Personal view

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 5 6 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 Autobiographical prose

Autobiographical prose
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."

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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?" John Updike GETTY IMAGES

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

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 Fiction

Fiction
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
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.

Ada
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 "Höhensonne 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 Singing Detective
The television series The Singing Detective—based on a scenario by Dennis Potter¹⁹—has had a great impact; patients call it an important source of information²⁰ 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.

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
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

Discussion
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.

Frans Meulenberg, General practitioner, Dutch College of General Practitioners, Oudegracht 16, 3511 AN Utrecht, Netherlands 

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