Dermatological conditions and the relationship to self-image

In the June 2022 issue of Contemporary Pediatrics^® Colleen Powers, MD; Hannah Badon, MD; and Thy Huynh, MD, describe 3 commonly seen dermatological conditions, (eg, atopic dermatitis, acne, vitiligo) with a focus on recognizing the dermatological differences in a diverse population. The authors review the condition, epidemiology, role of genetics, clinical presentation, and treatment considerations for the three conditions. I believe the article is important to read for all pediatric health care providers. Additionally, I believe it is equally important for pediatric and family nurse practitioners (PNPs, FNPs) caring for children and adolescents with dermatological conditions to be comfortable talking about the conditions with children, adolescents and their parents.

Ways children and adolescents have presented with dermatologic conditions

I am often very concerned at how much a child or adolescent has endured both physically and emotionally prior to presenting to primary care with a treatable dermatological condition. I have cared for children whose parents, not knowing the diagnosis was treatable (atopic dermatitis) wrapped their arms and legs with bandages to prevent the constant scratching. I have cared for adolescents who were not socializing with others as they were fearful of what their friends thought about the ‘marks on their face,’ not realizing that the condition was acne and treatable. I have cared for children and adolescents who were depressed over the comments other children have made about noticeable changes in skin color on their face, arms and/or legs due to the diagnosis of vitiligo. The importance of speaking with the child, adolescent and parent using words that they understand about the diagnosis and treatment planning cannot be overemphasized. Equally as important is assessing the self-image/self-esteem and emotional status of the children and adolescents, at that moment in time, to help them begin the process of meaningful change about their personal feelings regarding their self-image, their emotional growth and interactions with peers.

Self-image/self-esteem in children and adolescents presenting with dermatological conditions

In clinical practice and education, I use the words ‘dermatological conditions’ and not dermatological disorders or diseases when speaking with children, adolescents and their parents. The idea to a child or adolescent that they have a ‘skin disease’ can be very traumatic affecting not only their self-image/self-esteem and overall mental health but also their desire to go to school to ‘be seen’ and interact with peers. A comparison study of self-esteem and dermatological quality of life in adolescents with a diagnosis of atopic dermatitis as compared with adolescents without a skin condition showed that those with atopic dermatitis displayed lower levels of self-esteem than healthy controls.The authors recommended psychological support for adolescents with atopic dermatitis.¹

The KidKINDL questionnaire for children² and adolescents³ contain four questions with Likert scale responses that can be used to asses self-esteem and quality of life in primary care settings. The responses reported by the child or adolescent provide insights into their self-esteem status which may be managed by a PNP or FNP or may support a referral to a psychologist or mental health provider to enable the child or adolescent building self-esteem while managing a chronic condition. If a practitioner does not want to use a questionnaire, one or more questions relating to self-image or self-esteem may be helpful to evaluate how the child or adolescent feels and to establish a treatment plan: “How do you feel about your skin condition?” “Is your skin condition affecting your friendships or activities that you do with friends?” “What activities do you do with friends?”

Focusing on positive outcomes

For the child who presented with all extremities wrapped in bandages, the child needed immediate management of the skin infection directly related to atopic dermatitis and a referral to dermatology. Care management was achieved by frequent visits to dermatology as well as in the primary care setting. As the child’s condition improved, the parent and child were taught how to assess and feel for the most minor atopic eruptions to immediately manage the condition before it became out of control. Children, adolescents and parents need to understand that Atopic Dermatitis is a chronic condition that requires daily attention to details to prevent the onset of the itch-scratch-itch cycle.

Managing adolescents with ACNE also requires attention to details. Educating the adolescent and parent on skin care and appropriate use of prescribed medications and ways to minimizeinitial medication side effects is essential. Appropriate anticipatory guidance also supports the adolescents’ self-image. If treatment of ACNE does not respond as expected, a dermatology referral is needed.

Children and adolescents with vitiligo are often emotionally challenged by the condition. Their peers often do not understand the condition. They may not be selected to participate in social or play activities at school. It is critical to assess the emotional status of children with a diagnosis of vitiligo and refer for treatment and to follow the children closely in the primary care home. Drs. Powers, Badon and Huynh discuss the use of cosmetics which should be recommended for children who vitiligo not only on the face but also in all visible body areas such as arms and legs. I have found that expert cosmeticians play a critical role in helping improve the self-image/self-esteem of children and adolescents who have a diagnosis of vitiligo.

Summary

Dermatological conditions that alter the appearance of the skin making skin conditions visible to others, often adversely affect the self-image/self-esteem of children and adolescents. PNPs and FNPs need to assess the feelings of those presenting with skin conditions and help the child, adolescent and parents put into action strategies that will improve their self-image. PNPs and FNPs must use the best available evidence for prescribing medications to treat the specific condition, as recommended in the article by Powers, Badon, and Huynh and encourage appropriate follow-up care. Telehealth visits can be used for follow-up care and to further assess the emotional health of the child or adolescent. Referral to a school psychologist or social worker may be an option for further care at school to improve the emotional health and self-image/self-esteem of the children and adolescents with dermatological conditions.

References:

1. Erturan, I. Aktepe, E. Balci, DD. Yildirim, M. Sonmez, Y. Ceyhan, AM. Evaluation of self-esteem and dermatological quality of life in adolescents with atopic dermatitis. Archives of the Turkish dermatology & venerology/Turkderm, (2013).47(1): 39-44. (6p). Accessed June 18, 2022. DOI: 10.4274/turkderm.23230

2. Ravens-Sienerer, U. Bullinger, M. Assessing health related quality of life in chronically ill children with the German KINDL: first psychometric and content-analytical results. Quality of Life Research, (1998a), 4, 7. Assessed June 18, 2022. Retrieved from https://www.kindl.org/english/questionnaires/

3. Ravens-Seiberer, U. & Bullinger, M. News from the KINDL-Questionnaire – A new version for adolescents. Quality of Life Research, 7, 653. Assessed June 18, 2022. Retrieved from https://www.kindl.org/english/questionnaires/