The emotional and mental issues that a child can have about a scar are far-reaching and variable. This three-part series of articles will examine the psychological impact of scars in children from a variety of medical problems. The first part of this series focuses on scars from dermatologic conditions.
There are a multitude of dermatologic conditions that can cause scars in children. The most notable of these conditions is acne, although many others can also have lasting effects after the primary skin disease has resolved; such conditions include epidermolysis bullosa, hemangiomas, atopic dermatitis and more. The scars these conditions can cause may have a comorbid psychological effect, especially if the scar reminds children of the illness or is associated with deformity.
There are also a number of factors that influence an individual’s perception of his or her scar and the emotional issues tied to it, according to the dermatologists who treat these children and the literature on the subject. One study found that scars affect individuals in five main areas: physical comfort and functioning; acceptability of self and others; social functioning; confidence in the nature and management of the condition; and emotional well being.1
However, there is limited data about the impact of scars from dermatologic conditions in children. A review by Gupta and Gupta in 2003 examined psychiatric and psychological co-morbidity in patients with dermatologic disorders.2 While two of the conditions reviewed — acne and atopic dermatitis (AD) — are primarily pediatric skin conditions, the psychological impact of these conditions in children specifically is not analyzed.2 In addition, acne and AD, infrequently, can occur in adults.2,3 Another difficulty in researching and understanding this topic is that much of the attention focuses on the impact of the condition as it occurs and not the residual effects, like scarring.
Despite the lack of evidence in the literature for this correlation, many dermatologists agree that the psychological impact of these scars in pediatric patients is significant and worthy of more attention. This three-part series of articles will examine the psychological impact of scars from dermatologic diseases, burns, and other injuries and medical procedures, all focusing on pediatric patients. The objective is to help clinicians better understand these issues and provide tools for managing pediatric patients with psychological issues related to a scar. This first installment will focus on scars from dermatologic diseases.
Observations From Practice
An important distinction is that the lack of literature is very specifically related to the impact of the scars, not the primary dermatologic disorder; a great deal of information exists on how patients — children and adults alike — feel about a skin condition and the related social, emotional and occupational issues. This existing information, coupled with knowledge of child development and the role of the parents in a child’s feelings of worthiness and level of self-confidence, can be an effective way of examining the psychological impact of scars from dermatologic conditions in children.
“The impact of scars on children varies based on a lot of factors — the age of acquisition, the location, how deforming the scar can be — which is partially qualitative and partially viewed psychologically,” explains Lawrence Eichenfield, MD, chief of pediatric and adolescent dermatology at the University of California, San Diego (UCSD) School of Medicine. “The child may be influenced in terms of how the scars are handled by the family.”
Acne is a widespread, very common condition that serves as a prime example of the psychological impact of a condition, both as it occurs and afterward. Acne is most common in adolescents and young adults; it is estimated that as many as 85% of people between the ages of 12 and 24 suffer from it.4,5,6 Scarring occurs frequently in patients with acne; patients with more severe disease and acne that is extensive are more likely to experience scarring.7,8 A paper in Dermatologic Therapy from 2006 examining psychological problems in the acne patient identifies four basic tenants: “(1) acne can elicit negative emotional reactions in affected patients, including depression, anxiety, anger, helplessness and frustration; (2) stress and negative emotional states can exacerbate acne; (3) acne sufferers can experience impaired functional status and decreased quality of life; (4) psychocutaneous interventions may avert or reverse some of these negative sequelae.”9
Figure 2 (right): Severe acne scarring on the face.
Photo courtesy of Joseph B. Bikowski, Jr, MD.
Research shows that as many as 95% of acne patients experience scarring, but the psychological impact of these scars has not been studied, and the literature on this impact and guidelines for management are lacking.10,11 This is also true for literature on the impact of scars from other dermatologic conditions, such as epidermolysis bullosa (EB), hemangiomas, and hypertrophic and keloid scars.
“Searching for ‘acne scarring’ on PubMed results in multiple studies, none of which assess its impact on quality of life,” explains Cameron West, MD, a former fellow in the department of dermatology at Wake Forest University in Winston-Salem, NC, who is now in a Master’s program at Texas Tech University. “It is understood that acne scarring is unwanted, but no studies investigate the psychological impact of it or its impact on quality of life.”
Dr. Eichenfield “absolutely concurs” that there is a disconnect between what is being seen in practice on a regular basis and the material in the literature.
“If you do a PubMed search on the psychological impact of scars in children, there’s a real gap in the literature,” he explains.
However, there is a silver lining to this paucity of data. Because of the lack of written guidelines and treatment protocols, dermatologists who have hands-on experience with these cases have a great deal of insight and evidence to share about managing these patients. According to the physicians who work with these children, there are steps dermatologists can take to help a child who appears to be experiencing psychological distress because of scars from a dermatologic disease.
A Child-Centered Approach
The most effective tool dermatologists have in these situations is the ability to gain a very clear perspective on what the child is thinking and feeling that is not influenced by external factors.
“Skin lesions can lead to a lot of psychiatric distress,” explains Bari Cunningham, MD, of the Comprehensive Dermatology Group in Encinitas, CA. “[Children] take their clue from the parent. If the parents are very blasé about it, then the child tends to be very blasé about it.”
Sheila Fallon Friedlander, MD, is a pediatric dermatologist and clinical professor of pediatrics and medicine at UCSD. Dr. Friedlander explains that the impact of parents on the child’s perception of his or her scar is often set at an early age and can have a long-lasting impact.
“If a parent says to a child, ‘Oh, that’s your mark, and it’s not a big deal,’ or, ‘Oh, that’s your mark, it’s something that makes you special,’ that completely alters how the child views it,” Dr. Friedlander says. “Once they get into school, depending on the personality type, things could take a much different turn. But, if they have been invested with that sense of self from the parent and that sense of ‘I’m me, and of course I have some things, but it’s not a big deal,’ then the way they relate to other kids becomes completely different.”
Because of this impact that the parents may have on a child’s outward vocalization of their feelings, pediatric dermatologists agree that the first step to managing a child’s psychological issues about a skin condition is to gain a straightforward, unbiased opinion from the child about his or her feelings.
“It can be very hard to access what’s making the child self-conscious,” Dr. Cunningham, who is board-certified in both dermatology and pediatric dermatology, explains. “But, when you can gain their trust and excuse the parents from the room and really have a heart-to-heart with the child, you can delve a little deeper.”
A 1998 study in Pediatrics examined the parent and child coping and adaptation practices in families where a child had a facial hemangioma.12 Of the four themes described by the researchers, two focus on the parents’ feelings about their child, including parental emotion and adaptation (the parents’ sense of the loss of the imagined child, guilt or self-blame, acceptance, etc.) and parent-child interactions (helping the child know what the hemangioma is and be able to talk about it, not taking the child out in public because of the hemangioma, etc.).12 Because this study examines the parents’ feelings and actions related to the child’s skin condition, and because hemangiomas can leave scars after involution or resolution, it provides a unique example of how one study can be used in conjunction with others that are specifically about the child’s perception of his or her scar to learn more about the child’s opinion in comparison and conjunction with the parent(s).
Joel Cohen, MD, FAAD, is the director of AboutSkin Dermatology and DermSurgery in Colorado. In his experience, identifying the disconnect between the parent’s opinions and the child’s feelings can be crucial before any action can be taken to deal with the scar.
“The goal is to treat children who are having issues related to the scars,” Dr. Cohen explains. “If it’s a situation where the child absolutely doesn’t want to have any treatment done and the parents are all for it, then we won’t force it on the child. It’s difficult, because the parents are the ones who sign the consent forms, but, nevertheless, there are always ways to say, ‘I don’t feel comfortable doing this, the child really needs to be a part of it, and if they’re not going to be a part of it and be cooperative, it’s going to be very difficult to do the treatment, so we might have to talk about some other things, having some sort of sedation or even general anesthesia. So, there are ways to get around it, to get a sense of when the kid is absolutely not bothered by it and the parents are doing it just because they want to do it.”
A significant factor that can impact all facets of a child’s psychological state about his or her scar is age.
“I think 12 is the age where I see most kids start to be concerned about their personal appearance,” explains Robert L. Buka, MD, JD, Section Chief of the Department of Dermatology at Mount Sinai School of Medicine and Founder and Medical Director of Upper West and Williamsburg Dermatology in New York, NY. “We see [psychological issues] a lot more in kids than adults, I think, because they’re more fragile, they’re at a more vulnerable time. Kids are learning their sense of self during the adolescent period. A scar can be sexually embarrassing, [at a time] when kids are getting their sense of attractiveness. A scar can weigh heavily.”
Dermatologists agree that keeping the child’s age in mind when evaluating the psychological issues from a scar will help physicians better understand the root of the issues and what treatments may be warranted.
Management and Treatment
Once a distinction has been made between the child’s feelings and how those may be the same or different from the parents, and after the child’s age has been taken into consideration, the dermatologist is able to help the child deal with the psychological issues. The most powerful impact dermatologists can have for these children is the ability to reduce or eliminate the scars that are leading to the issues in the first place. One of the most important parts of this step is determining how significant the impact of the scars are, as some children who have a very minor anomaly are very upset by it, while other children who have severe acne scars may not be very bothered by it. To some degree, this distinction can be made when talking to the child without the parent, but dermatologists agree that it is a crucial piece of information to have.
“You may look at something that is [clinically] minor, but, to them, it may be very significant,” explains Dr. Cohen, who adds that this situation may also warrant referral to a psychologist or psychiatrist in addition to physical treatment. “For some of those people, you may want to send them onto a psychologist. Doctor-patient communication plays as important a part, or sometimes an ever bigger part, as physical diagnosis, so I think it’s important to talk to your patients about potentially difficult situations or something that they’re really concerned about that you don’t think about as much of a concern, and vice versa.”
The evolving laser technology is a significant step forward in the dermatologist’s ability to remove or reduce a scar.
“It’s a very exciting time in dermatology and in pediatric dermatology,” Dr. Eichenfield explains. “We’ve had a large set of conditions, over time, that create scars, and we recognize the significance of the scars, but we haven’t really had very good approaches to manage most of them. We’re very excited by new laser technology and other tools that can really allow us to help children who might be impacted by scars.”
For more information about the psychological impact of skin conditions and the situations where referral to a mental health professional may be warranted, please see the article “Managing the Psychological Comorbidities of Skin Disease” in the May 2012 issue of The Dermatologist.
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