Skin is the largest organ of the body.

It also contains the highest concentration of nociceptors, alerting us to pain at the surface level with the intent to mitigate harm from noxious stimuli.

A veritable trip wire for threats from the external environment, it offers palpable and visible responses in the dermatological layer, providing opportunities for intervention to avoid, eliminate, or resolve problematic exposures.

The skin is also a message delivery system from the internal structures of the body, illustrating organic and somatic strain, injury, and disease through aggravation at the topical level.

The skin is an organ of sensation—tactile, indeed, but perhaps most importantly, for listening—to hear the warnings and wailings of the world within and around us, inviting us to investigate and intervene on behalf of health.

Pain, from the surface level, is an incredible informant, alerting us to threats of harm from both acute and insidious sources.

Are we willing and able to listen?

The sharp sting of a burn or laceration can be difficult to ignore, with reflexive action drawing our hand away from the hot stove or sharp object, with little thought as to whether we should or could continue the current course.

The dull ache or lingering twinge can be easier to dismiss. Often attributed to a poorly chosen sleep position or a recent change in activity, the cries for help from viscera can go unheard for extended intervals, often worsening and wielding ever more intense symptoms, surface and systemic, ultimately requiring deeper investigation.

Skin is also the site of expression of stress and is associated with a vast array of psychological disturbances. Whether the primary manifestation of psychological pathology, an accompaniment to a complex presentation, or an exacerbation at the surface level due to escalating mental and emotional strain, the skin can demonstrate pain happening in the mind through surface-level aggravation.

Tactile topical irritation, both seen and felt, can be incredibly distracting, impacting self-image and the capacity for focus, and interfering with the ability to rest, recreate, and recover from daily challenges.

When we are uncomfortable at the surface level, our ability to be present in any situation is affected.

There are many treatments and regimens to optimize the health of our skin. These can provide relief and rejuvenation, offering helpful reprieve and, in certain situations, resolution of the issue.

Resistant and refractory conditions invite us to be curious and creative, considering alternative sources of the pain and irritation demonstrated in the dermis, and showing a willingness to look deeper—to listen through to the core of the messages being offered at the outermost layer.

Identifying the root cause of any disease, particularly those expressed by pain that seems otherwise inexplicable, can be the most perplexing and satisfying aspect of the practice of medicine. Taking time to observe, listen, inquire, and synthesize broadens the perspective of possibility—that the why of the sting, itch, rash, lesion, or knot arriving as a chief complaint at the surface level represents something else, deeper and reflective of environmental relationships within or external to the individual.

This has happened for me as both patient and physician on multiple occasions, two of which stand out for their extremity.

As a second-year medical student, I developed a severely painful case of what was eventually determined to be nummular eczema—so intense, I became the patient no one wants to be at a teaching institution, where every resident, student, and visitor was invited into the exam room to see the extent of the issue. With a lifelong history of atopic dermatitis, on one level it was not entirely surprising, but it was nonresponsive to previously effective treatments, and the whole-body impact was unlike anything I had ever experienced. We considered foods (no changes in diet), topical exposures (relatively consistent utilization of soaps, clothing, etc.), and tried ever-higher concentrations of emollients to relieve the endless irritation. When, upon completion of the first round of boards, the lesions almost immediately dissipated, I paused to consider how I might have been exceedingly more stressed (emotionally pained) than I had realized. Subsequently, now some decades later, I also recognize a change in my personal life and living situation concurrent to the onset of symptoms, and I believe my body was also providing a warning of impending harm.

As a physician, in my first year in solo private practice—having left a large health care system where my specialty was often the caboose of medical evaluation and landed now as the engine—a patient presented with rib pain and sought my expertise with the anticipation of treatment with osteopathic manipulation. On hearing the patient’s story and completing an exam, it was clear this was felt on the surface of the body but was driven by something much deeper and more concerning than a dysfunctional rib. With careful discernment, discussion, and additional testing, it was determined this was pancreatic cancer, speaking to the patient through superficial pain.

These moments, among many throughout my life and career, have shown me the importance of looking beneath the surface, listening beyond superficial symptoms, validating the truth of the experience, and holding space for what more might be contributing to the pain we experience, so that we might find the source and, in that seeking, discover the solution.

Amelia L. Bueche is an osteopathic physician and founder, This Osteopathic Life.