Cosmetic apprehensions are increasingly pervading western societies, and all are in the hunt and the search for perfect skin. Cosmetic dermatology is a rapidly growing specialty where cosmetic dermatologists are frequently consulted to evaluate asses and treat various cosmetic defects.¹

Dysmorphophobia, body dysmorphic disorder (BDD), body image disturbance, or imagined ugliness syndrome is a condition where patients are unnaturally concerned with minimal or non-existent faults, most frequently in their skin (e.g. facial acne, scarring and wrinkles) and hair (e.g. hair loss and thinning). They aim for the image of ‘perfection’. Most patients with BDD spend considerable amounts of time in self-reflective, time-consuming and unproductive ponderings.¹ They are preoccupied with an imagined or slight defect in appearance; where the appearance concerns are extreme and exaggerated. Those patients have the belief of being misshapen, twisted, deformed, ugly, or unattractive.

Such patients avoid social events, depressed and endure occupational or academic impairment. Those severely ill patients may grow to be housebound or develop suicidal ideation and attempt suicide. In many instances those patients become violent toward their physicians. It is better not to argue about the diagnosis; pay attention and listen carefully with sympathy to the patient’s story, and allow enough time for discussion of their main concerns.² Body image is the mental picture we have of ourselves in our mind eyes and are influenced by the surroundings. Those patients cannot articulate realistic changes they desire.

Sometimes that cognitive distortion becomes an obsession, and the thoughts cause considerable distress and become difficult to suppress.

Skin concerns usually involve the facial skin but may focus on other parts of the body as well (such as, the back, legs, or arms). Skin complaints usually include acne, scarring, wrinkles, skin discoloration, or skin marks (e.g. red marks, white marks, veins, spider veins, or moles). Whereas, hair concerns constitute in many instances the perceived balding or excessive facial or body hair.²

Also the habit of unintentional skin picking has been acknowledged for many years in the dermatology literature, and it is called as well as ‘dermatillomania’ and ‘neurotic excoriation, where it involve the use of pins, knives, staple removers, tweezers, and razor blades. All of which might lead to considerable disfigurement (e.g. notable lesions, sometimes with secondary infection, or deep scarring, and an expose to the underlying vessels.³ Those patients are always none satisfied and they try to ameliorate their distress by resorting to a cosmetic dermatologist for a quick fix. Such patients usually request extensive work-ups, consult numerous physicians, and pressure dermatologists to prescribe unsuitable and ineffective treatments. Other ways they resort to is applying a camouflage with make-up or garments like wearing scarves to cover a perceived scar on the neck; use of skin lighteners or tanning creams; excessive tanning; repeated mirror-checking (whereas some avoid mirrors because of the anguish associated with viewing themselves); and asking other people (including their dermatologist) for reassurance about how they look like. Patients with BDD may request various dermatological treatments however they never feel happy or content and most of those patients are dissatisfied with dermatological treatment and, even if the outcome is impartially satisfactory.

Practitioners need to be vigilant to those kinds of patients. Focusing on the distress and disability caused by their concerns, rather than on how they actually look, may be helpful in persuading patients to accept psychiatric referral (psychodermatology), or seen by a dermatologist with an interest in psychological medicine.

In contrast to dermatologic treatment, selective serotonin-reuptake inhibitors (such as citalopram, escitalopram, fluoxetine, sertraline, paroxetine, fluvoxamine, and clomipramine) as well as cognitive-behavioural approaches often appear to be effective.³

References
1. Castle DJ, Phillips KA, Dufresne RG Jr. Body dysmorphic disorder and cosmetic dermatology: more than skin deep. J Cosmet Dermatol. 2004 Apr; 3(2):99-103.
2. Kuhn H, Cunha PR, Matthews NH, Kroumpouzos G Body dysmorphic disorder in the cosmetic practice. G Ital Dermatol Venereol. 2018 Aug;153(4):506-515. doi: 10.23736/S0392-0488.18.05972-2. Epub 2018 Apr 18.
3. Higgins S, Wysong A. Cosmetic Surgery and Body Dysmorphic Disorder – An Update. Review. International Journal of Women's Dermatology. Volume 4, Issue 1, March 2018, Pages 43-48