ARTICLE
Skin disease has been recognised as having a detrimental effect on the
quality of life of patients [1, 2]. This psychosocial aspect of skin disease
has important implications for the optimal management of patients. Dermatoses
may have a significant impact on relationships with others, self-image
and self-esteem in ways that are different from the impact of other non-dermatological
diseases. To address this problem, disease-specific indices of disability
have been developed for several dermatoses [3, 4]. Since these cannot
be used to compare different skin diseases, the Dermatology Life Quality
Index (DLQI) [5] was developed as a measure of the quality of life which
proved practical, reliable and valid in its original English as well as
in other translations and cultural contexts [6, 7].
It has been shown that poor patient satisfaction can lead to poor adherence
to treatment with consequently poor health outcomes [8]. Renzi et al.
recently demonstrated that the likelihood of dermatological patient satisfaction
is increased by the physician's ability to show empathy, but decreases
with symptom-related poor quality of life [9]. Based on this observation
we hypothesised that the application of decorative cosmetics might be
advantageous in these patients, since i) covering visible signs of the
disease can minimise stigmatization, and ii) consulting on the issue of
cosmetics with a professional along with the use of state-of-the-art products
underlines empathy with the patient's condition. In this pilot investigation,
we analysed the effects of decorative cosmetics on the patients' quality
of life in relation to type and severity of their underlying diseases.
Materials and methods
Patients
In order to introduce as few variables as possible, we intended to include
only female patients in this pilot investigation. Each female patient
presenting as an outpatient at the Department of Dermatology at Frankfurt
University with disfiguring dermatoses affecting the face was offered
additional consultation by our medical cosmetician. The first 20 female
outpatients (age 16 to 69 years) who gave informed consent to participate
are documented here. Eight patients with acne papulopustulosa and acne
conglobata, 9 patients with rosacea, 2 patients with chronic discoid lupus
erythematodes, and 1 patient with vitiligo were included. These patients
were referred for either initiation of systemic treatment or to intensify
the therapeutic regimen due to lack of clinical improvement under the
preceding medications. The interval between their first visit and initiation
of an alternative treatment was used to conduct this pilot investigation.
Treatment
Unifiance® is a decorative cosmetic product manufactured
by La Roche-Posay, France. It is a non-comedogenic water-in-oil emulsion
primarily marketed for teint correction. The patients were instructed
by our cosmetician how to use the product. It was then applied daily for
two weeks by the patients who purchased the product themselves. The use
of this decorative cosmetic results in a convincing camouflage effect
on the patients' skin lesions, but elevated lesions such as papules can
still be seen upon careful inspection (Fig.
1). Patients were followed for at least two more weeks for a possible
flare-up of their respective diseases.
Since the investigation was performed during the time interval between
the patients' first visit and the initiation of a new treatment, the clinical
course of these patients was fairly constant throughout the observation
period.
Monitoring
The clinical course of the patients was documented by standardized photography.
Quality of life was determined applying a validated German translation
of the Dermatology Life Quality Index (DLQI) [6] at the day prior to the
first use of Unifiance®‚ as well as after 14 days
of continuous daily application.
The DLQI consists of 10 items covering symptoms and feelings, daily
activities, leisure, work or school, personal relationships, and treatment.
Each question has 4 alternative responses: "not at all", "a little", "a
lot", and "very much", with corresponding scores of 0, 1, 2 and 3, respectively.
The total score is calculated by adding the score of each question, and
total scores range from a minimum of "0" to a maximum of "30", with higher
scores representing greater impairment of quality of life. The DLQI has
been shown to be a reliable and valid measure of quality of life in English
and other cultural contexts including Germany [5-7].
Statistics
Analyses of the DLQI data were performed using the non-parametric Wilcoxon
matched pairs test. Statistical significance was assumed when the p-value
was < 0.05.
Results
Characterization of the cohort
The patients suffering from acne were younger compared those with rosacea
(means: 26.3 versus 55.8 years) (Table
I). However, there was no correlation between DLQI scores and the
patients' ages (Fig. 2a).
Moreover, quality of life was equally impaired in these two groups with
no significant difference regarding the DLQI scores (acne: 7.8, rosacea:
9.0) (Table I).
Clinical course
Although Unifiance® is thought to be non-comedogenic
we were concerned regarding possible exacerbations, namely of diseases
affecting the sebaceous glands, due to possible occlusive effects. It
was therefore remarkable that an increase of disease activity was not
noted in any of the patients either during the two weeks of using decorative
cosmetics or during follow-up (data not shown).
Development of the patients' quality of life
depending on the underlying disease
Overall, application of decorative cosmetics resulted in a significant
improvement of the patients' quality of life as mirrored by a significant
reduction of the DLQI score from 9.2 (SD: 7.7) to 5.5 (SD: 6.7) (Table
I). Of the 20 patients enrolled in the study, 16 reported an improvement
of their quality of life. All patients with acne experienced such an improvement
resulting in a significant decrease of the DLQI score from 7.8 (SD: 7.8)
to 2.8 (SD: 2.9) (p = 0.0078) (Table
I). In contrast, only 5 of 9 rosacea patients experienced an improved
life quality, 3 reported no change, and one patient complained from an
even greater impairment upon application of the cosmetic. Consequently,
the decrease of the DLQI score did not reach statistic significance (from
9.0 +/- 7.3 to 7.2 +/- 7.5, p = 0.16) (Table
I).
Development of the patients' quality of life
depending on its initial impairment
The initial impairment of life quality might influence the outcome of
measures intended to improve it. Thus, we analyzed the impact of the DLQI
score before application of the cosmetic on its development. To do this,
patients were re-grouped according to their initial DLQI score. A DLQI
of ¾ 10 was considered to be indicative for a mild impairment of
life quality, since this equals a mean of 1 point per item ("a little"
impairment). Of the 20 patients of our cohort, 13 exhibited DLQI scores
of ¾ 10, whereas 7 had DLQI scores > 10 indicating moderate to
severe diseases. When analysing these two groups separately, we found
a significant decrease of the DLQI score in the "little impaired" group
(from 4.2 +/- 2.8 to 2.4 +/- 2.1, p = 0.007), but only a similar
trend in the "a lot to very much" impaired group (from 18.4 +/- 4.5
to 11.1 +/- 8.5, p = 0.06) (Fig.
2b). A more detailed analysis of the data showed that among the 7
patients with an initial DLQI > 10 two reported no change, whereas
the others felt a good or even dramatic improvement of their situation
with 3 of the remaining 5 patients showing a > 50% decrease of their
DLQI scores (patients 01, 11 and 18) (Table
I).
Discussion
Our study shows that application of decorative cosmetics has a positive
impact on patients' quality of life. Patients with acne and those with
a modest impairment of their life quality are most likely to benefit from
this approach.
The DLQI score of the cohort studied was 9.2. This must be considered
to reflect a profound impairment of the quality of life, since this score
is in the range Finlay and Khan determined e.g. for psoriasis when
initially validating the DLQI [5]. Additionally, the scores of 7.8 and
9.0 for acne and rosacea, respectively, are slightly higher when compared
to many other publications measuring the DLQI of patients with these diseases
[5, 7, 10]. Thus, our cohort is characterized by an above-average impairment
of quality of life.
Although the DLQI is not a direct measure for disease severity there
is good evidence that DLQI scores show such a correlation. Hahn et
al. reported that the DLQI paralleled the Dermatology Index of Disease
Severity (DIDS) [11]. With regard to acne, Klassen et al. documented
a correlation between the DLQI and disease severity [12] assessed by the
Leeds grading technique [13]. On the other hand, there are reports on
patients with only slight skin changes feeling greatly hindered [14].
Still, we feel that we can assume cum granu salis that our patients
also suffer from relatively severe dermatoses.
A positive impact of the application of decorative cosmetics in our
cohort was found to be at least in part determined by the underlying skin
disease, since we observed a significant decrease in DLQI scores in patients
with acne but not rosacea. This was not due to the initial impairment
of life quality, because there was no statistical difference of DLQI scores
between both groups of patients. There was, however, a clear difference
in age with rosacea patients being considerably older than acne patients.
It has previously been reported that there is no relationship between
age or gender and quality of life in patients with psoriasis [15]. Therefore,
we do not consider age to be the relevant parameter causing the different
impact on quality of life by decorative cosmetics. This interpretation
is supported by our finding that there is no statistically significant
correlation between age and DLQI score in the cohort studied here (Fig.
2a).
Another important parameter was found to be the initial impairment of
the quality of life with patients exhibiting DLQI scores ¾ 10 show
a significant decrease, whereas those with DLQI scores > 10 do not.
Given the correlation with disease severity, this may indicate that patients
with mild dermatoses are primarily concerned with regard to cosmetic
aspects/appearance, whereas those with more severe diseases do not
benefit by camouflage alone knowing that this does not affect the course
of the disease. On the other hand, only two patients with initial DLQI
scores > 10 were "non-responders", both of them suffering from rosacea.
The other 5 patients reported a striking improvement of their quality
of life. Thus, applying decorative cosmetics might still be a valuable
aspect of treating also more severe dermatoses.
Patient satisfaction is an important factor in the interaction between
provider and patient. Renzi et al. demonstrated that complete overall
satisfaction was more frequently reported among patients with a better
quality of life [9]. Since increased patient satisfaction is likely to
have a positive effect on treatment adherence and health outcomes, measures
improving the patients' quality of life represent an important facet in
the therapeutic strategy followed.
The question to what extent dermatologists should become involved in
the field of cosmetics and cosmetology is very important with regard to
future developments of this speciality. Acknowledging the demand and the
need of a significant portion of the population for qualified consulting
and treatment regarding cosmetics two prominent dermatologists postulated
that this task should be performed on the sound grounds of science [16].
In agreement with this postulation we feel that cosmetic measures such
as the application of decorative cosmetics need to be evaluated in the
same way conventional medical measures are investigated, too. This is
particularly important given the potential risks of these methods; in
our particular study we were most concerned about exacerbations of diseases
affecting the sebaceous glands due to occlusive effects. Studies like
this one may therefore pave the way towards "evidence-based cosmetic dermatology".
CONCLUSION
In summary, we have shown that patients with disfiguring dermatoses affecting
the face showed significant improvement of their quality of life. This
effect of decorative cosmetics might be helpful in improving the overall
satisfaction of the patients leading in turn to an improved compliance
and health outcomes. We therefore suggest that decorative cosmetics can
complement the treatment of disfiguring skin diseases.
Acknowledgements
We are thankful to Prof. Andrew Y. Finlay for fruitful discussions and
his most helpful suggestions. I.P. is supported in part by a grant from
La Roche-Posay.
Article accepted on 26/08/02
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