Dermatology, a medical  specialization that  deals  with  skin  care,  emerged from the  study  of venereal  diseases. The  first schools of dermatology were established in 18th-century France  and  early dermatologists specialized, for example,  in the treatment of diseases  such  as syphilis. In the United States,  the link between sexual  disease  and  skin  disorders such  as lesions  continued to shape  the  direction of the profession. Indeed, American medical  journals such  as The Archives of Dermatology and Syphilology, first published in 1870,  reflect  the  degree  to which  the treatment of sexual  disease  and  skin ailments were inextricably bound. Victorian assumptions that  one’s complexion was a reflection of virtue  would  lead medical professionals and  laypeople to incorrectly conclude that  skin  disorders such  as acne were a result  of immoral behavior, particularly sexual deviance, a notion that would  linger well into  the 20th  century.

Regardless of its cultural implications, blemishes and other imperfections have encouraged generations of Americans to  seek  some  kind  of help.  However, in the  20th  century an  emerging beauty  industry created competition for  dermatologists, who  relied  on their  medical  stature to carve out  a distinct niche. Many working-class Americans would  never  dream  of seeking  a specialist  for treating skin disorders like acne.  However, by the 1920s  and  ’30s men  and  women, especially youths, sought to improve their  complexions with  store-bought products such  as Pond’s  Extract  or Lily Face Wash.  They  also frequented beauticians, who were often  trained in hair  and  skin care, were more  familiar  to their  patrons, and were less costly than dermatologists. Above all else, home remedies continued to persist  and  meant that  rather than setting  up an appointment with a doctor, do it-yourselfers might  simply cut off a troublesome wart, bleach  skin to temper the tone, or spend hours in front  of a mirror picking  and squeezing.

Throughout the 20th and into the 21st century, dermatologists have continued to warn  against  non–medical professionals who  may not  understand the  underlying cause  of a particular skin  ailment. Dermatologists undergo specific  training in skin  disorders, cancers, and  diseases, as well as issues  that  relate  to aging and other cosmetic conditions. These professionals also use topical  and systemic medications, surgery, and cosmetic surgery, as well as therapies using  lights and lasers. There are several subspecialties in dermatology, including venereology, the specialty  that  treats  sexually  transmitted  diseases, and  phlebology, which  deals with the venous system. To be sure, acne remains one of the most  common complaints  that dermatologists deal with, yet dermatitis or eczema, a red rash or recurring  irritable area of the  skin,  is also a common ailment that  has  many  different causes  and follows many different patterns. Stress can actually cause dermatitis or make  it worse  by suppressing the  normal immune response, while hand dermatitis results from external contact with household chemicals and  cleaning agents. Psoriasis is another common rash  and  tends  to be genetic  as well as influenced by many  environmental factors.  It can  range  in  severity,  and  some  people  may even  need  to be hospitalized for treatment. Finally, skin  cancer, now  considered an epidemic, is the most  serious skin disorder. Techniques like mole-mapping can be used  to keep track  of skin abnormalities to closely monitor atypical moles,  but frequent visits to a dermatologist are now routine for many Americans.

Cosmetic Dermatology

Along with increasing health concerns, cosmetic dermatology, the branch of dermatology that  specializes in aesthetic issues,  is growing, but  not  without controversy. Cosmetic dermatologists deal with the treatment of whatever society deems to be common skin flaws. While  worries  over acne  jumpstarted the development of cosmetic dermatology in the early 20th century, an ever-beauty-conscious consuming public  has  made  the  specialization part  of mainstream popular culture, including reality  shows. Less  invasive  treatments are  designed to  deal,  for  example, with age spots,  which  are brown patches of skin associated with sun  exposure  that  appear  as a person matures. Age spots  are harmless but  are an aesthetic concern. Similarly,  birthmarks, though usually  harmless, sometimes cause  skin problems and  require treatment or  removal. Moles  are  round, brown spots  on the skin. They  can develop  over time or may be present at birth. Though usually harmless, they can develop into skin cancer and must be closely monitored. Many people  choose to have them  removed due to cosmetic concerns. Rosacea  is a skin affliction  characterized by facial redness that  usually  affects  fair-skinned adults and can be treated with either  topical  or oral medications.

These skin  flaws and  their  cultural implications change over  time  as a result of evolving  standards of beauty. These conditions are  all completely harmless to  one’s  overall  health, but,  like cosmetics, the  treatment of them  is meant to enhance one’s  overall  physical  appearance in  order  to  meet  certain (and  everchanging) beauty  standards. For example, wrinkling of the skin is a perfectly natural part of the aging process, yet it fuels the growth of a rich array of procedures to mitigate  the effect of sun  exposure, smoking, and dieting that  can exacerbate the wrinkling effect. Cosmetic dermatologists have long prescribed or recommended products to deal with wrinkles, but  in recent years the use of injectable products like Botox  has become common. Botox is a surgical  procedure in which  the toxic protein botulinum is injected into the skin in small doses  in order  to improve the skin’s  texture and  appearance. It is sold  commercially under the  names Botox, Dysport, and  Myobloc. The  use of these  products has become the  most  popular cosmetic procedure that  dermatologists perform.

Dermatology is currently considered one of the more lucrative medical  specializations, but  it still fails to keep up with demand. It was noted in 2008  that  there were  approximately 10,500 dermatologists in the  United States,  but  health and beauty  patients have outpaced the number of available physicians. These numbers could  be changing quickly  because the specialty  offers a much more  controllable lifestyle  for  medical  professionals. Dermatologists don’t  need  to  carry  beepers, have weekends off, and  the salary can almost  reach  that  earned by a general  surgeon.  With  increasing demands for  cosmetic treatments coupled with  growing concerns over skin cancer and other health issues, dermatology seems headed toward a two-tier industry that  leaves frustrated patients at times  waiting  longer  for skin cancer checks than for Botox injections. Cosmetic dermatology patients typically have money  to spend and,  in contrast to those  requiring cancer screenings, they do not need to negotiate the bureaucracy of insurance companies. Physicians can spend 10 minutes checking a patient’s skin for melanoma and be reimbursed $60–$90, or they can make  $500  spending the same  amount of time administering the  latest  anti-aging miracle.  Research in 2008  found that  patients with  real medical  needs  often  waited  longer  than those  scheduling a cosmetic procedure. Some  dermatologists have embraced the  division  that  now  seems  almost  inherent  in the  profession and  even have different offices and  answering services,  further  bifurcating their  medical  practice. Patients seeking  cosmetic treatments find themselves in a luxurious spa-like atmosphere, while they are faced with the more clinical,  cattle-car setting  when  dealing  with  a medical  condition. In fact, some dermatologists have even opened businesses in shopping malls and provide Botox injections as if they were just another trendy fashion, even though the field of dermatology has long sought to define  itself as distinct from the business of beauty.

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