Journal of Nursing and Midwifery Sciences

: 2020  |  Volume : 7  |  Issue : 1  |  Page : 36--41

Comparative effectiveness of cognitive-behavioral group therapy and reality therapy on the quality of life of patients with seborrheic dermatitis

Ahmad Alipour1, Mohammad Oraki1, Mehran Zarghami2, Gholam abbas Mollazadeh Mahally1,  
1 Department of Psychology, Payam Noor University of Tehran, Tehran, Iran
2 Department of Psychiatry, Psychiatry and Behavioral Science Research Center, Mazandaran University of Medical Sciences, Sari, Iran

Correspondence Address:
Gholam abbas Mollazadeh Mahally
PhD Student, Department of Psychology, Payam Noor University of Tehran, Tehran


Context: Skin diseases contribute to considerable psychological consequences and low quality of life (QOL) in these patients; it is believed that psychological status can be effective in the improvement of the disease. Aims: Therefore, this study aimed to compare the effect of cognitive-behavioral therapy (CBT) with reality therapy (RT) on QOL in patients with seborrheic dermatitis. Setting and Design: This semi-experimental study with pre- and posttest conducted in the private clinics of Sari and Ghayemshahr. Materials and Methods: Forty-eight cases selected by purposive method and randomized in three groups of control, cognitive-behavioral, and RT. Participants in three groups' evaluated pre-posttest and follow-up (3 months after intervention) by skin QOL index Wang (1994). Intervention groups received 10 weeks intervention, whereas the control group did not receive any intervention during this study. Statistical Analysis Used: The data were analyzed using SPSS-20 software through mixed covariance analysis. Results: There was no significant difference found between the two intervention groups (P > 0.05). The comparison of the effect size of two groups showed higher effect size for CBT group 0.81 versus 0.51. Conclusion: According to the findings of the research, it can be concluded that CBT and RT are effective on QOL and severity of skin disease.

How to cite this article:
Alipour A, Oraki M, Zarghami M, Mollazadeh Mahally Ga. Comparative effectiveness of cognitive-behavioral group therapy and reality therapy on the quality of life of patients with seborrheic dermatitis.J Nurs Midwifery Sci 2020;7:36-41

How to cite this URL:
Alipour A, Oraki M, Zarghami M, Mollazadeh Mahally Ga. Comparative effectiveness of cognitive-behavioral group therapy and reality therapy on the quality of life of patients with seborrheic dermatitis. J Nurs Midwifery Sci [serial online] 2020 [cited 2023 Jun 5 ];7:36-41
Available from:

Full Text


Seborrheic dermatitis is a common chronic inflammatory skin condition, characterized by scaling and poorly defined erythematous patches. It is associated with pruritus, and it primarily affects sebum-rich areas, such as the scalp, face, upper chest, and back.[1] The prevalence of disease in the general population estimated about 1%–3% and often affects people aged 18–40.[2] In this age, most people are in sensitive stage of their lives, such as marriage, creating social interactions, and making professional life. The physical appearance and body image affects all of these functions.[3]

Although the etiology of this disease is not known, it is frequently associated with anxiety, depression, and stress.[4] Stress and rumination about the illness and fear of appearance negatively affect the quality of life (QOL).[5],[6],[7] Comparing of skin involved disease cases with normal people indicated a lower QOL.[7] Common treatments for this disease are pharmacologic therapies, which usually do not succeed completely and even leads to some side effects and risk of relapse is always remind very high.[8],[9]

The researchers are almost agree regarding potential relationship between mental health and skin disorders. Therefore, psychological treatments are suggested to reduce the psychological and physical symptoms of these diseases. One of the most well-known and effective psychotherapy is cognitive-behavioral therapy (CBT) that has been shown as effective in increasing the mental health and QOL of people with skin problems.[10],[11],[12]

This approach, through combining cognitive and behavioral techniques, influences negative automatic thoughts, underlying assumptions, and the cognitive process of thinking, memory, and attention, through the neural relationship between the brain and the body in biological systems affect the emotions and functions of the body and cause different symptoms.[13] Based on the Beck's cognitive pattern, cognitive therapy in patients with skin disease seeks to identify and restructure ineffective thoughts and beliefs that have extreme emotional and psychological reactions related to skin symptoms.[14]

Another successful treatment that shown as effective in many psychological and physical problems is the reality therapy (RT), which developed, based on choice theory. This approach effects through helping clients to take responsibility for their behavioral choice rather than accepting that they were victims of their own impulses, also motivates clients to make dramatic changes by identify and meet the essential needs.[15] In general, reality-therapeutic approach suggests that human beings be viewed as a being with inherent self-determination. Even in those who are physically and psychologically restricted, their lifestyle and performance make it clear what they want to do in the future.[16]

According Tümlü et al. and Dizjani and Kharamin, RT is a successful psychological treatment enhancement of QOL.[17],[18] Rumsey in a review study concluded that CBT is one of the most effective psychological approaches in improvement of patients involved with dermatitis disorders.[19] Bundy et al. reported effectiveness of CBT intervention in the improvement of QOL of patients with psoriasis.[20]

Some researchers believed that CBT could be effective on the improvement of QOL of patients involved skin disorders as they are highly involved with stress and cognitive bias.[19],[20] Although in a recent study, Hedman-Lagerlöf et al. reported no significant effectiveness of CBT intervention on QOL of patients with atopic dermatitis.[12] In term of effectiveness of RT on QOL limited studies published and in the context of skin problems, the effectiveness of RT was not found. Therefore, this study aimed to compare the effect of CBT with group RT on QOL in patients with seborrheic dermatitis.

 Materials and Methods

This study was a field trial which included three groups with pre- and post-test quasi-experimental design. Proposal of research approved in the Ethical Committee of Payame Noor University with number of IR.PNU.REC.1398.055. The research population included all skin disorder infected patients who referred in two private skin clinic (one in Qaemshahr and one in Sari city) during March 2018–August 2018. Sample size calculated based on previous studies using the Cochran formula considering, α = 0.05 and β = 80%, 16 samples in each group estimated (total = 48) who randomized in control, CBT and RT, 38 cases remind after drop out.

Inclusion criteria

The inclusion criteria were as follows: diagnosed as a patient with moderate and severe Seborrheic Dermatitis patient by physician, educated at least up to high school, fluency in Persian, and lack of acute economic, mental, and physical problems.

Exclusion criteria

Criteria such as other chronic illness, unwillingness to continue cooperation, noncomplete training sessions, smoking, and drug change in the treatment process, psychological illness have coincided with another study.

All participants were male, age range 18–36 years, with mean age of 30.5 ± 5.6 and duration of disease (1–10 years); with mean 4.54 ± 2.34 years. Patients examined through semi-structural interview by researcher aimed to screen mental health disorders. The cases with psychotherapy history and mental health disorder were excluded from the study. Participants of three groups evaluated in the pre test-post test and follow up stages (3 months after intervention) with the following tools: demographic information questionnaire (age, marital status, occupation, degree of education, social support status of the place of residence, number of children, history of physical diseases, history of other skin diseases and severity of seborrheic dermatitis, and history of participation in psychotherapy).

Skin quality of life index (dermatology life quality index)

This questionnaire developed by Wang (1994) consists of ten questions about patient's experiences in the previous week. The questionnaire graded by Likert method. Wang et al. checked the validity and reliability of the questionnaire among 236 skin patients in the dermatology clinic. Factor analysis confirmed the validity of the structure of the questionnaire and the reliability coefficient of the questionnaire with the Cronbach formula was 0.87.[21] The content validity supported in Iranian study and reliability reported equal to 0.77.[22] The Cronbach alpha was 0.69 in this study.

Cognitive-behavioral cognitive therapy sessions held weekly (120 min) for eight sessions based on Beck and Allis theory according to previous studies.[23] Each session started with the training of relaxation techniques and continued with communication skills techniques, problem-solving, expressing, identifying, and challenging with automatic thoughts and anger management techniques that integrated the health issues of patients. RT sessions[24] held weekly (120 min) for eight sessions based on based on Glaser's theory according to previous studies [Table 1].{Table 1}

For data analysis, descriptive statistics (mean, standard deviation, percentage, and frequency) and mixed covariance analysis were used to examine and compare the effectiveness of therapies. Time series measurements considered as between factor and treatment as within factor. Data analyzed through SPSS 20 software (Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp. IBM Corp). The significant level was considered as P > 0.05.


Participants were homogeneous in terms of age, marital status, and education. The QOL scores of participants in the three groups did not show any significant difference before the intervention (P > 0.05). To analyze this hypothesis, repeated variance analysis was used. In this test, the phases (pretest, posttest, and follow-up) were tested between and within the subjects. The normal distribution of the data was verified by Kolmogorov–Smirnov test. Box's M with a value of 11.12 (F = 1.70, P > 0.05) was not statistically significant. Thus, the homogeneity assumption of the variance–covariance matrix is established. Levine test was not significant in pre- and post-test and follow-up periods (P < 0.05). The results of the mixed covariance analysis below presented between and within subjects [Table 2].{Table 2}

According to the findings, there was a significant difference between the mean scores of QOL (F(2, 35) = 6.55, P > 0.05; ƞ = 0.27) between experimental and control groups. In terms of time (F(2, 35) = 5.38, P> 0.05; ƞ = 0.13), significant difference was observed. Although interaction of time and group was not significantly different F (2, 35) = 1.50, P < 0.05; ƞ = 0.07, the findings of the pair-wise comparison showed there is a significant difference between the mean scores of the cognitive-behavioral group and the reality of therapy compared to the control group (P > 0.05). There was no significant difference between the two intervention groups. The comparison of effect size of two groups showed higher effect size fir CBT group 0.81 versus 0.51 [Table 3].{Table 3}


The results of analysis indicated that the QOL of the majority of participants was low. QOL of patients with skin disorders was reported to be similar in the findings of the studies of Ghaderi et al.[25] and Kwak and Kim.[26] In this study, 11,113 people who participated in the national plan during the period of 2010–2012 were surveyed. The results showed that these people had high stress and low QOL when compared with healthy people.

In justifying this finding, it can be said that especially with regard to the age range of the infected patients who are affected by skin disease at an early age. Negative body perception leads to low self-esteem and thereby increases the likelihood of stress and depression, resulting in a person reporting low QOL in different dimensions.

The results of the comparison of cognitive-behavioral intervention and RT with control group showed participants' scores in both intervention groups have significantly decreased compared to the control group. Since the questionnaire used in the survey consisted of ten questions in the past week, the patient about the signs of skin disease (itching, discomfort, pain, or burning sensation), feeling sick (shame, embarrassment, and nervousness), daily activities (shopping jobs home), dress, social activities, entertainment, sports, and education and interpersonal relations (relationship with spouse, friends, relatives) is. This implies patients improve in skin disease signs, feeling, and social activities.

This finding is inconsistent with the results of the study conducted by Hedman-Lagerlöf et al.[12] aimed to determine the effectiveness of CBT along with the exposure on the QOL of patients with skin disease. In this study, nine individuals with chronic skin diseases treated with CBT therapy for 10 weeks. The results showed no effectiveness of intervention in QOL although anxiety and depression decreased. This is explainable with difference of tools, lower age of cases in our study, and larger number of samples in the present study. In line with this study, Faridhosseini[27] surveyed the effectiveness of cognitive-behavioral stress management therapy on anxiety, depression, and QOL of patients with skin disease among 16 patients with psoriasis diagnosis. The results showed that mean scores of QOL in the experimental group significantly improved in compare to the control group. Bundy et al. (2013) also confirmed the same results.[20]

In harmony with the present study, Khodabakhshi Koolaee et al. also reported effectiveness of RT on the improvement of QOL.[16] However, the results of the present study was not in harmony with results of Parizadeh et al.,[28] as they found existential group therapy and Group RT was not effective on the problem-solving of women after mastectomy surgery. The reason for this difference is due to the difference in samples. Since the present study included males and the participants in the study were involved in a skin superficial disease.


In general, the findings of this study suggest that CBT and RT were effective treatment for participants with skin disease. However, the effectiveness of CBT was higher. This difference is explainable due to the wide range of cognitive-behavioral techniques and involvement of the cases with real-world behavioral techniques. However, the participation in RT groups also showed impartment in QOL as the techniques used is effective in reduction of depression and stress. CBT techniques works through cognitive restructuring (identify, challenge, and change the negative thoughts), in addition using behavioral rehabilitating enhance the patient ability to management thoughts and stress.

This study has some advantages as a few studies examined the QOL of people with dermatitis problem and the effectiveness of the psychosocial program rarely conducted with long-term follow-up design in these patents. In addition comparison of two psychotherapies was the other advantages of this study Study involved with some limitations such as limited sample and high sample drop. The sample selected by convenience method and samples were not homogenous in case of income and economical level. On the other hand, the physiological and neurological conditions of cases dose were not examined because of the lack of facilities and limited financial sources. It has been suggested that large number of samples should be selected randomly to compare the effectiveness of intervention in different age, gender, and income level groups. The measurement of neurologic and physiological changes of patients before and after interventions was also suggested.

Conflicts of interest

There are no conflicts of interest.

Author's contribution

Mohammad Oraki supervised and edited all the procedures of intervention, data collection, drafting paper. Mollazadeh developed idea, reviewed the studies, gathered data, drafted reports. Ahmad Alipour drafted paper, supervised intervention, and contribute in writing. Mehran Zarghami contributed in the analysis of data, translation, and drafting. Nourbakhsh contributed in data collection, laboratory reports, and writing reports.

Financial support and sponsorship

This study was self-financed and was not supported with any one. This paper presents part of PhD dissertation submitted to Payame Noor University of Tehran.


We appreciate the cooperation of Dr. Nourbakhsh and Dr. Saberi as study conducted in their clinics. We are thankful for the patients who participated in this study.


1Berk T, Scheinfeld N. Seborrheic dermatitis.P T 2010;35:348-52.
2Mokhtari F, Faghihi G, Golchin S, Hosseini SM, Nilfroushzadeh MA. Evaluation of the effectiveness of topical zinc acetate 1.2% for pruritus and erythema of seborrheic dermatitis in patients under treatment with ketoconazole 2% solution. IMS 2016;34:362-6.
3Corazza O, Simonato P, Demetrovics Z, Mooney R, van de Ven K, Roman-Urrestarazu A, et al. The emergence of exercise addiction, body dysmorphic disorder, and other image-related psychopathological correlates in fitness settings: A cross sectional study. PLoS One 2019;14:e0213060.
4Sanders MG, Pardo LM, Franco OH, Ginger RS, Nijsten T. Prevalence and determinants of seborrhoeic dermatitis in a middle-aged and elderly population: The Rotterdam study. Br J Dermatol 2018;178:148-53.
5Gül Aİ, Karaaslan Ö, Çölgeçen E. Personality traits and common psychiatric conditions in patients with seborrheic dermatitis. Arch Clin Psychiatry (São Paulo) 2017;44:6-9.
6Zakeri MM. Effectiveness of processing emotion regulation strategies training in psychological distress of patient with Vitiligo. Health Psychol 2017;23:39-56.
7Borda LJ, Wikramanayake TC. Seborrheic dermatitis and dandruff: A comprehensive review. J Clin Investig Dermatol 2015;3:10-9.
8Bidhendi N, Ahmadi Ashtiani H, Ayatollahi A, Yadangi S, Ghorban Dadras O, Firooz A. Comparison of the efficacy and safety of a herbal extract lotion with clotrimazole 1% lotion in the treatment of seborrheic dermatitis: A randomized clinical trial. J Dermatol Cosmet 20171;7:189-99.
9Elgash M, Dlova N, Ogunleye T, Taylor SC. Seborrheic dermatitis in skin of color: Clinical considerations J Drugs Dermatol 2019;18:24-7.
10Alipour A, Zare H, Naser Emadi S, Abdollahzade H. The impact of group CBT therapy on the disease severity and mental health of psoriasis patients. Dermatol Cosmet 2013;4:196-204.
11Jha A, Mehta M, Khaitan BK, Sharma VK, Ramam M. Cognitive behavior therapy for psychosocial stress in Vitiligo. Indian J Dermatol Venereol Leprol 2016;82:308-10.
12Hedman-Lagerlöf E, Bergman A, Lindefors N, Bradley M. Exposure-based cognitive behavior therapy for atopic dermatitis: An open trial. Cogn Behav Ther 2019;48:300-10.
13Esmaeilnia M, Dousti Y, Mirzaian B. Structural relationships between early maladaptive schemas and body dysmorphic disorder mediated by anxiety and over-concern. Community Health (Salāmat-i ijtimāī) 2019;6:80-9.
14Dhopte A, Patil S, Barde N, Thakre R, Harsh S, Nisal S. Sympathetic dysfunction dermatitis in a revascularised upper extremity after near-total amputation – A case report and review of literature. Indian J Plast Surg 2018;51:327-30.
15Wubbolding R. Counselling with Reality Therapy. London: Routledge; 2017. p. 28.
16Khodabakhshi Koolaee A, Mosalanejad L, Mamaghanirad B. The effectiveness of group training of choice theory on quality of life and hope in blind people. Iran Rehabil J 2017;15:199-206.
17Tümlü GÜ, Akdoǧan R, Türküm AS. The process of group counseling based on reality therapy applied to the parents of children with disabilities. Int J Early Child Spec Educ 2017;9:81-98.
18Dizjani F, Kharamin S. Reality therapy effect on marital satisfaction and women's quality of life. Armaghane Danesh 2016;21:187-99.
19Rumsey N. Psychosocial adjustment to skin conditions resulting in visible difference (disfigurement): What do we know? Why don't we know more? How shall we move forward? Int J Womens Dermatol 2018;4:2-7.
20Bundy C, Pinder B, Bucci S, Reeves D, Griffiths CE, Tarrier N. A novel, web-based, psychological intervention for people with psoriasis: The electronic targeted intervention for psoriasis (eTIPs) study. Br J Dermatol 2013;169:329-36.
21Wang XL, Zhao TE, Zhang XQ. Assessment on the reliability and validity of the dermatology life quality index in Chinese version. Zhonghua Liu Xing Bing Xue Za Zhi 2004;25:791-3.
22Adibi N, Shafiei K, Izadi B, Afshar H, Bagherian-Sararoudi R. Evaluation of psychological profile of patients with skin lesions. J Isfahan Med Sch 2013;31:236-48.
23Hosseini SH, Rafiei A, Gaemian A, Tirgari A, Zakavi A, Yazdani J, et al. Comparison of the effects of religious cognitive behavioral therapy (RCBT), Cognitive Behavioral Therapy (CBT), and sertraline on depression and anxiety in patients after coronary artery bypass graft surgery: Study protocol for a randomized controlled trial. Iran J Psychiatry 2017;12:206-13.
24Farmani F, Taghavi H, Fatemi A, Safavi S. The efficacy of group reality therapy on reducing stress, anxiety and depression in patients with Multiple Sclerosis (MS). Int J Appl Behav Sci 2015;2:33-8.
25Ghaderi R, Saadatjoo S, Khoshzaher S. Comparison quality of life for patients with alopecia areata and healthy individuals. J Birjand Univ Med Sci 2011;18:200-9.
26Kwak Y, Kim Y. Health-related quality of life and mental health of adults with atopic dermatitis. Arch Psychiatr Nurs 2017;31:516-21.
27Faridhosseini F. Effectiveness of cognitive-behavioral stress management on anxiety, depression, and quality of life in patients with psoriasis. Med J Mashhad Univ Med Sci 2016;59:337-44.
28Parizadeh H, Hasan Abadi H, Mashhadi A, Taghizadeh Kermani A. Investigating effectiveness of existential and reality group-therapy in treatment of body-image problem in women who undergo mastectomy. Iran J Obstet Gynecol Infertil 2012;15:27-35.