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Neil H. Shear, MD Lee Graff

Camouflage Cosmetics in Dermatologic Therapy

SUMMARY
Psychological well-being is based on multiple factors, one of which is satisfaction with physical appearance. The use of cosmetics is helpful for many women, as has been shown in psychological studies and implied by market sales. People with obvious cutaneous defects (e.g., port-wine stains, pigmentary disorders) may suffer a range of distress reactions, induding diminished self-esteem. Specially designed camouflage cosmetics are an ideal adjunct to other therapies for successful treatment of such skin conditions. New products are appealing because they are readily available, safe, and inexpensive. To enjoy optimum use of these products, patients should be assessed and advised in a professional setting. The results are extremely gratifying for both patients and physicians. (Can Fam Physician 1987; 33:2343-2346.)
Key words: dermatology, cosmetics, camouflage
Dr. Shear is an assistant professor of Medicine and Pediatrics at the University of Toronto and a practising dermatologist at Sunnybrook Medical Centre. He is also the Director of the CosMedic Clinic at Sunnybrook Hospital. Mrs. Graff is the cosmetician at the CosMedic clinic. Requests for reprints to: Dr. N.H. Shear, CosMedic Clinic, Sunnybrook Medical Centre A-3, 2075 Bayview Avenue, Toronto, Ont. M4N 3M5

RESUME
Le bien-etre psychologique est fonction de facteurs multiples dont la satisfaction de son apparence physique. L'usage de produits de beaute est utile a bien des femmes, comme le demontrent les etudes psychologiques et tel qu'en temoignent les ventes au detail. Les personnes atteintes de defauts cutanes evidents (e.g. taches de vin, desordres pigmentaires) peuvent souffrir de nombreux desagrements, incluant la perte de l'estime de soi. Les cosmetiques conqus specialement pour dissimuler les imperfections sont un complement ideal aux autres therapies permettant de traiter avec succes de telles affections cutanees. Les nouveaux produits sont attirants parce que facilement accessibles, inoffensifs et peu cou'teux. Une evaluation et des conseils professionnels permettront aux patients de retirer le maximum de ces produits. Les resultats sont extremement gratifiants tant pour les patients que pour les medecins.

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HE RANGE AND QUALITY of camouflage or masking cosmetics have advanced tremendously over the past three years. The positive effect of specialized make-up has been widely appreciated by individual patients and cosmeticians since Lydia O'Leary inCAN. FAM. PHYSICIAN Vol. 33: OCTOBER 1987

troduced Covermark in the 1930s. She created this product to conceal her own port-wine stain and found that it changed her life. Doors opened that were previously closed to her. She regained her confidence, got a job, and ultimately started her own company. Despite this enthusiasm, early camouflage products were under-utilized because of limited availability and their thick heavy consistency. The recent development of elegant cover-ups has resulted in increased appeal. Newer products have features such as sun protection, water resistance, noncomedogenicity, easy application, and wide colour selection, making them a powerful adjunct to dermatologic therapy. When Derm'age products became available in Canada in 1985, we started a special hospital-based clinic to assess the usefulness of camouflage
cosmetics.

Appearance and Health

Psychological well-being depends
on multiple factors, one of which may be satisfaction with physical appearance. Physical attractiveness effects the way that others perceive us. In one study observers perceived people who

had had professional make-up applications as more attractive, tidy, mature, sociable, confident, poised, organized, and willing to make an effort.' Moreover, the more attractive you are, the more highly you think of yourself.1 Cosmetics have been shown to improve self esteem in adults,1 including the elderly.2 Children and adolescents have not been studied, although a recent survey of health concerns of teenagers found that their number-one "health" concern was a cosmetic problem: acne (47% of respondents).3 Patients with skin disease may also exhibit psychological impairment.4 5 We
2343

have seen patients whose skin problems resulted not only in a diminished self-image but also in impaired socialization, fixation, anger, and depression. Other patients are able to lead full, happy lives despite skin blemishes, but admit that when the offending skin is covered, they feel tremendously relieved and renew-ed. Several patients expressed the sentiment that successful camouflage resulted in a new beginning to their life. The psychological impact of skin conditions such as vitiligo, rosacea, acne, and melasma is well appreciated.4-7 Moreover, several authors hold that many of these conditions can be exacerbated by psychologic stress.6 For some patients, this would suggest that camouflage therapy which decreases the stress of poor self-image might improve the skin condition. Many people have misconceptions about persons who wear cosmetics. Stories from antiquity have suggested the use of cosmetics is associated with vanity, and that vain people should be punished. According to one story8 a girl called Miriam (circa 70 A.D.) asked her father for an excessive allowance to purchase cosmetics. Consequently, her life ended in ruin, and she was forced to forage in animal waste for food.8 More recent assessments have attempted to profile cosmetic psychology.9 Women felt greater self-confidence and were more sociable when using their regular cosmetics. Women who were dissatisfied with their physical appearance or who were self-conscious were more prone to use cosmetics. Subjects who used make-up more frequently were assessed as believing less in serendipity than in ability or efforts as factors in success. In other words, make-up was a means to an end. In fact, most of the patients referred to us are seeking help for a simple but troublesome problem and are sensitive, understanding people. Cover-up make-ups are now highly acceptable to patients, but there is a problem with access. How can we be confident that patients will be directed to the right product? A physician who recommends this therapy usually asks the patients to find a specific pharmacy and seek their own treatment.

pared with drug-store counters or beauty salons. A hospital-based clinic provides both accessibility for patients and their referring physicians, and privacy for the patients. The latter factor has proven to be critical for men, children, patients with problems away
from the face or forearms, and those who are seriously troubled by their skin condition. The clinic environment also allows us to use as many products as we can so that patients have the widest selection. The patient is assessed in the clinic by a dermatologist (N.H.S.) and cosmetician (L.G.) using a four-step approach. This approach is discussed in detail below.

viously misdiagnosed. For example the misdiagnosis of a sclerosing basal cell carcinoma as a scar or tinea versicolor as vitiligo would greatly effect the choice of therapy. The role of the dermatologist is to make an accurate diagnosis. The most common diagnoses seen at the clinic are listed in Table 1.

oma. Even though all of our patients are referred, several have been pre-

Choice of Therapy The various modalities of cosmetic therapy are outlined in Table 2. Often combinations of therapy can give the best results. The choice depends on multiple factors such as the diagnosis, the availability, safety, and cost of Diagnosis therapy, and the patient's preferences. Our greatest fear is that a patient Cosmetics are reasonably cheap, might go to a drug store and buy a though they are not covered by provinproduct to cover a malignant melan- cial health plans and only by one insur-

Figure 1 Port-Wine Stain

Hospital-based Therapy
hospital- or office-based clinic as com- make-up.
2344

There are several advantages to a A 13-year-old with a port-wine stain, before application of camouflage
CAN. FAM. PHYSICIAN Vol. 33: OCTOBER 1987

ance company. They provide non- comedogenic products are necessary traumatic treatment and are easily for acne-prone skin), and water resisreversible. Camouflage products are tance (for exposed areas, heavy perwidely available at pharmacies and spirers). No single product has all of some department stores. these features, and so the choice must be matched to the most important indiChoice of Cosmetic vidual needs. The cover-ups which we If it is agreed that a camouflage cos- have found to be most helpful are metic is an appropriate therapeutic Derm'age, Dermablend Leg Cover, choice, we need to choose the most ap- and Covermark Leg Magic. These propriate product. Our primary objec- products are easy to apply, come in a tive is to find a single product that will wide range of shades, and despite the cover the defect and match the normal name, can be used anywhere on the skin colour. The mixing of colours body. For reference we have listed the makes the procedure more complex for Canadian distributors in Table 3. the patient. Ancillary make-up (lipstick, blush, eye-liner) is used only Patient Education when appropriate for the patient. We After experimenting and choosing aim to interfere as little as possible the cosmetic, the cosmetician teaches with a person's normal routine. Other the patient about application. This is a concerns are the sun-protection factor relatively simple procedure. The (for vitiligo or photosensitive condi- make-up is applied, allowed to set for tions), the comedogenicity (non- a moment, and then a setting powder

(e.g., talc) is applied. Patients are given a list of stores that carry the specific product they need. Results
Over 90% of the 200 patients seen in our clinic have found camouflage cosmetics helpful, and there have been
Table 1 Conditions Seen for Cosmetic

Cover-Up * Pigmentary Disorders hyperpigmentation-melasma

-racial

-post-

-nevoid

inflammatory

vitiligo
* Vascular

port-wine lesions telangiectasia -idiopathic

-steroid-induced
-acne rosacea

vericose veins

Figure 2 Camouflage of a Port-Wine Stain

Kaposi's sarcoma * Scarring

acne-related traumatic

surgical
Table 2 Alternative Cosmetic Therapies 1. Topical - cosmetic
- prosthetic - chemexfoliation 2. Medical - injections-collagen,

corticosteroid
- bleaches

(hydroquinones)
3. Surgical -scar revision - dermabrasion - laser
- epilation

Table 3 Canadian Distributors of Camouflage Cosmetics Dermablend Corrective Cosmetics P.O. Box 202 Postal Station "U" Toronto, Ontario M8Z 1 PO 6600 Trans Canada Highway, Suite #750 Point-Claire, Quebec H9R 4S2 Covermark 125 Norfinch Drive Downsview, Ontairo M3N 1W8
2345

Derm'age

Colour separations sponsored by Derm'age/Dormer Laboratories Inc.

CAN. FAM. PHYSICIAN Vol. 33: OCTOBER 1987

4 PRESCRIBING INFORMATION >

ANUSOL*-HC ointment/suppositories hemorrhoidal preparations

INDICATIONS: For the relief of the pain and discomfort following anorectal surgery of all types and that which is associated with the acute phase of common anorectal disorders. These include hemorrhoids, internal and external (including those accompanying pregnancy) whether or not complicated by thrombosis and prolapse; pruritis ani; proctitis, cryptitis, fissures and incomplete fistulas; and other congestive allergic or inflammatory conditions. CONTRAINDICATIONS: Should not be used in patients with a sensitivity to any of the components. Not to be used in the presence of existing tuberculous, fungal and viral lesions of the skin. PRECAUTIONS: Until an adequate proctologic examination is complete and a diagnosis made, any preparation containing hydrocortisone should not be used. In addition, specific measures against infection, allergy and other causal factors must not be neglected. Prolonged use could produce systemic corticosteroid effects, although none have been noted to date. As with all medication that is applied locally, if idiosyncratic reactions occur, medication should be discontinued. The safe use of topical corticosteroids during pregnancy has not been fully established. Therefore, during pregnancy, they should not be used unnecessarily on extended areas, in large amounts, or for prolonged periods of time. ADVERSE EFFECTS: Occasionally patients may experience burning upon application, especially if the anoderm is not intact. Local sensitivity reactions have been rare. OVERDOSE: The chances of overdosage are very rare, and no toxic reactions or side-effects have been reported. In case of accidental ingestion, perform gastric lavage followed by a purgative dose of magnesium sulfate. DOSAGE: OINTMENTS: Administer in the morning and again at bedtime, and after each bowel movement. Continue this treatment until the acute phase of pain and discomfort passes and the inflammation subsides. SUPPOSITORIES: Insert 1 suppository in the morning and 1 suppository at bedtime and after each bowel movement. Continue this treatment until the acute phase of pain and discomfort passes and the inflammation subsides. SUPPLIED: Ointment: Available in 15 g and 30 g tubes with a plastic applicator. Suppositories: Available in boxes of 12 and 24 suppositories. Suppositories Ointment INGREDIENTS: Zinc Sulfate 0.5% 10 mg Monohydratet Hydrocortisone 0.5% 10 mg Acetate TUCKS*
A soothing, cooling, medicated wet dressing and cleansing wipe for hemorrhoids,feminine hygiene and personal itching problems. Soft wipes medicated with Hamamelis water 50%, glycerin 10%, distilled water, q.s. DIRECTIONS: Gently wipe and cleanse affected area. For additional relief, apply Tucks for 15-30 minutes, 3 to 4 times daily. SUPPLIED: Available in jars of 50 wipes.

some dramatic success stories. Three examples are representative. * One 35-year-old woman had a lcm-diameter nevus on her upper lip. When she talked, it was hard not to stare at the mole. It was the size, colour, and shape of a roach. A plastic surgeon considered that excision could leave an unacceptable scar. A simple application of make-up made the lesion disappear. "This, she told us, is application of make-up made the lesion disappear. "This", she told us, "is the beginning of a whole new life. " * A 37-year-old man had severe herpes zoster of the ophthalmic branch of the trigeminal nerve with corneal involvement. When the infection subsided, he was left with dramatic red and purple scars on the skin. We were happy that his sight was unaffected and that the infection was gone, but he refused to go back to work because of the obvious disfigurement. Camouflage cosmetics gave him the confidence to return to a normal life. * A 13-year-old girl had a port-wine stain (nevus flammeus) (Figure 1). At this stage in her life she felt keenly aware of her birthmark. The results of camouflage make-up are shown in Figure 2.

conditions. This therapy can have great impact on the life of a patient, but it should be delivered in a professional environment. If a medical setting is not feasible, a knowledgeable, caring esthetician can be a tremendous help.

Acknowledgements
We would like to thank Mrs. Cheryl Coles for preparing the manuscript. Dr. Shear is supported by a career scientist award of the Ontario Ministry of Health. The results and conclusions are those of the authors, and no official endorsement by the Ministry is intended or should be inferred.

References
1. Graham JA, Jouhar AJ. The importance of cosmetics in the psychology of appearance. Int J Dermatol 1983; 22:153-6. 2. Kligman AM, Graham JA. The psychology of appearance in the elderly. Dermatol Clinics 1986; 4:501-7. 3. Feldman W, Hodgson C, Corber S, et al. Health concerns and health-related behaviours of adolescents. Can Med Assoc J

Conclusions
The majority of people seen in the clinic have not been vain; rather, they have been very normal people who are impaired by the manner in which others react to their visible difference. We have found these patients tremendously gratified that some therapy was available and that their differences could disappear. It is possible that part of the effect of cosmetics is placebo5 and may eventually decrease. However, in a follow-up study that we conducted, we found that more than half of our patients are still using camouflage make-up regularly, more than three months after the initial assessment. Camouflage make-up is a critical adjunct to the cosmetic therapy of skin

1986; 134:489-93. 4. Porter JR, Beuf AH, Lerner A, et al. Psychosocial effect of vitiligo: a comparison of vitiligo patients with "normal" control subjects, with psoriasis patients, and with patients with other pigmentary disorders. J Am Acad Dermatol 1986; 15:220-4. 5. Melli C, Giorgini S. Aesthetics in psychosomatic dermatology. I Cosmetics, self-image, attractiveness. Clinics Dermatol 1984; 2:180-7. 6. Panconesi E, Cossidente A, Giorgini S, et al. A psychosomatic approach to dermatologic cosmetology. Int J Dermatol 1983; 22:449- 54. 7. Giorgini S, Melli C. Aesthetics in psychosomatic dermatology. II Skin changes experienced as cutaneous disease. Clinics Dermatol 1984; 2:188-200. 8. Benedict L. Cosmetics. In: Landman I, ed. Universal Jewish Encyclopedia. New York: 1941; 3:371. 9. Cash TF, Rissi J, Chapman R. Not just another pretty face: sex roles, focus of control, and cosmetics use. Personality Soc Psychol Bull 1985; 11:246-57.

ANUSOL*-HC

*Reg. TM. of Warner-Lambert Canada Inc. Parke-Davis Canada Inc. auth. user TUCKS* *Reg. TM. of Parke, Davis & Company, Parke, Davis & Company, Ltd. Registered user
Colour photographs courtesy of Derm'age/Dormer Laboratories Inc.

Product Monograph available upon request.

___~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~-------------. .

PARKE-DAVIS .Scarborough. Ontario Parke-Davis

Canada Inc

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