Impact case study database
Reducing psychological distress associated with skin conditions: Impacts on policy recommendations, clinical guidelines, training, and psychological interventions
1. Summary of the impact
Sheffield research on the psychological consequences of skin conditions has helped to shape policy recommendations to increase psycho-dermatology services and clinical guidelines to improve patient care. Sheffield research has also been incorporated into: training for health professionals, including e-modules for NHS/social care personnel (730 completed modules) and dermatology nurses (800 views/month) and a leading practitioner handbook on cognitive behavioural interventions for visible conditions (559 sales worldwide); psychological interventions for people with skin conditions, including self-help online resources provided by the British Association of Dermatologists (6,000+ visits/year) and NHS/IAPT services (6,000+ visits/year); and collaborations with skin charities.
2. Underpinning research
Context
Skin conditions comprise the fourth leading cause of nonfatal global disease burden. 60% of the UK population suffer, or have suffered, from a skin condition (British Skin Foundation, 2020). In 2016, over 13 million people visited their GP with a skin condition, costing the NHS £723m; 85% reported that psychosocial aspects were a significant part of their condition (Dermatology Expert Working Group, 2018). Research and development (R&D) investment in skin conditions in the UK is underfunded by £155m p.a. (APPGS, 2020).
Research
Research at Sheffield led by Thompson (funded by ESRC, METRC, Healing Foundation, British Skin Foundation, Psoriasis and Psoriatic Arthritis Association, Alopecia UK) has documented the severity of psychological reactions to living with common skin conditions (e.g. alopecia, eczema, psoriasis, vitiligo), highlighted a substantial and unmet need for psychological interventions, identified key variables underlying people’s psychological reactions, and developed and evaluated interventions to reduce psychological distress.
Psychological consequences of skin conditions and the need for psychological interventions
An influential review (200+ citations) of adaptation to disfigurement by Thompson and Kent identified substantial gaps in knowledge of the psychosocial consequences of visible skin conditions [ R1]. These included a lack of research and understanding of the role of psychological variables and the challenges experienced by people living with appearance-related conditions, along with a lack of evidence-based interventions.
To address these research gaps, Sheffield researchers subsequently conducted: (i) qualitative studies to investigate people’s experiences of living with skin conditions – e.g. R2 highlighted the “overwhelming” experience of living with vitiligo and the use of a range of cognitive and behavioural strategies that helped people to adjust psychologically; and (ii) systematic reviews and meta-analyses on the psychological impact of skin conditions and the effectiveness of psychosocial interventions – e.g. a Cochrane review [ R3] reported some positive effects of psycho-educational interventions on disease severity and quality of life in childhood eczema, but also highlighted the sparseness of evidence-based interventions.
Psychological determinants of adjustment to skin conditions
In response to the need to develop evidence-based interventions, Sheffield researchers have conducted research on the psychological predictors of adjustment to skin conditions (e.g. attentional bias, cognitive flexibility, mindfulness) [ R4]. This research, along with our qualitative work [ R2], has been used to develop interventions to reduce psychological distress associated with skin conditions, including psycho-education, attention refocusing and relaxation [ R5].
Psychological interventions for people with skin conditions
Based on this underlying research, Sheffield researchers have developed and evaluated a number of self-help interventions for specific skin conditions. R5 found that a psychosocial self-help intervention led to clinically significant reductions in social anxiety associated with vitiligo.
Thompson was also the regional principal investigator on the UK-wide ‘Appearance Research Collaboration’ study in 2013, which was the largest study (N=1265) conducted to date on visible difference. The findings formed the empirical basis of recommended cognitive behavioural interventions for people affected by visible difference (e.g. skin conditions) that were detailed in the first, and leading, practitioner handbook in the field [ R6].
3. References to the research
Sheffield authors are in bold.
Thompson, A., & Kent, G. (2001). Adjusting to disfigurement: processes involved in dealing with being visibly different. Clinical Psychology Review, 21(5), 663–682. https://doi.org/10.1016/s0272-7358(00)00056-8. (465 citations).
Thompson, A. R., Kent, G., & Smith, J. A. (2002). Living with vitiligo: Dealing with difference. British Journal of Health Psychology, 7(2), 213–225. https://doi.org/10.1348/135910702169457 (162 citations).
Ersser, S.J., Cowdell, F., Latter, S., Gardiner, E, Flohr, C., Thompson, A.R., Jackson, K., Farasat, H., Ware, F., & Drury A. (2014). Psychological and educational interventions for atopic eczema in children. Cochrane Database of Systematic Reviews, 2014(1), CD004054. https://doi.org/10.1002/14651858.CD004054.pub3 (277 citations).
Montgomery, K., Norman, P., Messenger, A. G., & Thompson, A. R. (2016). The importance of mindfulness in psychosocial distress and quality of life in dermatology patients. British Journal of Dermatology, 175(5), 930–936. https://doi.org/10.1111/bjd.14719 (49 citations).
Shah, R., Hunt, J., Webb, T. L., & Thompson, A. R. (2014). Starting to develop self-help for social anxiety associated with vitiligo: using clinical significance to measure the potential effectiveness of enhanced psychological self-help. British Journal of Dermatology, 171(2), 332–337. https://doi.org/10.1111/bjd.12990 (38 citations).
Clarke, A., Thompson, A. R., Jenkinson, E., Rumsey, N., & Newell, R. (2013). CBT for Appearance Anxiety: Psychosocial Interventions for Anxiety due to Visible Difference (1st ed.). Wiley-Blackwell. Available on request from HEI (110 citations).
4. Details of the impact
Policy recommendations and clinical guidelines
The All-Party Parliamentary Group on Skin (APPGS) 2020 Report [ S1] cited Sheffield research on the psychological impact of skin conditions [ R1, R2, R4] and educational and psychological interventions [ R3, R5] as evidence for policy recommendations for the routine psychological monitoring of people with skin conditions and increased access to specialist mental health support. The report specifically recommended including skin-specific care pathways in all IAPT services, highlighting a “model service” based on Sheffield research.
British Association of Dermatologists (BAD) 2020 clinical guidelines for the management of vitiligo were presented in 2020 at the European Academy of Dermatology and Venereology Congress [ S2]. The updated guidelines cited Sheffield research on the psychological impact of vitiligo [ R2] and the benefits of self-help [ R5] as evidence for recommendations that: clinicians discuss the psychosocial impact of vitiligo with patients (#3); quality of life and psychological distress are routinely monitored (#5); and self-help resources are provided for those experiencing mild psychological distress (#23). BAD has 1,000+ members. The guidelines were due to be published in 2020 but delayed until 2021 due to the coronavirus pandemic.
Sheffield research [ R3, R5, R6] has been cited as evidence for the recommended use of education and CBT in the management of atopic dermatitis in Europe (2018) [ S3], Malaysia (2018), India (2019) and Japan (2020) and pruritus in Germany (2016), and psychological work with vitiligo (American Academy of Pediatrics, 2015) and pigmentation disorders (American Academy of Family Physicians, 2017).
Training for clinicians
NHS e-health learning dermatology modules on psychosocial management, assessment, and interventions for dermatology patients, developed in collaboration with Thompson in 2017 and incorporating Sheffield research, form part of the British Association of Dermatologists’ consultant curriculum (there are 650 UK consultant dermatologists). They are freely available to NHS and social care workers in the UK and to international and private health and social care providers via a fee-paying provider. To date, [Text removed for publication] modules have been completed by NHS/social care personnel and fee-paying users [ S4].
British Dermatological Nursing Group (BDNG) training materials. Thompson has produced clinical skills training materials for nurses on the assessment and management of psychological issues in dermatology that incorporates Sheffield research. These have been published in the BDNG’s professional journal [Text removed for publication] and are available as clinical skills e-resources [Text removed for publication]. Thompson delivered associated training to 300+ practitioners at the 2018 Annual Dermatology Nursing Conference. These activities have “positively contributed to the strategic aims of the BDNG” to promote high quality care for dermatological patients [ S5].
The leading practitioner handbook on CBT for people affected by visible difference [ R6] with 559 sales across all world regions [ S6]. Recommended by the skin charity, Changing Faces, as “required reading” for practitioners [ S10].
Since 2013, Thompson has delivered 30+ training sessions based on Sheffield research to dermatologists, dermatology nurses, and NHS/IAPT staff [ S5, S10]. Thompson has also developed specific training for NHS/IAPT Psychological Wellbeing Practitioners (PWPs) on the assessment and management of conditions affecting appearance. [Text removed for publication].
Psychological interventions
The British Association of Dermatologists Skin Support website launched in 2015 contains resources and self-help materials developed by Sheffield researchers [ R5]. 2019 usage data indicates 6,313 visits to pages containing self-help materials. These materials can also be accessed via a Skin Support Personal Evaluation questionnaire (40,941 visits) [ S8]. Evaluations indicate very positive ratings: 80% of users would use the website again and 87% of dermatology professionals would recommend the website to someone with a skin condition [ S9].
Sheffield Health and Social Care NHS Foundation Trust introduced a skin-specific pathway into their health and wellbeing IAPT in 2018, based on Sheffield research and including Sheffield self-help materials [ R5] [Text removed for publication]. The APPGS 2020 Report highlighted this “model service”, recommending that all Clinical Commissioning Groups implement such a care pathway as part of IAPT provision [ S3]. [Text removed for publication].
Work of skin charities
Thompson has long-term collaborations, including advisory roles, with UK and international skin charities - Changing Faces (2019-present), Katie Piper Foundation (2013-2018), Alopecia UK (2018-2020), Vitiligo Society (2017-present), International Vitiligo Foundation (2014-present), and Vitiligo Support and Awareness Foundation, Nigeria (2013-2017). In these collaborations, Thompson has used Sheffield research to provide training materials and events for clinicians, develop and evaluate psychosocial support services, and support public awareness campaigns. As an example, Changing Faces concluded that Sheffield research “has had a significant impact on our work as the leading charity in the area of disfigurement that, in turn, has impacted on the services we provide to people living with visible differences” [ S10].
5. Sources to corroborate the impact
Clinical guidelines and policy recommendations
All-Party Parliamentary Group on Skin Report (2020) that cites Sheffield research as evidence for policy recommendations (p.14-16,35) and highlights the Sheffield IAPT “Living Well with a Skin Condition” care pathway as a model service (p.54-55).
British Association of Dermatologists updated clinical guidelines for the management of people with vitiligo cite Sheffield research were presented at the 29th European Academy of Dermatology and Venereology Congress, 2020.
European guidelines for the management of atopic dermatitis (eczema) (2018) cite Sheffield research as evidence for the recommended use of psychological interventions (p.869-870) ( https://doi.org/10.1111/jdv.14888)
Training for clinicians
[Text removed for publication].
[Text removed for publication].
Sales figures for CBT practitioner book for appearance anxiety.
Provision of psychological Interventions
[Text removed for publication].
Usage data for the British Association of Dermatologists SkinSupport website ( www.skinsupport.org.uk/about-us.html) that includes Sheffield self-help materials (e.g. http://skinsupport.org.uk/sites/default/files/Social%20anxiety%20in%20Psoriasis%20_developed%20with%20Reena%20Shah%20and%20colleagues_1.pdf).
Evaluation of BAD SkinSupport website ( https://derma.jmir.org/2020/1/e17052/).
Work of skin charities
Testimonial from Changing Faces. Covers evidence of support to charity, the impact on practice of specific Sheffield research and of the usefulness of the CBT practitioner book.