Dermatology Back o' Bourke

So I saw a guy some years ago.  He was from "the Interior" as we say in British Columbia, which means any place that isn't on the coast.  That's a lot of territory.

Because of the whole long distance problem, I try to set people up so that they can figure things out themselves, depending on what happens with Plan A.

"Common sense takes you a long way in medicine," I said. I say this all the time.

"It's the same in my business," he said.

"What do you do?"

"I'm a judge."

Another day at the office....

New England Journal of Medicine

Some years ago I saw I guy who by history and examination had swimming pool granuloma, a characteristic and relatively harmless infection with Mycobacterium marinum, usually involving the hands and forearms, usually acquired from water. That was in fact the diagnosis and he got better with treatment, minocycline.

At the initial interview he stated his distress at having chronic skin problems with no resolution.  He had requested consultation with a dermatologist.

"My GP told me he got an appointment for me with the best guy in Vancouver, in fact probably all of BC."

Despite my better instincts, I felt flattered.

"Great!" he had said. "When's the appointment?"

"In nine months."

"I said, 'Nine months!  I can't wait that long.  Send me to somebody else sooner!  Send me to a fucking witch doctor, it's OK with me.'"

"And that's why I'm seeing you."

Why don't people leak?

This isn't something that worries the general population.  As one of my neighbours once said, "It's not something a normal person thinks about."  We all take it for granted that when we step out of the bath we don't immediately start leaking water - which is most of our body - through the skin.  Equally, we don't expect to swell up and explode in the bath, osmosis being what it is.  Why is skin waterproof?  Who cares?

The waterproofing of skin is an interesting problem for which nature has engineered an ingenious solution.  It might not be the only solution but there's probably a reason for the madness.  As to who cares, the answer is that a small but dedicated band of skin geeks cares.  It's like the crazy people who conceived of laying submarine cables across the Atlantic.  It's nuts and yet we're obsessed.  Like submarine cables, the commercial implications are incomprehensible:  if somebody invents an array of microneedles capable of penetrating the Stratum Corneum and delivering a drug, some crazed zealot could assassinate anybody by laying a large Velcro-like pad filled with suxamethonium chloride on them.  Naturally, I'm jumping to the most bizarre implications.

Me, I'd like to have a Velcro-like array of microneedles through which I could inject triamcinolone acetonide, an anti-inflammatory steroid I now do through 30 gauge needles, themselves a miracle of engineering, into all kinds of inflammatory conditions of the skin.  We could use less drug to better effect if we had such technology.  Other important things like vaccines could also be delivered.  Further, we might be able to treat common conditions like hand dermatitis to better effect, not with the injections but with some kind of intelligent barrier modification.

But that's not really why the geeks are interested.  We're interested because it's cool.

The cool thing is that nature has figured out a way of doing whatever it has to do with whatever it has to hand.  Feathers come to mind.  I mean, there's a crazy idea.

Otto Lilienthal, ca. 1994

First we have multi-celluar organisms in the sea that crawl out onto land and don't die due to leakage.  Then, some of these use the same device - skin -  to become aerodynamic.  If you suggested that outcome during the early stages of evolution you would have been laughed out of the room.  You'd also be right.

So instead of flight we have waterproofing.  Not as sexy for sure, but essential.

...to be continued.

Glossy magazines cause brain damage in women...

There you go.

Flamingos in the Camargue

I once attended a meeting in the south of France on the permeability of skin, my professional interest. 

My colleague D___ (as they say in Russian novels) who was not from Vancouver, attended the same meeting.  At some point he made me a proposition: "I've got a car. Let's fuck off and get a drink in the Camargue."  I thought of Eric Newby and a botched British commando raid:

...beyond the soldiers were the planes.  I had never seen so many J.U.88's in my life.

"What I think we should do," George said, "is..."

"Fuck off," said a readily identifiable voice which was not that of an officer.  "That's what we should do, fuck off while there's still time."

The suggestion was so eminently sensible, and the person who made it so experienced in these matters, that it only remained to put it into practice.

So that's what we did.

The Camargue is a marshland area of coastal France, famous for bulls, horses, and flamingos.  The connection is obvious when you think about it.  Being France, we assumed there would also be wine and somewhere to drink it.  It was gorgeous yet after half an hour there was no wine or wine bar and we became increasingly irritated. "See anything?"  "No, just more fucking flamingos."  It went on like this. Eventually we were on the other side of the Camargue feeling cheated.  The motorway gave us a choice between Italy and Nîmes.  D___ was in no doubt, "There will definitely be a bar in  Nîmes. They've got a Roman Colosseum."

We drove fiercely down the motorway and into Nîmes, passing numerous Ferrari dealers.  The city centre came into view:  Colosseum, car park, and sidewalk cafes.  

After a glass of wine we observed little groups clustered around the Colosseum and moving through it, each with what seemed to be a leader. "Probably people from the Nîmes Historical Society," we said to ourselves, "conducting tours."  

"Thank God it's not us on a tour," we continued in the same vein.

The next night was the conference dinner in a lovely chateau, but before that there was a surprise and the conference buses got on the motorway headed back to Nîmes.  "Wouldn't it be funny," we said, "if the surprise turned out to be a tour of the Nîmes Colosseum."

It was.  As we stood in the car park where we'd been the night before, forming up in little groups with our tour guides, I was slipping into sheep-like acceptance (sheep are also a feature of the Camargue) when I was saved by a hand that dragged me gently backwards.  It was D___ directing me to the sidewalk cafe where we'd been the night before, from which we had the subsequent pleasure of observing our colleagues on their tours, and their frankly envious and resentful glances in our direction.

And so we come to the permeability barrier of skin.

Why don't flamingos explode?

This is an interesting question.  Osmosis being what it is, you'd expect that the bag of saline and feathers that is a flamingo would swell up and explode while standing in fresh water.  Well OK that's not fair, the Camargue isn't exactly fresh water.  But the question is also why don't human beings swell up and explode when in a dilute solution of urea that is a fresh water swimming pool.

The answer is a biological membrane that exists between cells in the outermost layer of skin.  Why is this remarkable?  Because if you put human red blood cells in water they swell up and explode.

This was the fundamental problem of sea creatures emerging on dry land, if you accept Darwin's evolution hypothesis.  Me, I think it's an excellent hypothesis but even if you don't, somebody came up with the idea of using biological membranes to protect the bags of saline and protein that are humans from melting down in air or swelling up in water.  The thing is, most biological membranes are permeable to water.

So, how does nature change permeable membranes to impermeable membranes?

That is the very interesting question that D___ and I were discussing  in a sidewalk cafe while our colleagues toured the Colosseum at Nîmes.

...to be contnued

Skin care systems and Bologna

Bologna is beautiful.... 

Some years ago, I went to a meeting in Bologna, set in a monastery converted into a conference centre.  For reasons still not clear, I had registered for the meeting without booking any accommodation.  As it turned out, the meeting was in the middle of year long celebrations of a significant anniversary of the city's existence - I forget the numbers but it was in centuries.

Jet-lagged, I arrived at the registration desk and went through the formalities.  I then asked the very nice Italian registration person if she could recommend anywhere to stay, me not having arranged that beforehand.  She looked at me in silence for a long moment.

"North Americans..." she breathed and not in a complimentary way, which was justified given the information that followed.  "You realize that this is the [x] hundredth celebration of Bologna?"  I think it might have been 1000.  Anyway, it was very close to the founding of the 900th anniversary of the founding of the University of Bologna.

I said I hadn't.  There was another incredulous silence after which she said, "The city is full.  The nearest available hotel room is in Florence."

"Oh, " I said.  More silence.

"As it happens," she said reluctantly, "one of our key speakers has cancelled at the last minute, and his room is free."

"Oh?" I said in a tone of voice that I hoped displayed appropriate hope and gratitude, without actually grovelling.

I then found myself in possession of a single room directly across the Via de' Chiari from the conference centre, in luxurious refurbished monks' quarters that in this case included a bidet.  Sometimes sloth is rewarded.  It is certain that I was the least important person at this meeting, yet staying in VIP accommodation.

Even more fabulously, I discovered at the end of the street on the Via Cartoleria, the Godot Wine Bar, that opened at about 6 in the morning with Italian coffee any way you wanted it, and then converted to wine at any time at all, and was open until 3 AM.  I spent the meeting ricocheting among the meeting, the luxurious monks' quarters and the Godot Wine Bar.  It was wonderful.  The moral of the story is that Bologna is different from baloney.

Spend your money on Bologna not baloney. 

What is a skin care system?  I tell patients who ask, who are almost all women but not quite, that a skin care system is a device designed to separate women from their money.  As it happens, I have very little street cred as a woman, and being what I call a "blue collar dermatologist" my advice is not always valued. I give the advice anyway because I think it's true.

"Save your money for clothes and shoes," is my usual line and that goes down better. I'm not saying the companies that sell "skin care systems" are evil or bad. If people like to use them - and some people do - then they will.  All I'm saying is I've never seen a skin care system anybody needed.

There are many "skin care systems" on the market:  here and here and here and here and here and here and here, it goes on indefinitely.....

The main thing about a "system" as far as I can see is that it has a number of parts, sold as a package, and a marketing department wants to convince you that the best result comes from using all the parts, which they will sell you.

Here's a well known example, the acne treatment Proactiv.  It has a "3-step" system, two of which contain 2.5% benzoyl peroxide, which is what works against acne.  Benzoyl peroxide acne treatments are available over the counter in concentrations up to 5%, which is the usual.  You only need one step.  I met a young female doctor who swore she couldn't live without Proactiv and fair enough, if it works it works.  I'm only saying it doesn't make any sense, and - guaranteed - there's no objective evidence that the "system" works better than any other benzoyl peroxide treatment, other than financially.

Once we get out of actual treatment into "skin care" it gets crazier.  You've got your cleansers, your toners, your exfoliators and your moisturizers and they're all terribly important if you want to look like Cindy Crawford.  Who exactly is Cindy Crawford anyway?  There you go, my street cred blown again.  I know who Justin Bieber is though, and he's fronting for Proactiv.  Really, if you want to know what works for acne, it's all laid out in a very useful article in the Canadian Medical Association Journal by two dermatologists from Toronto, and you can download it for free from PubMed Central.

They have a soul care system at the Godot Wine Bar.  I'm there.

Shortest distance from Armaroli Loretta Skin Care in Bologna to Godot Wine Bar

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