595175

research-article2015
CMSXXX10.1177/1203475415595175Journal of Cutaneous Medicine and SurgerySalsberg et al

Basic/Clinical Science

Journal of Cutaneous Medicine and Surgery

Impact of Cosmetic Camouflage on the 1­–5

© The Author(s) 2015
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DOI: 10.1177/1203475415595175

Disease and Their Families jcms.sagepub.com

Jennifer M. Salsberg1, Miriam Weinstein2, Neil Shear3,

Michelle Lee2, and Elena Pope2

Abstract
Background/Objectives: Cosmetic camouflage is known to improve quality of life in adults. Few data are available regarding
cosmetic camouflage in children, and thus it is not often selected as a mode of treatment. We sought to determine whether cosmetic
camouflage leads to improved quality of life of pediatric patients with visible dermatoses and their parent or primary caregiver.
Methods: Patients aged 5 to 17 years with visible skin disease and their parent were assessed with the Children’s Dermatology
Life Quality Index (CDLQI) and the Family Dermatology Life Quality Index (FDLQI) before and after consultation regarding
cosmetic camouflage.
Results: Twenty-two children with skin conditions were included in the study. The mean CDLQI decreased from 6.82 (SD = 1.28)
to 3.05 (SD = 0.65; P = .0014), while the mean FDLQI decreased from 7.68 (SD = 1.15) to 4.68 (SD = 0.92; P = .0012).
Conclusions: Our study highlighted improvement in quality of life in patients with skin disorders who were managed with
cosmetic camouflage.

Résumé
Contexte et objectifs : On reconnaît que le maquillage camouflant améliore la qualité de vie chez l’adulte. Mais il existe
peu de données sur l’utilisation de cette stratégie chez l’enfant; en fait, on n’y a pas souvent recours. Nous avons cherché à
savoir si le maquillage camouflant améliorait la qualité de vie chez des enfants présentant des dermatoses apparentes, celle
de leurs parents ou celle de leurs principaux soignants.
Méthodologie : Chez des patients de 5 à 17 ans présentant des affections cutanées apparentes et leurs parents, on a mesuré
l’indice de qualité de vie de l’enfant en dermatologie (Children’s Dermatology Life Quality Index – CDLQI) et l’indice de
qualité de vie de la famille en dermatologie (Family Dermatology Life Quality Index – FDLQI) avant et après la consultation
d’un médecin au sujet du maquillage camouflant.
Résultats : Vingt-deux enfants présentant des affections cutanées ont été recrutés pour participer à l’étude. Le CDLQI moyen
a diminué de 6,82 (écart type [ET] = 1,28) à 3,05 (ET = 0,65), valeur P = 0,0014, et le FDLQI moyen a diminué de 7,68 (ET =
1,15) à 4,68 (ET = 0,92), valeur P = 0,0012.
Conclusions : Les résultats de notre étude ont fait ressortir une amélioration de la qualité de vie chez les patients présentant
des affections cutanées qui ont eu recours au maquillage camouflant.

Keywords
dermatology, pediatric, pigmentary disorder, inflammatory dermatoses

There are many chronic dermatologic conditions for which
treatment proves difficult and sometimes impossible. For
patients with these conditions, tolerating the symptoms of
their skin disease becomes a daily reality. Furthermore,
conditions appearing on the face are visible to all and thus
may cause significant morbidity and impair social function-
ing. Visible skin disease has been shown in many studies to
be a significant emotional burden for patients, causing an
increase in depression, anxiety, and suicidal ideation.1-3
Studies have also shown that the degree of skin disease on
the face correlates with psychological impact on the
patient.4 Patients with visible skin lesions have impaired
1
Women’s College Hospital, Toronto, Ontario
2
The Hospital for Sick Children, Toronto, Ontario
3
Sunnybrook Health Sciences Centre, Toronto, Ontario
Corresponding Author:
Jennifer Salsberg, Women’s College Hospital, Division of Dermatology, 76
Grenville Street, Toronto, Ontario, M5S 1B2.
Email: Jennifer.kwinter@mail.utoronto.ca
2 Journal of Cutaneous Medicine and Surgery 
social and emotional functioning and decreased productiv-
ity at school and work.5 Studies have shown that in addition
to affecting the quality of life of the individual patient,
pediatric skin conditions have an impact of the quality of
life of family members as well.6-8
Cosmetic camouflage refers to the use of opaque, cream-
or wax-based cosmetic products applied to the skin to cover
visible cutaneous disorders. These specialized topical agents
have been designed specifically to blend into the skin, giv-
ing the cutaneous disorder and the surrounding skin a uni-
form appearance. Cosmetic camouflage agents can be
applied by the patient at home and washed off when desired.
In contrast with other over-the-counter makeup prepara-
tions, camouflage products are more opaque, are water-
proof, and are more adherent to the skin, providing longer
wear.9 These products also have low allergenic potential and
therefore are acceptable for use in patients with a variety of
skin conditions. Since it can take more than 1 product to
adequately cover an area affected by skin disease, it is opti-
mal for patients to attend a consultation with an individual
well versed in the application of cosmetic camouflage
makeup. At the consultation, appropriate products are
selected for the patient, and patients are taught exactly how
to apply the camouflage so that they can replicate the appli-
cation on their own.10
The use of cosmetic camouflage is well established in
adults with visible skin conditions including vascular lesions,
pigmentary disorders, and scars as well as chronic skin dis-
eases such as acne and lupus. A number of studies examining
the use of cosmetic camouflage by adults with a variety of
dermatoses found a significant improvement in validated
measures of quality of life.5,11-16
While cosmetic camouflage is seen as a practical treat-
ment option in adults, few data are available examining its
use in children, and thus it is often not selected as a mode of
treatment in this patient population. Furthermore, most stud-
ies examining cosmetic camouflage focus on its effective-
ness in covering the skin, with a minority measuring the
impact that it can have on patient quality of life. Five studies
have examined the use of cosmetic camouflage in children,
suggesting that it is a beneficial treatment option.17-21 While
Tedeschi et al18 noted that parents of pediatric patients were
satisfied with the results of cosmetic camouflage, the inves-
tigators did not use a validated tool to measure parent satis-
faction.18 There are no other studies examining the impact
that cosmetic camouflage can have on family members.
We sought to determine whether the use cosmetic camou-
flage in the treatment of visible dermatoses leads to improved
quality of life of pediatric patients and their parent or pri-
mary caregiver. Few studies have looked at the impact of
camouflage on the quality of life of children, and none have
examined the effect that it can have on the quality of life of
parents. If proven to help improve quality of life, cosmetic
camouflage will be an easily accessible, low-risk treatment
option for a variety of skin conditions.
Methods
Approval for the study was granted by the Research Ethics
Board at the Hospital for Sick Children in Toronto, Ontario,
Canada. Patients aged 5 to 17 years with a stable skin disease
affecting the face or extremities (such as vitiligo, morphea,
capillary malformations, café au lait macules, ichthyosis,
scars, congenital nevi) were included in the study. Stable
skin disease was determined as (1) patients with inflamma-
tory conditions such as morphea or vitiligo that have not
demonstrated satisfactory response to treatment or patients
who continued to have visible disease despite current active
use of topical treatments and (2) patients with congenital
skin disorders (such as capillary malformations, café au lait
macules, congenital nevi) who either did not qualify for
treatment or continued to have stable lesions over the previ-
ous 6 months. Patients with elevated skin lesions, which in
the opinion of the investigator would preclude adherence of
the products, were excluded. All qualifying patients present-
ing to the clinic were offered inclusion into study. Upon
enrolment into the study, informed consent was obtained for
all participants. Children and their parent or primary care-
giver were assessed at baseline with the Children’s
Dermatology Life Quality Index (CDLQI),22 the Family
Dermatology Life Quality Index (FDLQI),23 and a study-
specific preintervention questionnaire. Children who were
too young to complete the questionnaires on their own were
assisted by their parent or primary caregiver. The CDLQI
and FDLQI are validated tools measuring the impact of skin
disease on the quality of life of children and their families,
respectively. Each instrument has 10 questions that are
scored to measure the severity of impact on quality of life.
Following completion of these questionnaires, a trained
nurse assessed each patient and determined the appropriate
formulations and application techniques of the cosmetic
camouflage products to cover their skin. Products were
selected from the full range of the CoverFX line, and the
regimen was tailored to each patient’s needs based on diag-
nosis, location, and extent of their condition. The treatment
for most patients included 1 or 2 different foundations, set-
ting powder, and brushes. The nurse applied the camouflage
product while instructing the patient and parents how to rep-
licate the application at home, giving them a chance to prac-
tice during their appointment. Patients were then provided
with enough camouflage products to continue applying the
cosmetic camouflage daily for 1 month at home as well as
blank copies of the same questionnaires to be filled out at 2
weeks following their initial assessment.
Alteration in quality of life as measured by changes in the
CDLQI and FDLQI scores following instruction and repeated
application of the cosmetic camouflage products was the pri-
mary outcome measure of this project. A comparison of pre-
and postintervention scores served as the basis for the
statistical analysis. Furthermore, predictors for improved
quality of life with use of cosmetic camouflage were also
Salsberg et al
Table 1. Predictor Variables for Response to Camouflage Treatment as Measured by a Decrease in the Children’s Dermatology Life
Quality Index (CDLQI).
Variable
Age, mean (SD), y
Female gender, %
Duration of skin condition, mean (SD), y
Nonpalpable lesions, %
examined. STATA v10.0 (StataCorp, College Station, Texas)
statistical software was used to perform descriptive statisti-
cal testing and t-test analysis on the results of the question-
naires to determine whether the results were statistically
significant. Significance was implied by a P value of less
than or equal to .05.
Results
Twenty-two children with Fitzpatrick skin types II through
IV were included in the study. The ages of the children
ranged from 6 to 17 years with a mean age of 12 years (SD =
3.3 years), and 19 (86%) of the participants were female.
Skin conditions included vitiligo (n = 8), morphea (n = 4),
capillary malformations (n = 4), café au lait macules (n = 3),
ichthyosis (n = 1), scars (n = 1), and congenital nevi (n = 1),
with the most common diagnosis being vitiligo (n = 8, 36%).
Patients had been affected with the skin conditions for a
mean of 7 years (SD = 3.9 years), and the majority of patients
(n = 17, 77%) had their condition previously treated with
medication, while 41% (n = 9) had tried using makeup to
cover their condition in the past.
The mean CDLQI at initial assessment was 6.82 (SD =
1.28), demonstrating a moderate effect of disease on quality
of life, which decreased significantly to 3.05 following appli-
cation of the cosmetic camouflage products (SD = 0.65; P =
.0014), a small effect of disease on quality of life. Primary
caregiver participants were mostly mothers (n = 21, 95%) of
the children in the study, and the mean FDLQI decreased
from 7.68 (SD = 1.15), demonstrating a moderate effect, at
baseline assessment to 4.68 (SD = 0.92), a small effect, fol-
lowing the use of camouflage products (P = .0012). The
score differences between the CDLQI and FDLQI before and
after use of cosmetic camouflage were compared using a
paired t test, but no significant difference was found (P =
.33), likely due to the relatively small sample size. A linear
regression analysis looking at response and correcting for
baseline CDLQI and FDLQI did not demonstrate a signifi-
cant difference (P = .39). Most patients were happy with the
end result (77%). The frequency of application of the prod-
ucts varied, with equal amounts of patients applying the
product daily (n = 5, 28%), 1 to 3 times per month (n = 5,
28%), and for special occasions only (n = 5, 28%). A smaller
proportion of patients applied to product 1 to 3 times per
week (n = 3, 17%). Variables such as age, gender, duration of
3
Pre and Post P Value
12.3 (3.5) vs 12.17 (3.12) .93
68 vs 32 .25
7.78 (3.75) vs 7.83 (4.75) .98
68 vs 32 .25
underlying condition, and palpability of lesions were not
shown to significantly predict improvement in quality of life
scores (Table 1).
Conclusions
The results of our study demonstrate that children with skin
disease as well as their families had improved quality of life
following the use of cosmetic camouflage. Interestingly, we
found no significant predictors of improvement in quality of
life scores. It is possible that this is due to the small sample
size and the fact that there were far more females enrolled in
the study than males. However, while age was not found to
significantly predict improved quality of life, it is worth not-
ing that older female patients were more likely to apply the
makeup more frequently, which could be expected given that
they are more likely to be using makeup despite their skin
disease.
Skin disease has been shown to significantly affect self-
esteem, relationships, and quality of life, and despite the
favourable prognosis of many skin disorders, the impact can
have a profound effect on daily functioning.1-3 While treat-
ment of these conditions can be slow and imperfect, a review
of the literature demonstrates that cosmetic camouflage can
have a significant impact on improving quality of life.9-16
Although studies have shown that the use of cosmetic cam-
ouflage improves the quality of life of adults with a variety of
dermatoses, very few studies have examined the use of cos-
metic camouflage in children, and to our knowledge this is the
first study examining the impact that cosmetic camouflage has
on the quality of life of families of children with skin disease.
Maskell et al17 conducted a prospective, multicenter, random-
ized controlled trial of 63 children with a history of burn with
mature scarring on a visible area of the body, which demon-
strated that individuals using the cosmetic camouflage prod-
ucts had statistically significant improvements in measures of
perceived physical appearance and social functioning after
using the products for 8 weeks. These results were more
marked in females versus males, as well as in adolescents ver-
sus younger children.15 Four other studies examined the
impact of cosmetic camouflage on the quality of life of chil-
dren with skin disease, and all suggested that there was
improvement in quality of life following the use of cosmetic
camouflage; however, 1 study did not use a validated tool to
measure quality of life,16 and another used the CDLQI but did
4 Journal of Cutaneous Medicine and Surgery 
not analyze the results for significance.18 Ramien et al21 found
significant improvement of the CDLQI after use of cosmetic
camouflage in 41 pediatric patients.
The results of this study demonstrate that in addition to
adults with skin disease, children with a variety of dermato-
ses and their families report improvement in their quality of
life when they are taught to cover their skin disease with
camouflage makeup and continue to use the products at
home. The ability to affect the quality of life of patients who
have been suffering with skin disease for many years in such
a short time is a testament to the importance of camouflage
as a treatment option.
Cosmetic camouflage is a relatively easy and inexpen-
sive option, with very few side effects. As early as 1985, a
survey of patients with facial port wine stains showed that
there were significant deficiencies in the camouflage advice
provided to these patients,19 and this remains true today.
Physicians remain hesitant to recommend camouflage to
their pediatric patients, possibly because physicians are
unaware of product availability and use, don’t consider
camouflage to be “medical” therapy, do not feel that cam-
ouflage is appropriate for children, or did not receive ade-
quate training in the importance of camouflage as a
treatment option. Studies such as this one demonstrate the
importance of increased awareness of health care profes-
sionals regarding the use of camouflage in children so that
more pediatric patients can be offered this valuable treat-
ment option.
While cosmetic camouflage can be very effective at cover-
ing skin conditions, we must note the importance of formal
instruction and selection of appropriate products. Interestingly,
a study examining quality of life in women with a variety of
facial dermatoses found that women using foundations to
cover their condition reported poorer quality of life than those
not using foundations.24 While it is possible that the women
using foundations in this study simply had more severe skin
disease, this finding may also be due to the lack of formal
instruction given to these women on how to properly apply
the makeup, leading them to feel frustrated and hopeless in
being able to cover their condition. While it can be time con-
suming and difficult to find trained individuals to assist with
teaching patients and their parents, these results confirm the
importance of formal instruction and consultation with each
patient in the use of camouflage makeup and show that using
the makeup without the initial lesson may not have the same
positive effect.
Limitations to our study include the small sample size as
well as the larger proportion of female patients. In addition,
we did not include patients with all skin disorders and thus
can only generalize the results to select conditions.
Our study demonstrates that cosmetic camouflage is an
important option to consider when treating children with vis-
ible skin disorders, and more studies with larger samples of
patients are needed to further assess its impact and which
skin conditions are most amenable. Given the ease of use of
cosmetic camouflage and its proven benefit on quality of
life, individuals treating children with visible skin disorders
should consider cosmetic camouflage as an additional thera-
peutic option.
Acknowledgments
The authors gratefully acknowledge CoverFx for donating all prod-
uct used in the study.
Authors’ Note
Presented in poster format at the Society for Pediatric Dermatology
40th Annual Meeting, Coeur d’Alene, Idaho.
Declaration of Conflicting Interests
The author(s) declared the following potential conflicts of interest
with respect to the research, authorship, and/or publication of this
article: Dr. Neil Shear is a shareholder of CoverFx who provided
the camouflage product for the study.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: This
research was supported by a grant from the Canadian Dermatology
Foundation.
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