Skin Disease and the History of Dermatology: Order Out of Chaos

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It is a heady time to be a dermatologist. The Wall Street Journal recently reported dermatology as the “it” job in medicine.¹ Surveys routinely rank dermatology as one of the most desirable medical specialties. While some might write off dermatology as a glamour field, never has medical dermatology had such a wide armamentarium of targeted therapeutic agents at its disposal. Just in my career alone the treatments for pemphigus vulgaris, atopic dermatitis, alopecia areata, prurigo nodularis, infantile hemangioma, and metastatic melanoma, among others, have all been revolutionized. The heyday of dermatology is now. To better appreciate where we stand as a field, it is instructive to look back where we have come from.

Dr Scott Jackson has masterfully done exactly this in his recent book, Skin Disease and the History of Dermatology: Order Out of Chaos (CRC Press; 2023). He presents, in detail, the entirety of dermatologic history from antiquity to the present day. This dense, scholarly, and thoroughly referenced single-author tome is a tour de force.

Dermatology as a formal field is relatively young. For much of human history, there was no such thing as medical specialization as we know it today. Thus, the bulk of the history of dermatology is a history of medicine and surgery as it relates to the skin. Since the time of Galen, it was established that all diseases, skin or otherwise, were products of the misalignment of body humors. Given that approach to pathophysiology, seeing a physician was understandably a bit of a crapshoot. A typical round of treatment might include techniques such as bloodletting, applications of leaches, violent purges with emetics or laxatives, or the administration of toxic medications verging on poisoning. As Dr Jackson points out, in the Middle Ages prayer routinely carried a higher success rate than most medical therapies.

Even during the Renaissance, therapies to treat skin disease as prescribed by a physician were routinely toxic. A 17th-century physician’s approach to “The Itch,” the colloquial term for scabies, might be to put the patient in a quicksilver (mercury) cloak to the point of incessant salivation and nerve palsy. While physicians approached “The Itch” as a disease of the blood, elsewhere village elders knew to cure scabies simply by extracting all the female mites with a needle from the afflicted. In 1687, when Giovanni Cosimo Bonomo and Diacinto Cestoni published that scabies was directly caused by a wandering itch mite in the skin,² the first modern description of an infectious disease was unsurprisingly almost completely ignored by the medical establishment.

It did not escape everyone that physicians had serious limitations. In the 16th century, the eccentric Swiss physician Paracelsus (Theophrastus von Hohenheim) recognized the failings of the ecclesiastical and academic medical establishment, writing, “The universities do not teach all things, so the doctor must seek out old wives, gypsies, sorcerers, wandering tribes, robbers, and such outlaws, and take lessons from them.” Physicians who had undergone training in the classics, however, would be quick to dismiss such “vulgar” sources of knowledge. Even groundbreaking ideas such as disinfection and aseptic surgical technique were initially dismissed as being nonsense. As late as the mid-19th century, delivering your baby at the unwashed hands of a physician could potentially increase your risk of life-threatening infection, sepsis, and death. The physician who first noted this, Ignaz Semmelweis, was ridiculed and eventually dismissed from his position. Later, after suffering bouts of depression, he was lured into a public “insane asylum” by none other than his friend and legendary dermatologist Ferdinand von Hebra, where he perished from infected wounds sustained in the process of being involuntarily committed.³ You could not compose a more ironic story if you tried.

Only once you are halfway through Dr Jackson’s book does dermatology as a field come into sharper focus. It was only in the 16th century that it was suggested that the skin, rather than being but a covering for the body, might in fact be subject to its own set diseases and in 1777, French physician Anne-Charles Lorry proposed that the skin was its own organ system. The denouement of the story occurs when the Scottish physician Seguin Henry Jackson proposed in his 1792 book Dermato-pathologica that the skin would “…with great propriety form a separate branch of physiology, under the title of dermatologia…” Thus, our specialty is no more than 233 years old.

Dr Jackson’s book details the progress in dermatologic classification made by pioneers, such as Joseph Jacob Plenck and Robert Willan, which in part forms the basis for our current understanding of the field today; hence the “order out of chaos” as his apt title suggests. However, also included are the plentitude of erroneous, fanciful, and frankly embarrassing ideas abundant at the same time about the skin, such as the supposition that the location of nevi might predict a person’s qualities and deficiencies. Or that the character of an individual might help differentiate whether their pustular eruption was scurvy or rather syphilis.

Until recently, dermatology dealt heavily in sexually transmitted diseases. It was far from a high-prestige specialty, as respectable physicians would steer clear of a specialty dedicated to treating the marginalized in society. Jean-Louis Alibert famously once called his esteemed dermatology clinic at the Hôpital Saint-Louis in Paris “the sewer of all the countries of the world.”⁴

Many of the antiquated and often horrific therapies that Dr Jackson details are painful to read, however, we should all be aware that the history of dermatology specifically, and medicine in general, has been rife with missteps. Infecting sex workers with syphilis so they might develop milder forms of the disease is but one example. The infamous Tuskegee syphilis experiments (1932–1972), although not directed by dermatologists, were a moral failure in medical history, which engendered long-term distrust in the medical system that we are still trying to overcome. And it was not all that long ago that multiple dermatologic pioneers at various institutions were performing dubious prison experiments, mostly on African American inmates.^5,6

Idealistically, we would like to think times have changed and that dermatology and medicine have become much more scientific, safe, inclusive, and ethical. Without a doubt, huge strides have been made. The fruits of decades of progress in immunology, cell biology, and biochemistry are paying handsome dividends not just for dermatology but all of medicine. Lest we get too self-congratulatory, however, recall that up until a few decades ago, psoriasis was considered primarily a disease of keratinocyte hyperproliferation. When daily I am baffled by a variety of inflammatory disorders and unable to tell my patients the cause of their lichen planus or granuloma annulare, as well as helplessly unable to cease their incessant eruption of nonmelanoma skin cancers, I find myself amazed that despite how much we know, we know so little. As a specialty, we have come a long way but still have a long way to go.

Dr Craig is a clinical dermatologist at Kaiser Permanente in Walnut Creek, CA, and the author of The Itch: Scabies.
Disclosure: The author reports no relevant financial relationships.

References

1. Chen TP. $500,000 pay, predictable hours: how dermatology became the ‘it’ job in medicine. The Wall Street Journal. November 18, 2024.
2. Mead R. An abstract of a letter from Dr. Bonomo to Signior Redi containing some observations concerning the worms of humane bodies. Philosophical Transactions. 1703;23:1296-1299.
3. Obenchain T. Genius Belabored: Childbed Fever and the Tragic Life of Ignaz Semmelweis. University of Alabama Press; 2016.
4. Alibert JL. Précis Théorique et Pratique sur Les Maladies de la Peau. 2nd ed. Baillière; 1835.
5. Hornblum A. Acres of Skin: Human Experiments at Holmesburg Prison. Routledge; 1998.
6. Mitford J. The America Prison Business. Routledge; 2023.