BMJ No 7123 Volume 315
The muses Saturday 20/27 December Christmas 1997 issue
The hidden delight of psoriasis
The visibility of psoriasis appeals to the imagination, perhaps because
of the chronic, variable, and unpredictable nature of the disease, and
has even led to literary language in the medical
literature.(2) For example, Ingram describes the plaques and
colourful configurations as patterns that "may rival the heavens for
beauty and design," to which he adds with a sense of drama: "To
leave a trail of silver scale about the house and blood-stains on the
sheets and to fear the public gaze - this is a cruel
fate."(3)
The psychosocial dimensions of skin disorders like psoriasis have been
described in the medical literature.(4-7) But psoriasis has
also been a theme in non-medical literature - autobiographies as well as
fiction. Novelist Connie Palmen pointed out in The Laws
that psoriasis seems to be "a perfectly visible, exterior, unhidden
disease, but it is precisely the disease of the one who
hides."(8) John Updike devoted the chapter "At war with my skin" to
psoriasis in Self-consciousness.(9) He argues
that psoriasis keeps you thinking: "Strategies of concealment ramify,
and self-examination is endless." The patient constantly invents new
ways of hiding the symptoms.
After an attack of measles in 1938 psoriasis paraded "in all its
flaming scabbiness from head to toe."(10) Disease is too
strong a word in his opinion, as psoriasis is neither contagious nor
painful, nor does it weaken the body. However, the disorder does
isolate the patient from the "happy herds of the healthy."
Updike was lucky. By now treatment with psoralens and ultraviolet A
(PUVA) had been developed. "It is pleasant, once or twice a week, to
stand nearly naked in a kind of glowing telephone booth." As a child
he never got used to psoriasis because it came and went. At the time
when Updike was working on his autobiography, he had been accustomed to
psoriasis for 50 years, and he had come to understand that the war with
his skin was solely a matter of self consciousness, self esteem, of
accepting himself. Of even more importance is this statement: "What
was my creativity, my relentless need to produce, but a parody of my
skin's embarrassing overproduction?"
The English author Dennis Potter suffered from arthritis psoriatica.
"With the extreme psoriatic arthropathy that I have you can't find a
point of normal skin. Your pores, your whole face, your eyelids,
everything is caked and cracked and bleeding, to such a degree that
without drugs you could not possibly survive. It was physically like a
visitation, and it was a crisis point, an either or situation: either
you give in, or you survive and create something out of this bomb-site
which you've become - you put up a new building. That's what it
amounted to."(15) When he was home alone, young Potter
listened endlessly to songs on the radio (songs make mankind
unanimal-like, songs awake the angel in man). "You know that
so-called cheap songs actually do have something of the Psalms of David
about them."(15) In Updike's novel The Centaur Peter Caldwell
cherishes his clothing as a disguise: "Otherwise, when I was in
clothes, my disguise as a normal human being was good. On my face, God
had relented; except for traces along the hairline which I let my hair
fall forward to cover, my face was clear. Also my hands, except for an
unnoticeable stippling of the fingernails."(1) He
undresses furtively, avoiding to be seen as much as possible, knowing
that his belly looks like it has been pecked by a great bird. Peter
Caldwell experiences the disorder as a disgrace and thinks it is
"allergic, in fact, to life itself."
From the Journal of a Leper
Ada
The Singing Detective
His condition is serious, his body temperature is so high that he
starts hallucinating, which causes the boundaries between fiction and
reality to blur. And in those visions he sometimes returns to his
childhood; at other times one of his books is revived in his fantasy,
allowing him to play the lead as the singing detective himself - an
entertainer who sings appropriate songs such as "Dry Bones" and
"I've got you under my skin." All the songs are remembered tunes
from Marlow's childhood.
Marlow, sunk in his scabby self, is neither communicative nor helpful.
This leads to fierce confrontations with his doctors. The nurses, too,
are targets of his snide remarks, except for the beautiful and, in
spite of herself, sensual, "diaphanous" nurse Mills. The hands of
nurse Mills rubbing his penis with ointment never fail to arouse him:
no matter how determined Marlow is to focus on boring things, he fails
at avoiding an erection.
Eventually, it is the psychologist who demolishes the facade. Marlow is
confronted with the fact that a chronic illness is a perfect shelter.
It is a hiding place of the same kind as the high tree in which young
Philip used to conceal himself in order to spy on the world.
The Unconsoled
All aspects known from medical literature are also found in
non-medical literature. Patients subject themselves to a deliberate
seclusion and keep psoriasis as a secret or at least hide it. In this
hiding place Peter Caldwell cherishes his daydreams. In the case of Leo
Brodsky these innocent daydreams have developed into sexual fantasies,
while in The Singing Detective, they
become veritable hallucinations of the protagonist Philip Marlow.
One of the surprising similarities is the role music plays in Peter
Caldwell's life, the former life of conductor Leo Brodsky, Dennis
Potter's memories, and the hallucinations he has provided Philip
Marlow with. The paradoxical combination of a monstrous appearance and
an artistic air is remarkable as well. This cannot be detached from the
fact that many protagonists are given artistic professions. This
transformation from disease to work of art parallels the metamorphosis
from a normal and clear skin to the tarnished body of a patient with
psoriasis.
In all works the past or memories of the past are overwhelmingly
present in the life of the protagonist. It is as if the authors argue
that you can understand the patient with psoriasis only when you have
fathomed his or her past. To what degree this can be realised remains
unanswered, especially since the patients seem to be reluctant or
unable to separate reality from the equally fascinating reality of
memory or imagination.
Psoriasis functions as a metaphor for the creative process. Psoriasis
is the result of the implosion of the artist, and the novels on
psoriasis cultivate the idea that the psoriasis plaque is the Achilles
heel of the introvert individualist, the artist who looks upon the
world as a guardsman from the ivory tower of his psoriasis. His
salvation is a make believe world or an entirely private world: the
imagined past or the world of art.
I thank John Updike for his encouragement and support.
Dutch
College of General Practitioners, References
1 Updike J. The centaur. London: Andre
Deutsch,1963.
2 Farber E M. The language of psoriasis. Int J
Dermatol 1991;30:295-302.
3 Ingram J T. The significance and management of
psoriasis. BMJ 1954;ii:823-9.
4 Wittkower E. Psychological aspects of psoriasis. Lancet
1946;i:566-9.
5 Gupta M A, Gupta A K, Ellis C N, Voorhees J J. Some psychosomatic
aspects of psoriasis. Adv Dermatol
1990;5:21-32.
6 Jowett S. Ryan T. Skin disease and handicap: an analysis of
the impact of skin conditions. Soc Sci
Med 1985;20:425-9.
7 Ramsay B. O'Reagan M. A survey of the social and
psychological aspects of psoriasis. Br J
Dermatol 1988;118:195-201.
8 Palmen C. The laws. London:Minerva,1992.
9 Updike J. Self-consciousness - memoirs. London:
Deutsch,1989.
10 Updike J. Footnotes to self-consciousness. In:Odd
jobs - essays and criticism. New York: Alfred
Knopf, 1991:865.
11 Nabokov V. Strong opinions. London: Weidenfeld
and Nicolson,1974.
12 Boyd B. Vladimir Nabokov.The Russian years.
London: Chatto and Windus,1990.
13 Nabokov V. In: Nabokov D, Brucolli MJ, eds. Selected
letters 1940-1977. London: Weindenfeld and Nicolson, 1990:25-6.
14 Boyd B. Vladimir Nabokov.The American years.
London: Chatto and Windus,1991.
15 Fuller G. Potter on Potter. London: Faber and
Faber, 1993.
16 Pouer D. Seeing the blossom - two interviews and a
lecture. London: Faber and Faber, 1994.
17 Updike J. From the journal of a leper. In: Problems and
other stories. London: Deutsch, 1980:181-97
18 Nabokov V. Ada or Ardor: a family chronicle.
London: Penguin Books,1971.
19 Potter D. The singing detective. London: Faber
and Faber,1986.
20 Lanigan S W, Layton A. Level of knowledge and information
sources used by patients with psoriasis. Br J Dermatol
1991;125:340-2.
21 Bennett P. Psoriasis - a problem shared. Practitioner
1991;235:241-6.
22 Ishiguro K. The unconsoled. London: Faber and
Faber,1995.
Autobiographical prose
Vladimir Nabokov concealed his psoriasis. For example, in the
collection of interviews with Nabokov the term psoriasis is never
used.(11) In February 1937 Nabokov suffered a bad
attack.(12) On 15 May of that year he somewhat pathetically
wrote to his wife, Vera: "I continue with the radiation treatments
every day and am pretty much cured. You know - now I can tell you
frankly - the indescribable torments I endured in February, before these
treatments, drove me to the border of suicide - a border I was not
authorised to cross because I had you in my luggage."(13)
His biographer mentions only one more exacerbation of psoriasis after
that, which occurred in the late 1960s when the strain of writing the
novel Ada fell from Nabokov's shoulders.(14) 
John Updike
Fiction
In addition to The Centaur, Updike devoted the
novella From the Journal of a Leper to
psoriasis.(17) This is the diary of an anonymous, bumptious
potter; 70% of his body is covered in psoriasis plaques. The diary
begins as he starts treatment with PUVA. "Falling in love with the
lights," as he calls it. The basis of the story is the erotic profile
of the patient with psoriasis: "Lusty, though we are loathsome to
love. Keen-sighted, though we hate to look upon ourselves."
Initially, he looks at women with desire; he loves Carlotta, his
mistress, longs to hide between the breasts of a waitress, lusts after
the nurse with the body of a puma, and dreams about a female fellow
patient. But as his skin clears up, Carlotta - who has saintly
tendencies - cools on him, once he no longer has the affliction. From
his part he becomes less and less interested in women. When he lies
next to her with a clear skin, he discovers blemishes and spots on her
skin, which once seemed so flawless. But while she loved him throughout
the previous years (in the morning she would carefully brush his flakes
off her body), the pale fire of his sexual desire dulls. And there is
an artistic transformation worked on him by his cure as well. He loses
perfectionism as a potter. He needed the affliction to create great art
in compensation.
Whereas Updike has written about psoriasis at length, Nabokov
devotes one page to the disease, in the novel
Ada.(18) He mentions "a spectacular skin
disease that had been portrayed recently by a famous American novelist
in his Chiron and described in side-splitting style by a
co-sufferer who wrote essays for a London weekly." The two patients
with psoriasis in Ada exchange notes with tips:
"Mercury!" or "HÍ-hensonne works wonders." Other pieces of
advice are found in a one volume encyclopaedia, and involve taking hot
baths at least twice a month and avoiding spices.
The television series The Singing Detective - based
on a scenario by Dennis Potter(19) - has had a great impact;
patients call it an important source of information(20) and
doctors even recommend it as such.(21) The main character,
Philip Marlow, is a former writer of detective stories, who has been
admitted to a hospital with a severe arthritis psoriatica. Potter
introduces him as follows: "Marlow is glowering morosely, crumpled
into himself, and his face badly disfigured with a ragingly acute
psoriasis, which looks as though boiling oil has been thrown over
him." He is an example of extreme psoriasis at its worst, "cracked,
scabbed, scaled, swollen, scarlet and snowy white and boiling with
pain." His medical history is impressive: coal tar, prednisone,
corticosteroids, gold injections, and methotrexate, after a positive
liver biopsy. All this in a cocktail with barbiturates and
antidepressants. He is in agony. His ex-wife is revolted by him because
he looks like a burns victim. This gains her torments of abuse from
Marlow with his blinding rage.
In the novel The Unconsoled by Kazuo Ishiguro we
find Leo Brodsky, a constantly drunken outcast, with a scabby dog as
his sole companion.(22) Brodsky, once a famous conductor, is
still in love with his former girlfriend, Miss Collins, even though
they have not spoken for decades after a quarrel. He dreams of her, but
he cannot fulfill his erotic fantasies because of the condition of his
skin: "My skin, I have these scales, they keep flaking off, I don't
know what it is." And he combines his disease - its name is not
mentioned in the novel - with his sexual fantasies: "They smell like
fish too, these scales. Well, they'll keep falling, I won't be able
to stop that, she'll have to put up with it, so I won't complain
about her pussycat smelling the way it does, or the way her thighs
won't part properly without clicking, I won't get angry, you won't
see me trying to force them apart like something broken, no no."
Brodsky is a tragic man, crippled and wrinkled by lust and psoriasis. Discussion
Oudegracht 16,
3511 AN Utrecht,
Netherlands
Frans Meulenberg, General practitioner
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