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.
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.