Correspondence

Cognitive behavioral therapy for acne and other chronic

skin disorders

We read with interest the report by Jung and Hawang

describing the knowledge and behavior of patients with
acne; some patients had unorthodox beliefs about the
cause and treatment of their acne and as a result had
adopted unhelpful and potentially counterproductive
behaviors.1 The authors emphasize the need for patients
to establish a clear understanding of the nature and treatment of acne to allow optimum management and therefore satisfactory outcomes to occur. However, knowledge
alone may not be enough to predict intention or practice
of health behaviors. Research in adjustment to illness has
shown that perceptions of illness are important in determining patients' response to treatment and coping with
their condition.24 Accordingly, patients form perceptions
about their condition and its treatment, which are more
elaborate than attitudes. These include perceptions about
identity, cause, timeline, consequences, and curecontrol
over illness. The researchers in this paper label knowledge
that could well be perceptions over curecontrol. Therefore, the inference the authors make of their findings, i.e.
that improving knowledge would result in improved
behaviors, is rather weak.
The authors make no mention of any emotional morbidity of these patients. Cognitive behavioral therapy, as
pioneered by Beck, helps patients understand and address
dysfunctional thoughts and feelings that influence behaviors.5 There are many potential negative feelings that a
patient with acne may have, including anxiety, sadness,
frustration, anger, annoyance, contempt, disgust, fear,
doubt, envy, shame, despair, disappointment, reduced
confidence, self-consciousness, embarrassment, hurt, and
guilt. These feelings may be triggered by negative
thoughts/beliefs, e.g. that they are unattractive, ugly, or
unacceptable to themselves or others, self-disgust and
self-hatred may occur, they may perceive themselves as
inferior to others, they may think they are unlovable or
unworthy, patients may see themselves as imperfect,
unclean, and in extreme cases patients may have suicidal
thoughts. The authors do mention some unhelpful behaviors in patients with acne. Other maladaptive coping
physical mechanisms include excessive use of commercial
tanning salons, repeated mirror checking or complete mirror avoidance, use of clothing, excessive make-up on
body parts to cover affected areas repeatedly, excessive
touching or interfering with the affected areas, compul 2013 The International Society of Dermatology

sive picking or squeezing of spots, excessive ritualistic

cleansing regimens, repeated reassurance checking,
repeated Internet searches for a miracle cure and purchasing many miracle acne products, regular comparison with
others or photographs in magazines, and avoidance of
social events.
In dermatology, cognitive behavioral therapy is helpful
in eczema, psoriasis, alopecia, acne excoriee, body dysmorphic disorder, and other cutaneous hypochondriasis,
including delusional infestation.6 It is important to note
that the patients' acne-related behavior in this study could
be better understood under another comorbid disorder,
e.g. BDD, which the authors did not take into account.
In the UK, the medical management of acne differs
from the Korean approach. Use of cosmeceuticals is not
standard practice. We suggest that the overuse of cosmeceuticals or recommendation of manipulation of lesions,
including extraction of comedones, in an at-risk patient
with a tendency towards compulsive behavior could be
harmful.
Patients with acne seek medical help because of how
acne makes them feel and how acne affects their daily
functioning. Studies have shown that the objective physical severity of acne does not correlate with the patients'
perception of severity and impact on their life. Therefore, it is crucial to focus on the patients' experience
and perspective. Those patients who report a large
detrimental effect on their quality of life are in need of
a personalized Cognitive behavioral approach to supplement conventional medical therapy. Other forms of
psychotherapy may be helpful in individual cases. This
need appears to be unmet often. Further research in this
area is desirable.
Andrew Affleck
Department of Dermatology
Ninewells Hospital and Medical School
Dundee
UK
E-mail: andyaffleck@doctors.org.uk
Zoe Chouliara
Shauna Kielty
Department of Clinical Health Psychology
NHS Tayside
Dundee
UK
1
International Journal of Dermatology 2013

Correspondence

Conflicts of interest: None.

doi: 10.1111/ijd.12093

References
1 Jung J, Hawang EJ. Do patients with acne need cognitive
behavioural therapy? An analysis of patient knowledge
and behaviour. Int J Dermatol 2012; 51: 13191324.
2 Broadbent E, Petrie KJ, Main J, et al. The Brief Illness
Perception Questionnaire (BIPQ). J Psychosom Res 2006;
60: 631637.

International Journal of Dermatology 2013

3 Moss-Morris R, Weinman J, Petrie KJ, et al. The Revised

Illness Perception Questionnaire (IPQ-R). Psychol Health
2002; 17: 116.
4 Weinman J, Petrie KJ, Moss-Morris R, et al. The Illness
Perception Questionnaire: a new method for assessing
illness perceptions. Psychol Health 1996; 11: 431446.
5 Beck AT. Cognitive Therapy and the Emotional Disorders.
NAL penguin Inc., New York, NY, 1989.
6 Galassi F. Cognitive-behavioural techniques. Clin
Dermatol 1998; 16: 715723.

2013 The International Society of Dermatology