Friday, July 21, 2017

The Dermatology of Greyscale


Game of Thrones is back! *fangirl scream*

In honor of the show's return, I was poking around in the scientific literature for a fitting article. I found an interesting little note in a dermatology journal concerning "greyscale."

Greyscale (also known as "Prince Garin's curse or "grey death") is a relatively uncommon but fatal disease in Westeros. It typically affects children living in cold, damp climates but everyone is susceptible. It is characterized by hardened and calcified skin that feels stone-like and cracks as a result of the body's movement. Severely affected areas have a scaly appearance. In advanced stages of the disease, the skin further hardens and becomes mottled grey and black as it dies, giving it a stony appearance. In the final stages, the internal organs harden, eventually spreading to the brain and causing insanity. Greyscale is very fast to contract but slow to kill, often taking many years. During those years, as the infection spreads over the entire body, an infected person becomes known as one of the "Stone Men." Children have a slightly better chance of surviving an infection, but it is rare. Should a person survive the disease, they are immune from contracting it again but are left disfigured.

A short but entertaining piece in JAMA Dermatology discusses possible epidemiological aspects of greyscale. (note: may contain minor spoilers from this point on)

Greyscale is often compared to leprosy (Hansen's disease), a bacterial infection caused by Mycobacterium leprae. But greyscale differs in that it is spread by skin (or possibly object) contact and has no leonine facies, dermal plaques and patches, neuropathy, etc. Well, what do we know? First, we know of the case of Shireen Baratheon, daughter of Stannis Baratheon and child survivor of greyscale. She has lingering skin changes described by the article as "ichthyotic plaques in a somewhat Blaschkoid pattern limited to the left side of the face and body." We also know that the Stone Men have disseminated skin changes and are mentally unstable, with aggressive behavior. But perhaps the most interesting and telling case is that of Jorah Mormont. Following skin-to-skin contact with a Stone Man, Jorah developed a skin lesion within only a day.  Leprosy, and most other infectious agents, are not nearly this contagious. The article hypothesizes that greyscale may actually be a virus that is as contagious as smallpox. In Shireen, it presented like a genodermatosis, which is genetically based, perhaps like a mosaic form of epidermodysplasia verruciformis. In the end, the clinical data and pathology reports coming out of Westeros are thin. With this new season, perhaps we can further follow Jorah's disease progression and maybe his cure as well.

Update 08-24-2017: Jorah is cured! And he got a new shirt too! Peeling of the skin (eww) and applying a salve of some kind did the trick. What was in that salve I wonder....


Lipoff, J.B. (2016) Greyscale - A Mystery Dermatologic Diseas on HBO's Game of Thrones. JAMA Dermatology. 152(8):904. DOI: 10.1001/jamadermatol.2015.5793


Details about greyscale and image via Game of Thrones Wiki.
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