Role of cosmetic camouflage in improving quality of life in dermatological disorders: A narrative review

Introduction

Skin, hair and nails are crucial organs of cosmetic importance and they form the medium of expression of one’s individuality. Flawless skin in today’s social media–driven lifestyle has become a goal for one and all. Even slight imperfections seem unacceptable and are a cause of concern for patients suffering from pigmentary disorders, vascular lesions or in fact any blemish on the visible parts of the body. The pursuit of flawlessness has become of utmost importance. The treatments for such disorders usually take time to show results, therefore the use of corrective make up to cover the lesions till they show a clinical response has been shown to improve the patient’s quality of life.

Camouflage, when simply described, is a system of techniques using cosmetics to conceal, diminish and disguise visible disfigurements of pigment or texture of skin mainly over visible areas. The main purpose is to help cope with the psychological effects by helping to normalise appearance and increase social acceptability. It was first introduced during World War II to help burn victims improve their appearance and then further integrated with medical management by Joyce Allsworth, who formed the British Association of Skin Camouflage.^1-4

A wide variety of options are available which can be used as camouflage cosmetics. The features common to all are that they should be opaque, waterproof, provide a good colour match, easy to apply and have good adherence to skin allowing long wear. The formulations of the camouflage cosmetics include creams, creamy and alcohol-based liquids, sticks and roll-ons. They usually have higher pigment content and fillers, thereby making them more opaque and more efficacious than commonly used make up. Various companies provide commercially available camouflage cosmetics in multiple colours, common ones being Dermacolor, Microskin and Dermablend Cover Creme Foundation. Theories of colour correction following the colour wheel and contouring to match skin’s imperfections also need to be considered for providing a good camouflage of lesions.^5,6

In order to help patients learn the subtleties of application of camouflage make up, the British Red Cross Society provides education services to patients in the United Kingdom free of cost in the Skin Camouflage clinic. These services are supplemented by Changing Faces which is a charity organisation providing trained practitioners of camouflage and teaching and providing patients with medical makeup free of charge. In the United States, state-licensed medically trained camouflage therapists are available, who not only have the knowledge to demonstrate but also educate patients on how to use make up correctly.^1,7.8

Despite evidence of the ability of camouflage to improve the quality of life (QOL) in patients of facial disfigurement, dermatologists still do not practice it regularly for their patients. A cross-sectional study published by Sandhu et al. demonstrated that dermatology residents, although aware about camouflage, did not recommend it regularly and were not convinced of its role in clinical dermatology practice. The study highlighted the need to include camouflage awareness and training during residency to increase acceptability among dermatologists.⁹

In today’s social media–driven world, the impact of various dermatological diseases on the QOL is being increasingly recognized and studied. To keep up with changing patient needs, a shift towards supportive care is the need of the hour whereby dermatologists institute camouflage or corrective make up to patients with dermatological disorders along with treatments to improve their QOL. To support this change, we present this review of studies assessing QOL in patients of dermatological diseases who were given camouflage therapy.

Material and Methods

A literature search of PubMed electronic database was performed using key words ‘camouflage’and ‘dermatology’. A total of 22 search results appeared. Studies including case reports, clinical study, clinical trial, Phase IV, controlled clinical trial, multicentre study, and randomised controlled trial focusing on dermatological disorders have been included in this review. The studies that assessed QOL improvement by any of the multiple available tools were included. Only five relevant studies were found and abstracts of these were studied and reviewed by the two authors. The relevant references of the included articles were also traced and included, making a total of 15 case series and clinical trials. Studies focusing on QOL improvement in burn scars, post-radiation scarring, surgical scars, and head and neck cancers were not included in this review [Figure 1].

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Figure 1:

Flow chart depicting the process of data collection and study analysis.

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The objective of the review was to collate and analyse the evidence to suggest the impact of camouflage techniques on QOL improvement in various dermatological disorders using the available QOL indices.

Results

Discussion

QOL of an individual is a major determinant of mental and social health, with ill health usually resulting in it’s deterioration. Dermatological disorders, especially chronic disfiguring dermatoses, are major contributors resulting in a decline of QOL and this has been well substantiated in literature. Over the years, physicians have tried to devise various techniques to help improve the QOL of their patients over and above therapeutic treatment. Camouflage forms an important subset of these techniques which, when used appropriately under the right guidance, proves to be an important tool in patients suffering from visible deformities of skin and associated structures.^27-29

This review included studies focused on quantifying improvement in QOL of various dermatological disorders after camouflage therapy using various parameters of assessment [Table 1]. It was observed that camouflage can be used for multiple indications which can broadly be classified as pigmentary disorders, acne, vascular abnormalities, and scarring.

Pigmentary diseases including vitiligo, melasma, lentigo, café au lait macules, and post-inflammatory hyperpigmentation were the most commonly evaluated indications, of which vitiligo was the most common. It was observed that DLQI assessment in these patients showed significant improvement in scores after camouflage use. Vitiligo was the most commonly studied pigmentary disorder, likely because it causes significant deformity in skin of colour as the colour discrepancy is more evident. These disorders prove to be an ideal dermatosis for camouflage therapy as the skin texture is maintained and only the skin colour needs to be corrected by a carefully matched skin shade. The improvement in QOL in these individuals was lesser when compared to other indications but this may be because of the stigma associated with it. This issue should be explored in larger studies.^30-32 Some authors believe that camouflage therapy may hamper the treatment of vitiligo but Li et al. in 2020 found that there was no difference in repigmentation and transepidermal water loss in patients using dihydroxyacetone containing camouflage as compared to controls.³³

Acne was another indication evaluated in the paediatric and the young adult population. Severe acne, mainly affecting the young adults, is an important cause of psychological stress leading to depression, anxiety and suicidal tendencies. Improvement in QOL with reduction in DLQI scores was observed in patients advised camouflage therapy in addition to medical treatment of acne.^34,35 Cosmetics usually are considered to exacerbate acne and rarely advised by dermatologists. But Hayashi et al. in 18 female patients observed that make up designed for acne-prone skin did not worsen the severity of acne; rather, it significantly improved the QOL.³⁶

Vascular lesions include a large variety like spider angiomas, port wine stain, haemangiomas, telangiectasia, etc., and the treatment options are often limited and have questionable efficacy. As observed, vascular lesions showed maximum improvement in QOL when compared to other indications. This may be due to the fact that these lesions especially on visible areas cause significant cosmetic disfigurement due to colour contrast. Camouflage using colour correction and correct skin matching may give an apparently normal appearance to the patients thereby improving QOL in lesions that may otherwise have minimal curative options.^37-40

Camouflage by using colour correction and concealing may give an apparently normal appearance to the patients and thereby improve QOL in lesions that may otherwise have minimal curative options. Scarring due to acne, post-surgery, post-trauma or radiation causes change in both colour and texture of skin causing a visible deformity with scarce options of correction. Scars, although symbolising survival and being inevitable, may be a source of anxiety and stress to patients. Thus, scars when corrected with camouflage using contour correction help improve QOL. Camouflage used in patients immediately post-surgery to cover scars has been shown to improve QOL and provide better recovery psychologically.^41-44

In the studies in this review, a vast array of scoring systems were utilised, the most common being DLQI which is a widely used and validated QOL measure designed for dermatology patients. As reviewed, camouflage therapy showed improvement in symptoms and feelings questions of the questionnaire signifying that it decreases the feelings of embarrassment and self-consciousness in the patients about their appearance due to the skin disease.^25,26 Other scoring systems also showed similar patterns of improvement in areas of appearance, self-esteem and psychological well-being. These scores helped to objectively evaluate the efficacy of camouflage in improving QOL and validate its utility in regular clinical dermatological practice.

Conclusion

The evidence presented here gives us an insight into the positive effects of camouflage/cover up make up when offered to patients with different dermatological conditions. It leads us to reflect and re-analyse the supportive clinical care of patients with visible disfigurements beyond standard treatment protocols and encourages us to explore the field of camouflage therapy to provide better QOL to our patients.