The Remarkable Life of the Skin
Author: Monty Lyman
This book is about what the author depicts as our largest, our most visible, and our most social organ. Noting that the skin is ‘the organ most overlooked by the medical profession’, the author set out to underscore the importance of the physical and psychological functions it performs, portraying it as a ‘familiar yet mysterious’ structure, and as a mirror that reflects a lot about our inner selves. The author also explores a bewildering range of skin disorders, carefully elucidating their causes, and describing the often cutting-edge treatments helping to alleviate them. In a wide-scoped approach that comprehensively addressed the diverse subjects related to the skin, the author provided very illuminating historical, cultural, spiritual, and philosophical contexts to each theme he covered (pages xiv, xvi and 21).
One of the most striking features of the book is its portrayal of how the skin combines ‘function and form to make a beautiful barrier’ for the body. He painted a portrait of the skin as ‘simultaneously wall and window‘ because of the way it serves both as a physical barrier and as ‘an exquisitely psychological and social part of our being’. He uses remarkably imaginative metaphors to further characterise the skin’s protective features, such as when he referred to it as a ‘wafer-thin wall‘ which ‘manages to keep your insides in and the treacherous outside out’, and when he compared the skin to ‘the intricate geometric tiles seen in medieval Islamic architecture‘. The diverse safeguarding role of the skin was also evident when the author referred to it as ‘the house in which our physical and mental selves are contained’, and when he referred to how the skin ‘protects us from, and connects us to, the outside world’. And with an intriguing moral perspective, the book also pictured the skin as a fragile ‘barrier between the flesh and the world’ which however frequently ‘yields to the desires of the flesh’ (page xv, 1, 7, 11, 21, 214 and 221).
The author dedicated a major part of the book exploring the embryological origin, structure, and constituents of the skin. For example, he noted that the brain and the skin have a common embryological origin, pointing out that this explains why skin disorders such as psoriasis and infections flare up with mental stress. As for its structure, he conveyed a sense of its vast expanse when he observed that it weighs a massive nine kilograms, and covers an area of two square meters. In conveying a sense of the complexity and intricacy of the cellular structure of the skin, the author remarked that the epidermis, which is responsible for ‘almost all the barrier functions of our skin’, is only about 1mm thick. Similarly, the author enriched his discussion of the tissues embedded in the skin with fascinating facts, for example when he noted that the sweat glands enhance romantic attraction, serve an ‘incest-avoiding‘ function, and produce ‘significantly less body odour‘ in East Asians. Other intriguing details the author related about the skin included the facts that leprosy ‘is actually one of the least transmissible infectious diseases’; smiling reduces blushing; four families in the world have adermatoglyphia – absence of fingerprints; and ‘red haired people are more resistant to a number of types of pain‘ (pages 144-150, xiv, 111-124, 3-16, 43, 56, 126, 208, 152 and 18).
Perhaps the most compelling feature of the book is the staggering array of skin disorders the author described. Even when discussing the most familiar of these, the book succeeded in imparting novel and practical information; this was perhaps most evident in its review of eczema, a condition which the author himself endures. The book establishes that about half of severe eczema sufferers have a mutation in filaggrin – a gene which regulates the production of a protein that is ‘essential for the integrity of the stratum corneum‘, and that many other sufferers have a mutation in CARD11 – a gene that is involved in activating skin immune cells. In a similar way, the author discussed familiar skin infections such as dandruff or seborrheic dermatitis – a disorder that results from overgrowth of the ‘fat-loving fungus’ Melassezia; acne which results from ‘the over-excitement of the bacteria Cutibacterium acnes‘; river blindness which is acquired when the black fly transmits the roundworm Onchocerca volvulus; and scabies, ‘one of the itchiest conditions known’ and which manifests when the parasite Sercoptes scabie burrows inside the skin. Of the rarer disorders covered in the book, a few stood out, for example harlequin ichthyosis which manifests with ‘areas of thickened, fish-like scales; keratosis pilaris, which manifests with a ‘chicken skin’ which looks like ‘permanent goosebumps’ and feels like ‘rough sandpaper’; trimethylaminuria or fish odour syndrome in which the sweat smells like ‘a rubbish dump cocktail of rotting egg and fish’; and xeroderma pigmentosum in which ‘the intricate DNA-repair mechanism responding to UV light is completely absent’ thereby predisposing the sufferers to skin cancer (pages 8, 53, 66, 24-25, 33-35, 2, 50 and 81-82).
The psychological dimensions of skin disorders was expectedly a key theme of the book, and the author explored various facets of this relationship. For example, he reviewed several distressing compulsive disorders which are primarily driven by underlying psychological factors, and amongst these are trichotillomania or hair-pulling; onychophagia or nail-biting; dermatophagia or skin-chewing; dermatitis artefacta – ‘where the patient intentionally causes skin damage to simulate disease’; and Rapunzel syndrome – ‘an extreme consequence of hair-eating’ which may result in bowel obstruction. Another prominent psychologically impactful skin disorder the author discussed is acne, a disease which he asserted is ‘in many ways…more a psychological disease than a physical one’, and one in which a fifth of sufferers contemplate suicide. Because of the heavy emotional toll of the disease, the author urged society, and particularly the medical profession, to take acne ‘much more seriously‘. The book also discussed rosacea and vitiligo – skin disorders which impose similar psychological burdens as acne (pages 144 and 158-163).
Some of the skin disorders the book highlighted are notable for their particularly high morbidity and potential mortality, and in this regard, malignant melanoma stood out for being ‘the most concerning skin cancer‘. In a narrative focused on the importance of early detection, the author reviewed the varied risk factors for melanoma, particularly highlighting the propensity of skin moles such as dysplastic and congenital melanocytic naevi to become malignant. The immune disorder epidermolysis bullosa is another life-threatening skin condition which the book reviewed with an emphasis on its emerging genetic treatment whereby viruses are used to correct the causative mutation in the LAMB3 gene. Another theme with a malign dimension is the skin manifestation of severe liver diseases such as jaundice, red palms, black armpit patches, spider naevus – ‘a central splodge of red with web-like radiating vessels’, and caput medusae – ‘engorged veins flowing out from the umbilicus like the serpentine hair of the Greek monster‘ (pages 74-75, 19-20, 45 and 56).
This book has succeeded immensely in redressing what it notes to be the neglect of the skin and its disorders by the medical fraternity and the wider general public. With an exhaustive, and quite graphic, account of the spectrum of dermatology, the book is not only a refresher of the familiar diseases, but it is also an update on cutting edge genetics and therapeutics. With an elegant prose, a focused approach, and illustrative anecdotes, the book has brought a much neglected and underestimated organ alive, and given it the rightful place it deserves in public discourse. Beyond the strictly medical themes of the book are insightful and illuminating perspectives on the cultural and spiritual dimensions of the skin which greatly enhanced the book’s contents.
The skin is without doubt the most social of the organ systems, and its afflictions carry both medical and cosmetic implications, their psychological burdens often outweighing their physical impact. This book highlights all these facets of skin disorders with appropriate sensitivity and delicate touch. It emphasises the links between the skin and other organs, and the burden of dermatological diseases on society. The book underlines the need for healthcare to appreciate the burden of skin disorders, and I recommend it to all doctors.
Publisher, Place, Year: Penguin Books, London, 2019
Number of chapters: 10
Number of pages: 283
Star rating: 5