Psychological Impact of Scars on Toes
In a world where the “beautiful” are given many advantages, it is easy to understand why appearance is weighted so highly. The old adage, “What is beautiful is good” is very still sadly true today, in fact especially today with the influence of social media, when being perceived as attractive creates a halo effect. Feet are no different then other parts of the anatomy, especially for women who tend to wear more open toed shoes and sandals then men.
Measuring quality of life is an important aspect of delivering holistic dermatological care to feet. The lesions on the tops of toes are trivial to most health professionals and my fellow podiatrists, some individuals adapt to the change in the appearance of their toes, however, others react negatively and have decreased psychosocial performance (functioning of emotional, social, mental well-being).
The management of scars is a challenge for professionals since these lesions can greatly impact quality of life. Although scars rarely pose a health risk, patients constantly present not only with physical discomfort, but also aesthetic, social and psychological distress.
Patients often believe these hypertrophic scars which are caused due to ill fitting footwear to be corns and self diagnose and use strong over the counter caustics to treat them, these patients may experience post-traumatic stress disorder due the traumatic nature of the subsequent scar. These lesions are cosmetically disfiguring for the patient and may even lead to depression, anxiety and problems with social interaction. Scars can have long-lasting physical and psychosocial effects, even if remedial and cosmetic treatment is sought.
The World Health Organisation (WHO) defines quality of life as “the individual's’ perception of their position in life, in the context of the cultural and value system in which they live and in relation to their goals, expectations, standards, and concerns” (1). Context is everything - society influences the worth placed on individuals. The media bombard the public with images of the "perfect body" and "perfect feet", fuelling society’s current preoccupation with elevated beauty standards. This pressure can lead to anxiety and negatively impact quality of life, and its burden is particularly felt by young women. Anxiety and depression following scarring are more likely in those under 50 years old (2), and female (3).
The most important characteristic that causes patients to judge scar aesthetic as poor is high visibility (4). Visibility, and not the size of the scar, is associated with a more negative body image (5). Being easily identifiable as "different" can be intimidating and isolating. Which is the reason why women ignore these scars in the winter when they are wearing boots but in the summer the psychological Impact of these scars is evident.
We are programmed to be averse to visible imperfections. Perception of an unusual feature may suggest a connection to contagious diseases or a lack of hygiene and thus initiate avoidance and social stigmatisation of the individual (6). Disfigurement or unsightly features are still used to portray evil in horror films, religious imagery, and fairy tales. Stigma is a constant social threat to a person's life experience whereby society creates a new identity for these poor souls and foists it upon them. The perception of stigma can change one’s identity to that of a devalued individual. Some may argue that this stigma is merely an unconscious bias that does not escalate to actions. However, individuals experience intrusive questions, stares (7), and strangers maintaining a greater distance from them (8).
Reactions from family and friends to scars, both positive and negative, can detrimentally affect patients' emotions. Lack of sympathy forces the patient to minimise their feelings, whereas concern evokes feelings of guilt for causing unnecessary distress in their loved ones (9).
When one thinks of oneself, a mental picture forms based on reflections, photographs, and comments from others. Scars cause a permanent identity change, and adjustment to the new outward and inner self-image is needed. The mismatch between appearance and identity can trigger a psychological shift and invoke feelings of anxiety and shame (3). Scarred patients often describe their new appearance as living with this trauma. This can trigger a cascade of feelings: shame, self-rejection, and self-consciousness (10).
Distorted body image is reflected in everyday interactions. Although not directly connected to feet, their is evidence that those with a history of acne scarring exhibit enhanced fixation on acne lesions and judged scarred faces more harshly (11) whilst also taking pains to hide scars and avoid reflective surfaces or conversely become obsessed with their reflection (9).
Scarring may be skin deep but their psychological impact goes deeper still. The evidence is decisive; the presence of scars can result in clear markers of mental disturbance in patients with associated symptoms of depression, anger, anxiety, and post-traumatic stress. A scar creates physical, emotional and psychological marks. Identity is called into question and individuals must integrate the scar with their sense of self in order to achieve psychological acceptance. This process causes a change of behaviour and reduced functioning, socially and psychologically, driven by a fear of being singled out.
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