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Notes From a Real Dermatologist

Our in-house MD breaks down the eczema on ‘The Night Of’

HBO
HBO

Rany Jazayerli is a Ringer contributor and a dermatologist practicing in the western suburbs of Chicago, so we asked him to weigh in. Here are his extremely informed thoughts:

I think The Night Of’s portrayal of John Stone’s eczema is generally accurate — and specifically strong on how patients with severe eczema have their life altered by the disease. But of course it’s overdramatized. Someone who’s had terrible eczema for years and years wouldn’t be buying over-the-counter remedies like Stone does, and it’s hard to imagine the first doctor he sees sending him away without a steroid prescription of some sort. (In fairness, the second doctor he sees basically called the first one a moron.) Applying a thick moisturizer and covering it with Saran Wrap is actually quite helpful, but Crisco is such an old remedy that it’s practically an old wives’ tale at this point — a thick, goopy moisturizer like Aquaphor is much better, and what I recommend to all my patients.

And then in Episode 4, Stone finally sees a doctor who seems to know what he’s doing; all the remedies he recommends (steroids, UV light, Clorox) have their uses. But again, it’s dramatized and simplified too much. Stone is prescribed steroid pills instead of a topical steroid cream, which is baffling — steroid creams are the mainstay first-line treatment for eczema, whereas pills are a short-term fix that I use in emergencies, but they can have side effects and can be taken for only a short period of time. A home UV lamp is expensive and not as effective as the UV phototherapy units we have in the office — it’s a great treatment and I use it on a lot of patients, but they need to come into the office two to three times a week, and we monitor their dose (i.e., how long they stay inside the light box) carefully. I might consider a home UV lamp for someone who has had eczema for years and has responded to treatment in the office but who doesn’t want to come in for treatments for the rest of their life, but it’s ridiculous to tell someone to shell out a couple thousand dollars for a home unit without knowing that it’s going to work. And the doctor seems to be telling John to douse himself in Clorox, when in fact you’re supposed to add a couple tablespoons to an entire bathtub of water. You’re basically chlorinating it a little to prevent the eczema from getting infected.

But the pharmacist! He is a complete moron. (Well, the pharmacist is a moron; Fisher Stevens, the actor who plays him, dated Michelle Pfeiffer for years, which is fairly definitive evidence that he is not, in fact, a moron.) Twenty milligrams of a steroid pill (presumably prednisone) is actually a low dose to start someone on — too low, even, to really be effective. I usually start at 60 mg for a week and taper down from there. But the pharmacist acts like the doctor prescribed John a Happy Fun Ball. And his “you’ll hit 75 homers” joke is a pet peeve of mine — the steroids we use to treat skin conditions are catabolic steroids, which break down muscle mass, meaning they are the exact opposite of anabolic steroids, which build muscle mass. No pharmacist worth his degree would make that joke.

Having said all that, it is gratifying to see a chronic skin disease — a very common one but one that, like all skin diseases, patients are generally embarrassed to share with the world — get so much coverage on a TV show. They’ve gotten the look of eczema down pretty well — major props to the makeup artists for the support group, as I imagine it’s hard to fake severe eczema, and all of those patients look fairly realistic to me. (Or maybe they cast real patients and told them to hold off on using their meds for a while?) Support groups aren’t very common, but they do exist, and I have to imagine if you can find one anywhere, it’s going to be in New York City.

So in summary, I think HBO has overdramatized and dumbed down the eczema enough for a dermatologist like myself to make fun of it — but it’s still the best portrayal of a chronic skin disease that I can remember seeing on television. It remains to be seen whether its prominence in the plot is for a specific reason that will reveal itself, or whether it’s there just to flesh out his character. But eczema, like a lot of skin diseases, is exquisitely sensitive to stress — we sometimes refer to it as a window to the soul — and so watching his eczema smolder and fester and stubbornly refuse to be tamed is not just a figurative metaphor for John Stone’s life, but a literal one.

Disclosure: HBO is an initial investor in The Ringer.