The case for skin camouflage in the management of upper limb scarring – A case series

Abstract

Introduction

For some people the appearance of their hands is as important as function. Upper limb scarring can cause some patients distress. Skin camouflage is an intervention that can be used to reduce the visual impact of a scar but there is limited published evidence for its use for hand scarring.

Methods

This is a case series study with a primary objective to determine whether skin camouflage reduces distress in patients with an upper limb scar and to evaluate this new service. Patients experiencing distress from an upper limb scar were recruited from a hand therapy outpatient clinic. The intervention delivered was a one hour skin camouflage session. Photographs of the upper limb pre and post skin camouflage intervention were taken. The patient-rated Michigan Hand Questionnaire (MHQ) and Derriford Appearance Scale (DAS24) were completed before treatment, at 1 week and 1 month after treatment.

Results

Six participants reporting distress from an upper limb scar received skin camouflage intervention. Only three out of six participants completed all follow-up. All three showed improvement in at least two domains of the MHQ (function and aesthetics) at one month post treatment. Increased confidence during functional and work-based activities was also reported on the DAS24. Participants reported increased engagement in daily activities as a result of being able to camouflage their scars.

Conclusions

This small case series shows that skin camouflage intervention may be beneficial for some patients who are experiencing distress related to an upper limb scar by increasing function and self-confidence.

Introduction

Upper limbs are vital for everyday tasks and hand therapists focus on the restoration of function through increasing range of movement, grip strength and improving sensation. However, for some patients the change in appearance of their hands or upper limb can have an equally debilitating effect as loss of function.

This is unsurprising as hands are one of the most visible parts of the body to others and are involved in everyday interactions including non-verbal communication, intimacy and social integration. While normal appearance of the hand often goes unnoticed, the scarred or deformed hand draws attention. ¹ Qualitative interviews with patients attending specialist scars services reported that the presence of scars reduced social functioning, patients perceived acceptability and emotional wellbeing. ² Being satisfied with one’s appearance is highly individualistic and may depend on occupation, age, sex and culture.^3–5 Therefore, it can be difficult to predict which patients will be affected by appearance related concerns and it may not be those who we expect.

Hand research trials have started to include hand aesthetics as one of the secondary outcomes and patient rated outcome measures, like the Michigan Hand Questionnaire, include questions on appearance. ⁶ However, no trials have focused just on the psychological distress of upper limb scarring despite one of the James Lind Alliance priority research areas being to improve scar outcomes following hand surgery and/or trauma. ⁷

Our tertiary referral centre treats approximately 35,000 children and adults with hand conditions or following major and minor hand trauma covering a population of over 3 million people (mixture of urban and rural communities). We began to identify in conversation during rehabilitation, a small number of patients (estimated to be less than 1%) who from a hand function perspective had returned to or close to pre-injury function levels. However, the presence of a visible scar was a barrier to them regaining social function. In some cases, the original injury was due to either a traumatic event, like a human or animal attack, or an acute episode of deliberate self-harm. The appearance of the scar negatively impacted these patients’ lives and as hand therapists we were unable to offer them an adequate solution.

Scars and disfigurements are often hidden by concealing clothing or gestures ⁸ and commercial or medical tattoos.^9,10 However, these options are not always practical for highly visible areas like the hands and face.

Skin camouflage products are specialist brands of pigmented cream that can be used to cover areas of skin colour abnormality blending with the natural skin colour. Its durability and, if applied correctly, water resistance differs from normal cosmetics. ¹¹ The skin camouflage reduces the visible colour difference of a scar but does not change the scar texture. A recent systematic review concluded that skin camouflage products have been successfully used to improve quality of life in a variety of conditions including scarring following aesthetic surgery or for facial cancers; and dermatological disorders including acne, rosacea and vitiligo. ¹² However, its use in camouflaging upper limb scars has not be reported.

Skin camouflage intervention has been reported to have a therapeutic benefit ¹² but there is no published literature on the role of skin camouflage in covering upper limb scars. Therefore, the aim of this study was to follow 6 patients who underwent skin camouflage intervention using a case series study design. ¹³

Methods

This is a prospective single site case series and the primary objective was to determine whether skin camouflage reduces distress in patients with an upper limb scar and to evaluate this new service.

The intervention was delivered as part of a routine hand therapy outpatients clinic and the assessments were approved by Health and Care Research Wales (HCWR) Research Ethics Committee (Ref: 18/YH/0384).

Participants

The study recruited consecutively eligible participants over a 6 months period from a Hand Therapy Outpatient Clinic at the Pulvertaft Hand Centre. Patients were eligible for inclusion if they were 16 years or older with a visible, healed scar on the hand or upper limb that was causing psychosocial barriers to everyday living. This was determined by a score of 10 or less on the appearance questions of the Michigan Hand Questionnaire. ⁶ Based on therapists’ experience, 10 or less was considered a suitable cut off. Any patients with scars originating from both trauma and elective hand surgery were included. Patients with medical and psychological comorbidities were included providing they lived independently and were able to attend an outpatient appointment. Patients with any scar on the upper limb causing distress were eligible, including those with keloid, hypertrophic or a history of scarring. Prisoners were excluded due to prison protocols limiting access to different products and challenges following up these patients. Patients with an unhealed wound were excluded; all participants were at least 3 months post surgery. Participants had to be able to complete follow up questionnaires in English. Informed consent was obtained from all participants. A sample size of 6 participants was chosen as this was typically the number of patients receiving skin camouflage treatment over 3 months.

Prior to skin camouflage intervention, a medical history relating to the upper limb scar was recorded. To provide an objective measure, the scar was assessed by a hand therapist using the Vancouver Scar Scale. ¹⁴ A photograph of the upper limb scar was taken pre and post skin camouflage intervention. Participants completed two patient rated outcome measures (PROMs): the Michigan Hand Questionnaire (MHQ) ⁶ and Derriford Appearance Scale (DAS24) ¹⁵ before treatment and then by postal questionnaires at 1 week and 1 month after skin camouflage intervention. At 1 week and 1 month follow up, participants were also asked the frequency of skin camouflage products used during the previous week (Likert scale of 5 options ranging from never to all of the time).

Intervention

Patients attended the Pulvertaft Hand Centre for all appointments as outpatients; they received no other hand therapy intervention during these appointments. They were all allocated 1 hour appointments. The skin camouflage session was delivered by a hand therapist with additional training as a qualified British Association of Skin camouflage practitioner (BASC) and no additional appointments were required. During the appointment a daylight lamp was used to mimic normal light. Initially, the therapist used a skin colour matching process to determine the underlying skin tone according to the Fitzpatrick scale. ¹⁶ This narrows the colour range and a variety of colours within this range were tested until a suitable match was found (usually 4 or 5 colours). Each consultation identified the most suitable product and colour acceptable to the participant with the choice of four brands all available on NHS prescription. For larger areas or areas of different pigmentation this may require more than one product. A setting powder is applied to ensure longevity, increase product endurance and prevent rubbing onto clothes. This also allows the wearer to get the area wet e.g. showering and swimming. The final colour match choice is made by the patient from the options suggested and discussed.

Following the colour match the patient was taught how to apply the camouflage, how to manage it during wear, the removal of product and skin care; sun cream and scar treatments such as silicone creams can be worn underneath the skin camouflage crème as long as they are not oil based product. Patients were advised where to obtain the camouflage products; either via prescription from their referrer or General Practitioner (GP) or self-funded. All patients in the case series obtained the skin camouflage products from their GP via a prescription.

Products used were only those currently available on NHS prescription. Pre- and post-intervention photographs were taken. Each patient was provided with a BASC information leaflet on the use of skin camouflage products including application and removal. Participants were also given their personal colour match product details to allow them to self-fund instead of waiting for a prescription.

A standard skin camouflage report briefly describing the appointment and colour match recommended was provided to the GP with research study details and a request to prescribe the products identified. All patients were placed on open appointments, allowing them to return to the department within 6 months if necessary.

Outcome measures

The Vancouver Scar Scale (VSS) is a subjective scar assessment scale. Scars are clinician assessed and scored on vascularity, height, thickness, pliability, and pigmentation. The VSS is scored from 0–13, with a higher score indicating a more severe scar. ¹⁷

The Derriford Appearance Scale 24 (DAS24) is a short version of the Derriford Appearance Scale DAS59. ¹⁵ It measures individual responses to living with problems of appearance. The DAS24 was selected because it has been validated on the general population and patients including those with post-traumatic scarring. It was developed and tested in a UK population and included some upper limb patients. It focuses on three main areas: general self-consciousness of appearance, social self-consciousness of appearance and sexual and bodily self-consciousness of appearance. The DAS24 measures the degree of distress and dysfunction experienced by people and is independent of the location of the feature causing distress or the cause of the problem. The minimum score is 11, and the maximum 96. The higher the score, the greater distress experienced. The minimal important difference has not been determined but the DAS59 has been reported to be highly sensitive as a measure of change during treatment. ¹⁸

The Michigan Hand Questionnaire (MHQ) has been widely used for the last twenty years in a variety of hand trauma and conditions. ¹⁹ The MHQ is a region-specific patient-reported questionnaire, used for the general assessment of all hand conditions. The questionnaire consists of 37 items that can be grouped into six main categories: pain, function, aesthetics, work, daily living and satisfaction. It rates separately the left and right hand and higher scores indicate better hand health. The overall minimal clinically important difference (MCID) for the MHQ is 14.7 points. Normative data for a United States population and MCID for the pain (9.3), function (5.6) and activities of daily living (1.9) domains have also been determined for patients experiencing trauma. ²⁰

Results

Of the 6 patients recruited into the study only 3 completed the study. All participants were female, Caucasian and had upper limb scarring resulting from trauma or surgery. The median age of participants was 34 (IQR 26–48). The patient demographics are summarised in Table 1.

Table 1.

Demographic information for the participants.

Participant	Gender	Age (yrs)	Scar type	Location	VSS
A	Female	39	Post op scar from trauma	Volar aspect wrist	6
B	Female	25	CRPS Steroid injection skin hypopigmentation	1st extensor compartment	5
C	Female	30	Self-harm; burns and cutting	Forearm volar aspect	8
D	Female	51	Zn1 extensor tendon repair	Middle finger	6
E	Female	53	Surgical scar	Shoulder	8
F	Female	22	Surgical scars – multiple surgeries	Dorsal and volar forearm	9

VSS: Vancouver Scar Scale; CRPS: chronic regional pain syndrome.

Table 2.

Michigan Hand Questionnaire (MHQ) and Derriford Appearance Scale (DAS24) scores at baseline, 1 week and 1 month for participants A, B and C.

Participant	A			B			C
MHQ Domain	BL	1 week	1 Month	BL	1 week	1 Month	BL	1 week	1 Month
Function	35	35	60	30	35	50	100	100	100
ADL	50	40	60	65	70	65	100	100	100
Pain	26	34	48	49	49	53	81	86	0
Work	15	25	50	45	35	50	100	65	95
Aesthetics	19	28	38	13	56	63	0	69	100
Satisfaction	8	33	50	33	16	41	100	96	100
DAS24	54	53	30	42	48	40	73	35	20

ADL: activities of daily living.

One participant relocated during the study and missed the final set of questionnaires. One was unable to complete the study as her GP declined to prescribe the skin camouflage treatment. A third participant decided to withdraw from the trial after completing the baseline questionnaires to seek professional mental health treatment for her appearance anxiety.

Before skin camouflage intervention the 6 study participants reported a wide range of scores for the function (median 75; IQR 45–90) and pain (median 55; IQR 32–64) domains of the MHQ, but all scored low on the MHQ aesthetic domain (median 16; IQR 9–23). Prior to treatment, the same study therapist evaluated all of the participant’s scars according to the Vancouver Scar Scale, allowing an independent evaluation of the scar (see Table 1). The median VSS was 7 (IQR 5–8) out of a maximum of 13.

The baseline median DAS24 score was 56 (SD 14) out of a possible 96. The 6 participants all reported that they experienced moderate distress at their reflection, were almost always self-conscious of their appearance and often adopted concealing gestures to hide their scar.

Immediately after the skin camouflage treatment, the 6 participants verbally expressed feeling better about their appearance and enhanced confidence in their visible appearance; several participants commented that their scar no longer felt painful. None of the participants reported any adverse side effects from the skin camouflage treatment. At one month post treatment two participants reported on the usage questionnaire that they wore the skin camouflage products most of the time. The third participant failed to return this questionnaire so their usage remains unknown.

The three participants that completed the study showed improvement in at least two domains of the MHQ at one month post treatment (Table 2).

Participant A showed an improvement at one month in 5 domains of the MHQ. However, she scored higher in the pain domain at one month compared to her baseline. The participant verbally reported she had experienced more pain because she was using her hand more in daily activities. Additionally, her DAS24 score dropped by 44% with improved scores shown in 14 of the 24 questions suggesting that she was not only physically and socially more active but felt more confident whilst doing these tasks in front of others.

Participant B improved in 3 MHQ domains (function, aesthetics and satisfaction) at one month and verbally reported using her hand more. Interestingly, despite having a diagnosis of chronic regional pain syndrome (CRPS), this increased use and function did not correspond with an increase in the MHQ pain domain. The DAS24 scores for this participant remained very similar throughout the study.

Participant C had clinically normal hand function, scoring 100 on the MHQ function, throughout the study. However, she reported high levels of pain and the worst possible score for the aesthetics domain at baseline. She was extremely self-conscious of her scars and was the participant who scored the highest at baseline on the DAS24. However, having the ability to camouflage her scars had a dramatic effect and she improved to 69 points at one week and then 100 at one month on the MHQ aesthetics domain. Her DAS24 score also decreased to 20 and she reported substantially reduced pain at one month.

Discussion

The aesthetics of the upper limb is often considered secondary to the restoration of function. However, for some patients distress at the visual appearance can be as debilitation as the loss of function

In this small case series the three participants who completed follow-up had improved MHQ scores in at least 2 domains at one month and increased confidence in their appearance during functional and work based activities according to their DAS24 scores. Although, a small exploratory study, this work is supported by the major findings of a systematic review into improved quality of life after skin camouflage treatment. ¹² The 6 randomised controlled trials (RCT) included in the review report significant improvements in participants’ quality of life and psychosocial health outcomes after the use of camouflage. These RCTs have focused primarily on facial aesthetics from scarring, burns and cancer surgery. Like this study, the majority of the participants were female, although two of the RCTs included children.

All of the 6 participants recruited into this study were female. This was unsurprising as although both sexes report disfigurement as being a stressful experience, women experience a greater impact on their quality of life. ²¹ Of 18 papers included in a systematic review of skin camouflage outcomes, the majority either only included females or had a higher majority of female participants. ¹² In addition, all participants were Caucasian. This is the pre-dominant ethnicity of the population treated at the centre so is not surprising. One limitation of this study is that participants of different ethnicities were not recruited and therefore it is difficult to extrapolate these finding to other ethnicities that may view appearance differently according to their culture. However, since establishing the service, males and people of different ethnicities have been treated using skin camouflage. Any future work must consider recruiting patients of different ethnicities.

This study only followed up participants to one month post treatment. It is unknown if participants continued to use the products after this time and whether their improved scores remained. It is important that future studies consider extending the follow up period to address this.

None of the participants reported any negative side effects from the skin camouflage treatment. The participants who withdrew from the study reported being satisfied with the skin camouflage appointment and the products they had been prescribed. Taking part in the research study changed one participant’s awareness of her appearance related concerns and she decided to drop out of the study to focus on seeking mental health support. The negative impact of mental health on hand injury recovery and rehabilitation is well known ²² so it is unsurprising that some patients will need extra mental health support alongside skin camouflage treatment. In addition, one participant had to withdraw from the study because their GP was unable to prescribe the camouflage make up as not all Clinical Commissioning Groups fund skin camouflage products for areas other than the face. Before initiating skin camouflage treatment, patients should consult with their GP to ascertain whether the CCG will fund their skin camouflage product prescription. Future studies into the use and effectiveness of skin camouflage should consider how participants will obtain their products and have a pathway to manage mental health concerns raised during any trials, for example liaising with participants GP.

The limitations of this study are the small sample size and also the high loss to follow up. It is also unknown whether the improved appearance scores and behaviours were due to the skin camouflage products themselves or the therapeutic benefit of discussing appearance concerns with a hand therapist. The potential for bias was reduced by the participants completing their follow up questionnaires by post rather than face to face with a researcher. However, without a non-treatment comparator group, bias cannot be excluded. Further research ideally a randomised controlled trial containing a non-treatment/placebo arm, needs to be carried out.

Despite its limitations, this work demonstrates that future research into the area of upper limb aesthetics is warranted. Some audit work is required to identify the number and extent of the problem and to establish the feasibility of a larger trial. The MHQ and DAS24 were able to detect therapeutic changes but any future work should consider adding a global measure of change. Immediately, post camouflage treatment, participants verbally reported their scar feeling less painful. This was an unexpected finding, and any future studies should consider assessing pain pre-, immediately post treatment and at follow up using a specific pain questionnaire. Patient and Public Involvement (PPI) would be valuable in informing any future study design and provide insights into study barriers. A RCT with a waiting list control group would be ideal but currently it is unknown how feasible this would be. Qualitative research alongside a RCT to understand the impact of scarring and how participants feel about the skin camouflage treatment would be valuable. Also it would be important to include males and different ethnicities in this work.

One barrier to future multi-centre research is the number of hand therapists trained to deliver skin camouflage treatment and whether funding is available to make this a scalable intervention. In addition, Clinical Commissioning Groups currently fund only limited treatments for aesthetic concerns.

Conclusions

This small case series shows that skin camouflage intervention appears to be beneficial for some patients who are experiencing distress related to an upper limb scar by increasing function and self-confidence. The patients’ perception on the aesthetics of the hand post injury should be considered alongside the need to restore function. More research is required to better understand the patient population suitable for this intervention and several feasibility questions need to be answered before a larger trial is conducted.