The visible nature of skin disease

All the above roles are relevant to dermatology, but not special to it. What distinguishes skin disease from other kinds of illnesses is that it is much more visible to the world. This means that its social effects are often far greater than for other illnesses of comparable seriousness, and that the patient's self-image is often harmed. Healthy people, including many health professionals, do not sufficiently understand these aspects, and do not cope adequately with them. Consumers and patients can help them understand and learn what matters to people with various skin conditions. In the case of vitiligo, for example, doctors sometimes base treatment decisions on how they perceive the degree of distress. Many think that white patients suffer less than those with darker skins, but studies as well as anecdotal experience have shown that this may not be true.1 Nor is the extent of the disease always the most important factor in the patient's suffering. Self-esteem, self-image, the site of the lesions, the degree to which the patient feels disabled by the disease, and the support networks available to the patient all need to be considered. A study of psoriasis has found that the patient's opinion of disease severity can differ from the physician's and that the degree of distress depends on how far the disease affects everyday life.2 These findings underline that the assessment of psoriasis (whether by doctor or patient) influences the choice of treatment. Patients may well prefer treatments that will address the disfiguring social effects of the disease to those that reduce the size of the lesions.

Although lip service is sometimes paid to the psychosocial aspects of skin disease, very little is done to address them. Treatment should include the option to refer patients for appropriate professional psychological help and this should be an integral part of treatment guidelines. It could be argued that some patient support groups (PSGs) perform this function. Although they can provide opportunities for members to share experiences and give practical advice, they are not equipped to give either medical advice or indepth psychological help. Commenting on a small study of cognitive behavioural therapy (CBT) used for vitiligo patients,3 Picardi and Abeni4 state that this approach might help patients with vitiligo, and possibly other skin diseases and suggest: "If the efficacy of CBT were confirmed, a new weapon could be added to the therapeutic arsenal of the dermatologist. This would be a substantial step ahead in the management of a disease for which no known cure can ensure complete clearance...".

Dermatology differs notably from other branches of medicine in the way it shades off into borderlands of cosmetics and cosmetic surgery, and in the often blurred boundaries between treatment, prevention and aggravation of skin problems. Even something as innocuous as washing can be a form of prevention (for example washing a chemical off one's hand), treatment (for example ridding the skin of an accumulation of excess scale) or aggravation (causing irritant contact dermatitis through frequent hand-washing with soap). The dual function of the skin as both a large and important organ and a superficial covering of the body that is important in social "display" can lead to trivialisation. Some skin conditions, like acne and vitiligo, are often considered purely cosmetic problems, particularly by some general practitioners.

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