psychodermatology march 15.cdr

skinpsychology
The aesthetics industry has progressed
significantly in the past decade. Today,
aestheticians are armed with greater
knowledge, expertise, products,
ingredients, equipment and results, thus
potentially improving the health of the
skin and condition of client's skin to a
greater extent than ever before. Skincare
clinics have therefore become a real
option for clients who are desperate for
your professional expertise and
knowledge to treat skin disorders such as
acne, hyperpigmentation, rosacea,
eczema, elastosis, psoriasis, or
manifestations that are as a result of
illness, medication, poor treatment
outcomes, etc.
Even ageing can be a deep-rooted
emotional issue for some women.
Clients place their trust in you to
improve their appearance and meet their
expectations. Some clients may have
already exhausted the medical option,
and so seek the help of skincare clinics to
solve their skin issues. However, reports
of negative experiences with
therapists/aestheticians (as there is with
doctors and dermatologists) are
common. Therapists/aestheticians were
reported as not only having poor
comprehension of the pathogenesis and
correct treatment protocol for skin
disorders (unrealistic promises made,
poor treatment outcome, disease or
scarring is worsened), but they were also
often insensitive to their client's
e m o t i o n a l s u ff e r i n g , a n d e v e n
trivialising their client's disease. The
complexity of clinical scenarios and the constraints on the therapists
should be acknowledged, however, therapists should also be educated
in the potential psychological effects of skin diseases, and how to
correctly manage these problems with empathy and care for best longterm results and benefits.
PSYCHODERMATOLOGY
More than skin deep
Considering the emotional, psychological
and social implications of skin disorders
By Matoyla Kollaras
The need to deal with the whole person when addressing their
skincare needs is not a new concept. As a skincare practitioner
you are constantly increasing your knowledge, skills and
training to better understand, treat and manage skin conditions.
This will no doubt mean that you will frequently encounter
challenging skin conditions that will also significantly impact
the client's emotional and psychological state of mind.
Matoyla is a qualified therapist and the Director of Skinfactors
Cosmeceuticals. She is passionate about skin health and skin
treatments and is highly committed to constantly staying at the
forefront of research and new advances in skin science and
cosmetic ingredients. In this article she addresses the allimportant issue of psychodermatology and innovatively
approaches the topic through the eyes of patients that reveal
their emotional turmoil.
“…You become introverted, avoid contact, and become depressed,
obsessive in looking at other people, hoping to see someone else who
is affected. You undergo a personality change very slowly, and bit by bit,
a strong person is reduced to isolation. You become angry, sad and
desperate. After time, it becomes an operation just to go out your front
door…” This is a 27 year-old female discussing her 15-year vitiligo
history1.
APJ 30
THE SKIN YOU'RE IN IS ALL YOU HAVE
“A shocking 47% of people with a skin disease in the UK have been
victims of verbal abuse one or more times from a member of the public.
A total of 729 people were asked a series of questions relating to their
skin disease, or that of the person they care for. Questions were asked
on the ways skin disease affects daily life, including forming of sexual
relations, social life and work life. The results show that the long-term
effects of skin disease can have a devastating impact on sufferers' lives
that few would expect.”2
The skin is extraordinary, and when you learn to read it correctly it is
potentially an excellent diagnostic tool; indeed, quite often being the
first 'red flag' that something is not quite right internally. The skin is
also our largest organ, and has long been recognised as an 'organ of
expression' (Sack, 1928); it is, after all, our first point of contact
between the outside world – environment, meeting people and our
own selves. The skin is an organ that can directly respond to external
stimuli (a rash caused through contact of a toxic substance), and
reflect what is happening inside our bodies, both physiologically and
psychologically (blushing when embarrassed, acne due to hormonal
factors, auto-immune lupus butterfly rash, dry, itchy skin due to
organic disease such as diabetes).
Dermatological diseases have been shown to have a negative impact
on physical communication, sexual contact and, in particular, are
often implicated in an elevated sense of fear, anxiety, shame, and in
severe cases, thoughts of suicide.
Are you the parent of a teenager, who is continually bullied at school
and would rather hide in their room, excluding themselves from social
involvement due to their acne condition? Does your child refuse to
take swimming lessons, or show any part of their body because of their
psoriasis? Do you have a friend who refuses to be without makeup,
even in front of their partner, due to melasma? Does your partner live
with stage 2 or 4 rosacea and every day deals with day the ruddy, red
skin coloration and the unsaid question of “Have you been drinking?”
Or perhaps you have a client whose hands are riddled with eczema,
and so they are too afraid to touch people lest they receive a negative
response?
yes, it does matter but they don't have to live with acne marks all over
their face. When people talk with you, the first thing they see is your
face. And what do I feel? I feel like they're looking at my flaws, like
they're disgusted for even talking to me. I can't tell you how much I've
cried because of my look. I feel like a monster. And if I had one wish, it
would be for my skin to be clear. It's the only thing I need to be happy
again.”5
Sadly, having a skin disease can also have implications for romantic
and sexual relationships. Many sufferers have cited their skin disease
as the reason for relationship breakdowns, or lack of finding a partner.
Some people will even go as far as not marrying and/or not having
children for fear that they will pass on the skin disease.
Furthermore, approximately 50% of those living with skin disease
suffer from sleep deprivation caused by pain and/or itching. As a
result this creates more stress due to fatigue and frustration. This state
Unlike most internal illnesses, skin disease is often immediately
visible to others, and thus can prove to be a hugely stressful and a
heart-breaking experience for the individual that has to live with the
skin disease on a daily basis. To add to this problem, “relatively little
attention has been paid to the psychosocial problems experienced by
skin diseases sufferers”.3 And yet it has been estimated that between
40% and 80% of people with dermatological conditions have
experienced significant emotional, social and psychological
problems.
“Patients with skin disease often feel enormously upset about their skin
condition, as it affects their confidence and self-esteem in so many
different ways. All too often the impact of skin disease is
underestimated, and our research makes it very clear that it is common
for individuals with skin disease to consider suicide. Many patients
consider skin conditions to be more psychologically damaging than
diabetes or heart disease.” 4
Many skin diseases such as psoriasis, vitiligo, etc., are very
noticeable, visually striking and often provoke a response. As a result
many people with these manifestations often fall victim to regular
bullying, and yet more concerning is that one in eight had suffered
from some form of physical abuse from a member of the public.
Negative reactions and a fear of negative reactions from others is a real
challenge for those living with skin disease.
More common conditions such as acne and eczema, which often have
a chronic manifestation, can affect people on a long-term basis.
Clients who suffered from severe acne as teenagers and adolescents
can quite often carry the burden of lasting physical, psychological and
emotional scars long into adulthood. Acne scarring is a daily reminder
of a difficult period, and its impact on self-esteem, confidence and
depression is well established. I am sure we have all come across the
introverted acne client, who has chosen a life of the avoidance of
behaviours, places and events, or doesn't care for the way they dress,
or perhaps is working in a menial job rather than chase their career
dream because they fear rejection in the interview process. Are they
really introverts? Do they really not care about themselves and their
life? I would probably guess that they are not introverts, and actually
care very much for how they look and their life's path. However, their
acne has rendered them unable to look beyond the pain and
disfigurement; instead, the acne has become who they are.
“I feel disgusted when I look at myself. People don't understand. They
say to me “your look doesn't matter; it's who you are on the inside”. And
of being of course in turn impacts on the emotions, and most
importantly due to the stress, cortisol spike, skin immune suppression
cycle, the disease is worsened. There are clear indications that stress
plays a profound role in the exacerbation and at times onset of skin
disease such as acne, eczema, vitiligo, psoriasis and urticaria.
There are two further significant concerns that are faced by those
living with skin disease:
1. Because skin diseases are noticeable and draw people's
attention, this can “remove the feeling of personal control from
the sufferer”,6 thus rending the disease 'public property', unlike in
the cases of many internal diseases where the sufferer is able to
“control who knows about their condition and when”.7
2. Skin disease has often been associated with myths
surrounding poor hygiene and contagion. This often means
people will act negatively towards the sufferer, and hence often
trigger feelings of stigma by the sufferer.
CLINICAL MANAGEMENT
“I had acne when I was a teenager. After it went away I was left with
indented scars. I went for laser resurfacing at the age of 53 that made
things much worse for me. He burnt my face and left me with dents, fat
loss and more scars. I have been homebound for the past seven years
because of this. I stopped doing everything and I mostly stay inside. I
don't want friends or family to see me. I shake when I get up seeing the
damage the laser did to me, day after day. I wouldn't wish this on
anyone.” 8
Until you have walked in the shoes of skin-disease sufferers you
cannot possibly comprehend the daily torment that they face. In the
greater scheme of things, it may seem quite insignificant to one who
APJ 31
does not, or has not experienced such skin conditions, but imagine for
just one moment that you awake one day to a condition that becomes
the first thing people see when they look at you, and perhaps a defining
characteristic such as: “Hey, you know who I am talking about, the
woman with brown patches on her cheek.” 9
Clinical management of skin conditions therefore requires a
perspective beyond the skin and its lesions. Through heightened
awareness and support you can help these clients, not only through
your skills, treatments and products you offer, but by your ability to
develop an empathetic, trusting and caring client/therapist
relationship.
Your initial consultation therefore, is a crucial component of the
treatment process. Allow ample consultation time, ask many relevant
questions, and more importantly, listen with your ears, eyes and heart.
When a client is struggling with their appearance, they often feel alone
in their struggle. For this reason, you should also aim to become your
clients' skincare partner or coach by gaining their trust and
confidence.
Be mindful in your approach. It is critical to treat these clients with
sincerity, respect and sensitivity. Most importantly, be honest and
realistic. Don't make promises that you cannot guarantee by making
exaggerated claims of what treatment outcomes you can achieve –
always under-promise and over deliver. Be honest also with your own
capabilities, and be realistic with what your clinic can offer the client.
Consider whether you can truthfully help this client. Do you know
how to best approach and treat their skin condition? Do you have the
appropriate tools and knowledge, or will you make compromises and
make do with what you have on hand, which may not be the best
approach, or potentially worsen the condition?
You may also need to discuss the possibility that your client may need
to consult health professionals such as a dermatologist, psychologist
and nutritionist – skin diseases can generally respond well to dietary
improvements and a thorough health assessment of digestive
abnormalities and other underlying inflammatory conditions. Know
when to refer.
On the other hand your client may have already exhausted all medical
avenues and you could be their last resort. Again approach the
problem truthfully. Can you offer a solution, or should you refer your
client to another reputable skin clinic who may have products and
treatments better suited to the treatment of their problem?
IN CONCLUSION
When dealing with problematic skin conditions there is clearly a
necessity for the therapist to also carefully consider the non-tangible
need of the patient's or client's emotional and psychological state
when determining treatment choice and protocols. More specifically,
there is a need to ensure consideration is also given to the important
role of empathy and compassion in supporting their road to recovery
and improving self-esteem.
Always remember that for many living with a skin disease, which is
often chronic in nature, has had a life-altering impact. Professionals
must always remember that aside from the physical manifestation that
the skin disease will have on the sufferer, there is often emotional
consequences, social aspects and psychological stresses involved.
Furthermore, these clients have more than likely had many treatments,
used many products, and spent hundreds if not thousands of dollars in
the hope for better skin and happiness. Therefore, you must avoid
being the reason for further disappointment; these clients already
come to you in a fragile state of being. Ensure that expectations are
realistic and never set your client up for greater grief and yourself up
for losing a client.
Work together with them within realistic parameters, and aim for
improved, healthier skin on the outside, and a confident, healthier
customer on the inside. Sometimes all it takes is a 10% improvement
to give them hope, and although this small change may not be obvious
to you, to the client it could well mean the world and a step in a more
positive direction.
References:
1. Psychodermatology: The Psychological Impact of Skin
Disorders, Carl Walker, Linda Papadopoulos
2. British Skin Foundation press release – Half the people with a
skin disease have been verbally abused.
3. Psychological Impact of Skin Disorders – Carl Walker, Linda
Papadopoulos
4. Dr Anthony Bewley, British Skin Foundation press release – Half
the people with a skin disease have been verbally abused.
5. Castiel – Readers Respond: How Has Acne Affected Your Life?
http://acne.about.com/u/ua/yourselfesteem/Emotional
AcneScars.htm
6 & 7. Psychological Impact of Skin Disorders, Carl Walter, Linda
Papadopoulos
8. STS Readers Respond: How Has Acne Affected Your Life?
http://acne.about.com/u/ua/yourselfesteem/Emotional
AcneScars.htm
9. The Emotional Aspect of Treating Skin Conditions, Michelle
D'Allaird
APJ 66