Body dysmorphic disorder: A critical appraisal of diagnostic,screening, and assessment tools

Body dysmorphic disorder (BDD) is a psychiatric condition characterized by profound concern about a minor or imagined defect in the appearance of individuals and increased preoccupation with the imagined/perceived defect. Individuals with BDD often undergo cosmetic intervention for the perceived imperfection but rarely experience improvement in their signs and symptoms after such treatment. It is recommended that aesthetic providers evaluate individuals face-to-face and screen for BDD with approved scales preoperatively to determine the candidate's suitability for the procedure. This contribution focuses on diagnostic and screening tools and measures of disease severity and insight that providers working in nonpsychiatric settings can use. Several screening tools were explicitly developed for BDD; others were designed to evaluate body image/dysmorphic concern. The BDD Questionnaire (BDDQ)–Dermatology Version (BDDQ-DV), BDDQ–Aesthetic Surgery (BDDQ-AS), Cosmetic Procedure Screening Questionnaire (COPS), and Body Dysmorphic Symptom Scale (BDSS) have been developed explicitly for BDD and validated in cosmetic settings. The limitations of screening tools are discussed. Given the increasing use of social media, future revisions of BDD instruments should consider incorporating questions relevant to patients’ behaviors on social media. Current screening tools can adequately test for BDD despite their limitations and a need for updates.     

Psychosocial issues and body dysmorphic disorder in aesthetics: Review and debate

Body dysmorphic disorder (BDD) is a serious and debilitating psychiatric condition that disproportionately presents in dermatologic and cosmetic surgery patients. BDD is currently underrecognized in cosmetic medical settings and is thought to be underdiagnosed by behavioral health professionals. The significant comorbidities associated with this disorder, as well as potential harm done to both patient and physician, raise ethical and medicolegal concerns regarding its treatment. Although cosmetic interventions have historically been discouraged in BDD, recent studies have provided controversial evidence of benefit in certain cohorts. The rise of “snapchat dysmorphia” and the proposed explanatory phenomenon of perception drift have generated further debate around the de novo development or unmasking of BDD. We critically review and summarize existing debates around the treatment of BDD in cosmetic medicine. We provide guidance for screening, clinical interviewing, and the provision of psychoeducation in cases of suspected BDD.     

Detección de trastorno dismórfico corporal en pacientes con acné: estudio piloto

Introduction

Body dysmorphic disorder (BDD) is a mental health condition that is difficult to diagnose; it can cause a great deal of suffering, and treatment is often complex and challenging.

A review of exosomes and their application in cutaneous medical aesthetics

Background

Exosomes have gained recent popularity in aesthetic medicine; however, there is still a dearth of understanding on the etiology of exosomes, their physiologic function, and regenerative capabilities.

Objective

The purpose of this article is to summarize some of the physiologic functions of exosomes, their mechanistic role, and current commercial landscape in regenerative aesthetics.

Methods

A Medline search was conducted with the keywords, exosomes, extracellular vesicles, stem cells, skin rejuvenation, and cutaneous aesthetics. MeSH term “exosomes” filtered by relevant subheadings was also utilized. Pertinent original articles encompassing animal studies, cell studies, and human studies were included. We restricted to articles published in the last 10 years.

Results

Pre-clinical studies have demonstrated the therapeutic capabilities of exosomes in wound healing, scar modulation, alopecia, and skin rejuvenation. Exosomes primarily exert their effects in a paracrine function and modulate the interactions between keratinocytes and other cells of the skin. Exogenous exosomes can be utilized in a variety of settings to bring about desired aesthetic outcomes and to date, has only been approved for topical administration.

Conclusion

The safety, efficacy, potency, and dosages of exosomes remains to be determined via robust human clinical trials. Isolation and purification techniques have yet to be standardized, and this would be required for regulatory approval of all delivery modes. Overall, exosomes deliver yet another therapeutic option in regenerative aesthetics.     

Treatment of acne in the aesthetic patient: A round table update

Background

The popularity of social media appears to be increasing the acceptance of cosmetic treatments, prompting more consumers to seek cosmetic treatments. As the estimated prevalence of acne vulgaris among adult women may be as high as 54%, acne is commonly observed among patients presenting for cosmetic treatments. Concomitant treatment of acne in the aesthetic patient population will improve overall clinical outcomes.

Aims

The goal of this work was to deliver a high-quality ethical and evidence-based educational program to physicians and adjunctive health care providers to advance patient care.

Methods

This paper is based on a webcam presentation with roundtable discussion by several notable experts in their field.

Results

A range of topical medications, injectable products, chemical peels, and energy-based devices are available for treating acne vulgaris. In most instances, these are compatible with rejuvenation procedures in the aesthetic patient.

Conclusion

The growth of social media is raising awareness of aesthetic procedures and appears to be increasing the number of patients seeking aesthetic treatment. Educating patients about the importance of treating acne vulgaris can improve overall treatment outcomes. In most instances, the presence of acne is not a barrier to aesthetic care.     

Screening for Psoriatic Arthritis in Korean Psoriasis Patients Using the Psoriatic Arthritis Screening Evaluation Questionnaire

Background

Psoriatic arthritis (PsA) is chronic seronegative inflammatory arthritis that causes irreversible joint damage. Early recognition of PsA in patients with psoriasis is important for preventing physical disability and deformity. However, diagnosing PsA in a busy dermatology outpatient clinic can be difficult.

Objective

This study aimed to validate the Psoriatic Arthritis Screening and Evaluation (PASE) questionnaire for the detection of PsA in Korean patients with psoriasis.

Methods

The PASE questionnaire was prospectively given to 148 patients diagnosed with psoriasis but without a previous diagnosis of PsA. All patients underwent radiologic and laboratory examinations, and a subsequent clinical evaluation by a rheumatologist.

Results

Eighteen psoriasis patients (12.2%) were diagnosed with PsA according to the Classification Criteria for Psoriatic Arthritis. The PASE questionnaire scores of differed significantly between PsA and non-PsA patients. Receiver operator characteristic analysis showed an area under the curve of 0.82 (95% confidence interval: 0.72, 0.92) for PASE score. A PASE score cut-off of 37 points had a sensitivity of 77.8% and specificity of 82.3% for the diagnosis of PsA.

Conclusion

The PASE questionnaire is a simple and convenient screening tool for detecting PsA in Korean dermatology clinics. A PASE questionnaire score of 37 points appears to be an appropriate cut-off for screening Korean psoriasis patients.     

Macrocystis pyrifera ferment-containing creams for optimizing facial skin rejuvenation

Background

There is an increasing demand for facial skin rejuvenation. Specialized aesthetic skincare treatments may be one of the first steps to help prevent or treat facial signs of aging. This article discusses aesthetic skin care for facial skin rejuvenation, particularly data on two creams containing Macrocystis pyrifera ferment.

Methods

The authors convened a dermatology advisory board to discuss challenges and practices in using skincare for facial rejuvenation, combining their expert opinion and experience on facial rejuvenation with preclinical and clinical data on two creams containing Macrocystis pyrifera ferment and a review of the literature.

Results

Preclinical and clinical studies on Macrocystis pyrifera ferment and two creams containing the ferment exhibit anti-inflammatory, anti-aging, and healing properties. In preclinical studies, the ferment demonstrated collagen type I enhancing properties in ex vivo skin models, and skin cells treated with the ferment migrated faster than untreated cells in the in vitro study. In clinical studies measuring visible anti-inflammatory activity, the ferment alone and the ferment-containing products significantly decreased erythema, and in anti-aging studies, they improved visible skin aging parameters. Finally, in clinical studies on the stratum corneum, the two creams increased moisture levels and decreased transepidermal water loss (TEWL), reflecting healing by enhancing barrier strength and recovery.

Conclusions

The Macrocystis pyrifera ferment and creams containing the ferment are effective skin care treatment products to decrease the visible effects of inflammation and signs of aging while promoting healing by enhancing barrier resilience and recovery.     

Standards for aseptic techniques in medical aesthetic practices in the Benelux: Consensus recommendations

Introduction

While the demand for aesthetic procedures is rising, complications are rising alongside. Infection is a frequent complication, there is therefore an increased need for strict aseptic technique, particularly in procedures breaching the skin. The level of training of practitioners carrying out these procedures varies and there are no comprehensive guidelines on aseptic aesthetic practice in the Benelux region.

Objective

Developing a step-by-step procedure for achieving and maintaining a high standard of aseptic conditions in a standard aesthetic practice in the Benelux region.

Methods

A consensus group of 10 aesthetic medical practitioners (dermatologists, plastic surgeons, and cosmetic physicians) representing the Benelux region convened to discuss best practice for aseptic techniques in medical aesthetics. Step-by-step procedures were recommended to achieve optimal aseptic practice in private facilities and define important considerations for reducing infection risk. Recommendations were based on current evidence and extensive clinical experience.

Results

Recommendations were made to achieve and maintain a high standard of asepsis and infection control. Guidance included maintaining high standard aseptic conditions of the injecting room, the injecting area on the patient, the injection procedure, the materials, and procedures commonly used to achieve aseptic conditions.

Conclusions

This expert consensus summary publication recommends aseptic procedures, setting a standard with the goal of minimizing rates of complications in aesthetic clinical practice in the Benelux region.     

Energy-based devices in the treatment of acne scars in skin of color

Background

Acne scarring is disfiguring and psychologically taxing on patients. Many energy-based modalities have emerged and been studied for the treatment of acne scarring; however, there is a paucity of these studies in skin phototypes IV–VI.

Objective

To review the medical literature and discuss the most significant studies regarding safety and efficacy of energy-based devices (ablative lasers, non-ablative lasers, and radiofrequency microneedling) in the treatment of ethnic skin (skin phototypes IV–VI).

Methods

A literature search was conducted using the PubMed database and bibliographies of relevant articles.

Results

Ablative and non-ablative lasers have proven to be effective for treatment of acne scars in ethnic skin. The risk of developing adverse effects such as post-inflammatory hyperpigmentation is contingent upon several factors including skin phototype, laser device, fluence, and moreso density settings. Non-ablative fractional lasers have been considered first line for the treatment of acne scars in skin of color due to their better safety profile; however, they are less efficacious and require more treatments compared to ablative lasers. Studies regarding efficacy and safety of radiofrequency microneedling for treatment of acne scarring in skin of color are limited, but are promising.

Conclusion

Ablative lasers, non-ablative lasers, and radiofrequency microneedling are all useful treatments for acne scarring in ethnic skin when appropriate settings are used. Further head-to-head studies are needed to evaluate their efficacy and safety in darker skin phototypes V–VI.     

Prevalence and clinical features of psoriatic arthritis in psoriasis patients in Spain. Limitations of PASE as a screening tool

Background

Diagnosing and initiating treatment of psoriatric arthritis (PsA) as early as possible is essential to prevent irreversible joint destruction and poor clinical outcomes. Dermatologists are uniquely placed to identify early symptoms of PsA in psoriasis patients but levels of under- and late-diagnosis remain high.

Objective

To evaluate the prevalence and clinical features of PsA in Spanish psoriatic patients attended by dermatologists and then referred to rheumatologic units for PsA diagnosis confirmation.

Methods

a multicenter, non-interventional, cross-sectional trial conducted at 40 hospitals in Spain. Patients were initially screened for PsA by a dermatologist based on clinical evaluation and results from the Psoriatic Arthritis Screening and Evaluation (PASE) Questionnaire. All patients were then evaluated by a blinded rheumatologist for the presence of PsA using Moll and Wright criteria and Classification Criteria for Psoriatic Arthritis (CASPAR).

Results

Of 375 psoriatic patients enrolled at dermatology units, 28.6% patients scored ≥44 in PASE, whereas 32.3% patients screened positive for suspicion of PsA (clinical evaluation and/or PASE). Correlation of suspicion of PsA by dermatologists and PASE score was 0.368 (Pearson correlation coefficient). Following rheumatologic assessment, prevalence of PsA was 22.9% (86/375 patients) according to Moll and Wright and CASPAR criteria. The correlation of diagnosis of PsA between dermatologists and rheumatologists was 0.410 (Kappa Index).

Conclusions

Prevalence of PsA in our study was within the range reported in other studies. Our analyses found only a moderate correlation in the diagnosis of PsA between dermatologists and rheumatologists. The screening questionnaire, PASE, showed a moderate predictive value for the diagnosis of PsA.

     

A screening programme for dermatologists as a guide to request psychological consultation in routine clinical practice

Background

The psychosocial impact of skin conditions is usually evaluated in research settings.

Objectives

To define predictors that can be used by dermatologists to refer patients for psychological consultation or psychotherapy using a simple screening instrument.

Materials & Methods

A questionnaire to evaluate possible anxiety and depression (12-item General Health Questionnaire [GHQ-12]) was routinely used over a period of two months in an Italian dermatological reference centre.

Results

Of 651 patients, 508 (78%) completed the GHQ-12. Of the total sample, 35.2% scored 4 or more (psychological consultation suggested), and 15.7% scored 7 or more (psychological consultation recommended). Probable depression or anxiety was more frequent in women than in men, in patients born in foreign countries, and in patients with leg ulcers, pemphigoid, and psoriasis.

Conclusion

Our results indicate that a simple instrument may be useful for dermatologists to detect patients at risk of psychological problems and subsequently refer them for psychological consultation.

     

Safety of infraorbital hyaluronic acid injections: Outcomes of a meta-analysis on prospective clinical trials

Background

Hollowing of the infraorbital region represents a common concern among aesthetic patients. In the past decade, an increasing number of patients have resorted to noninvasive aesthetic procedures to treat these concerns. The objective of this study was to evaluate the safety profile of infraorbital hyaluronic acid injections for aesthetic rejuvenation.

Methods

Through a systematic review and meta-analysis of prospective clinical trials, investigators sought to answer the research question “Does the use of needle versus cannula during infraorbital HA injections result in the same incidence rate of adverse events?” The primary outcomes of interest were the incidence rates of ecchymosis and edema in subject groups treated with a needle or cannula.

Results

Subjects treated with needles had a statistically significant greater incidence rate of ecchymosis, compared to those treated with cannula. Conversely, subjects treated with cannula had a statistically significant greater incidence rate of edema, compared to those treated with needles.

Conclusions

The incidence rates of adverse events following the administration of hyaluronic acid injections in the infraorbital region vary depending on whether a needle or cannula is used; with needles being associated with a greater risk of ecchymosis and cannulas being associated with a greater risk of edema. These findings should be discussed with patients prior to treatment consultation. Finally, as with most techniques, it is usually prudent to develop expertise with one technique before using a second, especially in cases where both approaches can be used and have different adverse event profiles.     

Acne-specific quality of life questionnaire (Acne-QoL): translation, cultural adaptation and validation into Brazilian-Portuguese language

BACKGROUND

many studies about the psychosocial impact of acne have been reported in international medical literature describing quality of life as a relevant clinical outcome. It is well known that the patient''s perception about the disease may be different from the physician''s evaluation. Therefore, it is important to use validated instruments that turn the patient''s subjective opinion into objective information.

OBJECTIVES

to translate into Brazilian-Portuguese language and to culturally adapt a quality of life questionnaire, the Acne-Specific Quality of Life Questionnaire (Acne-QoL), as well as to evaluate its reliability and validity.

METHODS

measurement properties were assessed: 1) validity: comparison between severity and Acne-QoL domain scores, correlations between acne duration and Acne-QoL domain scores, and correlation between Acne-QoL domain scores and SF-36 components; 2) internal consistency: Cronbach''s α coefficient; 3) test-retest reproducibility: intraclass correlation coefficient and Wilcoxon test.

RESULTS

Eighty subjects with a mean age of 20.5 ± 4.8 years presenting mild (33.8%), moderate (36.2%) and severe (30%) facial acne were enrolled. Acne-QoL domain scores were similar among the different acne severity groups except for role-social domain. Subjects with shorter acne duration presented significant higher scores. Acne-QoL domains showed significant correlations, both between themselves and with SF-36 role-social and mental health components. Internal consistency (0.925-0.952) and test-retest reproducibility were considered acceptable (0.768-0.836).

CONCLUSIONS

the Brazilian-Portuguese version of the Acne-QoL is a reliable and valid satisfactory outcome measure to be used in facial acne studies.     

Screening for depression in adult acne vulgaris patients: tools for the dermatologist

Summary Background Adult dermatological out patients have a 40% prevalence of psychiatric co‐morbidity. If psychiatric co‐morbidity is unrecognized, undetected and untreated, the consequences may be fatal. Acne is the most common skin disorder of the second and third decades of life. Acne and its treatments may cause depression. Aims To identify a screening tool to identify depression in adult acne patients. Methods The literature was reviewed to identify validated screening instruments for depressive disorders. Questionnaires studied included the Hospital Anxiety and Depression Scale (HAD), the Brief Patient Health Questionnaire (B‐PHQ), the General Health Questionnaire‐12 item version (GHQ‐12), and the World Health Organization‐5 Well Being Index (WHO‐5). Results WHO‐5 performed best in terms of sensitivity (0.93 for a cut‐off score of 13) as well as taking least time to complete (2–5 min) and evaluate (0.5–2 min). Conclusions WHO‐5 can be recommended as part of a two‐step screening process for depression in acne patients. Step 1 is the WHO‐5. In the case of a positive score, step 2 is a detailed psychosocial assessment.     

Aesthetic considerations when treating patients of African descent: Thriving in diversity international roundtable series

Background

Black patients of African descent are an ethnically diverse demographic and have unique anatomical features, aging processes, and responses to aesthetic procedures that must be considered when planning treatment.

Aims

To discuss similarities and differences in the anatomy and treatment preferences of Black patients of African descent and explore how these differences may influence aesthetic practices.

Patients/Methods

In support of clinicians who wish to serve a diverse patient population, a 6-part international roundtable series focused on diversity in aesthetics was conducted from August 24, 2021, to May 16, 2022.

Results

The results of the third roundtable in the series, the African Patient, are described here. The expertise and perspectives of African physicians, US physicians who treat African American patients, and physicians practicing within Latin America and Europe who treat patients of color (POC) of African descent are included, as well as information gleaned from injection demonstrations.

Conclusions

Black African patients seek aesthetic treatment for a variety of conditions. Patients with darker skin can benefit from treatment with fillers, neurotoxins, and energy-based devices, but the application of these approaches should take into account the unique characteristics of each individual patient and the cultural and biological influences that impact treatment outcomes.     

Clinical validation of the upper face first principle—A clinical,prospective, interventional split-face study

Background

Previous clinical and anatomic investigations have identified the clinical relevance of facial biomechanics. Based on this new understanding, principles for facial aesthetic procedures were established: Lateral Face First, Deep Layers First, and Upper Face First.

Objective

To test the upper face first principle by showing that an injection sequence, starting in the upper face is superior to an injection sequence starting in the lower face.

Methods

This study was designed as an interventional split-face study administering the same amount and type of soft tissue filler for the upper, middle, and lower face but in a different sequence: upper, middle, lower face versus lower, middle, and upper face. A total of 15 patients (5 males and 10 females) with a mean age of 39.4 years (9.6) and a mean BMI of 23.4 kg/m² (1.7) were studied. Follow-up at D0, D30, and D90 was conducted utilizing semiquantitative scores and objective 3D imaging.

Results

Despite not reaching statistical significance, midfacial volume and jawline contouring were rated better at every follow-up visit (D0, D30, D90) when treated with the upper versus the lower face first injection algorithm. The global aesthetic improvement scale showed statistically significantly better values for the upper face first algorithm when compared to the lower face first algorithm at all evaluated time points with all p < 0.001.

Conclusion

Applying the upper face first injection algorithm seems to result in better aesthetic outcomes when directly compared to the lower face first algorithm. Semiquantitative and objective outcome measurements confirm its clinical effectiveness.     

Sexual and Reproductive Dysfunction in Young Female Cancer Patients

Purpose of Review

This review summarizes the current literature about sexual and reproductive dysfunction in female cancer survivors and points toward future directions for research.

Recent Findings

Sexual dysfunction is a common condition seen in this population and as the incidence of survivorship grows, so will its prevalence. It is a comorbidity that has a significant effect on the quality of life. While research in this area is emerging, patients are still underserved in both recognition and treatment.

Summary

Research has conclusively shown that female sexual dysfunction after cancer is a major medical issue. Future steps should be taken to educate both medical providers and the public to improve screening and recognition, targeting early treatment with implementation of multidisciplinary care. While several single treatments have shown promise, optimal outcomes will ultimately be achieved through an approach that specifically addresses a patient’s medical, social, and psychological needs.

     

The scrotum: A comparison of men's and women's aesthetic assessments

Background

Cosmetic surgery is a growing trend. Opportunities for an individual to attain their personal aesthetic ideal via plastic surgery have now extended as far as the genital area. Adaptive surgery on intimate areas of the body may take place for physical complaints, but may instead be due to a desire to conform to a particular ideal. Breast operations, labia reductions, and penis lengthening are long-established interventions, the motives for which a number of previous studies have examined. Tightening of the scrotum, by contrast, is a new trend in the aesthetic surgery market. Notwithstanding its rapid increase, studies have yet to investigate aesthetic preferences as regards the scrotum.

Aims

Accordingly, the aim of the present study is to compare men's and women's evaluation of various sizes of scrotum, to the end of assisting people opting to undergo this procedure in taking decisions on their visual preferences.

Material and Methods

The participants in this study rated a number of photographs of scrotums, in nine different lengths and widths, and completed a questionnaire whose aim was to determine whether assessments differed by gender. Further, we considered whether the variables of age, extraversion, openness to experience, and consumption of pornography influenced participants' evaluations.

Results

We found no significant differences in evaluation of the aesthetic of scrotums in relation to any of these personality traits. The results show what sizes (lengths and widths) of scrotum the participants judged to be the most and least attractive.

Discussion

The esthetics of the scrotum is little explored. In this study, only normal deviations were considered, i.e. within one standard adjustment. Further studies should consider extremes.

Conclusion

Ultimately, it was barely possible to identify a “beautiful” scrotum; we must instead speak of the least ugly.     

Views of dermatopathologists about clonality assays in the diagnosis of cutaneous T‐cell and B‐cell lymphoproliferative disorders

Background

Appropriate use criteria have been developed for many tests using expert judgment, evidence‐based practice and clinical experience. In this context, we report the opinions of practitioners about clonality assays in various clinical scenarios where cutaneous lymphoma is suspected.

Methods

An Appropriate Use Criteria Task Force sponsored by the American Society of Dermatopathology (ASDP) synthesized clinical scenarios for cutaneous lymphoproliferative disorders (LPDs). We conducted, summarized and presented a relevant literature search to an audience of 144 dermatopathologists with a variety of practice experiences at the 53rd Annual Meeting of the ASDP in Chicago, IL.

Results

Twenty‐seven clinical scenarios for LPDs (13 T‐cell and 14 B‐cell) were defined. Forty relevant studies for T‐cell receptor gene clonality assays and 20 relevant studies for IgH/IgK clonality assays were identified. Audience response data from participating dermatopathologists reflected a wide variety of approaches to the application of clonality assays in the evaluation of LPDs, based on practice setting, personal experience and test availability.

Conclusions

Our clinical scenario analysis and literature review revealed well‐supported clinical scenarios and identified opportunities for additional research to further define the utility of clonality assays in some clinical scenarios.