God's Tattoos

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An experienced dermatology provider explains how his differential has broadened, thanks to one patient’s unique outlook, writing, "I try to keep in mind that while I can give a name to a disorder and treat it, the patient’s perception of the pathology should never be overlooked."


Having worked in dermatology more than 10 years, I have seen a variety of skin conditions. As in any other specialty area, a small number of diagnoses account for the majority of patient visits. When patients call to make a dermatology appointment, they often describe their particular skin condition using the same few key words.

Every morning, I peruse the day’s upcoming schedule and challenge myself to see how accurate a diagnosis I can make in advance, based solely on the four- to five-word description written by the assistant who booked the appointment. About six months ago, one particular listing read, “Rash on elbows and knees.” Most likely psoriasis, I thought—but then had second thoughts and changed my suspected diagnosis to eczema. Later that day, when the patient in question arrived, I recalled that presumptive diagnosis.

I entered the exam room to see a healthy-appearing 28-year-old man, wearing a long-sleeved, red plaid shirt and tattered jeans. Wisps of sandy brown hair peeked out from under his well-worn baseball cap.

“My name is Stephen, and I am a PA. It’s good to meet you,” I began. “Tell me what brings you here today.”

“Well, boss, you see, I have this rash on my elbows,” he said, rolling up his sleeves. “Not just on my arms, but my knees, too. It’s been getting worse over the past three months, and my girlfriend is getting worried.”

I took note of the silvery scales on his elbows and knees, and asked, “Any flakes on your scalp?”

He nodded in agreement and replied, “The hat helps control it. But you know, I got this tattoo a few months ago, and now it’s looking just like my rash.”

He lifted up his shirt to reveal a tattoo on his scapular region, where the scales of psoriasis had also emerged. I looked closely at the intricately detailed tattoo, in which a serpent of some sort poked its head out of the eye socket of a grimacing skull. The outline of the calavarium was highlighted with psoriatic scales. Inwardly, I bet myself that the tattoo artist had never heard of the Koebner phenomenon. Although I could appreciate the amazing artistry that had gone into the tattoo, I had to wonder whether the patient’s mother would approve of such a gory image.

The patient had a clear-cut case of psoriasis—my original supposition from earlier that day. Therapeutic options for psoriasis have blossomed over the past few years, and the state of the science allows for marked improvement in a majority of cases. The patient and I talked about treatment options and came up with a plan. I was confident that if my first recommendation didn’t yield optimal results, something else in my remaining armamentarium would.

In addition to the psoriasis, however, I noticed that the patient had significant vitiligo—nearly total depigmentation periorbitally and on his hands. “Vitiligo is also within the realm of dermatology,” I ventured, opening the door to discuss treatment options.

“When the white spots first came, it wasn’t a big deal—just a few on my hands and fingertips,” he said. “But I started to worry when I saw a spot on my eyelid. It was small at first, but it grew and grew. Next thing I knew, I had white spots around both of my eyes. Most of the other kids in school were worried about zits and what to wear. I was worried about the freak I was becoming.”

“Teenagers can be brutal to one another—and even more brutal to themselves,” I commented.

“Tell me about it,” he replied. “Doctors can be rough, too. I went to a couple of dermatologists for a year or two. They drew blood from me and even biopsied my skin. I used so many tubes of useless creams. For a while, I had to miss school to sit in a light box three times a week. And nothing, absolutely nothing, helped. I just got so tired and frustrated.”

Aware that there is still no known key to treating vitiligo effectively, I told him, “From the beginning, you need to know that I may not be able to fix this, either—but I’ll give it my best. Some new modalities have come about in the past ten years that you may not have tried. Maybe one of these will work.” A familiar story with vitiligo, I added to myself. Trial after trial with lackluster results would cause anyone to give up. What were the chances that one of these newer options would prove more reliable?

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