles. No one seemed especially surprised that the emotion of loss should manifest on the skin, but that didn’t make it less awful for Adam. Grief, combined with the stress of searching for work before we moved back to Sydney from Singapore, had evidently compromised his immune system. This triggered the varicella zoster virus, dormant since a childhood bout of chickenpox. It’s easy to blame every ailment under the sun on stress but, as Monty Lyman says, ‘with what we understand about the effects of mental stress on the skin, it shouldn’t be surprising that the mind is often the gateway to physical disease.’¹⁸ Shingles can affect a segment of skin called a dermatome, an area supplied by a single nerve emanating from the spine.¹⁹ (‘Dermatome’ sounds to me like a book bound in human skin, which is a subject I encountered in my research but chose not to write about.) Our bodies contain thirty dermatomes from top to toe. Their usually invisible boundaries can be marked out by shingles, not that I would recommend contracting it so as to observe them. For Adam, neuropathic pain tracing tree-shaped nerve lines across his torso echoed the emotional pain within.

Siri Hustvedt’s novel What I Loved has a devastating description of grief made visible on a bereaved woman’s skin.²⁰ Leo, an art historian who is the book’s narrator, has lost his son in an accident. Later in the novel his best friend, Bill, an artist, dies. Leo visits Bill’s widow, Violet. ‘When I turned from the window and looked at Violet, she was so pale that her skin looked transparent, and I noticed a rash on her neck. Beneath her lowered eyes were faint purple shadows. I knew what I was seeing: dry grief, grief grown old and familiar.’ Grief mixed with anxiety can, in a moment of crisis, produce the opposite of dark rings and pallor. I remember emerging from an ultrasound early in my pregnancy with our second son, Toby, and running to the clinic’s bathroom. The scan showed everything was fine, but I was consumed by the tragedy presaged by my previous ultrasound experiences. Worrying that my racing heart might rupture, I looked in the mirror and saw a lurid rash across my face, neck and chest, as if my upper body were about to ignite. I splashed cool water on as much skin as I could, trying to extinguish the roiling emotion. But it was coming from the inside.

Stress, you won’t be surprised to learn, is bad for the skin. Rather than recalling undergraduate philosophy seminars on the intricacies of the mind–body problem, let us agree that the brain and the skin are connected. This means, as one writer in the New York Times expressed in a relatable way, ‘When one senses embarrassment, the other blushes. When one senses pain, the other processes it. And when one bears the burden of a pandemic, political unrest, systemic racism and the ever-worsening effects of climate change . . . well, the other gets a pimple.’²¹ Cortisol, the body’s main stress hormone, can deplete the skin’s sebum, water and microbiome. Sometimes the best way of treating your skin with your mind is to take deep breaths and calm down. But don’t de-stress with a strong drink, because alcohol can bring on a flush, which when it happens to me apparently suggests a tendency to rosacea. For people with Asian backgrounds, flushing after a glass of wine is commonly caused by a lack of the enzyme that breaks down alcohol.

If I’m nervous before speaking in public, a surge of adrenaline might generate a blush across my face. I don’t mind too much about this energising dilation of blood vessels on my cheeks because it helps with the task at hand. And makeup is my friend. There’s a lovely scene in the classic Canadian novel Anne of Green Gables, where Anne gives a verse recital for a fundraising concert at the White Sands Hotel, dressed in white organdie, her new beads hanging around her ‘milk-white throat’. Overwhelmed by stage fright, she sees Gilbert Blythe – her enemy but eventual paramour – at the back of the room. She vows that he will never, ever laugh at her again, as he once did by calling her ‘Carrots’ on account of her despised red hair. She shines at her recital and returns to her seat ‘blushing with shyness and delight’. Called back for an encore, ‘smiling, blushing, limpid-eyed’, she again triumphs.²² Blushing because of embarrassment, humiliation or awkwardness is an altogether different matter.

It is all too easy for most of us to pick a ‘made-my-face-burn-with-shame’ recollection from our mind’s storehouse of embarrassments. The act of remembering might reignite the original sensation, making us radiant for the wrong reason. It is as if our skin – cheeks, forehead, neck, even our ears – turns red because it too is embarrassed for us. Whose side are you on, skin? Here’s one incident from thousands I might share, one I can laugh about now. Once, I had to answer a question in biology class in the Mexican high school where I was an exchange student for a year. The answer required the word ‘carbohydrate’ (carbohidrato). I could only pronounce it in a way that was evidently hilarious. The whole class, as I recall to this day, was laughing and shouting ‘starch!’ (la fécula) at me, a word that is indeed easier to pronounce. But I didn’t say it, because I didn’t know what it meant. A scarlet face reflected my inadequacy and compounded it.

Literature offers a rich inventory of the index of emotions that blushing can express. (A good actor can make themselves cry, but because it’s near impossible to make yourself blush it is rare to see a stricken character turn red at precisely the right moment on stage or screen.) Were Victorian literature across the nineteenth century and into the twentieth assigned a theme-colour it would be vermilion, thanks to Jane Austen, George Eliot, Charles Dickens, Edith Wharton and others. Seeking examples of flushing and blushing in the books themselves can quickly overwhelm a reader, as one of my friends found with Wharton’s The Age of Innocence. He began marking references to blushing or its opposite, paling, intending to send a few lines relevant to my project. Blood must have been rushing to his own temples as he compiled close to a thousand words’ worth of examples: ‘deep blushes rising’, ‘colour draining from the face’, ‘dusky blushes’, ‘vivid blushes’, ‘reluctant blushes’, ‘creeping blushes’. Enough to make you blush.

Analyses by academics such as Pamela K. Gilbert, who examines skin through a literary lens, suggest that when critics find themselves scrutinising characters’ complexions in salons, theatres, dining rooms, parlours and bedrooms, or outside during genteel walks and desperate rambles, their own scholarly colour rises with excitement. Professor Gilbert’s research into the medical history of skin is fascinating, but more exciting is her excavation of blushing, or rubor. If a blush is a bodily manifestation of affect, as she says, tied to self-consciousness or self-knowledge, it happens precisely at the moment before we articulate that emotion. We are flooded, involuntarily, by a blush almost before we can identify its cause, whether it be embarrassment, yearning, innocence or vexation. Gilbert writes that during the nineteenth century, blushing became a focus for explaining human behaviour (Darwin called blushing ‘the most peculiar and most human of all expressions’) and an important device in novels. But not all blushes were created equal; Victorian readers were tasked with decoding each in ways we shameless twenty-first-century readers are incapable of.²³

Blushing is not always welcome, but it can be a way for the skin to speak when other forms of expression are repressed. One critic noted that Jane Austen’s blushing characters ‘reveal things about themselves that would be difficult for them – living, as they do, in a highly-mannered world – to reveal in speech’.²⁴ For young women and girls, blushing could be a sign of fertility and sexual awakening, or could signal modesty and virtue. On the other hand, not blushing might mean you knew too much to be ashamed.

Blushing was not generally celebrated in men, and that remains largely the case. There is a wonderful scene in Pride and Prejudice when Elizabeth Bennet sees Fitzwilliam Darcy (who she misreads as arrogant) facing George Wickham (who she misreads as charming) for the first time. She notices, ‘Both changed colour, one looked white, the other red. Mr Wickham, after a few moments, touched his hat – a salutation which Mr Darcy just deigned to return. What could be the meaning of it? It was impossible to imagine; it was impossible not to know.’ One imagines Elizabeth’s cheeks growing rosier just thinking of the delicious possibilities. Later she learns that ‘Darcy’s was the pallor of righteous anger, and Wickham’s the rubor of shame.’²⁵ Here, cheek colour demonstrates contrasts of character that Elizabeth eventually sees herself: she agrees to marry Darcy. Before that denouement, there is an intensely romantic, even erotic, moment where, ‘Their eyes instantly met, and the cheeks of both were overspread with the deepest blush.’

Anger can cause us to redden through the whole-body phenomenon that is flushing. Nina Jablonski cites evolutionary reasons for this, writing that ‘“turning red in the face” is synonymous with the most forceful expressions of anger in many cultures’.²⁶ Except for the libidinal skin of sex, anger prompts a more extreme bodily response than other emotions: heart rate and blood pressure rise, the skin sweats, the face turns red and an artery might bulge through the skin of the neck. It is unpleasant to live through, whether you are the person about to blow a gasket or the target of someone else’s rage. One theory suggests that increased blood flow to the face can be a kind of safety valve for dangerously high blood pressure. Going red might stop an aneurism, although Vesuvius can erupt in other ways.

In evolutionary terms, the red flush of anger can mean ‘Step back and stay clear!’ It is most frequently directed by one man at another. Women seethe, believe me, but are socialised not to express it. We learn to suck up grievances and ruminate on them instead.²⁷ Women’s anger is often vilified, facial redness adding ammunition to mockery. Journalist Rebecca Traister, referring to the #MeToo movement, includes this quote from Sara Robinson in her book Good and Mad: ‘Women’s rage has been sublimated for so long that there’s simply no frame for what happens when it finally comes to the surface.’²⁸

Angry women are rarely the protagonists in films with plots driven by fury and revenge. Frances McDormand, however, won an Oscar in 2018 for her performance in Three Billboards Outside Ebbing, Missouri. Perhaps there is no scene in that film quite as gratifying as Thelma – or was it Louise? – blowing up a sexist trucker’s oil tanker in Thelma and Louise. Or comparable to the lasting catchphrase from Jack Nicholson’s shouty ‘You can’t handle the truth!’ speech in A Few Good Men. But in Three Billboards, anger about the murdered daughter of the character she plays seeps into every pore of McDormand’s body and soul. It’s visceral.

Sweating is another emotional response that happens via skin. One way of measuring the activity of our nervous system, should you be so inclined, is through electrodermal activity on the skin. When our nervous system is aroused we sweat differently to the sweat of exertion. While it seems too good to be true, many people quote psychoanalyst Carl Jung after he observed a process of measuring a sweating response to emotional arousal: ‘Aha! A looking glass into the unconscious.’²⁹ Sweaty palms can signify anxiety and other emotions, although not necessarily guilt, however much lie-detector tests in movies would have you believe they are foolproof.

The world sweated over the outcome of the 2016 US election. The choice of Republican candidate ended tragically for the country, but a 2015 Republican presidential candidates’ debate produced a funny moment. The line-up of potential nominees – Trump, Cruz, Rubio, Christie, Santorum et al. – all became increasingly red and shiny-faced, gulping water under studio lighting as the air-conditioning seemed to fail. This sweat-fest prompted a hilarious tweet from the actor Albert Brooks: ‘There’s so much sweating going on in this debate I just got a residual from Broadcast News.’³⁰

Brooks, with Holly Hunter and William Hurt, starred in the 1987 film Broadcast News. He plays a television reporter in a now-classic scene of prolific sweating. Perhaps because of the hot lights, or the pressure to succeed, when his character fills in as weekend anchor his skin seems to spring a leak. Live on air, sweat pours down his face, drenching his shirt-collar and the rest of him. The crew scrambles for sponges, towels, hairdryers and fresh shirts, but nothing can stem the torrent. In the control room, a producer jokes that the anchor’s flop sweat is worse than Richard Nixon’s, whose perspiring performance in a television debate against John F. Kennedy is said to have cost him the presidential election. Albert Brooks equally could have tweeted about Rudy Giuliani’s 2020 press conference where he seemed to melt. While he stood there claiming the result of the presidential election was illegitimate, Giuliani’s mix of sweat and hair dye looked like cosmic retribution.

The goosebumps and cold sweat of fear are another observable phenomenon. Here is a true story. One night I lay awake thinking about this book, my hand resting on my husband’s bare shoulder. Suddenly, his body tensed. I felt goosebumps prickling, his skin turning clammy beneath my hand. Had I turned on the light, I expect I would have seen the colour draining from his face. He was having a nightmare. Generic perhaps, but scary enough to prompt a cutaneous response, he’d dreamt he was being chased by a dark presence. I was, of course, deeply concerned for Adam’s emotional wellbeing. But what a gift for the amateur researcher, one equipped with notes reading ‘each hair follicle has an arrector pili, a small bundle of muscle cells that can contract and pinch the hair follicle in such a way that the skin pulls out, producing goosebumps’, to witness the phenomenon in her own bed.

The relationship between skin and the subconscious demands a journey within the circumlocutions of psychoanalytical theory, but I’m ambivalent about jumping on board for a scenic tour of the unconscious. The field is marked by language so dense it scans like poetry, so comprehension can be tentative and fleeting. Theorising and philosophising about the body – embodiment, corporeality, subjectivity, identity – requires more knowledge of Freud, Jung or Lacan than I possess. I cannot pretend to fully grasp the significance of the late French psychoanalyst Didier Anzieu’s concept of ‘skin-ego’, but I love the idea. ‘Skin-ego’ is described as projecting the skin in the mind so it generates an envelope or container for our sense of self. Scholar Sarah Jackson writes about skin-ego, and happens to articulate a familiar list of skin’s contradictions and ironies. Skin, she writes, quoting Anzieu, is ‘permeable and impermeable, superficial and profound, truthful and misleading. It is regenerative, but caught up in a continual process of desiccation . . . The skin is both solid and fragile.’³¹ And I might add, heaven can make merry on our skin, or all hell can break loose.

‘I don’t think I realized how much psych there was in dermatology,’ board-certified dermatologist Dr Rachel Nazarian revealed to Cosmopolitan in 2020. She added, ‘Often you see a lot of psychiatric diseases manifesting in dermatology, whether it be picking out of anxiety, or malnourishment because of depression or drug abuse.’³² Truth be told, I have long been aware of this derm–psych connection. Were Dr Nazarian to ask me how so, I could produce hard evidence: two scarifying essays I read when they were first published. The first by Atul Gawande, published in the New Yorker, is called ‘The Itch’. The other, ‘Devil’s Bait’ by Leslie Jamison, is from her collection The Empathy Exams.³³

When people ask where the idea for this book came from, my stock answer defaults to my own experience with non-melanoma skin cancers. ‘That really got me thinking,’ I say. The more honest – if less straightforward – response would recount the awe these two pieces of writing inspired in me, that intricate combination of wonder, fear and dread. (At one point I thought about giving this book the title Skinsanity). The central facts of Gawande’s and Jamison’s narratives, and the sensations they evoked, settled into the riverbed of my mind. I deferred the task of re-reading the essays until this book’s deadline was closing in and it could be put off no longer. Churned up once again in the waters of my psyche, it is time to draw the spectre of the itch and the horror of the thread back to the surface.

Gawande’s 2008 essay opens with M., an educated Boston woman. She has a degree in psychology, a job in health care and two children, but M.’s life has derailed, catastrophically. The reader assumes that her severe drug addiction and the blistering shingle-sores on her scalp and forehead caused by HIV must surely be the apex of her physical problems. But no. She tells Gawande, ‘I felt like my inner self, like my brain itself, was itching.’ What do people do when they have an itch? They scratch. Gawande quotes the philosopher Michel de Montaigne, as if preparing his audience for the horror they are about to read. ‘Scratching is one of the sweetest gratifications of nature, and as ready at hand as any . . . But repentance follows too annoyingly close at its heels.’ A paragraph later, M., whose life has become more stable except that no medication or therapy can alleviate her urge to scratch, does something unthinkable: in her sleep, she scratches through her skull to her brain.

Gawande’s description is more graphic than this, but the very idea of what he reports sends me weak at the knees. Added to my horror is the likelihood that were I to swoon, I would be scratching my head as I fell. What if I too couldn’t stop? I apologise for coopting unsuspecting readers into a pruritus (itchy skin) experiment, but why does thinking or reading about an itch make you scratch, even when you don’t have eczema, flea bites or any skin condition clinically proven to make you itch?

Gawande’s shocking and unforgettable essay is about the mysteries of this ‘peculiar and diabolical sensation’, and the research being undertaken into it. Although, as you would imagine from M.’s story, it is Gawande’s case studies that capture readers’ attention. We learn less about another man, H., than we do about M. But the basic fact about H., as reported by M., who was in the same hospital in a locked ward, is that he had shingles on his neck, scratched through his carotid artery and died. Gawande switches register to impart basic facts about itching: ‘It can be triggered chemically (by the saliva injected when a mosquito bites, say) or mechanically (from the mosquito’s legs, even before it bites). The itch-scratch reflex activates higher levels of your brain than the spinal-cord-level reflex that makes you pull your hand away from a flame. Brain scans also show that scratching diminishes activity in brain areas associated with unpleasant sensations.’ Which is why scratching a mosquito bite feels good. It’s why scabies in German, as we’ve seen, is krätze, the scratch. It’s why itching and scratching are two sides of the same coin, one you don’t want to keep in your pocket for long.

I transcribed something Professor Pablo Fernández-Peñas said in a webinar that sounded more philosophical than dermatological. ‘Hmm, pruritus. Itch is the topic nobody, no physician, understands. They think itch means histamine so you need antihistamines. As you know, itch means inflammation in most cases, so you need anti-inflammatories.’ But what if your itch lies beyond the boundaries of ‘most cases’? When you cross the border from dermatology into the land of neurology, psychiatry and beyond, into unexplored badlands. Is the itch a manifestation of OCD or a psychosis? Is it not produced by the mind, but an actual sensation caused by the skin’s sensors going into overdrive? Someone like M. is trapped in an infernal feedback loop. For me, a gentle scalp scratch now and then as I write this is within the bounds of normal, even if the itch begins in my mind.

As Gawande writes, if perception were entirely about physical reception – we feel exactly what our nerves experience, not what we think we feel – why would phantom limb pain, where amputees feel pain in their missing limbs, be a verified scientific fact? Why do so many people live with chronic back or pelvic pain for which tests find no cause? Gawande writes about promising experiments that reset perception – what the brain sees and perceives – with clever use of double-mirror therapy to ‘trick’ the brain. He suggests such therapy might be useful for M., whose condition has improved but who still itches in the final paragraph, having at one point spent two years in a hospital wearing a padded football helmet at night, her gloved hands tied to the bed. She has few nerves left that are able to feel itchiness, but her brain keeps firing signals that make her itch chronic. The article ends before we know whether she tried the mirror therapy. I hope she did, and that it saved her from further depths of misery.

Gawande happens to mention in his essay that psychotic patients can have ‘cutaneous delusions’. They think their skin is crawling with ants or laced with tiny bits of fibreglass. What if you were one of these ‘deluded’ people? You know your condition is real because your skin extrudes fibres that must be real, because you keep them in a matchbox. That the medical establishment disputes the existence of your symptoms doesn’t make them any less real to you. Your condition has a name: Morgellons syndrome. The Centers for Disease Control and Prevention (CDC) took this ‘unexplained dermatopathy’ seriously enough to undertake an investigation into it, with more than one hundred patients, in 2012. It found that patients’ scarred, pocked and punctured skin was caused by self-inflicted scratching or picking abuse. The filaments and fibres they had collected, it said, came from bandages or clothing. The CDC concluded the condition was most likely ‘delusional parasitosis’ – an imagined infestation of parasites. But you know you’re not mad, because you connect with other people experiencing the symptoms through the internet. They, like you, reject these official findings.

Leslie Jamison writes in ‘Devil’s Bait’, her essay about Morgellons, that ‘The sickness can start as blisters, or lesions, or itching, or simply a terrible fog settling over the mind, over the world.’ Morgellons is characterised by unidentifiable matter emerging from the skin: threads, fibres, fuzz, specks, grit, crystals and – ohmygod – larvae. In Japan it is called ‘cotton erupting disease’. Re-reading Jamison’s essay reacquaints me with a word I had suppressed: formication, the sensation of insects crawling on skin. There is no cure for Morgellons, but desperate people experiencing the condition will try anything, including, for example, high-dose anti-parasitical medicines made for farm animals. The singer Joni Mitchell, perhaps the most famous person to have publicly identified as having Morgellons (who does not appear in Jamison’s essay), describes it as lyrically as you would expect: ‘Fibres in a variety of colours protrude out of my skin like mushrooms after a rainstorm: they cannot be forensically identified as animal, vegetable or mineral.’³⁴

Jamison goes to the annual meeting of ‘Morgies’, as the Morgellons community calls themselves, in Austin, Texas, in the aftermath of the CDC report. The attendees are mainly middle-aged women, and Jamison muses that the disease might iterate a complicated history that extends back to the nineteenth century when women were diagnosed with hysteria. (Our only recourse when faced with something inexplicable and uncomfortable may be to say it isn’t real. But that doesn’t mean it is real.) Walking into the Baptist church where the conference is being held, she sees a banner that reads ‘Searching for the Uncommon Thread’. She reproduces its words without comment; she hasn’t come to ridicule. By the coffee station inside she talks to people and sees photos of their skin and its extrusions, or their actual skin. She meets a woman who runs a Morgellons hotline, picks up snippets of conversation, goes to a session presented by an Australian doctor, who becomes the star speaker perhaps by virtue of being a member of the medical establishment who listens, who doesn’t dismiss. She says he comes across as ego-maniacal, or possibly a saviour. How to tell the difference in this inward-looking world, where one imagines everyone is focused on tiny skin-specks.

The essay’s driving question is not whether Morgellons is real, but how to feel empathy ‘when you trust the fact of the suffering but not the source’. One reason Jamison’s essay has stayed with me is her declared decision not to treat Morgellons as a metaphor, ‘a corporeal manifestation of some human tendency’, but to witness an array of unbidden human suffering.³⁵ Eschewing dispassion might, possibly, make a writer suggestible; she notices odd strands that appear on her own skin. Blue fluff curled in on itself becomes sinister and alien. ‘Morgies’ fetishise microscopes; when Jamison happens to win one in the raffle all conference attendees are entered into, I felt relief that she gives it away. Why step onto a slippery slope?

Jamison has of course read ‘The Itch’, another account of an ailment with no discernible cause. We believe M. because Gawande – a surgeon, and a reputable writer – believes her. If someone were to ask me straight out if I think Morgellons is real, my answer would be no. But do I think people who identify as having it feel pain and distress? Yes, absolutely. ‘Devil’s Bait’ was written years before QAnon conspiracy theories gained traction and before the viral contagion COVID-19 wreaked general havoc. Do Morgies get vaccinated, I wondered, or is their mistrust of medicine too acute? Perhaps they now see their disease as a weapon unleashed by the deep state, which, of course, is trying to shut them down. Named only in 2001 (after a seventeenth-century English doctor’s account of a skin disease afflicting French children), Morgellons feels like a disease for our times. A Google search took me to a Reuters Fact Check of a faked video claiming the swabs used for COVID testing were implanting Morgellons fibres in people’s noses.³⁶

I understand Jamison choosing not to use threads and fibres as metaphors; it is too convenient to think of an invading ‘other’ against which victims are powerless. Still, what if our ‘self’ becomes a collaborator with the enemy? Jamison writes that ‘the self – at least as I’ve experienced mine – is much more discordant and self-sabotaging, neither fully integrated nor consistently serving its own good’. We’ve all been there. But we don’t blame patients for their autoimmune disease when the body attacks itself. We don’t shame people about their skin cancers. We no longer see birthmarks or moles as signs of witchcraft. And delusional parasites mightn’t seem so crazy once you learn about the microbes living on our skin. The words ‘scabrous’ and ‘lousy’ describe conditions all too real. But I believe in the science – emerging and established – of the skin microbiome, of psoriasis, of eczema, of melanoma. Maybe science will come around to Morgellons, but it hasn’t yet. Dr Pimple Popper knows people will go it alone, so she offers advice on safe extractions. Can anyone predict whose occasional blackhead removal will slip into a full-blown psychiatric picking disorder? Slippage, for some, comes easily and can be unstoppable.

The descriptions in Jamison’s essay are so vivid that I imagine spotting a tiny thread on someone’s skin. Maybe my own. I tweezer a few millimetres out. Before long, I’m pulling and pulling as if the unbreakable thread is attached to a tiny anchor below, in the dermis. The strand gets as long as my body, but I keep pulling. I’m being undone. Stop.

I slip back into reality, thinking of all the weird and wonderful stuff that happens to skin. Thousands of conditions I’ve looked at in photographs, read about, heard about, talked about. Breaking out in hives because of stress. Injecting toxic substances into the face to smooth lines in our skin. Tiny blemishes that our minds persuade us are giant. Marks of death appearing on young men’s skin. Blushing bringing our unconscious selves to the surface. Reclaiming ourselves by inking and painting our skin.

Then there’s all the things that skin itself makes happen. How we self-identify and identify others through our skin and theirs. Skin colour being meaningless yet meaning so much, making a first impression and often a last one, too. The categories Black, White, Red, Yellow, are meaningless and simplistic. And yet, they matter. Brazilian-born photographer Angélica Dass photographs people from all over the world, then takes an 11-pixel square from their noses and matches their skin colour against one of the many options on offer in a Pantone swatch booklet. ‘A pursuit to highlight our true colours,’ she says. Her project Humanae is the result, showing the infinite polychromatic possibilities of skin, which exceed the thousands of Pantone hues available.³⁷ We might say, look, we come in all colours, so what does it matter? But clearly it does. Because dismantling our perceptions, our supremacist ideologies and our racist systems will take as many steps, big and small, as there are skin tones.³⁸

Skin, slipping from barrier to receptor and back, usually being both at once. It might slip too far one way or the other. It’s perfect and never perfect. We might pretend skin doesn’t matter, yet our skin can make us act as if our bodies and our very lives depend on it. Because they do. Skin protects us and makes us who we are. It’s just that we don’t always see it.