Skin Deep

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Alex: No, you're wrong! I'm a girl! (She pulls off her gown) Look at me! How could you say I'm not a girl? See! They're all looking at me. I'm beautiful!

House: Anger, it's just the cancer talking. Put your clothes back on. I'm going to cut your balls off. Then you'll be fine.

―Skin Deep

Skin Deep is a second season episode of House, which first aired on February 20th, 2006. A model with a heroin addiction collapses on the catwalk. Meanwhile, House's leg pain worsens because he misses Stacy.

Recap[]

A 15-year-old model is given Valium by her father before taking the stage at a big fashion show. After walking out, she gets into a violent confrontation with another model, then collapses on the runway.

House is suffering more leg pain than usual, but is more than happy to take on the case of the "teenage supermodel". He goes to meet the patient, who can't remember why she got angry. She describes being conscious, but unable to move or talk. House tells the patient she exhibited cataplexy, which he feels is drug-related. The father admits to the Valium, but House doesn't think that's the whole story. He orders blood and urine tests for a tox screen.

Cameron confronts House about his attraction to the girl. The tox screen shows she has been taking heroin and the team thinks she's addicted. House keeps going on about the patient's looks. They decide on a rapid detox procedure because they feel the drugs are masking another disease and they don't have time to wait four weeks to find out. They explain the risks to her father, who agrees to the procedure. They put the patient into an induced coma. She later goes into cardiac arrest, but they revive her. They explain to the father that if they bring her out of the coma before the detox is over, she will be in extreme pain.

The patient comes out of the coma, but shows signs of short term memory loss, which might be the result of brain damage from her cardiac arrest. However, House holds his breath for 30 seconds, proving that brain damage couldn't have occurred within a 30 second time frame. He insists that her brain is fine. He diagnoses her with post-traumatic stress disorder, as the result of sexual abuse from her father. Foreman accuses House of rushing everything because of his pain.

Meanwhile, the team does an MRI of the patient, but the patient keeps twitching, although she denies that she is. House confronts the father and, on the pretext of being bound by doctor/patient confidentiality, gets him to admit that he had sex with his daughter once.

However, the team finds elevated proteins in her cerebrospinal fluid, which indicates that it's not a stress disorder. The revelation of the sexual abuse leads Cameron to want to report it to social services. House claims doctor/patient confidentiality, but Cameron says that it doesn't apply in abuse cases. When Cameron presses the matter, House tears into her, noting he needs to keep the father around in the event he needs more information about his very sick patient. He orders a brain biopsy. Foreman goes to the patient and disregards the wish of the father to keep the risks of the procedure hidden from her. She agrees to the procedure and they drill a burr hole into her skull to extract a brain sample.

Cameron goes to Cuddy about the abuse. Meanwhile, Wilson does a MRI of House's leg to see if there is a problem. Wilson takes the opportunity to play God with the microphone and House plays along. Cuddy goes to House in the MRI to tell him to cooperate with the abuse investigation. The team discusses the ethics of the disclosure and Chase points out that, without the promise of confidentiality, the father would never have admitted to the abuse. Wilson diagnoses that House's worsening leg pain is psychological because he misses Stacy. In response, House strikes Wilson's leg with his cane and asks him if he misses Stacy, too.

Meanwhile, House is resigned to Cameron's disclosure to Cuddy, and the brain biopsy was normal. House comes up with a new diagnosis: paraneoplastic syndrome from cancer. To verify, they treat her with immunoglobulin, which immediately stops the twitching, confirming the cancer. The tumor's location, however, remains a mystery.

Meanwhile, House asks Cuddy for a shot of morphine. He doesn't want his team to know he is suffering, and Wilson thinks it's psychological. Cuddy agrees to give him the shot after he shows his atrophied thigh muscle.

When the team examines the patient, they can't find any tumors. House is unconvinced by the test results because the other symptoms fit. However, Wilson has checked everywhere. Despite that, the team agrees with House. The only explanation is that the patient is responding unconsciously to the anti-twitching medication. They try a placebo to see if the twitching returns.

The social worker visits the patient and dismisses the abuse allegations because both father and daughter deny it. Cameron confronts the patient, who admits that she regularly sleeps with men who can further her career. She slept with her father because she knew doing so would allow her to do as she pleases. The twitching returns, showing the patient is actually ill.

House shows Cameron the patient's medical history, which reveals that she has never menstruated, had little pubic hair, and has undersized ovaries. They do an MRI and find the cancer in her groin. House goes to the patient and explains that "he has cancer on his left testicle". The patient has complete androgen insensitivity syndrome. The disorder prevented the genetically "male" Alex from being able to process testosterone. Since the patient could only process estrogen, the patient developed female characteristics, such as clear skin and large breasts. This revelation disturbs Alex, who is unable to believe that she is actually intersex. This prompts a psychiatric referral from House, who remarks upon the irony that the ultimate woman is a "man". The surgery is a success.

House visits Cuddy for another shot of morphine. Cuddy admits the previous shot was saline solution - a placebo. The pain only returned after House solved the case, so it was psychological after all.

House goes home to play the piano. He reaches for his Vicodin.

Clinic Patient[]

The male patient is exhibiting a number of symptoms, including tooth pain, headaches, and nausea. House diagnoses sympathetic pregnancy; the symptoms mirror those of his pregnant wife. He tells the patient to stop whining about it.

Later, House dodges his clinic duty by saying his leg hurts too much. While Cuddy covers for him, she meets the patient again, who is now developing breasts. Cuddy gives the patient House's personal pager number when she notes House did not write down his prior diagnosis on the patient's chart.

Later, the wife arrives in labor, and the husband feels sympathetic pain. This leads House to realize that secondary sexual characteristics are based on hormones, like the estrogen coursing through the clinic patient's body. He investigates the possibility that his other patient is unable to process testosterone.

Major Events[]

After forcing Stacy out of his life once again, House struggles with his worsening leg pain.
Wilson gives House's leg a MRI and both men learn that nothing has changed.
House reveals his scarred leg for the first time in the series.
Cuddy is revealed to have given House a shot of saline, instead of morphine.

Zebra Factor: 10/10[]

Testicular cancer is one of the most common cancers in males. However, complete androgen insensitivity syndrome is very rare, occurring in about 1 of every 150,000 male pregnancies but also increasing the risk of testicular cancer.

Quotes[]

Foreman: Anterograde amnesia, short term memory loss, evidence of a hypoxic brain injury; might be the result of getting cut off from the oxygen when she flatlined. Probably the result of that rapid detox you told us to push on her. You gonna put that down? [House puts down his 'Celeb' magazine and inhales, holds his breath] You gonna sulk? [House shakes his head] I'm not gonna indulge you. [House checks his watch] Treatment for hypoxic brain injuries consist of... [House exhales]

House: Cameron, Chase and the dark one; Foreman, right? Patient flatlined for like 30 seconds, got to be oxygen deprived for longer than that to lose brain function.

Cameron: We can't be sure how long she was--

House: Her brain's fine.

Foreman: Memory loss. You're saying that's not a neurological symptom?

House: No. I'm saying what I'm saying. Her brain's fine.

Chase: She's faking?

House: She's got post traumatic stress disorder.

Chase: We got models fighting in Iraq now?

House: Show me a woman on heroin who looks like that [he hold up a magazine picture of Alex] and I'll show you a woman who's been sexually abused.

Cameron: Wilson already did an ultrasound, said her ovaries were undersized.

House: The ultrasound would be the way to go if you were looking for ovarian cancer.

Cameron: What are we looking for? [the machine beeps]

House: That.

Cameron: Oh my God.

House: Looks like a tumor doesn't it?

Cameron: But those are...

House: Yup.

Cast[]

Hugh Laurie as Gregory House
Lisa Edelstein as Lisa Cuddy
Omar Epps as Eric Foreman
Robert Sean Leonard as James Wilson
Jennifer Morrison as Allison Cameron
Jesse Spencer as Robert Chase
Cameron Richardson as Alexandria Robinson
Tom Verica as Martin Robinson
James DuMont as George
Stephanie Venditto as Brenda Previn
Karis Campbell as Pregnant Woman
Donzaleigh Abernathy as Brady
John Burke as Austin
Jim Hoffmaster as Surgeon
Julie Michaels as Fashion Show Patron

Trivia & Cultural References[]

The title of the episode is from the saying, "Beauty is only skin deep". The first recorded use of the phrase in reference to beauty was in 1613.
Madonna, of course, is the famous singer and actress.
The piano piece that House plays during the ending scene is the first part "Allemande" (german dance) from the French Suite No. 5 in G-major by J.S.Bach

Medical Goofs[]

*House’s position in the MRI machine is more associated with imaging the abdomen or pelvis. For a leg scan House would actually be lying so he would be facing the opening in the MRI machine, but if that were so, then he’d be able to clearly see Wilson talking into the microphone and the disembodied voice saying “House this is God” joke would be less funny

If you look closely House’s legs not in the correct placement in the machine to even be scanned

Links[]

Previous episode:
Distractions

Skin Deep

Next episode:
Sex Kills