patients with conditions such as psoriasis , eczema , and skin cancer frequently face psychologic challenges which , in turn , impact their social functioning and the kind of life that they lead .
patients may experience fearful anticipation of interaction with others , even when symptoms are not present , and develop avoidance - coping mechanisms .
this may prevent them from partaking fully , or at all , in social and recreational activities or employment .
ultimately , visible symptoms may change how patients see themselves and how they perceive their future .
multiple studies reveal consistently poorer quality of life and psychosocial functioning scores among patients with visible dermatologic skin conditions compared with those who do not have such conditions [ 25 ] .
the incidence of psychosocial comorbidities among such patients is high , as evidenced by a study which found that the risks of depression , anxiety , and suicidality attributable to psoriasis were 11.8 , 8.1 , and 0.4 per 1000 person  years , respectively ( table  1 ) .table  1the attributable risk of psoriasis for diagnosis with depression , anxiety , and suicidality mild psoriasissevere psoriasisall psoriasisdepression  attributable risk per 1000 person - years11.525.511.8anxiety  attributable risk per 1000 person - years8.08.18.1suicidality  attributable risk per 1000 person - years0.40.40.4reproduced with permission from arch dermatol .
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 adjusted for age and sex 
  the attributable risk of psoriasis for diagnosis with depression , anxiety , and suicidality   reproduced with permission from arch dermatol
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 adjusted for age and sex the dermatologist can play an important role in helping patients to overcome such substantial challenges and improve their overall quality of life .
we discuss several important considerations and propose strategies to assist dermatologists in addressing the important psychosocial side of treatment in patients with visible skin conditions .
studies have shown that successful treatment , which improves the patient s symptoms and changes their physical appearance , can lead to improvement in psychologic symptoms and a better quality of life [ 2 , 6 ] . however ,
it is important to note that , sometimes , greater life satisfaction is achieved by accepting that perhaps some symptoms will remain or recur , even if a patient generally responds well to treatment .
such acceptance involves acknowledging the existence of symptoms , but frees up the patient to pursue a meaningful life that is not overly limited by their condition .
it is also crucial that patients are provided with the tools to accept their remaining symptoms and to reduce the impact of these on everyday life .
as a clinician , one is familiar with the broad spectrum of available treatment options and the tools used to objectively measure outcomes in a clinical and/or academic setting .
treatment may be deemed successful if improvements in physical symptoms are in line with the results one would typically observe in other patients , or those that have been reported in clinical trials .
however , it is important to remember that other factors may influence the patient s own perception of treatment success .
patients have their own preferences and priorities regarding what treatment outcomes are more important to them .
for example , one patient may favor reduction or elimination of signs of disease that are visible to others when wearing typical clothes ( which may change with the season ) , whereas another patient may be more interested in reducing their level of physical discomfort .
patients satisfaction is strongly influenced by their initial expectations and the changes they were expecting to see , as well as those of their family and friends ; objective measures of symptom improvement may be less important to them . therefore , when evaluating treatment options , it is important to consider asking the patient what outcomes are most important to them and to discuss what it is reasonably possible to achieve .
as such , a broad outcome measure that includes psychosocial and overall quality of life measures , in addition to symptom remission , would be of particular value .
, clinicians may wish to discuss expected outcomes before treatment is initiated , including the degree of symptom improvement that can realistically be expected , the likelihood of success , and the timescales involved .
this would ideally be a two - way conversation , in which the clinician could ask the patient to explain their hopes and expectations as a result of their treatment .
there are several ways in which realistic expectations ( i.e. not too high and not too low ) will result in the best outcome for the patient .
if expectations are sufficiently high , a patient is more likely to be willing to initiate treatment and remain compliant , as they will be confident that they will eventually see an improvement in their symptoms .
similarly , if they have a tempered understanding of the expected degree of improvement , and when this may occur , they will be more likely to adhere to treatment without getting discouraged by seemingly poor results .
this is especially important in the case of complicated regimens , such as those associated with frequent or inconvenient drug administration , those that involve some degree of pain or discomfort , or those in which extensive treatment is required before symptoms begin to improve .
secondly , appropriate expectations can help a patient and their family to know when they need to return to the clinician and ask for a different treatment approach .
such a dynamic , interactive relationship between the clinician and the patient can ensure that the patient s needs are being met wherever possible , and may reduce unnecessary time and costs associated with treatment that is inappropriate or ineffective for that person . finally , focusing on the broad improvement of patient quality of life , and not just on the management of visible symptoms , may help to reduce the often excessive pressure placed on healthcare providers by patients with unrealistic expectations for improvement .
this can improve the clinician 's own sense of job satisfaction , as well as the overall relationship between the clinician and the patient .
impairment , however , is defined as the suffering that can be caused by symptoms , and may be physical , psychologic , and/or social .
the degree of impairment caused by a given symptom is often different in different people ; in fact , a patient can have a severe symptom but not be impaired by it at all .
conversely , a different patient may be greatly impaired by symptoms of relatively mild severity , with a tremendously negative impact on their life .
for example , an insecure teenager may feel extremely self - conscious about minor acne and avoid some social situations , whereas a confident young adult with much worse symptoms may hardly think about them .
when it comes to reducing the psychologic impact of a dermatologic condition and improving the patient s quality of life , it is crucial that we address impairment and not just symptoms .
it is possible for a patient to actively refuse to be unnecessarily limited by their symptoms , rather than be passively resigned to them .
however , support and encouragement are often needed in order for a patient to achieve this . as clinicians
, we have the opportunity to encourage patients to live  a big life , i.e. a life that is fulfilling , rewarding , meaningful , and interesting , and that has a positive impact on the world , in which the person accomplishes most of what they set out to do . in turn
, the patient may strive to be the person that they want to be , regardless of their health status .
other professionals , such as nurses , psychotherapists , or counsellors , who may be involved in the wider healthcare circle of a patient , can also assist in this regard . in some cases , an overly negative response to symptoms
can be indicative of low self - esteem , anxiety , or depression , which can warrant a referral to a mental health professional to help the patient cope , not only with their dermatologic condition , but also with other matters .
we can help patients to redefine themselves by asking the question ,  what would / could you do if you did not have these symptoms ? 
it should be emphasized that , although symptoms may affect how a patient lives their life , symptoms do not necessarily need to rule a patient s life .
we can also help patients to understand that tolerating discomfort may allow them to pursue more interesting goals in life .
mental health professionals can help more limited patients to learn better coping methods to deal with sometimes debilitating discomfort .
patients should , of course , be encouraged to follow the treatment regimen , and active engagement with the clinician will enable the patient to feel that they are in control of their condition and their treatment program .
however , we can emphasize to patients that it is important not to wait for complete symptom remission before pursuing a fulfilled life .
some patients restrict their social engagement because they feel self - conscious about their visible symptoms and do not know how to respond to people s questions about them , such as why they look that way , or whether the condition is contagious .
helping patients find the right words to explain their visible symptoms to others can help them feel more comfortable going out into the world .
this is particularly true of situations in which the patient is likely to encounter people who are more likely to make inappropriate comments , ask personal questions , or make incorrect assumptions , such as that the condition is highly infectious .
it is easier for the patient to cope and feel confident in such situations if they have an appropriate and informed range of responses prepared in advance .
patients can choose to share personal information , but they also have the right not to do so .
visible medical conditions such as psoriasis , eczema , and skin cancer often have a substantial psychologic and social impact on patients .
however , through appropriate discussion and interaction with a patient , the dermatologist can play an important role in helping to reduce this impact , potentially improving the patient s overall quality of life .
it is important to discuss expected outcomes before treatment is initiated , in order to ensure that realistic expectations are in place . it may also be beneficial to discuss whether total symptom relief is a necessary component to living a better life . in addition ,
helping patients to find the right words to explain their visible symptoms to others can help them feel less self - conscious and more confident in a public setting . helping patients to come to terms with their condition , and helping them to build the skills required to reduce the psychosocial impact of their condition
, may mean that they are more equipped to go out into the world and pursue a more meaningful life .
this article is based on previously conducted studies and does not involve any new studies of human or animal subjects performed by any of the authors .
 skin conditions such as psoriasis , eczema , and skin cancer often have a substantial psychologic and social impact on our patients . 
 some of these patients limit their life because they feel self - conscious about their symptoms . 
 sometimes , greater life satisfaction comes from accepting that perhaps some symptoms will remain or recur , even in an individual who responds well to treatment . 
 this acceptance involves acknowledging the existence of symptoms , thereby allowing the patient to pursue a meaningful life that is not overly limited by their potential presence . 
 this is not only liberating for the patient but also for the medical professional , who can sometimes feel pressured by patients unrealistic expectations to achieve symptom reductions that are not possible . 
 we discuss how to talk with patients about their expectations regarding treatment and whether relief of symptoms is a necessary component to living a better life . 
 helping patients to find the right words to explain their visible symptoms to others can sometimes help them feel less self - conscious in public settings and thereby more comfortable going out into the world to pursue a meaningful life . 