Treat the Inside: Easing the Psychological Discomfort of Dermatological Conditions
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
- Reinforce for the patient that his condition is being dealt
- Hold him accountable for any steps for which he is responsible
(eg, skin-care regimens or medication adherence); and
- 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
"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
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
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.
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.
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,"
Helping Patients Cope
By keeping a few simple strategies in mind, dermatologists can
equip patients to deal with the psychological fallout from their
- Show an interest in the patient that goes beyond the
- Point out progress, and remember that simply discussing
adjunctive treatments can help patients feel more comfortable and
- Offer social coping strategies - rehearse answers to awkward
questions to alleviate anxiety.
- Don't forget to recommend makeup tips and physical therapy when
If the patient's outlook doesn't show improvement, don't
hesitate to refer him to a mental health professional.