The Visible Wound

The field of psychodermatology — the study of the relationship between skin disease and psychological factors — is one of the most neglected areas in medicine. We know, with solid evidence, that stress exacerbates psoriasis, eczema, acne, urticaria, and a range of other dermatologic conditions. We know that patients with chronic skin diseases have rates of depression and anxiety that significantly exceed the general population. And yet, in the typical dermatology appointment — seven minutes, look at the rash, write a prescription, next — the psychological dimension of skin disease is almost never addressed.

Maria was my 10:30. She was a forty-two-year-old woman with a three-month history of a pruritic rash on her forearms and neck. The presentation was classic for contact dermatitis — erythematous, scaling, well-demarcated plaques in areas that would be exposed to an environmental allergen. I was preparing to prescribe a topical steroid and recommend hypoallergenic detergent when I noticed something in her expression — a tightness around her eyes, a tremor in her lower lip, the body language of someone who is holding something back.

I put down my prescription pad. I asked her: "Maria, what's going on at home?"

She started to cry. Not the polite, controlled tears of a patient who is embarrassed to be emotional in a doctor's office — the deep, convulsive sobbing of someone who has been holding it together for a very long time and has finally been given permission to fall apart. Her husband had lost his job six months earlier. They were facing foreclosure on their home. Her teenage son had been arrested for possession and was facing juvenile detention. She was working double shifts at a nursing home to try to keep the family afloat, and she hadn't slept more than four hours a night in months.

Her rash was almost certainly stress-induced. The topical steroids I had been about to prescribe would have helped temporarily, but they would not have addressed the underlying cause. What Maria needed was not a dermatologist — it was a social worker, a therapist, a support system. What she got was a physician who was willing to ask the question that her previous three doctors had not asked: "What's really going on?"

I treated her rash with steroids and referred her to a counselor and a social worker who could help with the practical challenges her family was facing. Her skin improved — gradually, incompletely — but the real improvement was in her mental state. She told me, at her three-month follow-up, that I was the first physician who had ever asked her about her life instead of just her symptoms. "You saw me," she said. "Not just my skin. Me."

I have thought about that phrase — "you saw me" — every day since. In a medical system that rewards speed and efficiency, the simple act of seeing a patient as a whole person — not just a collection of symptoms — is radical. It is also, I have come to believe, the most important thing we do.