To the Dermatologist

For several years I have watched a pigmented lesion at my left zygomatic arch.  Initial concern occurred maybe ten years ago.  Dermatologist in the building next to my office too a look at it, declaring it benign.  I did not intend the comprehensive skin inspection recommended for cancer screening for people my age and I had to get back to work so I declined the more extensive look-over and returned to my office reassured.  About two or three years ago, my doctor thought the skin exam was a good idea, recommending it without any prompting from me just based on age.  I have seen my share of malignant melanoma over the years, sometimes from patients who have had this in their histories when they come to me for something else, too often as hospital patients with metastatic disease.  Got it done, reassured the facial pigmentation was benign.

Time has proven that correct, though it is larger, and my wife found something that concerned her on my ear so it's time for another opinion, including whether it might be better just to have it excised.  The last dermatologist made a very good impression but she had moved on from her satellite university position, so it's back to the original office with a different doctor.  I waited quite a few months for the appointment.  They offered a sooner one with the Nurse Practitioner, but since the question of elective removal can require an intricate thought process and I was in no hurry, I waited to see what the fellow who does the surgery thinks.

It turns out that the lesion in question had started to get raised from the surface.  It is still benign.  Removal is possible but trades one discoloration for another and costs money.   It would be a hard sell to call this something other than cosmetic for Medicare to pay for.  We concurred, leave well enough a lone, take a photo with his good camera, and compare in a year.  The area on the ear is an hemangioma, which is what I suspected.  Totally harmless.  He noted scratch marks elsewhere.  I have some itching, usually in exposed areas and I scratch them but it never really bothers me and I never sought attention for this.  Leave well enough alone. 

I had been to that office some ten years ago.  It looked like a medical office.  There is now a presence of cosmetic dermatology everywhere, in-office presentations of topical everything and options for removing everything from freckles to tattoos.  But the doctor who tended to me yesterday seemed more energized by skin diseases than appearance, which probably subsidized the more serious elements of medical care.  He did professional examining, leaving the scribe work to his Physicians Assistant.  And on the walls, he had a warning to patients who needed modern biologics for their psoriasis, medicines that work well but pose a significant risk.  Diversion of medical attention from diseases to appearance would probably make me feel like less of a doctor.  We don't have that so much in endocrinology, though our diseases can have an adverse effect on appearance.  We do send women for hair removal.  Weight reduction surgery is an investment in health, in my mind, but sometimes the recipient seems more concerned about clothing size.  And we got into quite a lot of trouble prescribing Redux or Acomplia to make people look slimmer when the weight excess threatened their health less than the pills did.  Eye care for Graves seems entirely focused on protecting vision and the eye surface.

Since dermatology can be very lucrative and with a better personal lifestyle than may other specialties, with limited training slots, the best and most promising from each American medical graduating class in recent years seem to secure those slots.  Skin cancer, disabling pruritis, psoriasis, eczema, and cutaneous infections can be quite a challenge worthy of medical graduates of that caliber.  I'm less convinced that wrinkle stretching or botox injections should divert some of our best medical talent.  Give the public what they want and they'll come out in droves the Hollywood moguls accurately predicted.  And so we have professional dermatology teetering at the edge of vital medicine and patient vanity.