When should you see a dermatologist, and what do we treat once you get there? Those are the questions I want to answer this month.
Dermatology is a bigger field than most people realize. There are more than 3,000 diseases of the skin, hair and nails, and we are trained to diagnose and treat all of them — the common ones you have heard of and the rare ones you have not. Broadly, they sort into a few categories: rashes, growths, infections, cancers, and skin findings that point to disease somewhere else in the body.
What we treat
Eczema and psoriasis are the two inflammatory skin diseases most people know by name, and you have almost certainly seen the television commercials. There is a reason for all that advertising: the field has exploded with new treatments that are safer and more effective than anything we had before. Conditions that used to mean a lifetime of steroid creams and frustration are now, in many cases, genuinely controllable.
Then there are growths, of which there is an almost endless list, subcategorized by the cells they are made of and how they appear under the microscope. Some are dangerous. Most are not. The rule I give patients is simple: if you have a new growth, or one that is changing, come have it looked at. And if you are on the fence about whether something is worth a visit, come in. I would rather look at 10 harmless spots than miss one that mattered, and peace of mind counts for something.
Infections of the skin are common, and the usual culprits are bacteria and fungus. Acne involves bacteria along with oil production, clogged pores and hormones. Fungus is what causes ringworm, which despite the name has nothing to do with worms.
Skin cancer is technically a growth, but it earns its own category because of the gravity of the diagnosis and the depth of how we treat and monitor it. Last month I wrote about what happens during a skin check, and skin cancer will keep coming up in this column — it is the most common cancer in the country, and we live in a place that produces plenty of it.
Finally, we treat the skin manifestations of internal disease. Lupus and rheumatoid arthritis can both announce themselves on the skin, and sometimes a rash is the first clue that something systemic is going on. To sort any of this out, a biopsy is usually necessary — though there is plenty we can diagnose on clinical judgment alone.
Who reads the slide
When a skin biopsy is sent to the lab, the slide is usually read by a dermatopathologist, a physician who completed an additional year of fellowship training devoted to reading skin under the microscope. Dermatologists can also read their own slides if they choose. Certain skin tumors are better left to a dermatopathologist, but a great deal of what we biopsy is well within the scope of a dermatologist without that extra year of training.
Dermatology is a surgical field
This one surprises people. We can remove almost anything that sits on or in the skin, and in the fat just beneath it.
Some of what we remove is benign, meaning not dangerous: cysts, lipomas (fatty growths under the skin), skin tags, warts and a long list of others. Some of it is malignant, which in most cases means one of the several types of skin cancer. When we remove a cancer, we also take a margin of normal-appearing skin around it to be confident the whole thing is gone.
Mohs surgery, named for Frederic Mohs, the surgeon who developed it, falls into this category but is more specialized — enough so that it deserves a column of its own. It is reserved for skin cancers in high-risk areas where there is not much skin to spare: the face, head, neck and backs of the hands. Cancers in those locations carry a higher risk of recurrence, and closing the wound afterward is far more demanding than it would be on, say, the back.
Surgery can also be cosmetic, which brings us to the last piece of the field.
The cosmetic side
Cosmetic dermatology is much more than surgery. It includes injectables like Botox and fillers, biostimulators, chemical peels, lasers and more. On the surgical side, the range runs from cosmetic mole removals to lip lifts to face lifts.
Botox is a neuromodulator, which means it temporarily keeps a muscle from contracting. The most common place we use it is the face, where years of muscle movement etch fine lines and wrinkles into the skin over time. Stop the movement and the lines soften, and in some cases disappear altogether.
Fillers add volume where volume has been lost, or where more of it is desirable. The cheeks are the classic example of an area that deflates with age and can be rejuvenated with filler. The lips lose volume with age as well, though in younger patients filler is often used simply to add volume that was never there.
Biostimulators are solutions injected to prompt the skin to build its own collagen. Collagen declines as we age, and that decline is a large part of why aging skin looks thin and lined.
Chemical peels vary in depth. A superficial peel can be used for a condition like acne, while a deep peel resurfaces the skin of the face or elsewhere and softens fine lines and wrinkles. Lasers can resurface skin much the way a deep peel does, but they do other work as well: eliminating visible blood vessels, treating rosacea and removing tattoos and unwanted hair.
The bottom line
It is truly vast what dermatology spans as a field, and no single column can cover it. The practical takeaway is this: if something on your skin is new, changing or simply will not go away, it is worth having a dermatologist look at it. That is what we are here for.
Have a skin question you would like answered in a future column? Send it to skindermatologypv@gmail.com, and it may appear in this space next month.
Dr. Mitch Brady, DO, is a dermatologist in Ponte Vedra Beach.
