Dr. Faramarz DidarCosmetic Facial Uk Limitedwww.cosmeticfacial.co.ukinfo@cosmeticfacial.co.uk

22 years old female History of acne from 11 years to 18 years of age. Active Acne settled after using tepal of lily in Russian Vodka. She had been on topical

treatments as well as systemic antibiotic and COC prior to this traditional Russian herbal medicine.

Patient version of acne as severe and aggressive. She often slept with a towel on her pillow as my spots bled during the night.

Admitted spending lots of time researching acne treatment as well as makeup. She still does this as she has never been happy with her skin.

The first foundation she ever used made her skin ten times worse than better. Her family spent a lot of money on skincare products and treatments to try to help her.  Scrubbing and washing aggressively on daily basis. She still does. Doctors’ treatments did not help and instead made her skin dry,red and uncomfortable. There was history of picking on acne lesions as well as squeezing them. She never

admitted this despite many confrontation from her mother. Admitted her relationship with others were affected and still is. This hindered her education (in a minor way) as she stayed quiet and didn’t have as much

participation with other pupils. Social isolation in past as well as present as often felt/feels that people judged her or did

not like her. Today, despite not having acne for years she has scars which she find unattractive and

cover up with makeup daily.

Having aggressive acne throughout my teenage years (11-18) impacted me in many ways, both mentally and socially, and has also impacted me in later life.

it made her more aware of herself and her appearance. This resulted in lowered confidence. She thought acne comes from dirt and dirty hands. This belief mostly influenced her by her Grandmother.

She also felt embarrassed when having to look at people or them look at her as she felt she would be judged by her acne (that she didn’t stay clean etc, even thought that was not the case).

She became ashamed of the way she looked. This resulted in her staying at home and avoiding, having to put lots of makeup on (which is a lot of effort- particularly when just popping to the shops). She still put lots of make up on.

She has not ever been fully happy with her skin. She did not/does not feel attractive or comfortable in her own skin. She wished she was someone else.

She is still scrubbing and washing her face to stay clean.Assessment tools Dermatology Life quality index(DLQI) 15 Hospital Anxiety and Depression Scale(HADS) depression: 8 anxiety: 14 Skindex-29 psychosocial functioning 52 The Cardiff Acne Disability Index 6/15 The Acceptance and Action Questionnaire (AAQ-2) 43/70 The Acceptance and Action Questionnaire – Revised (AAQ-R) 79/136 Avoidance and Fusion Questionnaire for youth(AFQ-Y) 51/68Summarise issues possible Acne excoriee in past

Obsessive compulsive disorder in present

Body Dysmorphic Disoredr : BDS

Moderate anxiety

BCT as first line of treatment/approach. This approach failed as patient was unwilling to participate in ERP(exposure and response prevention).

ACT (Acceptance and Commitment Therapy) as alternative therapy to CBT.

Pharmacologic approach: SSRI(Paroxetine 20mg initially each morning increased gradually in steps of 10mg up to 40mg daily)

CBT resulted in higher quality of life, whereas ACT resulted in greater psychological flexibility, and, among those who completed treatment((Arch & Craske, 2008)

Jeanne Jung, MD, MS, and Eun Ju Hwang, MD, MS(2012), Do patients with acne need cognitive behavioral therapy? Emphasised on CBT as main approach in treatment of psychological aspect of acne.

Volker Niemier(2006): acne vulgaris psychosomatic aspects: Doctor +patient relationship is very important.

ACT is part of a larger movement in the behavioral and cognitive therapies toward the use of mindfulness and acceptance (Hayes, Follette, & Linehan, 2004),

ACT is a highly viable treatment alternative to CBT, Joanna J. Arch et al 2012 Volker Niemier(2006): Differential Diagnosis from psychosomatic point of

view in psychogenic excorietion: these patients have comorbid disorders like(OCD,BDD, eating disorder, borderline personality disorders) , recommended treatment is combination therapy like medical(SSRI) and CBT or alternative ACT.

study type CBT orACT

Method Opinion

Jeanne Jung et al 2012

questionnaire

CBT 136 patients with acne at Klaripa Clinic in Seoul , questions varied from etiology to their habits

Cognitive and behavioral therapy can be combined with the treatment of acne.

Arch & Craske, 2008

systemic review of RTC and other studies

Combine treatment

They reviewed RCT and systemic reviews studies in a certain period of time.

This article presents a critical examination of stereotypical differences between ACT and CBT for anxiety disorders. The general conclusion is that the treatments are more similar than distinct.

Stefan G. Hofmann 2008

Reviewing Arch& craske review

Combination therapy

Acceptance and Commitment Therapy: NewWave or Morita Therapy?

Some proponents of ACT view it as part of athird wave movement destined to replace cognitive behavioral therapy (CBT) as the dominant form of psychological therapy. This perception is problematic,because the criticism offered by ACT against CBT is based on a misrepresentation of the empirical evidence.

Francisco J. Ruiz

systemic review of RTC and other studies

ACT efficacy of ACT in a wide range of psychological problems and suggest that it is working through its hypothesized processes of change

component studies are showing thatacceptance-based protocols are usually more efficacious than other control-based protocols

Hofmann & Asmundson, 2008)

systemic review of RTC

Combination therapy

ACT has a sound model of psychopathology in EAD or psychological inflexibility

Significant improvement in patient psychological well being after 6month sessions of psychological intervention. This was in combination with micro-needling of facial skin in order to reduce scars of acne.◦ She was more social, less ashamed of her skin.◦ She was not scrubbing the face any more but still using make up.◦ She was more capable of handling anxiety situation by accepting them as part of her life.◦ She was living more in present than in past or future.◦ Her self-esteem improved.◦ She was Allowing thoughts to come and go without struggling with them.1. I put into practice the new theoretical knowledge of ACT in combination with CBT approach. 2. This one was a new task for me to approch a young patient who was initially reluctant to accept any

psychiatric intervention or assistant.Psychological assessment score before

Psychological assessment 6 months after

Dermatology Life quality index(DLQI) 15 Dermatology Life quality index(DLQI) 7

(HADS) depression: 8 anxiety: 14 (HADS) depression: 6anxiety: 7

Skindex-29 psychosocial functioning 52 Skindex-29 25

The Acceptance and Action Questionnaire 43/70 The Acceptance and Action Questionnaire 12/70

Avoidance and Fusion Questionnaire for youth(AFQ-Y) 51/68

Avoidance and Fusion Questionnaire for youth(AFQ-Y) 22/68

skin-picking and Acne psychological impact may, in certain cases, amount to a mental disorder. Effective communication skills are needed to explore this area.

Good assessment of patients’ history and personality traits are essential in initial assessment of chronic skin disorder.

selective serotonin reuptake inhibitors (SSRIs) may be useful in treating pathological skin-picking but psychological interventions are proven to be mandatory. Cognitive and behavioral therapy can be combined with the treatment of acne.

If CBT approach fails, ACT can be used as alternative treatment/approach studies should be conducted that combine ACT and CBT techniques in order to improve the efficacy of existing treatment protocols for specific disorders.

Health care professionals specially dermatologists and GPs should be aware of psychological impacts of chronic skin condition and address them

Perhaps the subspecialty of psycho-dermatology needs to be launch quickly.