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Given the potential for conditions that affect appearance to affect psychosocial wellbeing, there is a need for evidence-based interventions for this population. Objective severity is a poor predictor of distress associated with living with a visible difference, compared to societal and individual differences. Psychologically informed self-help interventions may offer a readily accessible and flexible form of support. This thesis therefore seeks to: (1) better understand the current state of research on self-help interventions targeting distress associated with having a visibly different appearance; and (2) test the acceptability and effectiveness of a specific self-help writing intervention. The first part of this thesis comprises of a systematic review of self-help interventions. This review offers an update to a similar review conducted in 2013, which explored the acceptability, usability, and effectiveness of psychologically informed self-help interventions developed for populations with conditions that affect external appearance. The current review identified 13 papers, which used a diverse range of methodologies to examine the acceptability, usability, and/or effectiveness of specific self-help interventions in this population. Based on ratings on quality appraisal tools, the quality of qualitative papers examining the acceptability and informing development were generally high, whereas the quality of randomised studies was generally poor. However, appraisals should be considered in the context of pilot and feasibility studies. Common limitations related to high attrition, particularly in intervention arms of studies. Self-help materials were generally rated positively. However, positive feedback did not necessarily translate to greater uptake, adherence, or effectiveness. While there was some limited evidence for compassion-based interventions increasing self-compassion, there was a lack of consistent evidence for effects on alternative measures of distress. The second part of this thesis reports the findings of a Randomised Controlled Trial, comparing a one-week functionality-focused writing intervention, to a control (creative writing). Of 451 adults with a dermatological condition randomised, 155 completed at least one post-intervention measure. For participants with relatively low and mid-range positive body image baseline scores, there was evidence of a positive effect of the intervention on measures of body appreciation and functionality appreciation. Effects were mostly maintained at one-month follow up and in intention-to-treat analysis, with smaller effect sizes. However, when compared to the control, there was no evidence of an effect of the intervention on measures of appearance anxiety, skin shame and dermatology quality-of-life. Feedback was generally positive. However, like many of the papers included within the systematic review, this study had high rates of attrition, limiting the ability to draw conclusions around the effectiveness of the intervention based on allocation rather than completion.

Acne is associated with a range of psychosocial impacts, including stigmatisation. Yet little is understood about the role of sociocultural context in acne-related stigma. Media representations and consumption are likely to play a role in the nature of such impacts. This thesis adopts a novel mixed methods, interdisciplinary approach to examine how media messages relate to stigma surrounding acne. An ethnographic content analysis (Study 1) of 637 magazine advertisements (1972 – 2008), indicated that acne was framed as a cosmetic concern, with acne opposed to the ideal of perfect skin. Within advertisements, acne was associated with negative characteristics and psychosocial maladjustment. However, several advertisements normalised acne. The frequency and content of acne-related advertisements differed over time and between magazines, suggesting a shift away from acne myths, yet increased pressures to meet unrealistic ideals. Thematic analysis of semi-structured interviews (Study 2) investigated 15 women’s experiences of acne in the context of contemporary media culture. Participants compared themselves to the media-disseminated ideal of perfect skin, describing themselves as looking and feeling different. Participants were frustrated by stigmatising messages and the absence of acne across media. However, participants also identified benefits to digital media, cautiously using online information to inform treatment, and seeking out images and experiences of acne. Within an online survey (Study 3) of 650 individuals with acne, negative comparisons mediated the relationship between photo-function use and feelings of stigma in Facebook (but not Instagram) users, although negative comparisons continued to predict feelings of stigma. Furthermore, self-compassion was consistently associated with lower levels of negative comparisons and feelings of stigma. The findings suggest that individuals with acne are exposed to idealised images of skin and stigmatising messages about acne, which influence feelings of stigma. Cognitive processes like comparisons appear to play an important role in feelings of stigma in this population.