Skating Along the Surface

One day in late August I was explaining to Maria how to apply hydroquinone to the extra pigmentation on her upper lip.

"It will work better after Labor Day," I said, "when the sun isn't so strong. Please apply it morning and night, and be sure to use sunscreen whenever you go outdoors. I'll see you back in 2 months."

"I may be in the sun then," she said. "I probably will be taking my son to Disney. He has leukemia, and the doctors say that they can't do anything more for him."

I was speechless. Here I was, discoursing on melasma to a woman planning Christmas in October for a little son on the brink of death.

"Edgar got sick when he was 10 months old," Maria said. "The medicines helped for a while. Now he's 7. But they don't work anymore. So we're taking him to Disney."

Like everyone, all our patients have stories. Some have several: banal, amusing, frustrating, tragic. At times we can infer them from their skin complaints or from conversational byplay. Mostly, however, we treat the superficialities, with barely any idea of what goes on underneath. It could hardly be otherwise; what's down there is not our business. And how much can you learn in a few minutes assigned to the skin?

Then someone like Maria comes along, to remind us of how limited our role actually is, how little we understand the people we take care of, how trifling, in the larger scheme of things, are the therapies we have at our disposal.

Earlier this year I had two such reminders on the same day. Laurel brought in Emma, her chunky 5-year-old. That Emma had atopic dermatitis was evident from her antecubital spaces even before she reached the exam table. Laurel shuffled in, looking unkempt and disheveled. She had dirty, two-inch nails. Her skin was sallow, her voice grating—a smoker who didn't take care of herself, no doubt. "Emma, get up on the table and sit still!" she rasped.

"Emma has eczema," I told her. "I'll give you some cream for it."

"Thanks, Doc," she said. "I'm trying to get things straightened out for her as much as I can. I have Lou Gehrig's disease, or at least that's what the doctors think. That's why I talk like this.

"I don't know how much longer I'm going to be able to take care of her. But there isn't anybody else. I have no family. There's just me." She forced herself clumsily to her feet. "It's a hard life," she said, lurching over to help Emma down. I handed her the prescription for a topical steroid. That is all I had to offer.

A few hours later a waif came in, accompanied by an attendant from an agency. The chart said Ellen was 12, though she looked no more than 8. Even a cursory glance made it plain that Ellen was gouging herself. Fresh wounds marred her arms, alongside healed scars. Common enough in adults, but not so much in a child.

"I scratch myself sometimes," she said. "My psychiatrist is helping me with that."

"Does your skin itch?" I asked.

"Sometimes," she said. "But sometimes I just get nervous. It depends on my foster parents. When I'm with a new family it takes me a while to feel at home. I worry that maybe they won't like me, and I'll have to move again.

"But now I'm in a good home!" She now spoke with urgency. "So I'm hoping I can stay with them for a while. And when I feel good, I don't pick at my skin so much."

Once again, I prescribed something, which is what I was expected to do. An application as an alternative to self-mutilation. Her psychiatrist could work on her self-esteem, even as her circumstances dismantled what was left of it.

Cases like these are, of course, exceptional. Ours is mostly a cheerful specialty. Such stress as we get wind of—a lost job, parent-teen tensions—are mild and conventional, or at least they seem that way to us. As outsiders, we have a conveniently limited role. We offer our superficial ministrations, skating blithely along the surface.

One day in late August I was explaining to Maria how to apply hydroquinone to the extra pigmentation on her upper lip.

"It will work better after Labor Day," I said, "when the sun isn't so strong. Please apply it morning and night, and be sure to use sunscreen whenever you go outdoors. I'll see you back in 2 months."

"I may be in the sun then," she said. "I probably will be taking my son to Disney. He has leukemia, and the doctors say that they can't do anything more for him."

I was speechless. Here I was, discoursing on melasma to a woman planning Christmas in October for a little son on the brink of death.

"Edgar got sick when he was 10 months old," Maria said. "The medicines helped for a while. Now he's 7. But they don't work anymore. So we're taking him to Disney."

Like everyone, all our patients have stories. Some have several: banal, amusing, frustrating, tragic. At times we can infer them from their skin complaints or from conversational byplay. Mostly, however, we treat the superficialities, with barely any idea of what goes on underneath. It could hardly be otherwise; what's down there is not our business. And how much can you learn in a few minutes assigned to the skin?

Then someone like Maria comes along, to remind us of how limited our role actually is, how little we understand the people we take care of, how trifling, in the larger scheme of things, are the therapies we have at our disposal.

Earlier this year I had two such reminders on the same day. Laurel brought in Emma, her chunky 5-year-old. That Emma had atopic dermatitis was evident from her antecubital spaces even before she reached the exam table. Laurel shuffled in, looking unkempt and disheveled. She had dirty, two-inch nails. Her skin was sallow, her voice grating—a smoker who didn't take care of herself, no doubt. "Emma, get up on the table and sit still!" she rasped.

"Emma has eczema," I told her. "I'll give you some cream for it."

"Thanks, Doc," she said. "I'm trying to get things straightened out for her as much as I can. I have Lou Gehrig's disease, or at least that's what the doctors think. That's why I talk like this.

"I don't know how much longer I'm going to be able to take care of her. But there isn't anybody else. I have no family. There's just me." She forced herself clumsily to her feet. "It's a hard life," she said, lurching over to help Emma down. I handed her the prescription for a topical steroid. That is all I had to offer.

A few hours later a waif came in, accompanied by an attendant from an agency. The chart said Ellen was 12, though she looked no more than 8. Even a cursory glance made it plain that Ellen was gouging herself. Fresh wounds marred her arms, alongside healed scars. Common enough in adults, but not so much in a child.

"I scratch myself sometimes," she said. "My psychiatrist is helping me with that."

"Does your skin itch?" I asked.

"Sometimes," she said. "But sometimes I just get nervous. It depends on my foster parents. When I'm with a new family it takes me a while to feel at home. I worry that maybe they won't like me, and I'll have to move again.

"But now I'm in a good home!" She now spoke with urgency. "So I'm hoping I can stay with them for a while. And when I feel good, I don't pick at my skin so much."

Once again, I prescribed something, which is what I was expected to do. An application as an alternative to self-mutilation. Her psychiatrist could work on her self-esteem, even as her circumstances dismantled what was left of it.

Cases like these are, of course, exceptional. Ours is mostly a cheerful specialty. Such stress as we get wind of—a lost job, parent-teen tensions—are mild and conventional, or at least they seem that way to us. As outsiders, we have a conveniently limited role. We offer our superficial ministrations, skating blithely along the surface.

One day in late August I was explaining to Maria how to apply hydroquinone to the extra pigmentation on her upper lip.

"It will work better after Labor Day," I said, "when the sun isn't so strong. Please apply it morning and night, and be sure to use sunscreen whenever you go outdoors. I'll see you back in 2 months."

"I may be in the sun then," she said. "I probably will be taking my son to Disney. He has leukemia, and the doctors say that they can't do anything more for him."

I was speechless. Here I was, discoursing on melasma to a woman planning Christmas in October for a little son on the brink of death.

"Edgar got sick when he was 10 months old," Maria said. "The medicines helped for a while. Now he's 7. But they don't work anymore. So we're taking him to Disney."

Like everyone, all our patients have stories. Some have several: banal, amusing, frustrating, tragic. At times we can infer them from their skin complaints or from conversational byplay. Mostly, however, we treat the superficialities, with barely any idea of what goes on underneath. It could hardly be otherwise; what's down there is not our business. And how much can you learn in a few minutes assigned to the skin?

Then someone like Maria comes along, to remind us of how limited our role actually is, how little we understand the people we take care of, how trifling, in the larger scheme of things, are the therapies we have at our disposal.

Earlier this year I had two such reminders on the same day. Laurel brought in Emma, her chunky 5-year-old. That Emma had atopic dermatitis was evident from her antecubital spaces even before she reached the exam table. Laurel shuffled in, looking unkempt and disheveled. She had dirty, two-inch nails. Her skin was sallow, her voice grating—a smoker who didn't take care of herself, no doubt. "Emma, get up on the table and sit still!" she rasped.

"Emma has eczema," I told her. "I'll give you some cream for it."

"Thanks, Doc," she said. "I'm trying to get things straightened out for her as much as I can. I have Lou Gehrig's disease, or at least that's what the doctors think. That's why I talk like this.

"I don't know how much longer I'm going to be able to take care of her. But there isn't anybody else. I have no family. There's just me." She forced herself clumsily to her feet. "It's a hard life," she said, lurching over to help Emma down. I handed her the prescription for a topical steroid. That is all I had to offer.

A few hours later a waif came in, accompanied by an attendant from an agency. The chart said Ellen was 12, though she looked no more than 8. Even a cursory glance made it plain that Ellen was gouging herself. Fresh wounds marred her arms, alongside healed scars. Common enough in adults, but not so much in a child.

"I scratch myself sometimes," she said. "My psychiatrist is helping me with that."

"Does your skin itch?" I asked.

"Sometimes," she said. "But sometimes I just get nervous. It depends on my foster parents. When I'm with a new family it takes me a while to feel at home. I worry that maybe they won't like me, and I'll have to move again.

"But now I'm in a good home!" She now spoke with urgency. "So I'm hoping I can stay with them for a while. And when I feel good, I don't pick at my skin so much."

Once again, I prescribed something, which is what I was expected to do. An application as an alternative to self-mutilation. Her psychiatrist could work on her self-esteem, even as her circumstances dismantled what was left of it.

Cases like these are, of course, exceptional. Ours is mostly a cheerful specialty. Such stress as we get wind of—a lost job, parent-teen tensions—are mild and conventional, or at least they seem that way to us. As outsiders, we have a conveniently limited role. We offer our superficial ministrations, skating blithely along the surface.