Running head: MBSR USE IN CHRONIC SKIN DISEASE

Mindfulness-Based Stress Reduction:
A Psychotherapeutic Intervention in Patients with Chronic Dermatological Diseases
Kylee Huebsch
Arizona State University

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Acknowledgments

Thank you, Dr. Charlotte Thrall, for agreeing to be my mentor. I am so
appreciative of your persistent guidance, patience, calm nature, and constant faith in
me. Only with all of your help, I did it!
Thank you to my parents for all of your love, support, and logged babysitting
hours. Throughout my entire life, you both have given me so much more than money
could ever buy. I love you both so very much.
Finally, to my husband, my best friend, my equal, the man who stood steadfast
by me and lovingly supported me, amazingly beyond human capability, through my
strokes, fears, uncertainties, and eventual recovery, who was my gentle voice of love
and support during our long infertility journey of multiple surgeries, frequent injections,
and countless tears from every emotional and physical pain, and every negative blood
result, who became the best nurse I have ever known, and who is the man who has
only ever encouraged me and never once gave up on me through the rigor,
frustrations, emotions, and chaos of graduate school. Lou, I thank you for your never
fading, always present love for our daughter and me. I dedicate this project in its
entirety to you both. I love you both so very much, and I pray that I have made you
proud. We made it!
Thank you, God, for all of these trials in my life that eventually worked out in
your name to become my triumphs.

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Abstract
Psychological stress plays a vital role in skin disease. The worsening and reoccurrence of signs
and symptoms of a wide array of skin diseases have been linked by various studies to stress.
Together, stress and skin disease synergistically inhibit occupational, social, and emotional
functioning resulting in diminished quality of life (Dixon, Witcraft, & Perry, 2019).
Heightened levels of stress may contribute to an assortment of immediate and future adverse
outcomes. These outcomes include triggering a skin outbreak, impairing function, behavioral
avoidance, intense negative emotions such as shame and embarrassment, and emotional
distress such as depression and anxiety (Dixon et al., 2019). The purpose of this paper is to
discuss the relationship of stress, anxiety, and depression to the specific chronic skin diseases
of acne vulgaris, psoriasis, vitiligo, rosacea, and atopic dermatitis. It will also discuss how a
psychotherapeutic intervention called mindfulness-based stress reduction (MBSR) may
decrease anxiety and depression in individuals affected by chronic skin diseases. This paper
will also highlight the impact of MBSR on treatment adherence to dermatological prescription
medications. A pilot program conducted in a dermatology clinic evaluates the effectiveness of
an online mindfulness-based stress reduction intervention to decrease patient anxiety and
depression. Results indicate clinical significance in that participants noted reduced anxiety and
depression symptoms and scores, enjoyed MBSR and would continue MBSR. The potential
benefits of this pilot program may include decreased patient anxiety and depression, increased
patient satisfaction, increased treatment adherence, improved patient satisfaction of
intervention, and improved patient outcomes.
Keywords: skin disease, anxiety, depression, mindfulness, stress, dermatology, MBSR

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Mindfulness-Based Stress Reduction: A Psychotherapeutic Intervention in Patients with
Dermatological Diseases
The psychological effects of skin disease are often more devastating for the patient than
can be objectively evaluated by a healthcare provider. Irrespective of its outward
manifestations and severity, conditions of the skin can cause severe negative psychological
impacts. Stress is a significant role player in all types of skin disease. Together, stress and skin
disease hinder physical, occupational, social, emotional, and mental functioning, resulting in
diminished quality of life (Dixon, Witcraft, & Perry, 2019; Salman et al., 2016).
Problem
One of the most common human diseases causing global burden is skin disease. The
World Health Organization's International Classification of Disease 10 classifies more than
1,000 skin or skin-related illnesses (World Health Organization, 2019). Psychological stress
plays an essential role in skin disease. The worsening and reoccurrence of signs and symptoms
stemming from a wide array of skin diseases have been linked by various studies to stress.
Together, stress and skin disease synergistically inhibit occupational, social, emotional, and
physical health and functioning resulting in diminished quality of life (Dixon, Witcraft, &
Perry, 2019; Salman et al., 2016). This paper will exclusively be looking at the psychological
effects of acne vulgaris, psoriasis, vitiligo, rosacea, and atopic dermatitis.
Heightened levels of stress can contribute to an assortment of immediate and future
adverse outcomes. Such outcomes include the triggering of a skin outbreak, impaired function,
behavioral avoidance, intense negative emotions such as shame and embarrassment, and
depression and anxiety (Dixon et al., 2019). Little attention is given to skin disease in the

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national and global health debate despite this information and profound impact (Hay et al.,
2013). The American Academy of Dermatology Association (2020) stated that in 2013 the
cost of skin disease to the United States (U.S.) health care system was $75 billion. The price of
skin disease to the U.S. health care system included preventative, medical, and prescription and
non-prescription drug costs.
In 2010, the World Health Organization (2011) estimated that the global cost of mental
illness was nearly $2.5 trillion. They projected this amount would increase to over $6 trillion
by 2030. Per the World Health Organization (2011), in 2009, the entire global health spending
was $5.1 trillion, the very next year in 2010, mental illness alone cost $2.5 trillion globally.
Almost half of the world’s global health spending has gone towards mental illnesses.
Depression alone causes a substantial economic burden. Between 2005 and 2010, the financial
burden of major depressive disorders in the United States increased from $173.2 billion to
$210.5 billion (World Health Organization, 2011).
In 2006, The Agency for Healthcare Research and Quality cited mental healthcare in
the U.S. cost $57.5 billion, which was equivalent to the cost of cancer care. However, unlike
cancer, the cost of care is not the major cause of the economic burden of mental illness, rather,
it is the expenses for social support, loss of income due to unemployment, and a variety of
indirect costs due to a chronic disability (National Institute of Mental Health, 2016).
Despite all of this information about the cost and effects of psychological disease,
anxiety and depression are under-recognized in dermatology clinics by the healthcare team
(Conner, 2017; Dalgard et al., 2014) and that this under-recognition occurs frequently (Picardi
et al., 2005). Further problems that were ascertained through personal communications with
various dermatologists across the Arizona valley is that dermatologists may feel uncomfortable

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having to address mental health issues in their patients. Some dermatologists state it would be
easier to refer their patients with anxiety or depression back to their primary care provider or a
therapist than to screen patients and intervene themselves. Other dermatologists stated they
feel they just don’t have the time or specialized knowledge to screen for psychological
disorders and then prescribe interventions.
Purpose and Rationale
The purpose of this paper is to discuss the relationship of stress, anxiety, and depression
to the specific chronic skin diseases of acne vulgaris, psoriasis, vitiligo, rosacea, and atopic
dermatitis. It will also discuss how a psychotherapeutic intervention called mindfulness-based
stress reduction (MBSR) may decrease anxiety and depression in individuals with chronic skin
diseases. Finally, this paper will highlight the impact of MBSR on treatment adherence to
dermatological prescription medications as well as evaluate post-implementation satisfaction.
This implementation project using MBSR desires to decrease stress levels in patients with
chronic skin diseases resulting in reduced anxiety and depression. Additionally, the use of
MBSR postulates that participants will show increased adherence to their dermatological
medications and find satisfaction in MBSR and the results they obtain.
Background and Significance
Skin Disease
Skin disease and its sequelae affect people of all races, genders, and ages around the
world. Hay et al. (2013) performed a systematic literature review using the skin diseases found
in the Global Burden of Disease Study 2010. In this review, Hay et al. (2013) found that in
2010 skin diseases expressed as years lost due to disability were the fourth leading cause of
nonfatal burden and was the eighteenth leading cause of worldwide health burden. The

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American Academy of Dermatology Association (2020) stated that in 2013, 84.5 million
Americans (one in four Americans) were impacted by skin disease.
As the most visible and most considerable organ of the body, the skin has a significant
effect on physical appearance. Normal healthy skin plays an essential role in the maintenance
of an individual's physical, social, and mental well-being (Salman, Kurt, Topcuoglu, &
Demircay, 2016). Studies have suggested that the skin is a significant influencer of self-esteem,
social relationships, and the development of personality.
People with the specific chronic skin diseases of acne vulgaris, psoriasis, vitiligo,
rosacea, and atopic dermatitis endure higher levels of stress and corresponding social anxiety
and depression as compared to those without chronic skin disease. Dixon et al. (2019) state that
33.4–47.5% of dermatology patients experience clinically significant social anxiety, 10.6–
45.8% express health anxiety concerns, and 8.7–40% meet the criteria for a generalized anxiety
disorder or "pathological worry." Anxiety is well known to cause various general adverse
outcomes and may even exacerbate some skin disorders. Research on skin disease has shown
significant associations between higher anxiety symptoms and adverse outcomes, including
lower self-esteem, stigmatization, worse quality of life, and skin symptom severity (Dixon,
Witcraft, McCowan, & Brodell, 2018). Interestingly, there may be a direct correlation between
anxiety and depression. Individuals with high social anxiety levels may also have high levels of
depression (Gül & Çölgeçen, 2015; Salman et al., 2016).
The pathology of dermatological diseases often extends more profoundly than the skin
itself, ultimately, into the very core of the individual, their mind (Connor, 2017). Depression
can be a severe psychological issue and is often associated with skin disease. Dalgard et al.
(2014) performed an observational cross-sectional multicenter study showing that out of 3,295

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subjects with prevalent dermatological conditions the rates of depression, anxiety, and suicidal
ideation were 10.1%, 17.2%, and 12.7%, respectively, as compared with 4.3%, 11.1%, and
8.3% in controls. Interestingly, there is a relationship between skin disease severity and
depressiveness. Pietrzak et al. (2017) state that in psoriasis patients, higher severity of
symptoms reflects depressiveness, and also, the presence of skin lesions exacerbates the course
of depression. Studies state that depression interferes with medication adherence in an array of
chronic diseases and, thus, negatively affecting treatment outcomes (Pietrzak et al., 2017).
A systematic review performed by Patel, Immaneni, Singam, Rastogi, and Silverberg
(2019) showed that 1 in 6 patients with atopic dermatitis had clinical depression and 1 in 8 had
suicidal ideation. After synthesizing eight studies on suicidal ideation, Singh, Taylor,
Kornmehl, and Armstrong (2017) found that patients with psoriasis were more than twice as
likely to have suicidal ideation than patients without psoriasis. Gül and Çölgeçen (2015) state
that female patients with acne ages 18-19 years reported suicidal ideation two times more often
than those without acne and the likelihood increased to three times more often for male patients
with acne ages 18-19 years as compared to those without acne.
MBSR
A psychotherapeutic method called mindfulness-based stress reduction (MBSR) is
beneficial for people experiencing a wide range of long-term health conditions, including skin
diseases. MBSR is a technique developed in 1979 by Dr. Jon Kabat-Zinn. The core of MBSR
uses guided body scans, yoga exercises, and meditation practices. Initially, MBSR was
designed exclusively for stress management. However, it has evolved to encompass treatment
for a variety of health-related disorders, including anxiety, depression, diabetes, hypertension,
chronic pain, cancer, and skin diseases (Niazi & Niazi, 2011). MBSR has been shown in

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multiple research studies to be a helpful non-pharmacological intervention in treating these
various chronic illnesses. A systematic review and meta-analysis showed that MBSR
demonstrates promising results in the decrease of anxiety and depression in patients with
chronic diseases such as skin disease (Victorson et al., 2015).
Though gaining in popularity due to its growing success in newer research, standard
medical treatment does not accept MBSR for the prevention or treatment of any illness or
disease. Niazi and Niazi (2011) note that over 200 medical centers around the world offer
MBSR as an alternative treatment option to patients with a variety of health-related disorders
suffering from physical, psychosomatic, and psychiatric disorders. Notably, recent studies
demonstrate the effectiveness of MBSR on the psychological sequelae from chronic skin
disease. Montgomery, Norman, Messenger, and Thompson (2016) found higher levels of
awareness achieved through MBSR to be associated with lower levels of psychological distress
as well as higher levels of dermatological quality of life in patients with chronic skin disease.
Montgomery et al. (2016) go on to say that these findings offer evidence that increasing
mindfulness may help reduce distress, including anxiety and depression, in people living with
visible chronic skin conditions. Interestingly, one study by Kabat-Zinn et al. (1998) suggested
that audio-taped guided MBSR practices accelerated the rate of skin clearing in psoriatic
patients when used in conjunction with their regular treatments. MBSR may have the potential
to decrease anxiety and depression in dermatological patients as well as improve their specific
skin condition when added to their skin treatment plan.
In-person MBSR programs led by an instructor is the most popular venue for MBSR.
Attending such programs involves individuals interested in engaging in mindfulness to find a
class, usually consisting of a larger group of people, and attend it at the pre-scheduled time, as

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well as find transportation. These difficulties of an in-person MBSR class have led to a demand
for and creation of an online MBSR class that can be performed at any time, therefore, creating
greater flexibility for the patient. It is noteworthy to mention that large groups of people in a
class or completing the standard eight weeks of MBSR intervention are not necessarily needed
to see positive results. Victorson et al. (2015) provide in their systemic review and metaanalysis of mindfulness-based randomized controlled trial evidence for MBSR interventions
with fewer than 20 individuals per group, as well as partial support for interventions that are
less than the standard eight weeks in duration. Furthermore, research supports the use of
electronics to deliver successful mindfulness interventions even though the use of other tools is
more often employed (Victorson et al., 2015). The use of electronics could include mobile
phone applications or internet-based guided practices via video or audio in which a single
person may utilize the MBSR application.
Internal Evidence
In a dermatology clinic in the southwestern United States that provides medical,
surgical, and aesthetic treatments, there is not an established intervention for patients with
anxiety or depression. The clinic does not routinely screen for anxiety or depression, but they
do realize the connection between psychological disease and skin disease. There is a great
desire within this clinic to improve the overall health outcomes of their patients.
Using MBSR as part of the clinic's holistic treatment plan for dermatological patients
may decrease patient anxiety and depression, increase patient adherence to treatment, provide
better healthcare outcomes for their patients, and increase patient satisfaction. By offering
MBSR, this clinic would like to improve the overall mental and physical health outcomes of
their patients with skin disease and see increases in patient treatment adherence.

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PICOT
This inquiry has led to the clinically relevant PICOT question, "In patients with specific
dermatological diseases of acne vulgaris, psoriasis, vitiligo, rosacea, or atopic dermatitis (P),
how does an online mindfulness-based stress reduction program (I), using the same group pre
and post-intervention (C), affect treatment adherence, anxiety, depression, and satisfaction (O)
over four weeks (T)?
Search Strategy
An exhaustive search of the following electronic databases was conducted to answer
the previously discussed PICOT question. The databases searched for the literature review
included PsychINFO, Allied Health Literature (CINAHL), PubMed, and the Cochrane Library.
Keywords included; skin disease, skin, disease, chronic, dermatology, acne vulgaris, psoriasis,
vitiligo, rosacea, atopic dermatitis, eczema, treatment adherence, adherence, holistic,
mindfulness, mindfulness-based stress reduction, MBSR, meditation, yoga, awareness, stress
reduction, stress, psychological distress, anxiety, depression, psychological, and suicide. The
initial search of disease and MBSR yielded 41 results in CINAHL (Appendix A, Figure A.1),
116 in The Cochrane Library (Appendix B, Figure B.1), and 80 in PubMed (Appendix D,
Figure D.1), all had limits set to English language, humans, any age, publication date from
2013-2019. PsychoINFO was used to search for skin disease and depression and anxiety,
yielding 88 peer-reviewed articles (Appendix C, Figure C.1). Combination words of skin,
disease, dermatology, and chronic were used in PubMed and CINAHL, as well as various
combination key words using anxiety, depression, and psychological disorder and mindfulnessbased stress reduction, MBSR, yoga, meditation, skin, disease, chronic. A separate search
of holistic, skin, skin disease, dermatology, adherence, and treatment adherence using an

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exclusion criterion of articles published within the last five years (Appendix A, Figures A.2,
and Appendix D, Figure D.2).
The Boolean connector "or' and "and" were utilized for the main features of the PICOT
question, including population, intervention, and outcome. Unpublished works, though
reviewed, were regarded as inappropriate for this review. Gray literature was reviewed with no
acceptable yields, and hand searching of references was utilized yielding two studies. Included
studies involved all people aged 15 years and older, specialty, and community settings in
various countries. An extensive review of the literature led to a large yield of articles that was
narrowed down to seventeen relevant articles and one professional opinion paper in which
research evidence and information were gleaned from for use in this paper. Four of the
seventeen studies acted as an auxiliary for each of the four survey tools used in the project
implementation discussed in this paper. One article supports the evidence-based practice
model, and one article supports the conceptual model, which are both used to guide this paper.
Of the thirteen remaining research articles that correlated with this paper, ten were considered
the best evidence for the examination of this PICOT question and placed in an evaluation table
for the analysis of external evidence (Appendix E).
Critical Appraisal and Synthesis
Seventeen research studies and one professional opinion paper were included in this
literature review. All research studies were evaluated using Melnyk and Fineout-Overholt's
rapid critical appraisal. The best ten articles were chosen to be used for synthesis and
evaluation (Appendix E and Appendix F). Six of the ten studies that best answered the PICOT
question were cross-sectional, creating lower levels of evidence. Of the final ten studies, there
were six cross-sectional studies, of which two were Level II, and four were Level III, and four

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systematic review studies were included as well (Level I) (Appendix E). Five of the research
studies looked specifically at the benefits of MBSR; One was a systematic review that
evaluated the effects of MBSR on various types of chronic diseases and the other four showed
a relationship between MBSR and chronic skin diseases only. The other five articles discussed
anxiety, depression, or stress in patients with chronic skin disease.
Most of the studies included minimal bias except for two studies in which one author
had a professional correlation with the research in some aspect, and the other article had a
study outcome that was not assessed blindly (Appendix E). Only two of the studies defined a
conceptual framework. Having an established conceptual framework is essential to recognize
because these structures help guide the researcher in multiple ways throughout the study. For
instance, frameworks help to determine if the demonstration of the relevance and need for the
research is satisfactory. They also aid in establishing a persuasive line of reasoning and
absolute academic rigor in the development of the design and analysis. Undefined conceptual
frameworks were extrapolated by observing the repetition of topics and themes within the
article. Additionally, some articles provided metaphors and analogies with underlying themes
that were deduced through analysis.
The majority of the ten research studies included heterogeneous research groups in that
they encompassed men and women from all ages greater and equal to fifteen years. However,
the rest were homogeneous because most participants were non-African American and of
lighter colored skin types such as Caucasian, Turkish, or Indian. Seven of the articles were
conducted outside of the United States, significantly decreasing generalizability (Appendix F).
However, most of these studies either had a large sample size, a high level of evidence, or were
congruent with previous similar research (Appendix E). Of the six articles that were not

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systematic reviews, two of them had a consistent weakness of small sample sizes. The
strengths of small studies are that they can be quick to conduct, usually do not cost as much as
more extensive studies, and they can often address a research question in a relatively short
amount of time. However, if an association is found, it is important to make clear in the
conclusions or discussion that it was from a hypothesis-generating study, and more extensive
confirmatory research is needed, which each article with this specific limitation did note.
Nevertheless, the results of these ten studies are transferable to those people with a
chronic skin disease who are patients of a dermatology clinic. All studies involved participants
specifically with chronic skin disease. The systematic reviews analyzed and reviewed studies
that utilized participants with chronic skin disease. The majority of participants in the chosen
ten studies were either under current dermatological care or had seen a dermatologist in the
past regarding their current skin condition. Additionally, to evaluate the participants for a
mental disorder, a questionnaire or specialist evaluation was used.
All the studies had strict inclusion and exclusion criteria, which translated into the
strength of the study (Appendix E). Also, the majority of the studies found at least one
significant result of p<0.05 regarding the variable they were studying. Additionally, nine of the
articles had results that were congruent with previous research, and one article found partial
congruence in their results as compared with previous research.
There were different variables used throughout multiple studies, including anxiety,
depression, quality of life, MBSR, meditation, acne vulgaris, psoriasis, vitiligo, rosacea, and
atopic dermatitis (Appendix F). Out of the ten chosen articles used in synthesis and evaluation,
two discussed depression and skin disease, two discussed anxiety and skin disease, three
discussed both depression and anxiety and skin disease, and three discussed MBSR and skin

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disease. Interestingly, in the five studies looking at depression, only three used the same
depression survey, HADS (Appendix E). It is often difficult to correlate results from various
articles when they use different questionnaires and scales of measurement.
All the ten studies found a significant relationship between at least one of their
independent variables with the dependent variable. Most of the studies used observational
techniques and researcher-developed questionnaires, while a few of them used tested
measurements and instrumentation (Appendix E). There were various measurement tools used
(Appendix F).
Since several variables were tested amongst multiple study topics, different
measurement tools were used. There is research lacking in the study of MBSR used as an
intervention specifically to skin disease. A few of the articles opted to use several forms of
non-validated questionnaires, making the reliability and validity of the results difficult to
ascertain.
A majority of the research articles used the statistical package for social sciences
(SPSS) to analyze their data (Appendix E). Interestingly, these ten studies used a variety of
statistical tests to determine outcomes. For example, half of the ten studies used some version
of SPSS to analyze data. The other five articles used either DisMod-MR, OpenMeta, Chisquare, Fisher's exact, Mann-Whitney and Wilcoxon, Student's t-test, Spearman Correlation,
and Pearson's correlation (Appendix E). Noticeably, only one of the four systematic reviews
used SPSS.
These ten studies show that chronic skin disease can cause various levels of depression
and anxiety, affecting multiple aspects of one's life. Though no direct causation can be made,
findings of these studies show that there is a negative correlation between MBSR and anxiety

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and depression, as well as a direct relationship between chronic skin disease and both anxiety
and depression. Studies have shown that stress is widespread and significant in people with
chronic conditions, including skin disease. From this stress, anxiety and depression can occur.
Additionally, certain psychological disorders can decrease treatment adherence causing
more negative patient outcomes. Evidence-based research suggests that MBSR could be
successful in reducing anxiety and depression so often seen in patients with chronic skin
disease, improving treatment adherence, decreasing stress, anxiety, and depression, and
ultimately improving patient outcomes.
Foundational Influence from Synthesis
Research synthesis has shown that MBSR is beneficial in many types of chronic
diseases, including chronic skin disease. The synthesis of the research has shown that only a
select few chronic skin diseases have been studied in research concerning MBSR. No research
was found evaluating the effects of MBSR on acute or intermediate skin care issues or
diseases. The chronic skin diseases that have been considered in analysis with MBSR are acne
vulgaris, psoriasis, vitiligo, rosacea, or atopic dermatitis. Therefore, this project
implementation only includes participants with one or more of these chronic skin diseases
shown in research to benefit from MBSR.
Additionally, the synthesis of research has stated that the standard MBSR program is
eight weeks long. Studies have shown a more significant impact on participant outcomes using
extended MBSR programs. However, due to time constraints, this project was conducted over
four weeks. Yet, research synthesis provided partial support for MBSR interventions that are
less than the standard eight weeks in duration.
Conclusions

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Clinicians have a persistent desire to care for patients in the best way possible. This
paper intends to explore the possibility of using MBSR to decrease the anxiety and depression
often found in patients with a skin disease as well as increase treatment adherence. In
achieving these outcomes, clinicians can aid their patients in reducing psychological distress,
thereby caring more holistically for the patient.
Research establishes the positive impact of MBSR as a non-pharmacological
intervention for various types of chronic diseases. Evidence suggests that a higher level of
mindfulness can result in decreased anxiety and depression. It has also eluded to the possibility
that MBSR can accelerate the rate of skin clearing in certain chronic skin diseases.
There are advantages to an online MBSR program. Firstly, there is little risk involved
with performing MBSR. Secondly it is cost effective as it can be found for free online.
Thirdly, it can be easily accessed and learned by patients, and patients can use these learned
skills for all types of stress and anxiety experienced in their daily lives. Fourthly, and
ultimately, MBSR may create an overall enhancement in patients' quality of life. Treating the
whole patient, including assessment of their psychological status as well as providing a
psychotherapeutic intervention if needed, can help patients in multiple ways. This type of
holistic care and intervention can decrease patient stress, anxiety, and depression, increase
medication and treatment adherence, produce more positive patient outcomes, and ultimately
improve overall patient satisfaction with treatment and results.
EBP Model and Conceptual Model
The ACE Star Model of Knowledge Transformation (ACE) is an evidence-based
practice (EBP) model that provides a framework to help understand the relationship between
various stages of knowledge transformation (Bonis, Taft, & Wendler, 2007). Each point of the

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star represents a transformation of knowledge (Figure G). Moving from one point of the star to
the next allows EBP to be placed into the proper aspects of this project's context.
Knowledge discovery represents new knowledge that is discovered through both
qualitative and quantitative studies found through empirical research. The evidence summary
shows how research is synthesized regarding a problem. Research that is summarized is
combined with other sources of evidence such as clinical expertise, and this extensive evidence
is translated into the specific population, which makes up the point of the star called translation
into practice recommendations (Bonis et al., 2007). This paper has executed an exhaustive
search of literature regarding the correlations between anxiety and depression, skin disease,
and MBSR. The most relevant research with the most exceptional levels of evidence has been
evaluated to be implemented in this paper and project. The ACE explains how knowledge from
this exhaustive literature search is converted into a viable and practical psychotherapeutic
intervention. The ACE also explains how MBSR affects the health outcomes of those with skin
disease.
Integration into practice stands for the implementation of practice change through
informal and formal methods. The application of MBSR is the practice change utilized in this
project to decrease patient anxiety and depression. It is also applied to increase treatment
adherence. Finally, the last point of the star is an evaluation, which includes evaluating the
practice change on the outcomes of patients and patient satisfaction (Bonis et al., 2007). At the
end of this four-week MBSR intervention, participants will be given repeat surveys along with
a satisfaction survey to evaluate outcomes and participant satisfaction.
The ACE provides concepts that are important to foster investigation and reasoning
regarding the psychological stress surrounding the various factors affecting or affected by skin

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disease. It helps explain how research is collected, reviewed, and applied towards an
intervention. This model delivers a framework for systematically putting evidence-based
research into practice through the application of practice processes. It helps explain how
research studying MBSR applied as an intervention for anxiety and depression in chronic skin
disease patients is collected and reviewed.
The ACE explains the nature of the knowledge needed to transform current practice.
Bonis et al. (2007) state that knowledge becomes increasingly more useful and useable within
patient care as it is translated into the next stage. It is essential to understand all types of
research, and put that research together through examination, review, and synthesis, and apply
it comprehensively to patients with skin disease. This model is useful in the development of
MBSR as a psychotherapeutic intervention for those with chronic skin disease because it
depicts the various stages of knowledge transformation as newly discovered knowledge is
moved into practice. Much of the research used to create this implementation project is
relatively new and not widely studied. This model helps incorporates previous scientific
evidence-based research as well as new evidence-based research.
The guiding theoretical framework for this research paper is the Self-Efficacy
Theory (SET). Taken from social cognitive theory, SET was originated by Alberta Bandura.
Self-efficacy is the belief that one has the power to complete a given activity or task related to
competency (Bandura, 1977). The ability of a patient's perception of being able to reach their
skin disease management goal is vital for patient adherence, the best patient health outcomes,
and a decrease in anxiety and depression. The deliverance of the SET can explain the possible
increase of self-esteem in patients with skin disease and a pursuant increase in self-efficacy.
The SET is being used in this research as an effort to understand and drive behavior change of

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psychological disorder through the rise of patient self-efficacy from engaging actively in
MBSR.
The three factors that influence self-efficacy are behavior, personal and cognitive
factors, and environment (Bandura, 1977) (Appendix H). Though different concepts, Bandura
(1997) states that self-efficacy and self-esteem are related. As self-efficacy increases, so too
does self-esteem. The thought is that MBSR, which produces positive patient outcomes of
decreased psychological distress, will increase patient self-efficacy, and therefore, their
treatment adherence will increase. This will ultimately improve patient outcomes and therefore
increase patient psychosocial attitudes and self-worth. The SET suggests that self-efficacy
develops from mastery in experiences and understanding of a regimen in which the patient is
directed and given the ability to overcome obstacles (Bandura, 1977).
The SET is useful to guide practitioners in using a regimen, such as a MBSR program,
to empower the patient to overcome any worries or frustrations associated with previous
treatment failures and to eliminate any negative preconceived notions of skin disease and its
management. Having these patients learn MBSR will theoretically provide them the ability to
utilize stress reduction tools that will empower them to work through their stress and decrease
their anxiety and depression. Furthermore, since depressiveness is widely known to interfere
with medication adherence (Connor, 2017), one would also presume as the patient's
psychological symptoms decrease, that their skin disease medication adherence will increase,
causing an improvement in their skin condition. The patient would additionally experience
improved psychosocial attitudes and self-worth from this improvement in skin condition.
Behaviors, such as treatment adherence, self-esteem, anxiety, and depression, are
determined by motivation, feelings of frustration, and performance of treatment regimens

MBSR USE IN CHRONIC SKIN DISEASE

21

(Bandura, 1977). SET is being used as the conceptual framework to understand how behavior
change increases patient self-efficacy. Once patients are empowered to adapt to MBSR and
learn tools to combat stress and anxiety in their daily lives, they will experience an increase in
self-efficacy, which will increase treatment adherence and provide increased positive patient
healthcare outcomes.
Methods
A pilot program was conducted in the Fall of 2020 over a four-week time frame in a
dermatology practice clinic in the southwestern United States. This project utilized two of the
dermatology clinic’s locations in Arizona, one in Phoenix and one in Scottsdale. Both sites
provide medical, aesthetic, and surgical treatments for patients. The key stakeholders include
the clinic, nurse practitioner, other providers, front office staff, advanced practice nursing
(APN) student, patients, and family/caregivers. Multiple adult patients aged eighteen years or
older who are currently under pharmacological treatment, or no treatment, or using any
physical modality or not, or are either on or off an antidepressant or an anti-anxiety medication,
are included in this project implementation. Other inclusion criteria: Prospective participants
are; established with the dermatology clinic, identified by the clinic nurse practitioner (NP),
speak and read English, have a documented diagnoses of acne vulgaris, psoriasis, vitiligo,
rosacea, or atopic dermatitis, and has access and ability to use a personal e-mail account.
The APN student conducted multiple weekly clinic visits for two weeks to recruit
participants. The APN student explained the project, MBSR logs to record daily practices,
surveys, and consents to each eligible patient. Eligible patients completed consent, baseline
surveys, a demographics form, and provided an e-mail address. The baseline surveys include
Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder (GAD-7), and possibly a

MBSR USE IN CHRONIC SKIN DISEASE

22

Dermatologist Directed Questionnaire (DDQ). The specific demographics obtained from
participants included ethnicity, age, comorbidities, use of antidepressants, anti-anxiety
medications, or prescription dermatological medications, and participants' previous experiences
with MBSR, and health insurance.
Many methods are available to assess anxiety and depression. However, one quick,
effective, and validated tool used to measure depression in a clinical setting is called the
Patient Health Questionnaire (PHQ-9). The PHQ-9 is a valid survey tool to measure
depression. It has a sensitivity of 75.7% and a specificity of 80.0% when used to measure
depression levels in diabetic patients at an outpatient clinic (Van Steenbergen-Weijenburg et
al., 2010).
Additionally, the Generalized Anxiety Disorder (GAD-7) questionnaire is also a quick
and validated tool to measure anxiety levels in a clinical setting. In a study conducted in the
general population by Löwe et al. (2008), the GAD-7 has a sensitivity of 89% and a specificity
of 82% in diagnosing a generalized anxiety disorder.
The Likert scale is a validated tool that this project utilizes to measure patient postintervention satisfaction with MBSR. The sensitivity and specificity of the Likert scale is 80%
and 89.5%, respectively (Koksel et al., 2019).
This project measures adherence to oral and topical acne treatments via the
Dermatologist Directed Questionnaire (DDQ), the mini-questionnaire versions. One version of
the DDQ is specific to oral therapy, and the other DDQ is specific to topical treatment. Both
DDQs consist of four questions. Both mini-DDQs have a sensitivity of 0.47 and a specificity of
0.89 (Pawin et al., 2009). Unfortunately, this tool has yet to be validated. However, there were
no other adherence tools specific to skin disease found in the current literature. The DDQ is the

MBSR USE IN CHRONIC SKIN DISEASE

23

only tool used in this project that is not of the public domain. Dr. Pawin, the lead creator of the
topical and oral DDQs, has given this project written permission via e-mail to use both DDQ
questionnaires.
Initially, ten female participants agreed to enroll in this project intervention. These ten
participants received weekly informational e-mails instructing them on what MBSR practices
to engage in for that week, along with a few words of encouragement from the APN student.
Participants derived the MBSR practices from a free online MBSR website that they were able
to access at any time of their choosing. A MBSR log was attached to each participants’ first email. Participants were encouraged to engage in MBSR practices daily. Participants were
instructed to record the date, type of MBSR practice they engaged in, and any additional
comments onto their MBSR log.
After three weeks of the project implementation, one participant dropped out. At the
end of the four-week project implementation, the remaining participants received a repeat of all
baseline surveys via e-mail, with the addition of a Likert satisfaction survey. Participants were
re-instructed to complete and turn in their online surveys and MBSR log. After one week, noncompliant participants were reminded via e-mail to complete and turn in their online surveys
and MBSR log.
Upon the completion of the project and after a reminder e-mail, only three participants
completed and returned all of their post-intervention surveys and MBSR log. The three
participants comprised of females ages twenty-five, thirty, and fourty years; two Caucasians,
and one Hispanic; and current diagnosis of a chronic skin disease of rosacea, acne vulgaris, and
vitiligo respectively. All participants had previously engaged in some form of MBSR: two had
tried yoga and one performed meditation. One participant had been taking anti-anxiety and

MBSR USE IN CHRONIC SKIN DISEASE

24

anti-depression medications for “years”. This particular participant was the only one to have
other co-morbidities of: Irritable bowel syndrome, attention deficit disorder, anxiety, and
depression. All other participants denied any co-morbidities. One participant was currently
using prescription topical medications for their skin disease. All participants had active
insurance.
Human Subject Protection
During initial recruitment, the APN student instructed all eligible participants that they
may opt-out of the project at any time, and they may refuse to answer any question with which
they are not comfortable on any survey or paperwork for the project. The consent for the
project also contained this information. A four-digit code of patients’ first two letters of their
first name followed by their birthday month in two-digit format was linked to all MBSR log,
surveys, demographics, and e-mail addresses in Qualtrics (survey program). All e-mails that
sent to the participants utilized their four-digit identifier code. All e-mails were sent to the
participants via the APN student’s school e-mail account, which required password and ID
name protection. Additionally, all data from Qualtrics employed the participant four-digit
code. The contact field was changed in Qualtrics so that only the external reference could be
viewed.
Once the data was collected, the APN student placed all de-identified data from
Qualtrics into a de-identified master datasheet. When all data was collected, this master data
sheet was printed and immediately locked in a file cabinet in the APN’s home office and was
only accessible by the APN student. After all information and data were retrieved from
participant e-mail, the APN student destroyed all patient e-mails as well as any electronic
MBSR logs. As soon as all information and data were extracted and analyzed and outcomes

MBSR USE IN CHRONIC SKIN DISEASE

25

were measured, the APN student destroyed all surveys and participant information, e-mail
addresses and e-mails, MBSR logs, data, and surveys and e-mail addresses on Qualtrics.
The master list and consents only existed until project completion, May of 2020. Once the
outcomes were measured and evaluated, the master list and consents were destroyed. No
digital copies of the master list, consents, or any other part of this project were kept at any
time.
This project did consist of a particular intervention detail. If either a participant’s pre
or post PHQ-9 or GAD-7 survey totaled ten or higher, or if there was any positive answer to
question number nine of the PHQ-9, “Thoughts that you would be better off dead or of hurting
yourself in some way,” the APN student would speak to the NP either at that time (found
during pre-survey) or the APN student would call the NP (discovered during post-survey) for
immediate referral, and have the dermatology clinic NP decide on the referral course of action.
Consents contained the participants’ four-digit code and names and would only be accessed
upon findings of an abnormal PHQ-9 or GAD-7 survey results. IRB approval from Arizona
State University for this project implementation was received on December 21st, 2019.
Data Collection and Analysis Plan
Budget and Funding
This project was managed and implemented solely on awarded grant funding and inkind donations. Other grant funding was provided by Arizona Dermatology and by involved
individuals who donated their time to the project. As need dictates, the dermatology clinic is
willing to aide in the sustainability of the program by continuing support and funding after the
project intervention period comes to an end (Appendix I.1 to I.4). Additionally, participants
who turned in their MBSR log and surveys at the end of the four-week project intervention

MBSR USE IN CHRONIC SKIN DISEASE

26

received a ten dollar Starbucks gift card. Ten dollars is generally considered an appropriate
“Thank you” amount, and it is not coercive. The money for these gift cards was provided for
by the APN student.
Results
Outcomes and Clinical Significance
Statistical analysis of the project data has limited power due to small sample size. Due
to the small sample size, other relevant statistical analyses, such as the effects of MBSR on
medication adherence, and the relationship of the frequency of performed MBSR exercises to
outcomes, could not be established.
A two-tailed Wilcoxon signed-rank test was conducted through Intellectus to examine
whether there was a significant difference between GAD-7 and PHQ-9 pre and post scores.
The results of the two-tailed Wilcoxon signed-rank test for GAD-7 scores were not significant
based on an alpha value of 0.05, V = 4.00, z = -0.58, p = .564. The results of the two-tailed
Wilcoxon signed-rank test for PHQ-9 scores were not significant based on an alpha value of
0.05, V = 4.50, z = -0.82, p = .414. These results indicate that the differences between GAD-7
and PHQ-9 scores are both explainable by random variation.
However, though not statistically significant, results are clinically significant. All
participants showed a decrease in pre and post GAD-7 and PHQ-9 scores and subjective
symptoms after engaging in the MBSR intervention. Of particular interest is that one
participant had been taking anti-anxiety and anti-depression medications for at least three
years. This participant showed a reduction in both anxiety and depression symptoms and
survey scores. This participant showed the greatest decrease in GAD-7 pre and post scores.

MBSR USE IN CHRONIC SKIN DISEASE

27

All participants reported enjoyment using MBSR, stated they would continue using
MBSR, agreed their skin condition improved with MBSR, and indicated they had a reduction
in their anxiety/depression symptoms after MBSR. Quotes from participants MBSR logs: “I am
sleeping better after using MBSR,” “I felt less stressed after doing my meditation,” “…easier
to fall asleep,” “I enjoyed the stretching,” “Felt my mood shift a bit after this to a more positive
mindset,” “It was really relaxing to me,” and “I feel calmer after trying visualization.” The
biggest barrier to engaging in MBSR practices was collectively agreed upon by the participants
as finding time in the day.
Implications and Sustainability
The literature agrees that anxiety and depression are prevalent in patients with chronic
skin diseases and that dermatology providers frequently under-recognized these psychological
disorders. This information leads to the implication that perhaps there is a role for
psychological screening for patients with chronic skin diseases who visit dermatology clinics.
Dermatology clinic policy will have to change to enforce this and establish protocols to
distinguish which patients to survey, to establish the types of surveys used, and to layout an
intervention and referral plan.
Due to the prevalence and impact of anxiety and depression in patients with chronic
skin disease, providers should, at the very least, inquire as to the psychological disposition of
their patients. The dermatologist can then ask further questions as appropriately needed.
Screening for psychological disorders such as anxiety and depression are just as
important as screening for diabetes, high blood pressure, and other physical diseases.
Screening is the first step in getting help for patients. Anxiety and depression can be severe

MBSR USE IN CHRONIC SKIN DISEASE

28

illnesses within the dermatological population. As research has shown, they can also
complicate other medical conditions and even lead to suicide.
There is a clinical gap in many dermatology offices in both the screening of chronic
skin disease patients and available options for timely, appropriate interventions. Providing
screening and support options such as referrals and MBSR for patients with chronic skin
disease is vital to help dermatological patients adjust psychologically in a positive manner to
the sequelae of their skin disease.
A noteworthy implication is that screening and supporting patients with chronic skin
disease suffering from anxiety and depression may help build a business case for increased
access to psychological services within dermatology clinics (Lamb et al., 2017). Additionally,
screening and supporting patients with chronic skin disease would improve patient access and
intervention to behavioral healthcare within a specialty setting.
MBSR has been shown in research to decrease anxiety and depression in
chronic skin disease patients. All three participants in this project intervention showed a
decrease in both their anxiety and depression after the implementation of an online MBSR
program. Dermatologists can comfortably and quickly provide MBSR. Furthermore, ancillary
staff can educate patients on MBSR, thereby avoiding interruption of the providers' daily
workflow.
Once anxiety and depression are recognized in skin disease patients, MBSR can be
used in conjunction with other interventions. Through screening and intervening, patients will
likely feel better, increase medication adherence, have lower levels of anxiety and depression,
show improved medical outcomes, all resulting in improved satisfaction with treatment.

MBSR USE IN CHRONIC SKIN DISEASE

29

Sustaining the MBSR project requires the dermatology clinic to either screen their
patients or, at the very least, initiate a discussion with their patients about anxiety and
depression. The site will have to keep offering their patients information and education
regarding MBSR. Providers and clinic staff will need to be educated on MBSR, and pamphlets
would be necessitated for ease of patient education. A company protocol regarding screening
and intervention would need to be established for MBSR sustainability.
Discussion
Limitations
The first apparent limitation to this study is that only three participants completed the
project. Lack of participants made descriptive data analysis inept, and it precluded any chance
of resultant correlations or significance through analysis. Additionally, all three participants
were female and had self-reported mild skin symptoms.
Part of this project was to look at the effects of MBSR on medication adherence.
However, no data analysis was able to be performed regarding this as only one participant was
currently taking oral prescription medication. Furthermore, that same participant was the only
participant who was presently taking anti-anxiety and anti-depression drugs, again, not
allowing for any type of analysis or comparisons to be made.
The MBSR online program was set up for the participants so that they could perform it
at home at a time of their convenience. However, this method did not create accountability for
the participant, and it was based on the honor system as there was no program to track the
number of completed practices.
This project did not, however, have complete blinding of participants; they knew the
purpose of the project and the desired end goal. The samples were drawn from one specialized

MBSR USE IN CHRONIC SKIN DISEASE

30

dermatology clinic. By including participants from only one clinic site, boundaries on the
generalizability of any results are created.
Recommendations for Future Research
Though the findings of this project were not statistically significant, each participant
did show a decrease in both their anxiety and depression levels after the MBSR intervention
and stated they had decreased skin condition symptoms. This decrease in anxiety and
depression from engagement in MBSR practices does agree with previous research. However,
future studies should use a MBSR program in which the participants’ involvement in each
exercise can be monitored. A more significant number of participants, both male and female,
and with a greater variety of skin disease severity should be used.
As research has stated, many dermatology clinics under-recognized anxiety and
depression issues in their patients. As evidenced by this project clinic site, no psychological
screening or communication about anxiety and depression is performed with chronic skin
disease patients. Therefore, future studies should examine the benefits of a clinic protocol for
screening and for anxiety and depression in patients with chronic skin disease.
Future research should also use multi-sites for recruiting possible participants. It would
additionally be beneficial to glean clinician ratings of skin severity to evaluate the effects of
MBSR on the outward signs of chronic skin disease. Finally, future studies need to look at a
greater variance of ethnicities. It is advisable to look at and evaluate participants' quality of life
and get participants who are on chronic skin disease medication to assess the impact of MBSR
on medication adherence.
This project did, however, find two important considerations for future studies to
continue to utilize. First, it was found very beneficial to have the participants record their

MBSR USE IN CHRONIC SKIN DISEASE

31

subjective comments after engaging in a MBSR exercise. Obtaining participant subjective
comments provides greater insight into the immediate benefits of MBSR. Secondly, the
evaluation of participant satisfaction to the MBSR program proved valuable. Having
participants complete a satisfaction survey after a MBSR program intervention provided a
better understanding of how participants felt about the program overall. A satisfaction survey
may expose the weaknesses and strengths of the MBSR program, aid in supporting the results
of the MBSR program, and better understand the benefits MBSR provided the participant.
Summary
Psychological stress is prominent in patients with chronic skin disease. Stress can
result in adverse outcomes for patients with chronic skin disease, including anxiety and
depression. Patients with chronic skin disease have increased levels of anxiety and depression
as compared to patients without chronic skin disease. MBSR is a psychotherapeutic
intervention that providers can comfortably and efficiently provide to their patients. Patients
can learn MBSR on their own and use the skills they acquire from it to combat all types of
stressors.
Implementation of this pilot program in a dermatology clinic showed that patients with
chronic skin disease experienced a reduction in anxiety and depression survey scores and
symptoms after engaging in MBSR. MBSR has the potential to help patients manage their
daily stressors better, increase their treatment adherence, and provide for them better overall
outcomes and satisfaction levels.

MBSR USE IN CHRONIC SKIN DISEASE

32

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MBSR USE IN CHRONIC SKIN DISEASE
Appendix A
Search Strategy 1
CINAHL
Figure A.1

FigureA.2

37

MBSR USE IN CHRONIC SKIN DISEASE
Appendix B
Search Strategy 2
Cochrane Library
Figure B.1

38

MBSR USE IN CHRONIC SKIN DISEASE
Appendix C
Search Strategy 3
PsycINFO
Figure C.1

39

MBSR USE IN CHRONIC SKIN DISEASE
Appendix D
Search Strategy 4
PubMed
Figure D.1

Figure D.2

40

MBSR USE IN CHRONIC SKIN DISEASE

41

Appendix E
Table 1
Evaluation Table
Citation

Theory/
Conceptual
Framework

Design/
Method/
Purpose

Sample/Setting

Dalgard et. al,
2018.
Dermatologists across
Europe
underestimate
depression &
anxiety: results
from 3,635
dermatological
consultations
Country:
Europe

Social and
behavioral
science theory

Design:
Observational
crosssectional
multicenter
study
Purpose: to
estimate the
concordance
between
clinical
assessment of
dep and anx
by a derma
and ass with
the HADS

N = 3,635
Demographics:
Not disclosed
Setting: 13 outpt
derm clinics in
Europe
Inclusion:
-read/write local
language
-not having severe
pscyh
-18 yrs & older
Exclusion:
-< 18 years
-non-derm pts

IV: dep
IV: anx
DV: HADS

Design:
Cross
sectional
Purpose:
gain insight
into pscyho
factors
affecting SD,
examining

N = 237
Demographics:
M = 76, F = 161,
over 18 yrs
Setting: online
Inclusion:
-over 18 yrs
-speak and read
English

IV: AS

Funding:
None
Bias: none
reported
Dixon et. al,
2018. Stress
and skin
disease quality
of life: The
moderating
role of anxiety
sensitivity
social concerns

Stress and
adaptation
model

Major Variables
Studied and
Their Definitions

Measurement/
Instrumentation

Data
Analysis

Time frame of the
intervention –
several wks

Level of evidence/
Decision for Use/Application to
Practice

HADS to
measure anx &
dep

SPSS 24
K
Fleiss

High conco
betw dermas
& HADS
when no dep
(79.7%) & no
anxiety
(70.8%).
Dermas
underes dep
in 5.8% of
consults and
anx 11.2%

Level of Evidence: II
Strength: high # of consults, results
were significant.
Weakness: did not disclose severity
of pt skin disease, pt reported anx &
dep, no detailed instr to dermas to
assess anx or dep
Conclusion: significant results of
this study agree with previous
literature and studies & showed
dermas in Europe underestimate
mood d/o’s

MTurk
ASI-3
Skindex-16

SPSS
statistics
version 23
PROCESS
macro for
SPSS
version
2.16.1
Sig level

Decreases in
AS result in
increased
psychological
well-being

Level of Evidence: III
Strength: sig results, results
congruent with previous studies,
Weakness: self-reported measures,
SD not verified by physician,
Conclusion: results suggest
decreasing AS improves
psychological well-being and breaks
skin symptom and stress cycle in

Time frame of the
intervention –
11//2011 to 2/2013

DV: SD
DV II: stress
DV III: QOL

Findings/
Results

# - number, aa – alopecia areata, ad – atopic dermatitis, AN – Asian, anx – anxiety, AS – anxiety sensitivity, ASI-3 – Anxiety Sensitivity Index-3, asses – assessment, AV – acne vulgaris, B – Black, BDI – Beck Depression
Inventory, betw – between, conco – concordance, dep – depression, derma(s) – dermatologist(s), derm – dermatology, diff – different, DLQI – Dermatological quality of life scale, d/o – disorder, ds – disease, du – decubitus
ulcer, dx – diagnosis, F – female, fsd – fungal skin disease, f/u – follow-up, HADS – Hospital Anxiety & Depression Scale, improv – improvement, info – information, instr – instruction, k – Kohen’s Kappa, lit – literature, M –
male, MBSR – mindful-based stress reduction, mc – molluscum contagiosum, med – medication, MTurk – Amazon’s Mechanical Turk through TurkPrime, neuro – neurological, NF – nonfatal, nmsc – non-melanoma skin
cancer, NOS – Newcastle-Ottawa Scale, NR – non-randomized, outpt – outpatient, PICOS - Population, Interventions, Comparators, Outcomes, Study Design, PRISMA – preferred reported items for systematic reviews and metaanalysis, psych – psychosis, psycho – psychological, pt(s) – patients(s), QOL – quality of life, RCTs – randomized controlled studies – sig – significance, SD – skin disease, SI – suicidal ideation, sig – significant, ST – short
term, tx – treatment, UK – United Kingdom, underes(d) – underestimate(d), USA – United States of America val – validated, vw – viral warts, W – White, yr(s) – year(s), wks - weeks

MBSR USE IN CHRONIC SKIN DISEASE

Citation

Theory/
Conceptual
Framework

Country:
USA
Funding:
None
Bias: author
R.T.B. is on
the
CONSENTYX
Advisory
Board and has
been the
Principal
Investigator of
clinical trials
performed for
Golderma
Laboratories,
L.P. and
Novartis
Gül &
Çölgeçen,
2015.
Personality
traits and
common
psychiatric
conditions in
adult patients
with acne
vulgaris
Country:
Turkey

Psycho-social
theory

Design/
Method/
Purpose

Sample/Setting

AS role and
its
relationship
to stress and
SD QOL

-location in USA
-current dx of skin
ds with active
symptoms over
past 4 wks
-no skin ds
exclusions
Exclusion:
-non English
speaking
- Attrition:

Design:
prospective
cohort study
Purpose:
investigate
personality
traits and
common
psych
conditions in
pts with adult
AV

N = 40
Demographics:
F = 34, M = 6, 2541 yrs of age
Setting:
Bozok University
Medical School
derm outpatient
clinic
Inclusion:
-current dx of adult
AV
-25 yrs of age or

42

Major Variables
Studied and
Their Definitions

Measurement/
Instrumentation

Data
Analysis

Findings/
Results

was 0.05
two tailed

IV: Adult pts with
acne
DV I: somatization
DV II: depression
DV III: anxiety

Symptom
checklist 90revised
Eysenck
personality
questionnairerevised short
form

SPSS
version 17
MannWhitney U
test
Spearman
correlation
analysis
<0.05 is sig

Level of evidence/
Decision for Use/Application to
Practice
SD.

Dep p<0.001,
anx p<0.001
Strong
positive
correlation
betw
somatization,
dep, anx and
AV

Level of Evidence: II
Strength: control group, results
consistent with previous studies, no
pts given systematic txt for AV
Weakness: self-reported by pts,
small sample size
Conclusion: common psych
conditions occur with considerably
high rates in adult pts with AV

# - number, aa – alopecia areata, ad – atopic dermatitis, AN – Asian, anx – anxiety, AS – anxiety sensitivity, ASI-3 – Anxiety Sensitivity Index-3, asses – assessment, AV – acne vulgaris, B – Black, BDI – Beck Depression
Inventory, betw – between, conco – concordance, dep – depression, derma(s) – dermatologist(s), derm – dermatology, diff – different, DLQI – Dermatological quality of life scale, d/o – disorder, ds – disease, du – decubitus
ulcer, dx – diagnosis, F – female, fsd – fungal skin disease, f/u – follow-up, HADS – Hospital Anxiety & Depression Scale, improv – improvement, info – information, instr – instruction, k – Kohen’s Kappa, lit – literature, M –
male, MBSR – mindful-based stress reduction, mc – molluscum contagiosum, med – medication, MTurk – Amazon’s Mechanical Turk through TurkPrime, neuro – neurological, NF – nonfatal, nmsc – non-melanoma skin
cancer, NOS – Newcastle-Ottawa Scale, NR – non-randomized, outpt – outpatient, PICOS - Population, Interventions, Comparators, Outcomes, Study Design, PRISMA – preferred reported items for systematic reviews and metaanalysis, psych – psychosis, psycho – psychological, pt(s) – patients(s), QOL – quality of life, RCTs – randomized controlled studies – sig – significance, SD – skin disease, SI – suicidal ideation, sig – significant, ST – short
term, tx – treatment, UK – United Kingdom, underes(d) – underestimate(d), USA – United States of America val – validated, vw – viral warts, W – White, yr(s) – year(s), wks - weeks

MBSR USE IN CHRONIC SKIN DISEASE

Citation

Theory/
Conceptual
Framework

Design/
Method/
Purpose

Funding: none
noted
Bias: none
noted

Hay et. al,
2013. The
Global Burden
of Skin
Disease in
2010: An
analysis of the
prevalence &
impact of skin
conditions
Country: UK,
USA,
Australia,
Italy, Africa,
Ethiopia,
India, other
global studies
utilized
Funding:
Grant from
Bill & Melinda
Gates
Foundation
Bias: none
stated

Sample/Setting

43

Major Variables
Studied and
Their Definitions

Measurement/
Instrumentation

Data
Analysis

Baysian metaregression tool
World databases
ICD 10

DisMod-MR

Findings/
Results

Level of evidence/
Decision for Use/Application to
Practice

older
Exclusion –
Neuro, psych,
medical, alcohol,
substance abuse comorbidities or med
that may cause
psych ds
Social
cognitive
theory

Design:
systematic lit
review
Purpose: to
determine top
derm ds NF
burden for
187 countries

N = 895 countryyears of data
Demographics:
M & F with
eczema, psoriasis,
AV, pruritus, aa,
du, urticaria,
scabies, fsd,
impetigo, abscess,
& other bacterial
skin ds, cellulitis,
vw, mc, & nmsc.
Setting: Data from
82 countries
Inclusion:
-1980-2010 with
data on relevant ds
Exclusion:
-self-reported data
unless val
-occupational
groups
-non-random
studies

IV: skin ds
DV: health burden
Time frame of the
intervention –
1990-2010

Skin ds
causes large
and sig
burden on
derm pts in
global
context

Level of Evidence: I
Strength: severity of ds was
considered, sig results
Weakness: missing quality data at
regional level, only focused on most
prevalent skin ds, may have
underestimated burden
Conclusion: in 2010, SD was 18th
leading cause of health burden
worldwide

# - number, aa – alopecia areata, ad – atopic dermatitis, AN – Asian, anx – anxiety, AS – anxiety sensitivity, ASI-3 – Anxiety Sensitivity Index-3, asses – assessment, AV – acne vulgaris, B – Black, BDI – Beck Depression
Inventory, betw – between, conco – concordance, dep – depression, derma(s) – dermatologist(s), derm – dermatology, diff – different, DLQI – Dermatological quality of life scale, d/o – disorder, ds – disease, du – decubitus
ulcer, dx – diagnosis, F – female, fsd – fungal skin disease, f/u – follow-up, HADS – Hospital Anxiety & Depression Scale, improv – improvement, info – information, instr – instruction, k – Kohen’s Kappa, lit – literature, M –
male, MBSR – mindful-based stress reduction, mc – molluscum contagiosum, med – medication, MTurk – Amazon’s Mechanical Turk through TurkPrime, neuro – neurological, NF – nonfatal, nmsc – non-melanoma skin
cancer, NOS – Newcastle-Ottawa Scale, NR – non-randomized, outpt – outpatient, PICOS - Population, Interventions, Comparators, Outcomes, Study Design, PRISMA – preferred reported items for systematic reviews and metaanalysis, psych – psychosis, psycho – psychological, pt(s) – patients(s), QOL – quality of life, RCTs – randomized controlled studies – sig – significance, SD – skin disease, SI – suicidal ideation, sig – significant, ST – short
term, tx – treatment, UK – United Kingdom, underes(d) – underestimate(d), USA – United States of America val – validated, vw – viral warts, W – White, yr(s) – year(s), wks - weeks

MBSR USE IN CHRONIC SKIN DISEASE

Citation

Theory/
Conceptual
Framework

Montgomery
et. al, 2016.
The importance of
mindfulness in
psych-osocial
distress and
quality of life
in dermatology
patients
Country: UK
Funding:
Ecomonomic
& social
research
council
Bias: none
reported
Niazi & Niazi,
2011.
Mindfulnessbased stress
reduction: A
non-pharmacological

Quality of life
theory

Mindfulness
Theory

Design/
Method/
Purpose

Design:
crosssectional
Purpose:
Examine
relationship
betw
mindfulness
& distress in
derm pts

Design:
systematic
review
Purpose:
determine
efficacy of
MBSR in tx

Sample/Setting

-sample size <100
-experimental arm
of clinical trial
-estimates found
and not data
-studied specific
groupings
N = 120
Demographics:
M = 35, F = 84, not
reported = 1, W =
104, AN = 5, B =
1, other = 8, not
reported = 2
Incl:
-pt at one hospital
-literate
-dx acne
Exc
-primary pscy dx
affecting skin
-skin cancer

N = 18
Demographics:
-both genders
Setting: multiple
Inclusion:
RCTs
-English-language

44

Major Variables
Studied and
Their Definitions

Measurement/
Instrumentation

Data
Analysis

Findings/
Results

IV: Mindfulness
DV I: anx
DV II: dep
Five Facet
Mindfulness
Questionnaire
Five point scale
SD subjective
severity
Skin Shame
ScaleBrief Fear
of Negative
Evaluation
HADS
DLQI

IV: MBSR
DV: chronic ds
Time frame of the
intervention –
anytime

-anx, dep, stress,
QOL
-recurrence &
relapse of ds

Hierarchical
regression
analyses

Researchers
abstracted
info
themselves
for each
article

Clinically sig
positive
correlation
levels of anx
(p<0.05).

All studies
showed
improv in ds
condition
after MBSR

Level of evidence/
Decision for Use/Application to
Practice

Level of Evidence: III
Strength: outcomes congruent with
previous studies, sig correlation
between mindfulness and pscyho
distress
Weakness: cross-sectional
precludes strong conclusions,
objective severity of SD used,
sample predominantly W F, samples
only from one derm clinic.
Conclusion: higher levels of
mindfulness are associated with
reduced psycho distress and
improved derm QOL

Level of Evidence: I
Strength: Pubmed and Cochrane
searched, initial results 2,607
articles, 32 found relevant after first
screen, and 18 of these 32 were full
text.
Weakness: no data analysis

# - number, aa – alopecia areata, ad – atopic dermatitis, AN – Asian, anx – anxiety, AS – anxiety sensitivity, ASI-3 – Anxiety Sensitivity Index-3, asses – assessment, AV – acne vulgaris, B – Black, BDI – Beck Depression
Inventory, betw – between, conco – concordance, dep – depression, derma(s) – dermatologist(s), derm – dermatology, diff – different, DLQI – Dermatological quality of life scale, d/o – disorder, ds – disease, du – decubitus
ulcer, dx – diagnosis, F – female, fsd – fungal skin disease, f/u – follow-up, HADS – Hospital Anxiety & Depression Scale, improv – improvement, info – information, instr – instruction, k – Kohen’s Kappa, lit – literature, M –
male, MBSR – mindful-based stress reduction, mc – molluscum contagiosum, med – medication, MTurk – Amazon’s Mechanical Turk through TurkPrime, neuro – neurological, NF – nonfatal, nmsc – non-melanoma skin
cancer, NOS – Newcastle-Ottawa Scale, NR – non-randomized, outpt – outpatient, PICOS - Population, Interventions, Comparators, Outcomes, Study Design, PRISMA – preferred reported items for systematic reviews and metaanalysis, psych – psychosis, psycho – psychological, pt(s) – patients(s), QOL – quality of life, RCTs – randomized controlled studies – sig – significance, SD – skin disease, SI – suicidal ideation, sig – significant, ST – short
term, tx – treatment, UK – United Kingdom, underes(d) – underestimate(d), USA – United States of America val – validated, vw – viral warts, W – White, yr(s) – year(s), wks - weeks

MBSR USE IN CHRONIC SKIN DISEASE

Citation

Theory/
Conceptual
Framework

approach for
chronic
illnesses
Country:
Pakistan

Design/
Method/
Purpose

Sample/Setting

of chronic ds

-humans
Exclusion:
-animal studies
-not full text
articles
-funded research

Design:
systematic
review

N = 106
Demographics:
Setting:
-M & F
Inclusion:
-cross-sectional or
cohort study
-assessed: AD
and/or suicide
-at least 20 subjects
with AD
-any language
Exclusion:
-reviews
-editorials
-duplicated studies

45

Major Variables
Studied and
Their Definitions

Measurement/
Instrumentation

Data
Analysis

Findings/
Results

Level of evidence/
Decision for Use/Application to
Practice
performed, only researcher summary
of results
Conclusion: MBSR may help a
broad range of pts cope with their
clinical and non-clinical problems

Funding:
None
Bias: none
noted
Patel et. al,
2019.
Association
between atopic
dermatitis,
depression,
and suicidal
ideation:
A systematic
review and
meta-analysis
Country:
USA
Funding:
None
Bias: none
noted

Cognitive
Theory

Purpose:
Determine
the complex
relationship
between AD
and dep

IV: AD
DV 1: suicide
DV 2: dep
Time frame of the
intervention –
1963-2018

NOS

OpenMeta

1 in 6
persons with
AD had
clinical dep,
1 in 4 dep
symptoms, 1
in 8 SI.

Level of Evidence: I
Strength: clinically significant and
relevant
Weakness: AD measured with diff
dep scales, self-reported dep
Conclusion: pts with AD have a
higher risk of dep and SI

# - number, aa – alopecia areata, ad – atopic dermatitis, AN – Asian, anx – anxiety, AS – anxiety sensitivity, ASI-3 – Anxiety Sensitivity Index-3, asses – assessment, AV – acne vulgaris, B – Black, BDI – Beck Depression
Inventory, betw – between, conco – concordance, dep – depression, derma(s) – dermatologist(s), derm – dermatology, diff – different, DLQI – Dermatological quality of life scale, d/o – disorder, ds – disease, du – decubitus
ulcer, dx – diagnosis, F – female, fsd – fungal skin disease, f/u – follow-up, HADS – Hospital Anxiety & Depression Scale, improv – improvement, info – information, instr – instruction, k – Kohen’s Kappa, lit – literature, M –
male, MBSR – mindful-based stress reduction, mc – molluscum contagiosum, med – medication, MTurk – Amazon’s Mechanical Turk through TurkPrime, neuro – neurological, NF – nonfatal, nmsc – non-melanoma skin
cancer, NOS – Newcastle-Ottawa Scale, NR – non-randomized, outpt – outpatient, PICOS - Population, Interventions, Comparators, Outcomes, Study Design, PRISMA – preferred reported items for systematic reviews and metaanalysis, psych – psychosis, psycho – psychological, pt(s) – patients(s), QOL – quality of life, RCTs – randomized controlled studies – sig – significance, SD – skin disease, SI – suicidal ideation, sig – significant, ST – short
term, tx – treatment, UK – United Kingdom, underes(d) – underestimate(d), USA – United States of America val – validated, vw – viral warts, W – White, yr(s) – year(s), wks - weeks

MBSR USE IN CHRONIC SKIN DISEASE

Citation

Theory/
Conceptual
Framework

Design/
Method/
Purpose

Sample/Setting

Pietrzak et. al,
2017.
Depressiveness, measured
with Beck
Depression
Inventory, in
patients with
psoriasis.
Country:
Poland
Funding:Medical University
of Lublin
Funds
Bias: selection
bias

Pyschodynami
c theory

Design:
crosssectional non
prospective
Purpose:
identify
demographic
and clinical
factors
predisposing
dep during
course of
psoriasis

N = 239
Demographics:
-pts with psoriasis:
ages 15-76 yrs
-31.8% F
-health controls:
123 pts ages 17-74
yrs, F = 32.5%

Salman et. al,
2016. Social
anxiety and
quality of life
in vitiligo and
acne patients
with facial
involvement
Country:
Turkey

Interpersonal
Theory

Design:
crosssectional
controlled

N = 74 acne study
participants
Demographics:
M = 34, F = 40,
over 18 yrs. 37
vitiligo, 37 acne, &
74 age/sex matched
health controls over
18 yrs
Setting: outpt derm

Purpose:
compare
levels of
depression,
anxiety, and

46

Major Variables
Studied and
Their Definitions

Measurement/
Instrumentation

Data
Analysis

Findings/
Results

Level of evidence/
Decision for Use/Application to
Practice

Multivariate
analysis =
independent
predictors of
any grade of
dep
correlated sig
with presence
of psoriasis

Level of Evidence: III
Strength: no pts on anti-depression
meds, results similar to majority of
past research
Weakness: cross-sectional,
selection bias, control group were
other derm pts
Conclusion: pts with psoriasis
regardless of severity are at
increased risk of dep

Social
anxiety,
depression
and anxiety
levels of acne
patients were
significantly
higher than
health
controls 6.4

Level of Evidence: III
Strength: all aspects of social
anxiety addressed, results congruent
with previous studies,
Weakness: cross-sectional design,
relatively small sample size
Conclusion: facial acne was shown
to cause increased levels of social
anxiety, depression, and impaired
QOL. It is important to have

IV: psoriasis
DV: dep
Time Frame: 20142016

Setting: a derm
medical center in
Poland
Inclusion:
-current dx of
psoriasis
Exclusion:
-hx of recent
myocardial ds
-mental disorders
-immunosuppressive usage
-no anti-depression
meds

BDI

IV: acne
DV1:
anxiety/QOL/depres
sion
Time frame of the
intervention –avg
interview 40 min

Subjective:
Visual analog
scale of 10 cm
Objective: EATG
LSAS (Sn
73.66% and Sp
76.70%)
HADS (Sp of
79& and Sn of

ShapiroWilk test
MannWhitney Utest
KruskalWallis test
Pearson’s
chi-square
Fisher’s
exact test
Spearman
rank
correlation
coefficients

SPSS
Kolmogorov
-Smirnov
test
Chi square
test
Student’s ttest
Pearson’s
correlation

# - number, aa – alopecia areata, ad – atopic dermatitis, AN – Asian, anx – anxiety, AS – anxiety sensitivity, ASI-3 – Anxiety Sensitivity Index-3, asses – assessment, AV – acne vulgaris, B – Black, BDI – Beck Depression
Inventory, betw – between, conco – concordance, dep – depression, derma(s) – dermatologist(s), derm – dermatology, diff – different, DLQI – Dermatological quality of life scale, d/o – disorder, ds – disease, du – decubitus
ulcer, dx – diagnosis, F – female, fsd – fungal skin disease, f/u – follow-up, HADS – Hospital Anxiety & Depression Scale, improv – improvement, info – information, instr – instruction, k – Kohen’s Kappa, lit – literature, M –
male, MBSR – mindful-based stress reduction, mc – molluscum contagiosum, med – medication, MTurk – Amazon’s Mechanical Turk through TurkPrime, neuro – neurological, NF – nonfatal, nmsc – non-melanoma skin
cancer, NOS – Newcastle-Ottawa Scale, NR – non-randomized, outpt – outpatient, PICOS - Population, Interventions, Comparators, Outcomes, Study Design, PRISMA – preferred reported items for systematic reviews and metaanalysis, psych – psychosis, psycho – psychological, pt(s) – patients(s), QOL – quality of life, RCTs – randomized controlled studies – sig – significance, SD – skin disease, SI – suicidal ideation, sig – significant, ST – short
term, tx – treatment, UK – United Kingdom, underes(d) – underestimate(d), USA – United States of America val – validated, vw – viral warts, W – White, yr(s) – year(s), wks - weeks

MBSR USE IN CHRONIC SKIN DISEASE

Citation

Theory/
Conceptual
Framework

Funding:
None

Design/
Method/
Purpose

Sample/Setting

QOL in acne
pts vs nonacne pts

clinic
Inclusion:
-over 18 yrs
-dx vitiligo or acne
(lesions visible at
least 1m)
Exclusion:
-another other
facial condition,
not mentally able to
use questionnaire
Attrition: 0%
N = 59
Demographics:
M = 25%
F = 75%
Setting: various
Inclusion:
-MBSR program 2
wks or longer
-RCTs
Exclusion:
-f/u, observational,
and NR studies
-intensive programs
-inpatient

Bias: none
noted

Victorson et.
al, 2015
Country:
USA
Funding:
None
Bias: none
noted

PICOS
Framework

Design:
systematic
review and
meta-analysis
Purpose:
Determine
benefits of
MBSR on
various
populations
and
conditions

47

Major Variables
Studied and
Their Definitions

Measurement/
Instrumentation

Data
Analysis

83%)
DLQI (Sp = 81%
and Sn = 83%).

IV: MBSR
DV1: various
population
conditions
Time frame of the
intervention – 2002
- 2012

PRISMA
Cochran
Collection

Hedge’s g
Cochrane
risk of bias
tool
SPSS
version 22

Findings/
Results

Level of evidence/
Decision for Use/Application to
Practice

+/1 6.2
(p<0.05).
QOL was
negatively
correlated
with social
anxiety and
depression

psychological assessment for each
acne pt.

Partial
evidence for
MBSR to
provide ST
benefits
across wide
range of
medicinerelevant
populations
-MBSR is
superior to no
txt at all

Level of Evidence: I
Strength: large # of studies,
significant evidence for ST benefit
of MBSR in managing symptom
burden and affecting modifiable
health behaviors
Weakness: publication bias was not
examined across included studies,
many studies failed to report risk
bias and/or blinding, for several
analytic comparisons, the
homogeneity of variance assumption
was not met
Conclusion: partial evidence for ST
effectiveness of MBSR on various
lifestyle medicine-relevant contexts

# - number, aa – alopecia areata, ad – atopic dermatitis, AN – Asian, anx – anxiety, AS – anxiety sensitivity, ASI-3 – Anxiety Sensitivity Index-3, asses – assessment, AV – acne vulgaris, B – Black, BDI – Beck Depression
Inventory, betw – between, conco – concordance, dep – depression, derma(s) – dermatologist(s), derm – dermatology, diff – different, DLQI – Dermatological quality of life scale, d/o – disorder, ds – disease, du – decubitus
ulcer, dx – diagnosis, F – female, fsd – fungal skin disease, f/u – follow-up, HADS – Hospital Anxiety & Depression Scale, improv – improvement, info – information, instr – instruction, k – Kohen’s Kappa, lit – literature, M –
male, MBSR – mindful-based stress reduction, mc – molluscum contagiosum, med – medication, MTurk – Amazon’s Mechanical Turk through TurkPrime, neuro – neurological, NF – nonfatal, nmsc – non-melanoma skin
cancer, NOS – Newcastle-Ottawa Scale, NR – non-randomized, outpt – outpatient, PICOS - Population, Interventions, Comparators, Outcomes, Study Design, PRISMA – preferred reported items for systematic reviews and metaanalysis, psych – psychosis, psycho – psychological, pt(s) – patients(s), QOL – quality of life, RCTs – randomized controlled studies – sig – significance, SD – skin disease, SI – suicidal ideation, sig – significant, ST – short
term, tx – treatment, UK – United Kingdom, underes(d) – underestimate(d), USA – United States of America val – validated, vw – viral warts, W – White, yr(s) – year(s), wks - weeks

COMPREHENSIVE ACNE TREATMENT
48
Appendix F
Synthesis Table

Year
Design/Level of
Evidence:

Dalgard
2018
CS/II

Dixon
2018
CS/III

Gul
2015
CS/II

Hay
2013
SR/I

Author
Montgomery
2016
CS/III

Niazi
2011
SR/I

Patel
2019
SR/I

Pietrzak
2017
CS/III

Salman
2016
CS/III

Victorson
2015
SR/I

Study
Characteristics
Demographics
Age (yrs)

18 yrs and >

18 yrs and >

25 yrs and >

All ages

18 yrs and >

All ages

All ages

15-76 yrs

18 yrs and >

All ages

Male/Female

Both genders

73/161

6/34

Both genders

35/84

Both genders

Both genders

163/76

34/40

Both genders
(25%/75%)

X

X

X

X

X

X

40

895

119

18

239

74

Setting:
AM
FO
Sample Size

X
X
3,635

Measurement
Tools Used
ASI-3
BDI
BFNE
BMRT
DASS-21
DLQI
EPQ
FFMQ
GSSS
HADS
LSAS
Previous Study
Results
SC 90-R
Skindex-16
SS
SSS
WD

237

X

106

X

59

X
X
X
X
X
X
X
X
X
X

X

X
X
X

X

X

X
X
X
X
X

AM – America, Anx – anxiety, ASI-3 – Anxiety Sensitivity Index-3, AV – acne vulgaris, BDI – Beck Depression Inventory, BFNE – brief fear of negative evaluation, BMRT –
Baysian meta-regression tool, CS – cross sectional, CST – cross sectional controlled, DASS-21 – Depression Anxiety and Stress Sclases-21, Dep – depression, DLQI –
dermatological quality of life scale, ds – disease, EPQ – Eysenck Personality Questionnaire, F – females, FFMQ – five facet mindfulness questionnaire, FO – foreign country,
GSSS – Global self-reported severity of skin disease, HADS – hospital anxiety and depression scale, HGF – high glycemic food, hr – hour, LSAS – Liebowitz social anxiety
scale, M – male, MBSR – mindful-based stress reduction, Mn – mean, N – number of total participants or studies, Pt – patient, QOL – quality of life, SC 90-R – Symptoms
checklist 90-revised, SD – skin disease, SR – systematic review, SS – subjective severity, SSS – skin shame scale, WD – world database, – increases, – decreases

COMPREHENSIVE ACNE TREATMENT
49
Interventions
Examination of
stress and its
relationship to SD,
anx, & dep
Dermatologists
assessed pt dep
Surveys
Review of literature
MBSR
Major Findings
Evaluatd Dep Level
Anxiety
Suicidal Ideation
shown to increase
with SD
Adherence to
Treatment
Anx shown to
increase with SD
Burden of SD
Mindfulness effect
on dep
Mindfulness effect
on anx
Dep shown to
increase with SD
Stress is related to
increased dep & anx
Benefit from MBSR
on various clinical
and non-clinical
symptoms in
multiple people
with and without ds
QOL



X

X
X

X
X




X



X
X
X








X






















X

















X




X
X

X

X





X

X



X

X

X



AM – America, Anx – anxiety, ASI-3 – Anxiety Sensitivity Index-3, AV – acne vulgaris, BDI – Beck Depression Inventory, BFNE – brief fear of negative evaluation, BMRT –
Baysian meta-regression tool, CS – cross sectional, CST – cross sectional controlled, DASS-21 – Depression Anxiety and Stress Sclases-21, Dep – depression, DLQI –
dermatological quality of life scale, ds – disease, EPQ – Eysenck Personality Questionnaire, F – females, FFMQ – five facet mindfulness questionnaire, FO – foreign country,
GSSS – Global self-reported severity of skin disease, HADS – hospital anxiety and depression scale, HGF – high glycemic food, hr – hour, LSAS – Liebowitz social anxiety
scale, M – male, MBSR – mindful-based stress reduction, Mn – mean, N – number of total participants or studies, Pt – patient, QOL – quality of life, SC 90-R – Symptoms
checklist 90-revised, SD – skin disease, SR – systematic review, SS – subjective severity, SSS – skin shame scale, WD – world database, – increases, – decreases

COMPREHENSIVE ACNE TREATMENT
50
Appendix G

The ACE Start Model of Knowledge Transformation

ACE Star Model of Knowledge [Online image]. (2012).

COMPREHENSIVE ACNE TREATMENT
51
Appendix H
Self-Efficacy Model

Self-Efficacy Model [Online image]. (2010).

COMPREHENSIVE ACNE TREATMENT
52
Appendix I
Estimated Budget Plan
Proposed Expenses
Figure I.1

Personnel
Project Director (Kylee
Huesbch, RN)
$40/hr for 20 hours/ week x
12 weeks
Consultant, Dr. Thrall, DNP,
RN, FNP-BC,
$60/hr for 15 hours/wk x 12
weeks
Kylee Huebsch, RN, Office
Assistant, gather and prep
data for analytics
$14/hr for 2 hours/wk x 12
weeks
Tirsa Quartullo, DNP, @
$75/hr
4 hours/week for 12 weeks
Lee-Anne Berumen, Office
Manager, 1 hour/week @
$30/hr for 15 weeks
Office staff/MA for pamphlet
education and patient
recruitment. $14/hr x 4hrs for
4 weeks.
Meeting Room &
Equipment
Meeting Room
(3) 90-minutes meetings at
$75/hr
Refreshments for Meetings
Up to 4 people at $12pp
Research & meetings
printouts, misc office supplies
Cell phone to call patients for
12 weeks
Travel Reimbursement for
Personnel
50 miles roundtrip x 8
recruitment of participants, x

Expenses

In-Kind Support

$2120 (21%)

$7680 (79%)

(0%)

$10800

(0%)

$336

$3,600.00

$450.00

$224.00

$225

$144
$70
$400.00

$540

COMPREHENSIVE ACNE TREATMENT
53
3meetings @ .45/mile
Tuition, books, fees
ASU May 2017 – May 2019
(estimated along with 1 year
leave of absence.)
TOTAL:

$78,000

$9500

$81,499

$32,590

Project Timeline Showing Quarterly Benchmarks
Figure I.2
Activity

Responsibility

1st Quarter Fall
2017

Project
Development &
IRB Approval

Project Director

X

Exhaustive
Evidence-Based
Literature
Review

Project Director

X

Baseline Data
Collection and
Analysis

Project Director/
APN/Office Staff

X

Present Initial
Data Analysis &
Project
Foundation to
Key
Stakeholders

Project
Director/APN

X

Project
Implementation
Guideline
Development

Project
Director/APN

Project
Evaluation, Data
Analysis,
Sustainability
Plan

2nd Quarter
Summer 2018

3rd Quarter Fall
2019

X

X

COMPREHENSIVE ACNE TREATMENT
54
Budget Plan: Projected Cost
Figure I.3

Projected cost
Expense Item
Personnel
Project director (DNP student)
$40/hr for ~20 hrs per week x
12 weeks
Advanced practice provider @
$45/hr for 15hrs/week x12 weeks

for

Expenses

In-Kind Support

$1,920 (20%)

$7,680 (80%)

$4,104 (38%)

$6,696 (62%)

Dermatologist DNP @ $75/hr
4 hours/week for 12 weeks

$3,600

Office manager 1 hour/week @ $30/hr
15 weeks

$450.00

Office staff/MA for pamphlet education
and patient recruitment. $14/hr x 4hrs for 4
weeks.

$224

Equipment/Materials
$100
Paper educational pamphlets $5/pt x 20
pts

Office/Operations
Utilizing dermatology clinic for
navigation
sessions and recruitment for
16 hours per
week for 12 weeks (office space,
electricity, air conditioning)

$600.00

Utilizing wellness center for outcome
data collection and statistical analysis
(office space, electricity, air
conditioning)

$400.00

$200
$10 Incentives for participants who
complete the intervention
$10,374
Total Expenses

$15,600

COMPREHENSIVE ACNE TREATMENT
55
Timeline with Quarterly Benchmarks: Project Timeline
Figure I.4