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Practice Management

Treat the Inside: Easing the Psychological Discomfort of Dermatological Conditions

Geri Clark

Tuesday, August 01, 2006

All physicians face the challenge of making patients feel better on the inside. But dermatologists face an extra challenge - often, their patients' diseases are sitting right there for the world to see. The psychological impact of looking different can create a need for treatment of more than just a patient's skin.

Although some patients may be clinically depressed or in need of counseling and/or medication for some other psychological problem, this is a small percentage, says Steven R. Cohen, MD, chief of dermatology at Albert Einstein College of Medicine in New York. Most patients simply need a little extra support that a dermatologist can and should be providing in the office.

Conditions that cause disfigurement or scarring mean a lot of stress for patients. Obviously, things like cystic acne, psoriasis, vitiligo, and atopic dermatitis can be difficult for patients to hide. And that's not just when a patient's face is affected, says Cohen. "If the condition is on a covered skin surface, a patient may be uncomfortable going to the beach or to the gym, or anywhere they can't cover up. It's socially limiting, and it interferes with intimacy." These patients can understandably be anxious, have low selfesteem, and even be mildly depressed.

Some patients also get uncomfortable questions about their disease and don't know how to answer easily or deflect attention from themselves. Although these challenges can be significant, they can also often be handled in the office by the dermatologist who takes a little extra time with her patients. Finding that time is a challenge, but, says Cohen, "the dermatologist is often better able to help the patient through this stress because we can explain the disease and help them work with it."

Dealing With Disease

"If a patient has a treatable condition, I suggest being as aggressive as possible," says Cohen. "Especially if the disease is interfering with the patient's happiness or social functioning." Not only will this likely mean the best chances at a cure for the disease, but it also makes the patient feel he's doing all he can to change a stressful situation.

"In fact, just starting treatment," for a condition that has been plaguing a patient can help improve her outlook and any low-level depression she may have been feeling, says Christopher Dannaker, MD, with the Monterey Dermatology Laser Medical Center in California. "Just the process of getting started can brighten [the patient's] outlook considerably."

Once treatment is started, frequent follow up can serve several purposes:

  1. Reinforce for the patient that his condition is being dealt with;
  2. Hold him accountable for any steps for which he is responsible (eg, skin-care regimens or medication adherence); and
  3. Allow the clinician to keep tabs on the patient's mood - if he seems to be getting more stressed, depressed, or anxious, the dermatologist can take steps to intervene and help.

For patients whose diseases are not curable, it's important to give them a clear understanding of the disease process and what they can expect from both the disease and any treatment.

"For my patients, concern about their appearance is entwined with their concerns about the process of their disease," says Maureen Mayes, MD, MPH, a professor in the Division of Rheumatology at the University of Texas Health Science Center in Houston. "I find if they understand the disease process and know what to expect, they handle it better, even though they cannot be cured."

Take an Interest

When dealing with patients whose diseases affect their self-esteem, it becomes even more critical to spend extra time with them and get to know them. "I do a lot of hand-holding and reassuring," says Marcy Street, MD, of Doctor's Approach Dermatology and Laser Center in East Lansing, Mich. "Most patients want to know you will be there to help them and that they aren't alone." Street says she makes an effort to know the whole patient - what his family is like, what his hobbies are - so she can talk to him about something besides his skin condition. "This gives us something positive to focus on," she says. "The teenager with disfiguring cystic acne can still be happy about his performance at soccer." This also helps the dermatologist gauge progress - if a patient withdraws from a favorite hobby, that can be a sign of worsening mental state. On the other hand, if he becomes more enthusiastic about things as treatment progresses, that can be a good sign.

As treatment progresses, point out improvements, says Cohen. Often, patients can't see how much better they look or how much healthier they are. "I like to say, 'Look how far you've come,' or encourage patients to ask close friends if they see an improvement," he says. Other dermatologists take photographs at regular intervals to show patients their improvement when it isn't easy for them to focus on the positives.

Practical Solutions

Often, patients just want strategies they can use in everyday life to help them deal with uncomfortable situations. "We counsel patients on how to use makeup to cover up anything they want to hide," says Street. Even if intense cosmetics aren't practical for everyday use, they can help a patient who has a special event to go to or wants an added degree of comfort in social settings, says Mayes. Some dermatology practices match patients with professional makeup artists who can teach them the right skills and products for their particular conditions. "People want strategies for feeling pretty, and we can help with that," says Mayes.

Patients with more unusual conditions, such as vitiligo or scleroderma, sometimes find themselves put on the spot when someone asks an abrupt, even rude, question about why their skin looks the way it does. Here again, dermatologists can provide a simple, yet invaluable service to their patients. "We will help patients work out a few good sentences that they can rehearse and use to address questions they might get," says Mayes. Some patients find that just being prepared to answer such questions takes away a lot of the anxiety that comes from anticipating them.

Other practical solutions include referring patients to physical therapy for functional impairments that can be helped in that way; recommending appropriate procedures like laser treatment to reduce scarring; and strategizing with the patient on ways to prevent picking at sores or acne.

Next Steps

Of course, a small percentage of patients really will need more psychological help than a dermatologist can provide. "You can generally tell when you work with them on all the coping strategies but they still don't feel better," says Street. Many of these patients may have had underlying psychological problems that are magnified by the stress of their disease, says Dannaker. "In these cases, I do not hesitate to get them outside services," he says. But the vast majority of psychological problems - even in patients with disfiguring conditions - can be helped in the dermatologist's office. "You just have to be willing to address the whole person," says Cohen.

Helping Patients Cope

By keeping a few simple strategies in mind, dermatologists can equip patients to deal with the psychological fallout from their conditions:

  • Show an interest in the patient that goes beyond the disease.
  • Point out progress, and remember that simply discussing adjunctive treatments can help patients feel more comfortable and hopeful.
  • Offer social coping strategies - rehearse answers to awkward questions to alleviate anxiety.
  • Don't forget to recommend makeup tips and physical therapy when appropriate.

If the patient's outlook doesn't show improvement, don't hesitate to refer him to a mental health professional.

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Disclaimer: The material above has been prepared by Physicians Practice. It has not been reviewed by the DermQuest Editorial Board for its accuracy or reliability. Reference to any products, service, or other information does not constitute or imply endorsement, sponsorship, or recommendation by members of the Editorial Board.