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| ORIGINAL ARTICLE |
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| Year : 2021 | Volume
: 8
| Issue : 3 | Page : 166-172 |
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Knowledge, attitude, and practice of cosmetic camouflage among dermatology residents
Jasleen Kaur Sandhu, Purva Pande, Mala Bhalla
Department of Dermatology, Government Medical College and Hospital, Chandigarh, India
| Date of Submission | 04-Jun-2020 |
| Date of Decision | 08-Sep-2020 |
| Date of Acceptance | 01-Mar-2021 |
| Date of Web Publication | 24-Nov-2021 |
Correspondence Address:
Dr. Jasleen Kaur Sandhu
Department of Dermatology, D block, 5th floor, Government Medical College and Hospital, Sector 32 C, Chandigarh 160030
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/Pigmentinternational.Pigmentinternational_
Background: Cosmetic camouflage, used to temporarily normalize appearance, has been shown to improve quality of life in patients with visible disfiguring skin disorders. Its integration into the daily dermatology practice is affected by many hurdles, including dermatologists’ perception about it. Knowledge gained during residency teaching likely affects future practices. Aims: This questionnaire-based survey study was planned to assess the knowledge, attitude, and practice about cosmetic camouflage among dermatology residents. Methods: Dermatology residents in four tertiary care hospitals were contacted for voluntary participation by anonymously filling out a questionnaire devised to assess the awareness of cosmetic camouflage among dermatology residents, various indications of recommendation, any inhibitions in recommending camouflage, problems faced while recommending, and so on. Results: Nearly all (30 of 31; 96.8%) of the dermatology residents in the survey were aware of cosmetic camouflage, but translation of this into practice was low as only about half (17 out of 31, 54.8%) had recommended it. Commonest indication known to the residents was vitiligo (27; 87.1%). The most frequent situation for recommendation felt by 20 (64.5%) respondents was in patients with significant disease related psychological morbidity. Most (18; 58.1%) respondents felt one or the other inhibition in recommending camouflage. The respondents felt that the commonest problem faced while recommending camouflage was availability of the camouflage products (21; 67.7%). Majority (13; 41.9%) thought it only had a “somewhat” role in dermatology. Conclusion: This study highlights the need to improve early education in residency regarding the option of cosmetic camouflage to address the cosmetic concerns of patients. Setting up of camouflage clinics in teaching hospitals may help in this.
Keywords: cosmetic camouflage, dermatology residents, knowledge and attitude, medical makeup, questionnaire
How to cite this article:
Sandhu JK, Pande P, Bhalla M. Knowledge, attitude, and practice of cosmetic camouflage among dermatology residents. Pigment Int 2021;8:166-72 |
| Introduction | |  |
Dermatological disorders such as vitiligo, melasma, rosacea, acne, and many others, which affect visible parts of the body especially face, can be a cause of significant psychological morbidity. Studies assessing quality of life (QoL) parameters in these diseases corroborate this fact and also show that clinical improvement with therapy leads to corresponding improvement in QoL.[1],[2],[3],[4],[5],[6] Most of these disorders have chronic relapsing course, which overtime leads to frustration in the patients and makes them impatient and desirous of immediate results with therapy. The dermatological therapies, be it medical, surgical, or laser/light therapies, usually take several weeks to months for improvement. Some of the conditions such as vitiligo, scars, certain facial melanosis, and congenital nevi may not always be amenable to complete resolution. Cosmetic camouflage using special medical corrective makeup to disguise abnormal skin lesions is a potential solution in these situations, where much improvement is not expected and also while waiting for the effect of therapies. Studies have demonstrated improvement in QoL indices after institution of cosmetic camouflage for visible disfiguring skin disorders.[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21]
Though there is no doubt in the benefits of cosmetic camouflage for dermatology patients, its integration into the daily dermatology practice is affected by many hurdles ranging from acceptance by dermatologists who may consider it a sub/nonmedical frivolous option to practical problems such as product availability, affordability, color match, and so on. Integration into clinical practice can be assessed by awareness and knowledge in the residents as teaching in residency ultimately shapes the future practice. Hence, this questionnaire-based survey study was planned to assess the knowledge, attitude, and practice about cosmetic camouflage among dermatology residents.
| Methods | | |
The study was performed from June 2019 to December 2019. Dermatology residents in four tertiary care hospitals were contacted for participation. After providing oral informed consent to enroll in the study, all participants were asked to fill out a questionnaire anonymously. The research was performed in accordance with the Declaration of Helsinki criteria.
Questionnaire
The questionnaire survey was devised by the investigators to assess the awareness of cosmetic camouflage among dermatology residents, various indications of recommendation, any inhibitions in recommending camouflage, problems faced while recommending, and so on. The validity of the questionnaire was pretested and some of the questions were refined to improve their clarity. The survey was sent to the residents via e-mail, which was obtained through proper channel, with a request to return the filled forms within a month. In case of nonresponse, two reminder e-mails were sent at fortnightly intervals.
Statistical analysis
Categorical variables were reported as counts and percentages. Group comparisons were made with the chi-square test or Fisher exact test. Age was presented as mean, standard deviation with range. A P < 0.05 was considered significant. All the statistical tests were two-sided and were performed at a significance level of α = 0.05. Analyses were conducted using IBM SPSS STATISTICS (version 22.0).
| Results | | |
A total of 53 surveys were sent to dermatology residents, out of which 31 responded. The response rate was 58.5%. [Table 1] shows the basic demographic and professional characteristics of the residents. Out of all 31 respondents, 30 (96.8%) were aware of the cosmetic camouflage, whereas only one (3.2%) was not aware. The commonest indication known to the residents was vitiligo (27 respondents; 87.1%). The most frequent situation for recommendation, felt by 20 (64.5%) respondents, was in patients with significant disease related psychological morbidity. A majority of 21 (67.7%) residents considered women to be the more receptive gender for camouflage advice. [Table 2] details the basic knowledge of cosmetic camouflage in the residents.
The number of residents who had actually recommended camouflage was 17 (54.8%), out of which 16 (94.1%) had recommended it for vitiligo. The frequency of recommendation was occasional with once in 2 to 3 months in 10 (58.8%), while it was less than that and fell in the category of rarely in the rest 7 (41.2%) [Table 3]. Maximum respondents knew only one brand of camouflage cosmetics (Dermacolor; 12 respondents, 38.7%). Only one (3.2%) respondent knew another brand, Dermablend, additionally. Rest 18 respondents (58.1%) were unaware of any brand. Interestingly, in these 18, there were also four residents who had recommended camouflage, but could not recall the brand name as they had recommended it under supervision of a senior and that too infrequently.
Most respondents (18; 58.1%) felt one or the other psychological inhibition in recommending camouflage, whereas 13 (41.9%) had no inhibition. The commonest inhibition, which was felt by 12 (38.7%), was that the camouflage will make the patient think the skin condition cannot be treated and camouflage is the only solution. When divided into two groups as “recommended” and “non-recommended” to compare in terms of inhibitions, it was seen that the recommenders had lesser inhibitions as compared to non-recommenders, though this did not reach statistical significance (P = 0.171). In the recommended group, more than half (9 out of 17, 52.9%) felt no inhibitions in using camouflage, but only one-fourth (4 out of 14, 28.6%) respondents in non-recommenders felt no inhibition, while three-fourths of them had one or the other psychological inhibition about this modality.
[Table 4] summarizes the perceptions of the respondents about the problems faced by dermatologists, benefits, and role of camouflage in dermatology. The respondents felt that the commonest problem faced while recommending camouflage was the availability of camouflage products (21 respondents; 67.7%), followed by improper color matching (14 respondents; 45.2%). Cost, a major concern with these products, was perceived as a problem by eight respondents (25.8%). The major benefit to the patients, according to the respondents, was that camouflage provides concealment until the medical/surgical treatments become effective (20 respondents; 64.5%). Only 12 (38.7%) thought that camouflage had “substantial” role in dermatology, while majority (13 respondents; 41.9%) thought it only had a “somewhat” role. | Table 4 Perception about practical problems, benefits and role of camouflage
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On correlating the level of knowledge of a resident in dermatology with his/her chance of recommending camouflage, there was a direct correlation between the two. More residents were to recommend camouflage as their knowledge in dermatology increased (from first year postgraduate resident to senior resident). Though this was not statistically significant (P = 0.075).
| Discussion | | |
Cosmetic camouflage is a technique using specialized makeup to conceal cosmetically unacceptable skin lesions [Figure 1]. The underlying principle is temporary normalization of the appearance of the skin. The major difference between these camouflage products and conventional cosmetics is their opacity. This quality enables concealment. Additionally, these products are available in multiple shades to match different skin colors and conditions.[22],[23] The most important benefit of cosmetic camouflage is the immediate result providing instant gratification. This provides a significant emotional benefit for patients with visible skin conditions and this is substantiated in literature with reported improvement in QoL indices after camouflage use.[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21] | Figure 1 Pre- and post-camouflage photographs in (a, b) nevus of Ota, (c, d) vascular malformation, and (e, f) vitiligo.
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A multicenter study, assessing the effect of camouflage in disorders of pigmentation, scarring, and vascular lesions, showed a significant improvement in dermatological life quality index (DLQI) scores before and after 1 month of cosmetic camouflage use.[8] Its role in patients with vitiligo has also been studied and was found to be of significant benefit.[7],[10] A systematic review indicated significant improvement in QoL after the use of cosmetic camouflage in patients with disfiguring skin diseases, with mean reduction in DLQI scores ranging from 1.4 to 6.4 signifying improvement in psychosocial parameters.[15]
Although there is plenty of literature to support the role of cosmetic camouflage in dermatology, there is a dearth of data on its usage in daily dermatological practice. This study assessed the knowledge of cosmetic camouflage, attitude towards it, and its use in day-to-day practice among the dermatology residents.
Nearly all (30 of 31; 96.8%) the dermatology residents in the survey were aware of cosmetic camouflage, but translation of this into practice was low as only about half (17 out of 31, 54.8%) recommended it. This signifies certain hurdles in its more common usage. Vitiligo was the commonest indication, of which both awareness and usage of cosmetic camouflage were high. This could be attributed to the stigma attached with vitiligo in Asian societies and the resultant higher psychosocial morbidity affecting the patients.[2],[3] In addition, incomplete resolution with the dermatological therapies in many vitiligo patients necessitates exploring of other solutions. The other reason could be more awareness about benefits of cosmetic camouflage in vitiligo patients as it was seen that of all indications, the most extensive literature was for vitiligo.[7],[10],[20],[21] There is a relative dearth of literature of its beneficial effects in many indications such as rosacea, ashy dermatosis, macular amyloidosis, and so on, and this indicates a need for more studies covering all indications of cosmetic camouflage.
The frequency of recommendation was also very low, with most recommending it once in 2 to 3 months or even less than that. A possible reason for this could be the perception held by the majority residents that cosmetic camouflage is for only those with associated significant psychological morbidity. Ideally, the option of cosmetic camouflage should be offered to all the patients with lesions on visible areas.[20] Psychological morbidity does exist to some extent in all these patients as has been proven by QoL studies, and in daily busy practice psychological assessment of each patient is not possible. It is the duty of the dermatologists to make the patients aware of this option, which provides immediate results.
The relatively low and infrequent usage of cosmetic camouflage seen among residents in this study, and the consequent lack of practical knowledge, is possibly multifactorial, but the main reason could be that the residents do not get introduced to this modality in their formative years as usage is not widespread in clinical practice. The usage could be affected by various psychological inhibitions and practical problems, as was seen in the study also. It was seen that there was an inverse relationship between inhibitions among residents about this modality and its usage. Three-fourths of non-recommenders felt one or the other inhibition. Almost one-third (38.7%) felt that prescribing cosmetic camouflage may make the patient think that the skin condition cannot be treated and camouflage is the only solution. This might be the case if this option is given to the patients without counseling. With proper counseling, patients can be made aware that cosmetic camouflage is an adjuvant measure, while awaiting results with therapy. The immediate results with its use have shown improved QoL in studies and this beneficial effect is likely to increase the patient’s confidence in treating dermatologist.
The most common practical problem faced while recommending cosmetic camouflage was the availability (67.7%), with most being aware of only one brand. This finding confirms the common knowledge of problems in supply of the camouflage products and one of the reasons for infrequent usage of cosmetic camouflage. Easy availability is necessary for successful adoption of a therapeutic modality. Many international brands, though available online, do not yet have seamless supply chains in most countries. Of the major cosmetic camouflage brands listed in [Table 5], the first three have direct presence in India with online availability through their websites. The latter two major brands have availability on online shopping portals, where these are sourced from other countries with resultant higher cost. In addition to availability, effective solutions to other common practical problems perceived by the residents regarding color match dissatisfaction, who should be doing the color match, and cost are important components in its successful recommendation.[22],[23] In many countries, there are specially trained camouflage therapists who do color match and teach its application to the patients. In absence of this facility, educating and training the dermatology residents about the benefits and basic principles of camouflage based on color scheme and its application, along with setting up of dedicated skin camouflage clinics at least in all teaching dermatology departments, may help in its incorporation into practice. More widespread use will likely create demand and more profits and that should lead to better supply chains and decreased cost.
In conclusion, this study is the first to assess the knowledge, attitudes, and practice of cosmetic camouflage in dermatology residents. It highlights the need to improve early education in residency regarding the option of cosmetic camouflage to address the cosmetic concerns of the patients. Every patient with lesions on visible areas should be offered this benefit. There is a need to address the psychological inhibitions and find solutions to the practical problems for successful incorporation of cosmetic camouflage in dermatology practice. Setting up of camouflage clinics in teaching hospitals will meet the needs of a large number of patients with skin imperfections as well as help in its teaching to budding dermatologists. Limitations of the study were a relatively small sample size and the self-report design leading to some bias.
ACKNOWLEDGMENTS
The authors would like to acknowledge Prof. G P Thami, Prof. Sanjeev Handa, Dr S Kumaran, Dr Dinesh Asati, and Dr Chandramohan Kudligi for their help to reach the dermatology residents in their respective departments at Government Medical College and Hospital Chandigarh, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, All India Institute of Medical Sciences (AIIMS), Bhopal, and Karnataka Institute of Medical Sciences, Hubballi. We are also thankful to the respondents for taking out time to fill the questionnaire.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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