Delusional parasitosis in dermatological practice

BACKGROUND: The accurate incidence of delusional parasitosis (DP) is difficult to assess. The aim of this study was to analyse the frequency of DP treated by dermatologists, and to evaluate the treatment modalities they applied. MATERIAL AND METHODS: A specially designed questionnaire was distributed to 172 dermatologists. A total of 118 doctors responded (68.6% of all subjects). The dermatologists were asked to answer questions concerning demographic data of the respondents and the frequency of DP observed in their everyday practice. Finally, methods of treatment used by the dermatologists to help patients suffering from DP were evaluated. RESULTS: During the whole working period the majority of dermatologists participating in the survey (84.7%) had seen at least one patient with DP in their practice. About one-third of the respondents (33%) had seen one or two cases of DP during the past 5 years, and 28% of the doctors treated from three to five such patients. Twenty-three per cent of dermatologists declared that they had diagnosed no cases of DP during the past 5 years. The rest of our respondents had seen more than five cases of DP during the past 5 years, and 7% of the doctors reported seeing more than 10 patients with DP within this period. Almost 20% of the dermatologists were currently treating a patient with DP. Our data show that 40.7% of the respondents always ask and 28.8% often ask for a psychiatric opinion about their patients with DP. More experienced dermatologists statistically more frequently (P<0.05) obtained a psychiatric opinion about their patients. Only a small group of dermatologists (15.3%) use their own pharmacological treatment. If they do so, they first use sedatives and anxiety-relieving drugs. CONCLUSION: DP is a quite common disorder, however not all dermatologists are sufficiently prepared to treat it. There is an urgent need for training on the dermatological approach to psychodermatoses.     

Body Dysmorphic Disorder

Patients with body dysmorphic disorder (BDD) often present to dermatologists and cosmetic surgeons. BDD is a relatively common yet underrecognized disorder that consists of a distressing or impairing preoccupation with an imagined or slight defect in appearance. Although any body area can be the focus of concern, preoccupation with the appearance of the skin, hair, and nose are most common. Typical associated behaviors include skin picking, mirror checking, and camouflaging (e.g., with a hat or makeup). Reassurance seeking is another common behavior that may be enacted with surgeons and dermatologists. BDD is associated with marked impairment in functioning, notably poor quality of life, and a high suicide attempt rate. The disorder appears relatively common in dermatologic and cosmetic surgery settings; in fact, dermatologists may be the type of practitioner most often consulted by patients with BDD. Psychoeducation is an important element in the treatment of BDD. For patients who compulsively pick at their skin, it is generally ineffective to simply advise them to stop picking. Educating them that the picking is a symptom of BDD, and is treatable, can be helpful. For skin pickers, a combination of psychiatric and dermatologic treatment may be best. It is probably best to avoid cosmetic procedures. Although definitive data on the treatment outcome of surgery and dermatologic treatment for BDD are lacking, and although no one can predict how a given patient will respond to such treatment, available data suggest that these treatments are unlikely to be successful and may even make the patient’s condition worse. Rather than referring the patient to another dermatologist or cosmetic surgeon, we recommend attempting to refer the patient to a psychiatrist for cognitive-behavioral therapy or pharmacotherapy. Available data indicate that serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors are often effective for BDD. In recent years, BDD has gone from being a neglected psychiatric disorder to one that is becoming better recognized and understood. Nonetheless, research on this disorder is still in its early stages, and much more investigation of BDD is needed, especially in surgical and dermatologic settings. Treatment recommendations will be modified in the future as more research is done. In the meantime, it is important that dermatologists and surgeons screen patients for BDD and accurately diagnose this condition, as available psychiatric treatments are very promising for patients with this distressing and sometimes disabling disorder.     

Rate of body dysmorphic disorder in dermatology patients

BACKGROUND: Dermatologists appear to be the physicians most often seen by patients with the psychiatric condition body dysmorphic disorder (BDD), a distressing or impairing preoccupation with a nonexistent or slight defect in appearance. The frequency of BDD among patients seeking dermatologic treatment is unknown, however. OBJECTIVE: This study determined the percentage of patients seeking dermatologic treatment who screened positive for BDD. METHODS: A validated self-report questionnaire and a reliable defect severity scale were used to determine the rate of BDD in 268 patients seeking dermatologic treatment. RESULTS: A total of 11.9% (95% confidence interval [CI], 8.0%-15.8%) of patients screened positive for BDD. Rates were similar in a community general dermatology setting (14.4% [95% CI, 8.5%-20.3%]) and a university cosmetic surgery setting (10. 0% [95% CI, 6.1%-13.9%]). CONCLUSION: BDD appears relatively common among patients seeking dermatologic treatment. Further research is needed to confirm these findings and to assist dermatologists in identifying these potentially high-risk patients.     

The impact of skin diseases on patients: comparing dermatologists' opinions with research data collected on their patients

BACKGROUND: Research data suggest that the detection of psychiatric disorders by dermatologists is not completely satisfactory, and that patients and dermatologists often assess patients' quality of life differently. Given that expectations influence perception and cognitia, these discrepancies might at least in part descend from conceptual models of skin disease that are prevalent among dermatologists. OBJECTIVES: We explored to what degree dermatologists' opinions about quality of life and prevalence of psychiatric disorders in several dermatological conditions corresponded to the actual data collected on their patients. METHODS: All dermatologists working in a large institution were asked to express on a five-point scale their opinion about the quality of life and the prevalence of depressive and anxiety disorders in different skin conditions. Physicians' opinions were then compared with the results of a large research project on quality of life and psychological well-being in dermatological out-patients performed in their institution some months before. RESULTS: Forty-six dermatologists (82%) agreed to participate and completed the research questionnaire. We observed a fairly good concordance between dermatologists' opinion about the impact of the various skin conditions on patients' lives and survey data on quality of life impairment. With regard to psychiatric morbidity, we found that dermatologists believe that psychiatric disorders are substantially less frequent than they actually are in many skin conditions. CONCLUSIONS: The belief that psychiatric morbidity is rare in patients with certain skin conditions might hamper, at least in part, the recognition of psychiatric disorders in these patients. Dermatologists probably should be more alert to the question of psychiatric morbidity in their patients. Allocating more space to this issue in training programmes for dermatologists might favour a shift in their conceptual models of skin disease.     

Psychiatric morbidity in dermatological outpatients: an issue to be recognized

BACKGROUND: There is a high prevalence of psychiatric disorders in dermatological outpatients. OBJECTIVES: To estimate the magnitude of this problem and to identify a set of variables associated with the presence of psychiatric disorder. METHODS: All adults attending the outpatient clinics of a dermatological hospital on predetermined days were given a questionnaire comprising the Skindex-29 and the 12-item General Health Questionnaire (GHQ-12). RESULTS: In total, 4268 questionnaires were given at admission, and 3125 were returned. Of these, 546 were blank or incomplete, leaving 2579 respondents (response rate 60.4%). Using a stringent cut-off threshold (> or = 5) for psychiatric case identification with the GHQ-12, scored in the conventional way, the overall prevalence of psychiatric morbidity was 25.2% (95% confidence interval 23.6-27.0%). We found a higher prevalence of psychiatric disorders in women and in widows/widowers, controlling for age. Health-related quality of life was a much stronger predictor of psychiatric morbidity than physician-rated clinical severity. High prevalence rates (> 30%) were observed among patients with acne, pruritus, urticaria, alopecia and herpesvirus infections, and in subjects without objective signs of dermatological disease. CONCLUSIONS: Our study has depicted the situation that is actually faced by dermatologists in their everyday practice, where they are in a unique position to recognize psychiatric morbidity and to take appropriate measures. The GHQ-12, being easy for patients to compile and for physicians or nurses to score, may be a practical tool to increase identification of patients with substantial psychological distress or formal psychiatric disorder in order to provide more comprehensive and appropriate intervention.     

A case of body dysmorphic disorder in an adolescent with hypohidrotic ectodermal dysplasia

We report the case of an adolescent with hypohidrotic ectodermal dysplasia, who had obsessive-compulsive disorder and was later diagnosed with body dysmorphic disorder (BDD). BDD is a highly distressing, adolescent-onset disorder that may lead to social isolation, the development of comorbid mental health disorders and suicidality. Patients typically lack insight into their BDD and frequently present to dermatologists for medical treatment. In this paper, we address the challenges faced when working with patients with BDD.     

A survey of vitiligo management among dermatologists in Saudi Arabia

Background  There are concerns that there is no uniform approach towards the management of vitiligo.
Objectives  To explore attitudes and strategies for the management of vitiligo among dermatologists.
Methods  A self-administered questionnaire containing 22 questions was distributed to 160 dermatologists attending a national dermatology conference in 2007.
Results  One hundred and twelve dermatologists responded to the questionnaire (70% response rate). We had 105 completed questionnaires (seven were excluded due to incompleteness). Active treatment of vitiligo was recommended by 96% in more than half of patients, while 79% recommended treatment at non-visible sites. Repigmentation was regarded as main treatment goal by 54%. Mid-potent topical steroids were widely prescribed for focal vitiligo (72% in children and 65% in adults). Use of tacrolimus and pimecrolimus was limited. The most common used phototherapy was 'narrowband ultraviolet B' (NBUVB; 36% and 40% for generaliased vitiligo in children and adults, respectively). The use of oral psoralen plus UVA (PUVA) was limited (8% for generalized vitiligo in adults). Few respondents (1–8% for different types of vitiligo) prescribed outdoor topical PUVA. Vitiligo surgery was advised mainly for segmental type (18% in adults and 5% in children). Depigmentation was the first option for universal vitiligo by 50% and 30% in adults and children, respectively.
Conclusions  Most dermatologists are enthusiastic about active treatment of vitiligo even in hidden sites. Overall, the most two common treatment modalities were topical steroids and NBUVB. Vitiligo surgery is underutilized. Development of national practice guidelines is needed.     

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.     

Common sources of skin care education: a cross-sectional study

Background  The resources used by the public to locate health information are important.
Aim  To expose the sources from which the public gains a knowledge of dermatology.
Methods  An anonymous, multiple-choice questionnaire was distributed to adults in college campuses, shopping malls, and community parks over a 4-month period.
Results  Sixty-six percent of individuals stated that they felt physicians had the most authority for making recommendations regarding the skin. When questioned about the sources of skin care advice, however, there was a discrepancy, with only 35% stating that they actually consulted professionals. Indeed, 37% admitted to using family and friends as their primary source of information, and 28% used the media first.
Conclusions  In our opinion, the best method to ensure healthy skin habits and early diagnosis of disease would be to combine the efforts of healthcare and the media. These public resources should make people aware of skin diseases and preventative measures, whilst encouraging regular check-ups with dermatologists and persuading patients to employ open conversation with their physicians regarding care of their skin.     

Career choices in dermatology

Reforms to both undergraduate and postgraduate training have resulted in limited exposure to clinical dermatology, and therefore we need to target advice and clinical attachments to the most appropriate stages of training to ensure that dermatology is considered as a career option by medical students. A questionnaire survey was undertaken to determine when and how doctors chose their career in dermatology. An electronic questionnaire was sent to 709 dermatologists (response rate 44%). Of the respondents, 49% considered dermatology after medical school attachment and 61% were influenced by the jobs they had done as a pre-registration house officer (PRHO) or senior house officer (SHO). Careers advice was lacking, with only 11% receiving it while at medical school and 29% during their PRHO/SHO years. Contact with an inspiring clinician was the most influential factor in choosing dermatology. Both medical students and junior doctors, should have opportunities to learn from and work with clinical dermatologists.     

A questionnaire study on the management of onychomycosis: a Canadian perspective

Background Onychomycosis of the toenails is a condition that responds poorly to griseofulvin. The introduction of terbinafine in Canada in May 1993 resulted in a marked shift in the choice of treatment for pedal onychomycosis. Methods A questionnaire survey was carried out in 1996 among Canadian dermatologists regarding the management of onychomycosis. Results There were 160 respondents from the roughly 350 practicing dermatologists. The dermatologists saw 8 ± 0.6 patients per week (average ± standard error (SE)) with suspected or diagnosed onychomycosis, with 5 ± 0.5 patients per week consulting the dermatologists for the first time. Most dermatologists performed mycological testing prior to starting treatment for onychomycosis. The management options for onychomycosis (mean ± SE) were oral systemic antifungal therapy 51 ± 3%, no therapy 31 ± 3%, and nondrug therapy 9 ± 2%. The majority of dermatologists (83%) used terbinafine as first-line therapy if, indeed, they used oral antifungal agents. In contrast, griseofulvin and ketoconazole were used as first-line therapy in 5% and 1% of cases, respectively. In Canada, there are no monitoring requirements when using oral terbinafine for onychomycosis. Therefore, it is not surprising that only 30% of dermatologists performed monitoring with terbinafine. In contrast, the frequency of monitoring with griseofulvin and ketoconazole was 40% and 80%, respectively. The subset of dermatologists who reported monitoring carried it out in only a fraction of their patients: 47%, 53%, and 83% for terbinafine, griseofulvin, and ketoconazole, respectively. Therefore, the overall number of patients in whom regular monitoring was performed was 14.1%, 21.2%, and 71.4% for terbinafine, griseofulvin, and ketoconazole, respectively. The perceived cure rates with terbinafine and griseofulvin (mean ± SE) were 83.7 ± 1% and 41 ± 3.1%, respectively. Conclusions In May 1996, within three years of the introduction of terbinafine to Canada, this agent has become the drug of choice for the treatment of pedal onychomycosis (at the time of the survey neither itraconazole or fluconazole were approved for onychomycosis). Terbinafine has been found to be very effective and safe, and only a minority of dermatologists perform regular monitoring with this drug.     

Hand eczema: causes, course, and prognosis II

Background:  Hand eczema is a common dermatosis, often with a chronic course.
Objective:  To follow a well-described cohort of patients with hand eczema for 5 years.
Patients and Methods:  522 consecutive hand eczema patients (175 men and 347 women) seen in a private practice of dermatology were sent a questionnaire once a year for 5 years.
Results:  After 1 year, the response rate was 80% (417 of 522), and after 5 years, the rate was 68%. After 1 year, 81% of the 417 respondents reported that they still had persistent or intermittent hand eczema. After 5 years, this number was 65% (232 of 355). The larger the area involved at the initial examination, the poorer the prognosis. After 1 year, 48% of the patients felt that their hand eczema had improved, while 6.7% felt that it had worsened. 25% of those who responded stated that they never used gloves. Few patients could provide new information about the cause of the dermatitis during the 5-year follow-up.
Conclusions:  Hand eczema is a chronic dermatosis. Although treatment may improve hand eczema, it rarely clears completely. Evidence-based measures need to be developed for the long-term management of hand eczema.     

Evidence-based review: Screening body dysmorphic disorder in aesthetic clinical settings

Background

Body dysmorphic disorder (BDD) is a psychiatric disturbance with high incidence in aesthetic clinical settings. Early recognition may avoid unnecessary elective procedures with ethical and medicolegal consequences.

Aims

To identify validated BDD screening tools and critically appraise current literature regarding its implementation and efficacy in aesthetic medicine and surgery scenarios, with the purpose of transposing the findings to the broad clinical settings in the field.

Methods

Data was collected using advanced search from PubMed (MEDLINE). Having satisfied the search parameters, 12 studies referring BDD definition according to Diagnostic and Statistical Manual of Mental Disorder (DSM-5) criteria and including a BDD screening tool in clinical aesthetic settings were selected.

Results

While BDD screening enables the recognition of at-risk individuals, further work is required to uncover the best screening tool for general aesthetic clinical practice. Level III evidence favored BDD Questionnaire (BDDQ)/BDDQ-Dermatology Version (DV), and The Dysmorphic Concern Questionnaire (DCQ) among the limited available validated screening instruments to be used outside the psychiatric environment. Based on level II self-classification, one study selected BDDQ-Aesthetic Surgery (AS) version for rhinoplasty patients. The validation process of both BDDQ-AS and Cosmetic Procedure Screening Questionnaire (COPS) had limitations. For BDD screening potential in avoiding postoperative complications, the limited studies found evaluating the outcomes following aesthetic treatments using validated BDD screening measures showed a trend toward less satisfaction with aesthetic treatment outcome among positive screening population against non-BDD counterparts.

Conclusion

Further research is necessary to establish more effective methods to identify BDD and evaluate the impact of positive findings on aesthetic intervention outcomes. Future studies may elucidate which BDD characteristics best predict a favorable outcome and provide high-quality evidence for standardized protocols in research and clinical practice.     

Dermatological surgery: a comparison of activity and outcomes in primary and secondary care

Background  Dermatological surgery is carried out by a variety of practitioners in primary and secondary care.
Objectives  To explore the activity and histopathological outcomes among different groups of dermatological surgeons dealing with skin cancers.
Methods  Reports for all new skin tumour specimens processed by our histopathology department over a continuous 3-month period were reviewed retrospectively.
Results  One thousand, one hundred and eleven new skin tumour specimens were identified. General practitioners (GPs) were least accurate in clinical diagnosis, with 42·8% (59/138) of their request forms including the eventual histological diagnosis, compared with 69·5% (328/472) for dermatologists (odds ratio, OR 0·33, 95% confidence interval, CI 0·22–0·48). Inappropriate procedures were most often performed by plastic surgeons, usually involving large excision biopsies for benign lesions in elderly patients [6·6% (20/305) of their specimens vs. 0% for dermatologists, exact P  <   0·001]. Excision biopsies performed by GPs had the highest rate of margin involvement by tumour of any specialty [68% (15/22) of such specimens vs. 8% (9/116) for dermatologists; OR 25·47, 95% CI 8·26–78·53]. As per National Institute for Health and Clinical Excellence guidance, 13·8% (19/138) of tumours operated on by GPs should instead have been referred to secondary care for initial surgical management.
Conclusions  This study presents a strong case for dermatologists to continue to provide the lead in diagnosis of skin lesions, and in selection and execution of dermatological surgical procedures.     

Skin cancer screening by dermatologists: prevalence and barriers

BACKGROUND: The incidence of skin cancers is increasing at an alarming rate, and there is currently no consensus by major health policy organizations regarding skin cancer screening. It has previously been shown that primary care physicians do not screen a majority of patients for skin cancer. OBJECTIVE: This study was undertaken to determine the prevalence of skin cancer screening among dermatologists and to detect barriers to screening. As a secondary objective, we set out to determine the prevalence of dermatoscopy use. METHODS: With the use of membership data from the 1999-2000 directory of the American Academy of Dermatology, a random sample of 464 American dermatologists was surveyed to assess their skin cancer screening practices and perceived obstacles to this practice. We then determined whether differences in knowledge of skin cancer screening recommendations, emphasis of skin cancer screening in training, or physician age affected the prevalence of screening. RESULTS: A total of 190 dermatologists responded (41%). Fifty-seven respondents (30%) reported performing full-body skin cancer screening on all of their adult patients and 93 more (49%) reported screening only patients perceived to be at increased risk. Eighty respondents (42%) reported lack of time as an impediment to screening. Only 18 (9%) did not screen patients because of potential patient embarrassment, whereas 17 (9%) did not perform screening because of lack of financial reimbursement. Sixty-two dermatologists (33%) reported being aware of official skin cancer screening recommendations, but they were not more likely to screen all patients (P =.64) or partake in screening of all patients or only those at increased risk (P =.84). One hundred nineteen respondents (63%) reported that skin cancer screening was emphasized during their medical training and they were more likely to screen all patients (P =.04) or either all or high-risk patients (P =.02). Younger age groups of dermatologists were significantly more likely to screen all patients for skin cancer (P =.03). Twenty-two percent of respondents reported using dermatoscopy for suspicious lesions. CONCLUSION: Dermatologists report a high rate of screening for skin cancer despite not having knowledge of skin cancer screening recommendations. Inadequate time to perform full-body skin examinations and lack of emphasis during training were identified as possible barriers to this practice.     

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.     

Obsessive-compulsive disorder in patients with chronic pruritic conditions: case studies and discussion.

BACKGROUND: Relatively few persons with obsessive-compulsive disorder (OCD) come to psychiatric clinics for treatment. Our hypothesis was that patients with a form of OCD that involves compulsive hand and body washing might initially seek treatment from a dermatologist. OBJECTIVE: Our purpose was to screen patients attending a dermatology clinic to determine the frequency of OCD cases and to help dermatologists recognize this disorder. METHODS: Randomly selected patients who presented with one of several chronic pruritic conditions were interviewed to determine the presence of anxiety disorders. RESULTS: A significantly high percentage of the patients (14%) were found to have previously undiagnosed OCD. Case studies of five of these patients are presented. CONCLUSION: A significant number of patients with undiagnosed OCD appear to present to dermatology clinics. Identification and referral for psychiatric consultation may aid in the treatment of both OCD and concomitant dermatologic conditions.     

Management of vitiligo. Results of a questionnaire among dermatologists in The Netherlands

BACKGROUND: Several therapeutic options are available for the treatment of vitiligo. Concern exists that there is no uniform approach towards the management of vitiligo among Dutch dermatologists. METHODS: A written survey concerning the management of vitiligo was sent to 332 dermatologists in The Netherlands. RESULTS: The response rate was 86%. "Giving information and reassurance concerning the nature of disease" was regarded by most dermatologists (68%) as being the most important goal in the management of vitiligo. Only 16% of the dermatologists aimed for active treatment in vitiligo. The reported therapy choices in children resembled those of adults, except that slightly more dermatologists did not prescribe active therapy in children. Nine different therapeutic modalities were mentioned as first choice therapies. Topical corticosteroids were indicated by most dermatologists as first choice therapy (241 out of 266, i.e. 91%); however, only 2% indicated that 50% or more of the patients achieved a successful treatment; 66% found that less than 25% of the patients were successfully treated with topical corticosteroids. Only 15% of the respondents reported that 50% or more of the patients were treated successfully with narrow-band UVB. The observed response profile to broad-band UVB therapy was found to be comparable with that of narrow-band UVB. The classical therapy with oral psoralen plus UVA (PUVA) was prescribed as first choice therapy by only 12% (32 out of 266) of the dermatologists. Only 6% of these respondents observed that 50% or more of the patients achieved successful therapy using oral PUVA. The recommended maximum treatment duration for topical corticosteroids, oral PUVA, and UVB therapy was found to vary from 3 to 12 months. CONCLUSIONS: Most dermatologists in The Netherlands do not offer active treatment in vitiligo, probably because the estimated effectiveness of (nonsurgical) repigmentation therapy is low. In cases where treatment is prescribed, there appears to be no consensus on the choice of therapies and treatment strategies. The development of practice guidelines may be helpful in reducing inappropriate care and improving treatment outcome.