Abstract
Introduction/Objective:
Visible differences from medical conditions and injuries are associated with body image concerns, particularly among females and young adults. We compared dissatisfaction with appearance and social discomfort between people with systemic sclerosis and burn injury, since the extent and implications of appearance changes are well-established in burn injury.
Methods:
We searched PubMed, PsycInfo, EMBASE, and CINAHL to 8 December 2024 for studies that used the Satisfaction with Appearance Scale among adults with burn injury or systemic sclerosis. We emailed study authors and requested Satisfaction with Appearance Scale Dissatisfaction with Appearance and Social Discomfort subscale means and standard deviations for subgroups defined by sex (female, male) and age (18–44 years, 45–64 years, ⩾ 65 years). For each subgroup, we conducted a random-effects meta-analysis to estimate the difference between mean scores for people with burn injury and systemic sclerosis.
Results:
We identified 17 eligible studies from nine unique cohorts. We obtained subgroup results from two of three eligible burn cohorts (2658 participants, 98% of total eligible) and five of six eligible systemic sclerosis cohorts (3402 participants, 99% of total eligible participants). Dissatisfaction with Appearance subscale scores were higher among people with systemic sclerosis compared to burn injury by 2.2 to 5.7 points (standardized mean difference = 0.20 to 0.53) for females and males across all age groups (p < 0.05 for males aged 18–44 and 45–64 years). For social discomfort, differences were close to zero (standardized mean difference < 0.10) for females aged 18–44 and 45–64 years. For females aged ⩾ 65 years and all male age groups, scores were higher in systemic sclerosis than burn injury (standardized mean difference = 0.22 to 0.45), although none were statistically significant.
Conclusion:
Dissatisfaction with appearance and social discomfort appear to be similar or greater among people with systemic sclerosis compared to people who have been hospitalized with a burn injury.
Keywords: Body image, burn injury, dissatisfaction with appearance, social discomfort, systemic sclerosis, visible differences
Introduction
Visible differences due to medical conditions and injuries are associated with poor body image esteem and diminished mental health.1–4 Across populations, greater extent, severity, and visibility of appearance changes are associated with more negative psychological outcomes.5–11 Among adults with visible differences from illness or injury and in the general population, female sex and younger age are also associated with greater appearance-related concerns.12–15
Scleroderma (SSc, systemic sclerosis) is a chronic autoimmune disease involving microvascular damage and fibrosis of the skin and other organs, including the lungs, gastrointestinal tract, kidneys, and heart.16,17 Many people with SSc experience visible appearance changes, including skin discoloration and tightening, particularly around the mouth area; changes to facial features; telangiectasias; sclerodactyly; and discoloration in the hands due to Raynaud’s phenomenon.18,19 Similar to other conditions, body image dissatisfaction and the negative social impact of visible appearance changes are most prominent among females and younger adults.5,20
Body image concerns, however, are less studied in SSc compared to other disfiguring conditions, such as burn injury, where there is more extensive evidence on the extent and implications of visible appearance changes.1,4,8 The 14-item Satisfaction with Appearance (SWAP) Scale, 21 which generates separate scores for Dissatisfaction with Appearance and Social Discomfort subscales, is commonly used in studies of adults with SSc and burn injury.22,23 Our objective was to compare SWAP Dissatisfaction with Appearance and Social Discomfort subscale scores between people with burn injury and SSc, accounting for differences in sex and age.
Methods
We used a systematic search to identify studies that used the SWAP in burn injury or SSc and contacted authors to request Dissatisfaction with Appearance and Social Discomfort subscale means and standard deviations for subgroups delineated by sex and age.
Identification of eligible studies, search strategy, study selection, and data acquisition
We sought studies on adults with burn injury or SSc that published SWAP scores and could potentially provide SWAP Dissatisfaction with Appearance and Social Discomfort subscale mean scores and standard deviations for subgroups defined by sex (female, male) and age (18–44 years, 45–64 years, 65 years or older). 24 Thus, we searched for studies that published results among adults with burn injury or SSc with any version of the SWAP (full 14-item version, 21 6-item Brief-SWAP, 25 15-item Adapted SWAP) 26 so that we could request data. We included only studies from North America or Europe to enhance comparability across studies since most data in burn injury and SSc have been collected in North American and Europe. We excluded studies of mental health interventions related to body image and studies of people receiving specialized services, such as burn reconstruction, as these typically select participants with pre-existing body image concerns. We excluded case studies and conference abstracts for which no full-text publications were available.
We searched the PubMed, APA PsycInfo (Ovid), EMBASE (Ovid), and CINAHL (EBSCOhost) databases for relevant articles since the inception of each database using the term “Satisfaction with Appearance Scale.” We conducted an initial search and an additional search prior to finalizing results to ensure that no eligible studies had been published since the initial search. Search results were uploaded into the systematic review software DistillerSR (Evidence Partners, Ottawa, Canada), where duplicate references were identified and removed. Two independent investigators reviewed titles and abstracts for eligibility. If either reviewer decided that a study was potentially eligible, it underwent full-text review, where it was independently assessed for eligibility by two reviewers. Any discrepancy at the full-text level was resolved through consensus, and a third investigator was consulted if needed.
We contacted corresponding authors of studies with SWAP data to request Dissatisfaction with Appearance and Social Discomfort subscale mean scores and standard deviations for our pre-defined sex- (female, male) and age-based (18–44 years, 45–64 years, ⩾ 65 years) subgroups. Each author was contacted three times, with a minimum 1 week between each attempted contact. If the author did not respond, we attempted to contact co-authors. When there were multiple publications from the same cohort, we prioritized data from the largest sample. If authors with ongoing studies had accumulated larger datasets than those included in their publications, we used results from the updated, larger dataset that they provided. For studies with SWAP scores at multiple time points, we included only the earliest time point.
Satisfaction with appearance scale
The 14-item SWAP was originally designed to measure non-weight-related body image concerns among individuals with burn injuries. 21 Items pertain to dissatisfaction with the appearance of particular body parts (Dissatisfaction with Appearance subscale) and social discomfort relative to disfigurement (Social Discomfort subscale). Respondents rate the degree to which they feel each item reflects their thoughts and feelings about their appearance on a 7-point scale ranging from 1 (strongly disagree) to 7 (strongly agree). Item scores are summed to calculate total subscale scores, reverse-scoring items pertaining to satisfaction with appearance. Total subscale scores range from 8 to 56 on the Dissatisfaction with Appearance subscale (eight items) and 6 to 42 on the Social Discomfort (six items) subscale. Higher scores indicate greater Social Discomfort and Dissatisfaction with Appearance. 21 The original SWAP was adapted for SSc by replacing the word “burn” with the word “scleroderma,” as indicated, 26 and has been shown to have good reliability and validity in SSc.22,25,27
Data extraction
For each included study, one reviewer extracted data from articles using a pre-specified standardized form, and a second reviewer validated the extracted data using the DistillerSR Quality Control function. Any discrepancies were resolved by consensus between the two reviewers, involving a third reviewer if necessary. For each included study, we extracted first author last name, publication year, journal, country, dates of data collection, study design, eligibility criteria, sample size, proportion of females, time since burn injury or SSc onset or diagnosis, and burn injury severity or SSc disease subtype (diffuse, limited, sine).
Statistical analysis
For each subgroup by sex and age, we conducted a random-effects meta-analysis of means to determine the pooled mean SWAP scores for burn injury or SSc and to estimate the difference between mean scores for people with burn injury or SSc. To do this, we used the meta-mean command within R’s meta-package, which uses an inverse-variance meta-analysis to pool the data. To assess heterogeneity, we calculated I2. We generated forest plots of mean SWAP subscale scores and associated 95% confidence intervals for all burn injury and SSc studies and for the difference. The forest plot was created using the ggplot2 package in R (R version 3.6.3, RStudio Version 1.2.5042).
We referred to commonly used, rough guidelines for interpreting the magnitude of score differences between burn injury and SSc: standardized mean difference (SMD) = 0.20 is small, 0.50 is medium, and 0.80 is large. 28
Results
Search results
We conducted initial database searches on 10 March 2024 and our final search on 8 December 2024. We identified 243 unique titles and abstracts. Of these, 168 were excluded after title and abstract review, and 58 after full-text review, leaving 17 eligible studies with data from nine unique cohorts. Investigators with data from seven cohorts provided data.22,23,26,27,29–31 We were not able to obtain data from one study on patients with burn injury from Sweden (N = 52) 32 and one study on people with SSc from Italy (N = 40). 33 Among the seven cohorts that provided data, two23,29 provided data for 2658 participants with a burn injury (98% of total eligible participants), and five22,26,27,30,31 provided data for 3402 participants with SSc (99% of total eligible participants). See Figure 1.
Figure 1.
Flow diagram.
Characteristics of included studies
As shown in Table 1, the two published studies of burn injury cohorts that provided data included patients with severe burns from five sites in the United States 23 and admitted patients from six sites in Belgium and the Netherlands. 29 Mean ages in the two studies were 43 years (standard deviation (SD) = 15 years) and 45 (16) years, and the percentages of females were 27% and 29%. Mean (SD) total body surface area burned was 20% (16%) for participants from the United States and 10% (12%) for participants from Belgium and the Netherlands. Most participant data were from the five sites in the United States (2455 of 2658, 92%).
Table 1.
Descriptions and characteristics of published studies from which data were obtained.
| First author Year | Country(ies) | Participants | N Participants a | N (%) Female a | Participant Mean (SD) Age in Years a | Index event and time since burn injury or systemic sclerosis onset | Severity a |
|---|---|---|---|---|---|---|---|
| Burn injury | |||||||
| Espinoza 23 2020 | United States | Adults admitted to 5 Model Burn Systems centers who met criteria for a severely burned person b | 1285 | 353 (27%) | 43 (15) | 6 months post-injury | Mean (SD) TBSA burn: 20% (16%) |
| Willemse 29 2023 | Belgium Netherlands |
Adults with burn injury admitted to 6 centers | 224 | 66 (29%) | 45 (16) | 3 months post-injury | Mean (SD) TBSA burn: 10% (12%) |
| Systemic sclerosis | |||||||
| Heinberg 26 2007 | United States | Adult outpatients with SSc from a single center | 254 | 217 (85%) | 53 (13) | NR | N (%) diffuse SSc: 69 (30%)c |
| Mills 27 2015 | United States | Adult outpatients with SSc from a single center | 207 | 172 (83%) | 54 (15) | Mean (SD) years since SSc diagnosis: 8 (8) |
N (%) diffuse SSc: 83 (40%) |
| Jewett 22 2017 | Canada | Adult outpatients with SSc from 15 Canadian Scleroderma Research Group centers | 856 | 751 (88%) | 57 (12) | Mean (SD) years since onset of non-Raynaud’s symptoms: 12 (9) |
N (%) diffuse SSc: 262 (31%) |
| Harel 30 2019 | Canada United Kingdom United States |
Adult outpatients with SSc from 28 Scleroderma Patient-centered Intervention Network centers in 7 countries | 926 | 813 (88%) | 56 (12) | Mean (SD) years since onset of non-Raynaud’s symptoms: 12 (9) |
N (%) diffuse SSc: 399 (43%) |
| Mattsson 31 2023 | Sweden | Adult outpatients with SSc from 3 centers | 134 | 108 (81%) | Median = 62 IQR = 53–71 |
Median (IQR) years since onset of non-Raynaud’s symptoms: 11 (6–18) |
N (%) diffuse SSc: 34 (25%) |
N: number; SD: standard deviation; TBSA: total body surface area; NR: not reported; SSc: systemic sclerosis; IQR: interquartile range.
Participant characteristics were extracted from published studies from which included datasets were identified. Some numbers differ from characteristics of cohorts for which SWAP subscale data were available and provided (see Table 2). Numbers of participants in provided datasets differed from publication numbers due to continued collection of data post-publication or because of missing sex or age data.
Participants met one or more criteria, which included (1) deep second- and third-degree burns greater than 10% TBSA in patients older than 50 years; (2) deep second- and third-degree burns greater than 20% TBSA; (3) deep second- and third-degree burns with serious threat of functional or cosmetic threat that involve face, hands, feet, genitalia, perineum, or major joints; (4) third-degree burns greater than 5% TBSA; (5) deep electrical burns including lightning injury; (5) burn injury with inhalation injury; and (6) circumferential burns of the extremity or chest.
Reported N diffuse = 69 and N limited = 159.
Published studies of SSc cohorts included outpatients from two single centers in the United States,26,27 three centers in Sweden, 31 a cohort with 15 Canadian sites, 22 and an international cohort with 28 sites in seven countries. 30 Based on the sites and dates when data were collected, no participant data were included in more than one cohort. Mean ages ranged from 53 to 57 years (one study reported only the median = 62 years), 31 and the percentage of females ranged from 81% to 88%. Mean years since onset of non-Raynaud’s symptoms ranged from 11 to 12 years in three studies,22,30,31 and mean time since diagnosis was 8 years in one study 27 (not reported in one study). 26 The percentage of participants with diffuse SSc subtype ranged from 25% to 43%. Over half of the participant data were from the SPIN Cohort (1960 of 3402, 58%).
Individual cohort scores on the SWAP Dissatisfaction with Appearance and Social Discomfort subscales for burn injury and SSc studies by sex and age groups are shown in Table 2.
Table 2.
SWAP dissatisfaction with appearance and social discomfort subscale scores by sex and age a .
| Dissatisfaction with Appearance | Social Discomfort | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Female | Male | Female | Male | |||||||||
| 18–44 Years N Mean (SD) | 45–64 Years N Mean (SD) | ⩾ 65 Years N Mean (SD) | 18–44 Years N Mean (SD) | 45–64 Years N Mean (SD) | ⩾ 65 Years N Mean (SD) | 18–44 Years N Mean (SD) | 45–64 Years N Mean (SD) | ⩾ 65 Years N Mean (SD) | 18–44 Years N Mean (SD) | 45–64 Years N Mean (SD) | ⩾ 65 Years N Mean (SD) | |
| Burn injury | ||||||||||||
| Espinoza 23 2020 | 328 22.6 (12.3) |
306 21.9 (11.1) |
91 14.9 (9.2) |
937 18.1 (11.0) |
639 17.8 (10.8) |
154 12.1 (8.3) |
328 14.1 (8.8) |
306 13.9 (8.9) |
91 8.0 (8.6) |
937 11.0 (8.5) |
639 10.7 (8.3) |
154 5.9 (5.3) |
| Willemse 29 2023 | 37 25.7 (12.2) |
18 24.5 (9.7) |
8 25.0 (9.1) |
61 20.4 (12.7) |
62 17.7 (10.0) |
17 21.7 (15.2) |
37 16.9 (9.6) |
18 12.7 (7.9) |
8 10.2 (4.3) |
61 12.3 (8.1) |
62 12.3 (8.0) |
17 11.9 (8.9) |
| Systemic sclerosis | ||||||||||||
| Heinberg 26 2007 | 54 22.9 (11.7) |
106 21.5 (12.0) |
39 21.2 (12.5) |
5 25.2 (12.4) |
18 17.0 (12.4) |
4 27.2 (15.8) |
54 10.0 (8.3) |
106 6.6 (8.3) |
39 5.2 (7.5) |
5 10.2 (11.3) |
18 9.0 (8.7) |
4 5.0 (5.7) |
| Mills 27 2015 | 40 31.4 (11.9) |
82 26.7 (12.5) |
42 24.9 (10.7) |
7 35.3 (11.9) |
18 25.2 (11.5) |
5 19.8 (9.1) |
40 20.2 (9.5) |
82 19.5 (9.5) |
42 17.7 (8.7) |
7 24.4 (7.1) |
18 21.1 (9.2) |
5 15.0 (8.2) |
| Jewett 22 2017 | 87 25.9 (7.5) |
468 26.0 (7.6) |
225 27.1 (8.5) |
15 25.1 (6.6) |
65 23.4 (7.1) |
28 24.2 (7.2) |
87 16.3 (4.9) |
468 15.8 (5.1) |
225 14.8 (5.6) |
15 15.9 (7.8) |
65 15.8 (4.1) |
28 15.0 (5.4) |
| Harel 30 2019 | 340 22.5 (12.2) |
958 22.4 (12.5) |
417 21.9 (13.6) |
32 19.8 (13.2) |
128 20.0 (12.8) |
85 17.9 (14.6) |
340 12.6 (10.2) |
958 10.6 (9.7) |
417 6.7 (8.1) |
32 9.9 (10.4) |
128 8.3 (8.7) |
85 6.6 (8.2) |
| Mattsson 31 2023 | 12 31.8 (13.1) |
49 26.3 (9.3) |
47 25.9 (12.8) |
6 19.7 (12.6) |
11 27.4 (15.9) |
9 18.1 (11.9) |
12 18.0 (9.1) |
49 13.5 (7.2) |
47 10.7 (5.6) |
6 14.0 (8.7) |
11 11.5 (6.7) |
9 9.0 (3.0) |
SWAP: Satisfaction with Appearance Scale.
Number of participants in some cohorts differ from total N per study in Table 1 due to continued collection of data post-publication or because of missing sex or age data for some participants.
Comparison of SWAP Dissatisfaction with Appearance and Social Discomfort subscale scores
Results of meta-analyses of burn injury and SSc subscale scores by sex and age subgroup are shown in Table 3 and Figure 2. For burn injury and SSc, all subscale scores were higher for females than males within the same age group, and scores decreased with increasing age for both sexes. Heterogeneity of estimated scores ranged from 0.0% to 98.6%.
Table 3.
Meta-analysis results of SWAP dissatisfaction with appearance and social discomfort subscale scores by sex and age a .
| Dissatisfaction with Appearance | Social Discomfort | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Female | Male | Female | Male | |||||||||
| 18–44 Years | 45–64 Years | ⩾ 65 Years | 18–44 Years | 45–64 Years | ⩾ 65 Years | 18–44 Years | 45–64 Years | ⩾ 65 Years | 18–44 Years | 45–64 Years | ⩾ 65 Years | |
| Burn injury (N = 2 cohorts) | ||||||||||||
| N participants | 365 | 324 | 99 | 998 | 701 | 171 | 365 | 324 | 99 | 998 | 701 | 171 |
| Mean | 23.6 | 22.3 | 19.5 | 18.8 | 17.8 | 16.2 | 15.1 | 13.8 | 8.8 | 11.3 | 11.2 | 8.5 |
| 95% CI | 20.8 to 26.4 | 20.5 to 24.1 | 9.6 to 29.3 | 16.7 to 20.8 | 17.0 to 18.6 | 6.9 to 25.5 | 12.5 to 17.7 | 12.9 to 14.8 | 6.7 to 10.8 | 10.2 to 12.3 | 9.7 to 12.7 | 2.7 to 14.4 |
| I2 | 53.3% | 16.7% | 88.9% | 52.2% | 0.0% | 84.8% | 65.2% | 0.0% | 35.5% | 31.8% | 55.5% | 86.6% |
| Systemic sclerosis (5 cohorts) | ||||||||||||
| N participants | 533 | 1,663 | 770 | 65 | 240 | 131 | 533 | 1,663 | 770 | 65 | 240 | 131 |
| Mean | 26.3 | 24.5 | 24.3 | 24.6 | 22.0 | 20.8 | 15.2 | 13.2 | 11.0 | 15.1 | 13.1 | 10.0 |
| 95% CI | 22.6 to 29.9 | 22.4 to 26.6 | 21.9 to 26.7 | 19.5 to 29.8 | 19.3 to 24.8 | 17.2 to 24.4 | 11.6 to 18.8 | 8.9 to 17.5 | 6.4 to 15.6 | 9.8 to 20.5 | 8.5 to 17.6 | 6.1 to 13.9 |
| I2 | 86.8% | 92.9% | 89.7% | 62.7% | 64.1% | 61.9% | 92.8% | 98.6% | 98.5% | 81.0% | 95.3% | 91.0% |
| Difference (systemic sclerosis – burn injury) | ||||||||||||
| Raw score mean difference | 2.7 | 2.2 | 4.8 | 5.9 | 4.2 | 4.6 | 0.1 | –0.6 | 2.2 | 3.9 | 1.9 | 1.5 |
| 95% CI | –1.9 to 7.3 | –0.5 to 5.0 | –5.3 to 15.0 | 0.4 to 11.4 | 1.4 to 7.1 | –5.4 to 14.6 | –4.4 to 4.6 | –5.0 to 3.8 | –2.8 to 7.3 | –1.6 to 9.3 | –2.9 to 6.6 | –5.6 to 8.5 |
| Standardized mean difference | 0.23 | 0.20 | 0.41 | 0.53 | 0.39 | 0.42 | 0.01 | –0.07 | 0.30 | 0.45 | 0.23 | 0.22 |
| 95% CI | –0.34 to 0.79 | –0.17 to 0.57 | –0.18 to 1.00 | 0.01 to 1.06 | 0.13 to 0.90 | –0.49 to 1.33 | –0.43 to 0.45 | –0.37 to 0.22 | –0.11 to 0.71 | 0.01 to 0.89 | –0.17 to 0.62 | –0.34 to 0.79 |
SWAP: Satisfaction with Appearance Scale; CI: confidence interval.
Number of participants in some cohorts differ from total N per study in Table 1 due to continued collection of data post-publication or because of missing sex or age data for some participants.
Figure 2.
Meta-analysis of differences in SWAP Dissatisfaction with Appearance and Social Discomfort subscale scores by sex and age.
As shown in Table 3 and Figure 2, Dissatisfaction with Appearance subscale scores were higher among people with SSc compared to those with a burn injury by 2.2 to 5.7 points (SMD = 0.20 to 0.53) for females and males across all age groups. Differences were statistically significant for males aged 18–44 and 45–64 years. For Social Discomfort, differences were close to zero (SMD < 0.10) for females aged 18–44 and 45–64 years. For females aged ⩾ 65 years and all age groups for males, scores were higher in SSc than burn injury (SMD 0.22 to 0.45), although none were statistically significant.
Discussion
Our main finding was that people with SSc across groups defined by sex (female, male) and age (18–44 years, 45–64 years, ⩾ 65 years) reported that they experience similar or greater dissatisfaction with appearance and appearance-related discomfort in social situations compared to people with a burn injury. Dissatisfaction with Appearance subscale scores were greater among people with SSc, indicating more dissatisfaction with appearance, for both sexes across age groups by 0.20 to 0.53 SMDs, suggesting small to medium differences, although this was only statistically significant for males aged 18–44 years and 45–64 years. For the Social Discomfort subscale, there were no statistically significant differences; score differences were higher among people with SSc for males across age groups (SMD = 0.22 to 0.45) and females aged 65 years or greater (SMD = 0.30) but close to zero for females aged 18–44 years and 45–64 years.
To the best of our knowledge, our study is the first that has compared levels of appearance dissatisfaction and appearance-related social discomfort across samples with different disfiguring medical conditions or injuries. Heterogeneity of estimates was high for most sex and age groups for both SSc and burns, but the overall pattern of scores highlights that body image concerns are at least as great among people with SSc compared to people with burn injury.
The associations of greater body image concerns with female sex and younger age among adults are well-established in the general population and among people with visible differences.12,13,15,34–36 Consistent with this, we found that within cohorts of adults with SSc and burn injury, dissatisfaction with appearance and social discomfort were greater among females compared to males and among younger age groups. Body image concerns and other psychological outcomes are also associated with the extent and severity of appearance changes.5–11 We were not able to account for the extent or severity of appearance changes in our analysis. However, 92% of participants with burn injury were from a United States Model Burn System site, and study eligibility required that they met American Burn Association criteria for a severe burn injury, which includes (1) deep second- and third-degree burns greater than 10% total body surface area (TBSA) in patients older than 50 years; (2) deep second- and third-degree burns greater than 20% TBSA; (3) deep second- and third-degree burns with serious threat of functional or cosmetic threat that involve face, hands, feet, genitalia, perineum, or major joints; (4) third-degree burns greater than 5% TBSA; (5) deep electrical burns including lightning injury; (5) burn injury with inhalation injury; and (6) circumferential burns of the extremity or chest burn injury. 23 SSc cohorts that were reviewed in our study, on the contrary, included any outpatient with SSc with no threshold for severity. Thus, it would seem unlikely that the similar or higher scores in SSc were due to an overrepresentation of people with more severe SSc compared to burn injury.
There are limitations that should be considered in interpreting our results. One is the small number of studies that have assessed dissatisfaction with appearance and appearance-related social discomfort using the SWAP in people with burn injury and SSc. Another is that, although we did not incorporate a risk of bias assessment, included cohorts were largely convenience samples. There are also strengths to consider. People with burn injury are predominantly males and younger adults, whereas people with SSc are mostly female and older. Evaluating results by groups defined by sex and age, which were provided by study authors, facilitated our comparison of people who were similar by sex and age. Our ability to obtain sex- and age-based results from 98% and 99% of eligible participants in cohorts from included publications was also a strength.
In sum, body image concerns, including dissatisfaction with appearance and social discomfort, appear to be similar or greater among people with SSc compared to people who have been hospitalized with a severe burn injury. People with SSc with body image concerns may benefit from interventions, which may include psychological37–39 and non-surgical cosmetic and other camouflage interventions. 40 Non-surgical cosmetic and other camouflage interventions are comprised of non-invasive techniques intended to minimize or disguise visible appearance differences. These may include the use of cosmetics (e.g. concealer), prosthetics (e.g. prosthetic eye), clothing and stylistic accessories (e.g. scarves), or hair (e.g. wigs). 40 Systematic reviews, however, have emphasized that few randomized controlled trials have tested intervention options and highlighted methodological shortcomings and substantial risk of bias in existing trials.37–40 Well-designed and conducted trials are needed to test interventions to support people with body image concerns due to visible differences from SSc and other medical conditions.
Acknowledgments
We are grateful to the authors of included studies who provided updated results from their cohorts by sex- and age-defined subgroups.
Footnotes
The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: All authors have completed the ICJME uniform disclosure form and declare no support from any organization for the submitted work and no financial relationships with any organizations that might have an interest in the submitted work in the previous 3 years. All authors declare no other relationships or activities that could appear to have influenced the submitted work. An Editorial Board Member of JSRD is an author of this article, therefore, the peer review process was managed by alternative members of the Board and the submitting Board member had no involvement in the decision-making process.
Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: There was no specific funding for this study. TDS was supported by a Fonds de Recherche du Québec—Santé (FRQS) Master’s Training Scholarship and BDT by a Tier 1 Canada Research Chair, both outside of this work.
ORCID iD: Brett D Thombs 
https://orcid.org/0000-0002-5644-8432
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