Dermatological notes

On my appointment with Dr. Monica Sandhu, dermatologist at Palo Alto Medical Foundation in Palo Alto (PAMF has a number of locations, so this description is not pleonastic), on Wednesday 6/7. On a referral (6 weeks ago — appointments are hard to get) from my primary care, who was concerned that various growths on my skin might be cancerous. Dr. Sandhu was to give me a top-to-bottom (literally: from my scalp to my toes) examination of the surface of my body, surveying all the growths and other dermatological oddities there.

(Previously on this blog: my 5/30/23 posting “On the dermatology beat”, about various skin conditions that, all together in a short period of time, improved or disappeared completely.)

Two things: the conclusions of the exam, which were gratifying; and the circumstances and setting of the exam, which I will subject to my usual participant-observer analysis: how did I come to have this particular doctor (on what was, as far as I can recall, my first visit to a dermatologist)?  how did they present themselves? how did they approach their task, coping with a new patient of advanced age, active engagement with his treatment, and a gigantic inventory of baroquely complex afflictions that unfolded during the interview? Very high marks here.

What Dr. Sandhu found. The bottom line: a huge array of seborrheic keratoses, skin tags, and moles, all benign. A bunch of things other than growths, also benign: lymphatic fluid scabs (not quite disappeared after my wound-dressing treatments), skin flaking (probably psoriasis, now much reduced after daily treatments with coconut oil), an actual mosquito bite. The growths that so puzzlingly disappeared, all together, recently (see previous posting), were (according to Dr. Sandhu) seborrheic keratoses that finally succumbed to my body’s recovery after being weaned from prednisone, plus my coconut-oil treatments, with maybe some help from the diuretic regime I’ve been on.

One of the disappearing growths was what I thought was a mole, now shrinking into insignificance, but the doctor looked at it under a hand magnifier and pronounced it too to be a seborrheic keratosis, soon to vanish.

All of this was wonderful news, but then the doctor frosted the cake by remarking on the excellent condition of my skin — tending to dryness (though I’m working on that), but amazingly resilient and unwrinkled for someone my age. Dr. S. went on to congratulate me on my success with the various self-treatments. (Everybody these days exclaims at how lean and muscular — how edema-free — my legs and feet are, thanks to the diuretics. Just a moment ago I bit the bullet and ordered new L.L. Bean slippers in size 12 instead of 14, because the old ones are now dangerously too large, inclined to slip off my feet.)

Background: the technicalities. First, from the Mayo Clinic site on seborrheic keratoses:

A seborrheic keratosis … is a common noncancerous (benign) skin growth. People tend to get more of them as they get older.

Seborrheic keratoses are usually brown, black or light tan. The growths (lesions) look waxy or scaly and slightly raised. They appear gradually, usually on the face, neck, chest or back.

Seborrheic keratoses are harmless and not contagious. They don’t need treatment, but you may decide to have them removed if they become irritated by clothing or you don’t like how they look.

… Experts don’t completely understand what causes a seborrheic keratosis. This type of skin growth does tend to run in families, so there is likely an inherited tendency. If you’ve had one seborrheic keratosis, you’re at risk of developing others.

(I have a hell of a lot of them.)

On the vocabulary here. seborrheic ‘like, resembling seborrhea’. And then from NOAD:

noun seborrhea (British seborrhoea): Medicine excessive discharge of [the oily secretion] sebum from the sebaceous glands [AZ: glands in the skin, associated with hair follicles, that secrete this oily matter to lubricate the hair and skin].

And from Wikipedia:

A skin tag, or acrochordon (pl. acrochorda), is a small benign tumor that forms primarily in areas where the skin forms creases (or rubs together), such as the neck, armpit and groin. They may also occur on the face, usually on the eyelids. Though tags up to half an inch (12.7 mm) long have been seen, they are typically the size of a grain of rice. The surface of an acrochordon may be smooth or irregular in appearance and is often raised from the surface of the skin on a fleshy stalk called a peduncle. Microscopically, an acrochordon consists of a fibrovascular core, sometimes also with fat cells, covered by an unremarkable epidermis.

… Skin tags are thought to occur from skin rubbing against skin, since they are so often found in skin creases and folds.

Acrochorda are very common, and seem to run in families. I have an especially large and notable one in the fold under my left pectoral muscle.

And from NOAD:

noun mole-2: a small, often slightly raised blemish on the skin made dark by a high concentration of melanin.

A fair number of these on my body.

The circumstances and setting of the exam.

How did I come to have this particular doctor? Went to PAMF Palo Alto’s Dermatology department page and looked at all the doctors currently accepting patients, aiming for someone young, female, and hyphenated — reasoning that such a person would have to be especially competent, because they had surmounted all these barriers. Among the choices was an Indian-American, and I have warm feelings for South Asians, thanks to my associations with this community at the University of Illinois, following on my having written a doctoral dissertation on Sanskrit — specifically on the morphophonological phenomenon called sandhi (literally ‘putting together’), referring to variation in the pronunciation of words according to the elements surrounding them in connected speech, as in the a vs. an alternation for the English indefinite article.

(Since I’m a sandhi guy, I’m prone to misspelling Monica Sandhu’s family name. A lot. As for that name, it’s a variant of Sindhu, a family name originally denoting the Indus River and the region it flows through, Sind. I know, peccavi ‘I have sinned’.)

How did she present herself? As brisk, but open and engaging — very much to the point, but empathetic.

And also, as I expected, an Indian American in the way I’m a Swiss American: at some time remove from the homeland, America-born and American-raised. In a way, she’s more American than I am, since her first name is more American than mine.

How did she approach the task, coping with a new patient with a gigantic inventory of baroquely complex afflictions that unfolded during the interview? Extraordinarily well, managing to fit each piece in as it came up, and commenting knowledgeably as we went along (she deftly did the interview while she was examining my body, multitasking efficiently). I was especially impressed at the breadth of her medical knowledge, and her willingness to cope with what a less composed person might have experienced as a barrage of curve balls. Necrotizing fasciitis, got it. Brief excursus on fallen arches. The weeping sores of lymphatic fluid. Life in Diuresis City. Dyspnea on exertion. Dreadful afflictions attending on prednisone withdrawal. Some autoimmune thing that mimics osteoarthritis. She rolled with it all, adding helpful comments as we went along.

Most impressive performance, all done with style and humor. She left me with information about using sun screen and an instruction to see her again in a year.

3 Responses to “Dermatological notes”

  1. Robert Southwick Richmond Says:

    Seborrheic keratoses are one of the most infelicitously named lesions out there – they have nothing to do with seborrhea, and most of them aren’t conspicuously keratotic. They have no malignant potential at all, including the infamous “irritated seborrheic keratosis”, which can look remarkably fierce either on clinical examination or under the microscope.

    Distinct from actinic keratoses, which have a different clinical and microscopic appearance, and are definitely pre-malignant.

    • arnold zwicky Says:

      Yes, a terrible name. Mildly in its defense, the name only asserts that the things *resemble* seborrhea — but unfortunately seborrheic can be understood as ‘involving seborrhea’, so confusion ensues.

      And yes, most are not actually keratotic, horn-like, though two of mine (two of the ones that excited my primary’s interest) were indeed brown and crusty.

  2. Mark Mandel Says:

    An interesting and successful strategy for finding a good doctor.

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