[Medical rehabilitation in dermatology : Goals, program content, and application process]

BACKGROUND

Medical rehabilitation plays an important role in the management of patients with chronic dermatoses and dermato-oncological diseases.

OBJECTIVES

Which dermatological indications qualify for a medical rehabilitation? What forms need to be completed for a successful application? Which treatments are provided and what are goals to be accomplished during dermatological rehabilitation?

MATERIALS AND METHODS

Evaluation of current guidelines, directives, and recommendations as well as exemplary reviews.

RESULTS

Dermato-oncological diseases and every chronic dermatological disease that is associated with a limitation of body functions and structures, activity and participation is eligible for medical rehabilitation. They include need, ability to absolve a rehabilitation, and a favorable prognosis. Treatments range from therapy of the underlying dermatological condition to interdisciplinary treatment of comorbidities with the aim of restoring functional health.

CONCLUSIONS

Medical rehabilitation follows a holistic approach and represents a significant addition to outpatient and acute inpatient care, often leading to a long-term improvement in clinical outcome, participation, and activity.

Prophylaxis and rehabilitation of patients with chronic dermatosis (review of literature)

The article covers main aspects of sanatorium-and-spa treatment in chronic skin diseases.

[Acupuncture--propagated indications beyond pain-relief therapy]

Acupuncture originates from China and has developed out of Traditional Chinese Medicine (TCM). Since the 1970s acupuncture has been carried out more and more in Germany - especially within the context of pain-relief therapy. Acupuncture is more or less considered to be a medically necessary measure in the case of chronic knee or back pains and of chronic headaches, even if the German Acupuncture Trials (GERAC) leave some issues regarding its effectiveness unresolved. Less known is the fact that acupuncture is not only used for pain-relief therapy, but that a lot more indications have emerged over the last 20 years. Acupuncture is increasingly used for the treatment of allergies, asthma bronchial, addictions, tinnitus, but also to stimulate pregnancy and against adipositas, neurodermitis and a lot of other diseases. The available statistics state that acupuncture is used in appr. 20% of all cases for indications apart from pain-relief therapy. There are about 150 indications for which acupuncture is used as a therapy. However, for the majority of the apparent indications no proof is available in the sense of medical studies of an acceptable scientific level. Very often acupuncture has mild side-effects and rather rarely serious side-effects or health hazards. Patients are fequently not informed about them sufficiently.

Randomized study of different anti-stigma media

OBJECTIVE

We designed our study to assess if computer-assisted anti-stigma interventions can be effective in reducing the level of psychiatric stigma in a sample of special education university students.

METHODS

We enrolled 193 graduate students. They had two study visits with an interval of 6 months. The participants were randomly distributed into three study groups: 76 students read anti-stigma printed materials (reading group, RG), and 69 studied an anti-stigma computer program (program group, PG), and 48 students were in a control group (CG) and received no intervention. We used the Bogardus scale of social distance (BSSD), the community attitudes toward the mentally ill (CAMI) questionnaire, and the psychiatric knowledge survey (PKS) as the main outcome measures.

RESULTS

After the intervention BSSD, CAMI and PKS scores significantly improved both in RG and PG. After 6 months in RG two out of three CAMI subscales and PKS scores were not different from the baseline. In PG all stigma and knowledge changes remained significant.

CONCLUSIONS

This study demonstrated that computers can be an effective mean in changing attitudes of students toward psychiatric patients.

PRACTICE IMPLICATIONS

A computer-mediated intervention has the potential for educating graduate students about mental disease and for reducing psychiatric stigma.

The Family Dermatology Life Quality Index: measuring the secondary impact of skin disease

BACKGROUND

Skin diseases are known to have a major impact on the lives of patients and their families. Many instruments are available to measure the health-related quality of life (HRQoL) of patients but no measure has been developed so far to quantify the secondary impact on family members of the patients.

OBJECTIVES

To develop and validate a dermatology-specific instrument to measure the adverse impact on the HRQoL of family members of patients with skin disease.

METHODS

Detailed semi-structured interviews were conducted with family members of patients to identify different aspects of HRQoL affected. An initial draft version of the questionnaire based on the main topic areas was pilot tested to assess the face and content validity. A 10-item questionnaire, the Family Dermatology Life Quality Index (FDLQI), was finalized after modifications to the draft questionnaire based on feedback from families and dermatology professionals and on item reduction. Psychometric evaluation was conducted on a new cohort of family members (n = 132) who completed the FDLQI and the patients (n = 109) who completed the Dermatology Life Quality Index (DLQI).

RESULTS

Fifty-nine different aspects of family members' HRQoL were identified from the analysis of the interviews, which were categorized into main topic areas. Factor analysis of 10 items of the final questionnaire revealed two factors and together these explained 60% of the common variance. The FDLQI demonstrated high internal consistency (Cronbach's alpha = 0.88) and test-retest (intraclass correlation coefficient = 0.94) reliabilities. The responsiveness of the instrument to change was shown by significant change in the family members' FDLQI scores in cases where patients' clinical condition either improved or worsened. Construct validity was assessed by testing a number of a priori hypotheses. A strong correlation was seen between the family members' FDLQI scores and patients' DLQI scores (r = 0.69), a significantly higher FDLQI score was seen for inflammatory skin diseases compared with noninflammatory diseases/isolated lesions (P < 0.0001), and there was a positive relationship between the family members' FDLQI scores and patients' disease severity (r = 0.49).

CONCLUSIONS

The FDLQI is simple and practical and seems to have the potential to be used as an additional outcome measure in clinical practice and evaluation research.

Effect of elastic compression stockings on oedema prevention in healthy controls evaluated by a three-dimensional measurement system

BACKGROUND/AIMS

The degree of oedema may differ at various sites on the leg. This study evaluated the degree of oedema at the calf, ankle and foot using a three-dimensional measurement system.

METHODS

By three-dimensional measurement system using the grid pattern projection method, the effects of four different types of elastic compression stockings on oedema prevention were compared in healthy subjects.

RESULTS

Without stockings, a significant increase in the circumference and volume was seen at the ankle and foot in the evening compared with morning values. The average increase in circumference was greater at the foot than that at the ankle. A significant increase in circumference and volume in the evening after a day without stockings disappeared when elastic compression stockings were worn during the day. The coefficient of variation was greater for measurements at the foot than for those at the calf and ankle.

CONCLUSION

Oedema develops easily in order of the foot, the ankle and the calf in healthy populations. Elastic stockings, even with a pressure as low as 8 mmHg, are effective on oedema prevention. In measurement at the foot, further developments are necessary to improve this system.

[Cosmetic dermatology in German dermatology departments--outcome of a national survey]

The demand for non-surgical cosmetic treatments has grown considerably in recent years. It appears German dermatology departments now also increasingly seem to offer many of these methods. In 2001 we evaluated the use of different non-surgical cosmetic techniques in German dermatology departments through means of a national questionnaire. Information was requested from 85 departments, of which 63.5% responded. The outcome revealed that 96.3% of the participating departments have lasers at their disposal to treat cosmetic skin lesions, 79.6% carry out injections with botulinum toxin, 59.3% perform chemical peels and 37% perform tissue augmentation with injectable fillers. Overall, the ratio between desired and adverse effects as well as the economic benefit of all evaluated methods was judged as positive by the interviewees. In a comparison of all evaluated modalities, the therapeutic index was considered most favourable with botulinum toxin and most unfavourable with injectable filling agents. With regard to cost-effectiveness, soft tissue augmentation was judged best, while chemical peels alongside lasers were regarded as least advantageous in this respect. Further evaluated topics were indications, substances, organisation and other issues. In summary the survey confirmed that a large number of German dermatology departments employ non-surgical cosmetic procedures matching the international upward trend of cosmetic dermatology.

Does enough quality of life-related discussion occur during dermatology outpatient consultations?

BACKGROUND

Dermatologists' assessments of how their patients' lives are affected by the skin disease are of importance for informing clinical decisions. However, there is no information about how often quality of life (QoL) issues are discussed in outpatient consultations.

OBJECTIVE

To examine the relationship between the extent of QoL-related discussion during dermatology outpatient consultations, and the current impact of the disease on patients' lives.

PATIENTS AND METHODS

A total of 238 consultations were observed in a teaching dermatology outpatient department for QoL-related discussion initiated by either the clinician or the patient. Following the consultation, all patients were posted a Dermatology Life Quality Index (DLQI) questionnaire to complete and return within 1 week.

RESULTS

QoL discussion was absent in 40% of consultations. Consultants initiated the fewest QoL discussions with patients, and nurses the most (P < 0.0001). One hundred and twenty-eight (54%) patients returned the DLQI, 114 (48%) of which were evaluable. The mean score was 5.6, SD +/- 6.6, median 3, range 0-29. The mean DLQI score for the patients with whom there was no QoL discussion was 4.0 +/- 4.7, n = 55, compared with the mean DLQI score for patients with whom QoL was discussed 6.8 +/- 7.2, n = 59 (P < 0.001).

CONCLUSION

This study demonstrates that little information concerning QoL is elicited during dermatology outpatient consultations.

An assessment of the quality of life in older patients with skin disease

BACKGROUND

There are few data regarding quality of life in older people with skin disease, particularly concerning those with skin cancer. Access to U.K. secondary care dermatological services is increasingly focusing on skin cancer, which may have a negative effect on waiting times for patients with rashes.

OBJECTIVES

To assess the quality of life in patients aged 65 years and over and to determine how this relates to type and extent of skin disease.

METHODS

One hundred consecutive new dermatology patient referrals aged 65 years and above had quality of life assessed by the Dermatology Life Quality Index (DLQI), the Hospital Anxiety and Depression Scale (HADS) and the Illness Perception Questionnaire. Patients were examined for type and extent of skin disease.

RESULTS

There were 49 men (mean age 75.1 years) and 51 women (mean age 75.0 years). Fifty-five per cent of patients had been referred with one or more lesions (76% premalignant or malignant) and 45% had rashes. There was no significant difference between the quality of life scores of men vs. women regarding all three of the questionnaires. However, patients with rashes scored significantly higher (i.e. poorer quality of life) on all but one of the questionnaire parts compared with patients with lesions. Patients with more extensive disease had significantly higher DLQI scores.

CONCLUSIONS

Older people suffering from rashes had significantly poorer quality of life than patients with lesions, even those with skin cancer. The quality of life is negatively associated with extent of skin disease. Access to specialist dermatological care should take into account the suffering caused by extensive skin diseases. DLQI and a general quality of life questionnaire such as the HADS are quick to deliver and to score, particularly in the setting of a busy outpatient department. They provide an excellent screening tool for psychological problems in older people with skin disease.

Rehabilitation von berufsbedingten Hauterkrankungen

The high incidence rates of occupational contact dermatitis, its poor prognosis, and the high social and economic impact of the disease for the affected individuals as well as for the medical insurance companies indicates a need to strive for the target of "rehabilitation instead of retirement". Here, we highlight the need and effectiveness of rehabilitation measures in individuals with work related skin diseases (mainly contact dermatitis and hand eczema). We discuss the measures for secondary individual prevention as well as tertiary prevention, which have been established in our department together with the state medical insurance companies, mainly the Berufsgenossenschaft für Gesundheitsdienst und Wohlfahrtspflege (BWG: Institution for Statutory Accident Insurance and Prevention in the Health and Welfare Service). The results of the multicentre study "Optimisation and Quality Assessment of Tertiary Prevention of Occupational Dermatoses" are presented and discussed. Both, the secondary as well as tertiary prevention measures have been successful, which has resulted in a decrease in the total annual rehabilitation costs to the BGW. A reason for this success story is the fact that in Germany these organisations are, in contrast to the health insurance companies, responsible for both acute treatment and the rehabilitation.

[The international classification of functioning, disability and health (ICF) in dermatological rehabilitation: conception, application, perspective]

Medical rehabilitation represents the interdisciplinary management of a person's functional health. This term implies concepts of functioning, disability and health and represents the core notion of the international classification of functioning, disability and health (ICF). Four components -- anatomic structure, body functions, activities and participation, environmental factors and personal factors -- make the ICF applicable from a biological, individual and social perspective. At present the ICF is used as a system of classification, a research tool and as a theoretical basis in rehabilitation medicine. Its clinical application will depend on the improvement of its practicability and compatibility with currently used tools in dermatologic rehabilitation. ICF offers the opportunity to define, weight and classify diseases of the skin and their psychosocial consequences.

[Dermato-oncological rehabilitation]

National insurance companies in Germany support health cures for patients with malignant tumors (malignant melanoma, squamous cell carcinoma, Merkel cell tumor, malignant cutaneous lymphoma). The clinical requirements are an invasively growing tumor, problems of self-assurance, and dis-integration of the patient regarding his social and/or professional environment. The decision for a health cure is made by the treating dermatologist in the hospital. In this context, the following sociomedical criteria should be applied: impairment, disability, and handicap. Usually, rehabilitation starts after the patient is discharged from the hospital. The inpatient rehabilitation program should be performed at an institution capable of providing dermatological and psychological treatment. The dermatologist acts as a manager for the members of the rehabilitation team (psychologists, physiotherapists, social workers, and ergo-therapists). In conclusion, dermato-oncologic rehabilitation plays an important role in re-integrating the patient into his professional life to avoid retirement.

[Guidelines for rehabilitation of dermatological diseases]

Guidelines for dermatological rehabilitation are based on the International Classification of Functioning, Disabilities and Health (ICF), which includes context factors such as physical environment, socioeconomic conditions, and the personal situation of the patient. Guidelines give specific recommendations for personal conditions of rehabilitation, staff, equipment, process of treatment, and evaluation. They assist doctors, patients, and public institutions in orientation and decision making. The latest publications are a joint summary obtained from experts, with substantial participation of the social insurance agencies, and demonstrate the growing importance of guidelines which are the result of a compromise between the conflicting interests of medical progress on the one hand and economic restrictions on the other. Consequences for allocation of financial resources in the health system are discussed.

Decorative cosmetics improve the quality of life in patients with disfiguring skin diseases

Dermatoses may have a significant impact on a patient's quality of life, namely the relationship to others, self-image and self-esteem. We therefore asked whether the application of decorative cosmetics might increase their quality of life. Twenty female patients (16-69 y) with skin diseases affecting the patients' face (acne, n = 8; rosacea, n = 9; chronic discoid lupus erythematodes, n = 2; vitiligo, n = 1) were investigated. The patients were instructed by a cosmetician how to use decorative cosmetics (Unifiance , La Roche-Posay, France) and applied it daily for 2 weeks. The dermatology quality of life questionnaire (DLQI) was performed before the first application and 2 weeks afterwards. The clinical course was documented by standardised photography. Unifiance was well tolerated and no side effects occurred. It completely masked the unwanted coloration and application resulted in a significant amelioration of the appearance. The mean DLQI score dropped significantly from 9.2 to 5.5 (p = 0.0009). Improvement of quality of life reached statistical significance among patients with acne (2.8 versus 7.8, p = 0.0078) and among individuals with a less severe initial impairment of quality of life (2.4 versus 4.2, p = 0.007). Thus, the use of decorative cosmetics in disfiguring skin diseases is an effective, well-tolerated measure increasing the patients' quality of life. We therefore suggest that decorative cosmetics can complement the treatment of disfiguring skin diseases.

Cosmetic camouflage advice improves quality of life

BACKGROUND

The subjective benefit of attendance at cosmetic clinics has not previously been reported.

OBJECTIVES

To assess the effect on perceived quality of life (QoL) of cosmetic camouflage advice.

METHODS

In a three-centre study, 135 individuals were invited to complete a dermatology-specific QoL measure, the Dermatology Life Quality Index (DLQI), before and 1 month after their first visit to a cosmetic camouflage clinic.

RESULTS

Eighty-two completed DLQI questionnaires were returned before the camouflage clinic appointment, and 56 corresponding questionnaires were returned 1 month after. The mean age of responders was 50 years, and the mean duration of their skin conditions was 15 years. The main conditions seen were pigmentary disorders (29%), scars (22%) and vascular disorders (13%). There was a significant difference in mean DLQI scores before and after the clinic visit (9.1 vs. 5.8, P = 0.0001).

CONCLUSIONS

When assessed at 1 month, attendance at a cosmetic camouflage clinic appears to improve QoL significantly.

[Sports as a risk factor and therapeutic principle in dermatology]

Sporting activities may exert positive and negative health effects. This applies not only to the cardiovascular and musculoskeletal system, but also to skin. During sporting activities a person is exposed to environmental factors such as temperature, irradiation, and allergens. These factors may play a key role in the development of skin diseases. Mechanical trauma is caused by acute injury as well as chronic damage. Infectious skin diseases caused by viruses, bacteria or fungi can be transmitted by body contact or the use of communal showers or locker rooms. Intake of performance-enhancing substances may provoke skin changes such as striae distensae, androgenetic alopecia, hypertrichosis and acne. Preexisting skin diseases such as psoriasis, lichen planus, vitiligo, polymorphous light eruption, lupus erythematosus, porphyria, urticaria, and acne rosacea may be aggravated by sporting activities. On the other hand, physical exercise has a therapeutic potential which has hardly been exploited by dermatologists. Especially in chronic skin diseases positive effects have been observed. Therapeutic use of team sports has been shown to decrease suffering, depression, and emotional disturbances and increase life quality in patients with atopic eczema, psoriasis, and venous leg ulcers.

Camouflage therapy

Camouflage cream was introduced over 50 years ago to assist in the rehabilitation of severely burned pilots injured during World War II. Today, camouflage therapy can be used to conceal discoloration such as postoperative bruising and erythema. Pre and postoperative teaching regarding camouflage therapies are very important parts of the healing process, and dermatology nurses can play a vital role in the teaching and healing process.

Impaired quality of life of adults with skin disease in primary care

BACKGROUND

Although 75% of skin problems are managed exclusively in primary care, most information on the impact of skin disease on quality of life is hospital based.

OBJECTIVES

To examine the ease of use of the Dermatology Life Quality Index (DLQI) in primary care and to measure the handicap levels found, analysed by skin disease, sex and age.

METHODS

The handicap levels identified were compared with those published for patients with the same conditions attending hospital clinics. Some conditions that rarely present in secondary care were also studied.

RESULT

S The overall mean +/- SD DLQI score was 7.37 +/- 5.71 (women 7.8 +/- 5.8, n = 196; men 6.8 +/- 5.6, n = 145). The scores for separate diseases were similar in ranking and only slightly lower than those in hospital-based studies. The possibility of bias towards surveying an unrepresentative sample of patients is discussed. There was no correlation between age and DLQI score.

CONCLUSIONS

The DLQI proved easy to use in general practice. The impact of skin diseases on the quality of life of patients seen in primary care is comparable with that of patients seen in secondary care. This information could be used to inform the planning of services for these patients.

Cosmetic rehabilitation

Appearance is one of the most powerful factors influencing social interactions with others. What patients with disfigurements experience from society on a daily basis is a very real stigma. Cosmetic rehabilitation is a system of cosmetic techniques devised for patients to use to assist themselves to cope constructively with the psychological and physical trauma of their disfigurements.

Dowling Oration 2000. Dermatology patients: what do they really need?

Dermatology services must be organized to meet the needs of patients. These needs change as society changes and medical knowledge increases. Considerable insight into the true needs of individual and groups of patients can be gained from the use of quality of life measures. Patients with widespread inflammatory skin disease are most severely handicapped by their skin disease and can be most helped by dermatology services. It is essential that such patients be given priority in the delivery of dermatological care. Where necessary, protected clinic time and specialist support services should be created to ensure that such patients are not adversely affected by pressures to review patients in other diagnostic groups.

Geriatric dermatology in chronic care and rehabilitation

The skin care of disabled elders living in nursing homes and adult congregate, subacute, and home health settings requires special effort and consideration. Practitioners who regularly assist elders in these situations may be unfamiliar with dermatology problems related to chronic disability. As the U.S. population ages, skin care in the elderly and disabled will continue to be a challenge. However, if the diseases and problems can be addressed in a knowledgeable and problem-oriented manner, treatment can be maximized.

[Value of psychotherapy in expert assessment of skin diseases. Recommendations and indications for additional psychotherapy evaluation in expert assessment from the viewpoint of dermatology]

Skin diseases, the psyche and psychological changes are often intertwined, especially in patients presenting for expert dermatologic opinion. In many cases an additional evaluation provided by psychotherapeutic medicine may be necessary. This resource may help with the diagnosis, explanation of the problem and estimation of the degree of disability. The different legal guidelines of the various evaluation boards must be considered. The role of psychotherapeutic evaluation is demonstrated through case examples. The evaluation of new possibly occupationally-related disorders such as multiple chemical sensitivity and mobbing is considered.

[Inpatient behavioral medicine in chronic skin diseases]

Behavioral medicine is a newer approach in the management of various diseases. In the last years, special programs have been developed for atopic dermatitis, psoriasis vulgaris and other chronic skin diseases. An increase in the patient's self-control could be achieved by optimizing the patient's skills in dealing with their skin disease. The article summarizes the principles and procedures of in-patient behavioral medicine, especially the strategies employed by dermatological training groups and psychotherapeutical groups to help the patient deal with their skin disorder.

[Psychosomatic disorders in dermatology--incidence and need for added psychosomatic treatment]

In a cooperative study involving the Department of Dermatology and the Department of Psychosomatic Medicine/Psychotherapy of the University of Düsseldorf, 187 patients were evaluated for psychosomatic disease and indenient psychological testing. The distribution of skin diseases and psychosomatic ICD 10 diagnoses are presented. It was found that patient evaluation-(symptom-complaint-questionnaire) and expert evaluation correlate positive. It therefore seems worthwhile examining dermatology in-patient's for psychosomatic problems in order to facilitate combined dermatological and psychosomatic approach not only in the hospital but also during the post-discharge ambulatory treatment.

Subfascial endoscopic perforator surgery is associated with significantly less morbidity and shorter hospital stay than open operation (Linton's procedure)

BACKGROUND

Subfascial endoscopic perforator surgery (SEPS) is the minimally invasive alternative to the open (Linton's) procedure. This new technique may allow perforating vein interruption with fewer complications and a shorter postoperative hospital stay.

METHODS

This study was a case note review of 67 procedures: 30 SEPS and 37 Linton's.

RESULTS

There were no significant differences between the two groups in age, sex and indication for surgery. SEPS was associated with a significantly reduced postoperative stay in hospital (median 2 (range 1-49) days) compared with the Linton's procedure (median 9 (range 3-36) days) (P < 0.01). Nine patients who had Linton's procedure suffered a calf wound complication compared with none who had SEPS. The presence of an open ulcer at the time of surgery did not prolong the duration of stay in either group, nor did it increase the incidence of calf wound complications.

CONCLUSION

In patients undergoing calf perforator interruption for chronic venous insufficiency, SEPS is associated with significantly less morbidity and a shorter hospital stay than Linton's procedure. SEPS can be performed safely at the same time as skin grafting and in the presence of an open ulcer without any increase in wound complications.

[Bath additives in dermatologic balneotherapy. Indications and approaches in current research]

Progress in dermatological research during the last years has provided new insights into the mode of action of additives to dermatological baths. The present paper reviews the pharmacokinetics of dermatological bath therapy additives such as sulfur, salts and trace elements, tars and ichthyol, lipids, antiseptics, astringents, plant extracts, surface-active agents and proteins.

[Indications for psychosomatically-oriented dermatologic rehabilitation]

Dermatological rehabilitation treatment can take different forms: climato-therapy, baths, phototherapy and psychosomatic treatments. Which of these treatments is of most benefit to any one patient depends on his or her illness. Accordingly, a psychosomatic approach to dermatological illness is indicated mainly when a psychological disorder and a dermatological disease coincide. In addition, dermatoses with psychological triggers or overlays, and also depression, pre-existing emotional disorders and special motivation for psychotherapy should be considered for psychosomatic treatment. Finally, patients who are having trouble accepting or confronting malignant skin tumours may also benefit.

Camouflage therapy

Camouflage therapy is a system of cosmetic techniques designed for patients to use to assist themselves in coping constructively with the psychological and physical trauma of their disfigurements. It is described as a "system" because these techniques are interrelated. A camouflage therapist may teach the patient to use one, two, or all of the techniques at the same time in order to normalize their appearance. Four basic techniques have been described in this article. They are as follows: (1) the use of opaque, waterproof cover creams to conceal scarring; (2) the application of pancake makeup for patients with oily or acne-prone skin; (3) color correctors to obliterate discoloration from postoperative trauma; and (4) recreating imperfections on the skin. For more information about the use of cosmetics to normalize the appearance of physical disfigurements, the following books are recommended.

[Experience of their environment and disease by facially disfigured patients--recognition of the handicap as a prerequisite for rehabilitation]

In an investigation of psychosocial strain in persons having a facial or skin impairment, a total of 25 patients of Fachklinik Hornheide (a special clinic for the treatment of tumors, tuberculosis, and for facial and skin reconstruction) had participated in in-depth interviewing. It was found with unexpected clarity that these clients are exposed to a high measure of negative environmental reaction. In addition to having to cope with stressful disease consequences, often entailing a "loss of face" with the major problems of self-worth this involves, these negative experiences in many instances lead to behavioural problems, withdrawal reaction, occupational repercussions, or severe emotional crisis in those concerned. The degree to which these patients can overcome their problems is to a large extent dependent on how parents, spouse, colleagues, and important others respond. Early enough involvement of significant others, possibly already at the time of medical information, as well as support during emotional crisis are capable of considerably alleviating the coping process. The psychosocial problems confronting persons with disfiguring facial conditions have to be taken into account during therapy in order to successfully enhance the purpose of integration into the social environment.