Raymond G. Dufresne

Body dysmorphic disorder. A guide for dermatologists and cosmetic surgeons.

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.

Actinic cheilitis. A treatment review.

BACKGROUND Actinic cheilitis is a common premalignant condition, significant for symptoms and potential development into invasive squamous cell carcinoma. Multiple methods of treatment have been reported for this entity. OBJECTIVE The purpose of this article is to review and compare the accepted treatment modalities reported for actinic cheilitis. METHODS The English language literature was reviewed for treatment options, efficacy and adverse effects. RESULTS Cryosurgery, electrocautery, 5‐fluorouracil, carbon dioxide laser, and scalpel verimilionectomy were all clinically effective. AH therapies, with the exception of chemical peeling, appear to have a low clinical failure rate. Histological clearance of disease was demonstrated in carbon dioxide laser‐treated patients. 5‐Fluorouracil failed to achieve complete removal of histologic dysplasia. The carbon dioxide laser may be associated with less scarring and an improved cosmetic outcome in comparison with the scalpel vermilionectomy. CONCLUSION Focal actinic cheilitis is easily treated with cryosurgery or electrosurgery. Extensive actinic cheilitis requires 5‐fluorouracil, carbon dioxide laser, or scalpel vermilionectomy for adequate treatment. The carbon dioxide laser offers some advantages over scalpel vermilionectomy.

Tanning in Body Dysmorphic Disorder

Tanning in body dysmorphic disorder (BDD) has not previously been studied. In this study, 200 subjects with BDD were evaluated with measures to examine the prevalence of BDD-related tanning—i.e., darkening ones skin color by direct exposure to sunlight or artificial light which is motivated by a desire to improve a perceived appearance defect (i.e., a BDD concern). We also examined clinical characteristics of individuals who engaged in BDD-related tanning. 25% (95% CI, 19.0%–31.0%) of subjects reported BDD-related tanning. Among tanners, the skin was the most common body area of concern (84.0%). All tanners experienced functional impairment due to BDD, 26% had attempted suicide, and quality of life was markedly poor. 52% of tanners had received dermatologic treatment, which was usually ineffective for BDD symptoms. Tanners were more likely than non-tanners to compulsively pick their skin. In conclusion, tanning—a behavior with well-known health risks—is a relatively frequent BDD-related behavior.

Body Dysmorphic Disorder: A Guide for Primary Care Physicians

Body dysmorphic disorder (BDD), a preoccupation with an imagined or slight defect in appearance, is a relatively common psychiatric disorder that often presents to nonpsychiatric physicians. Body dysmorphic disorder is associated with marked impairment in functioning, notably poor quality of life, and a high suicide attempt rate. Most patients seek and receive surgery or nonpsychiatric medical or dermatologic treatment, often with a perceived poor outcome despite an objectively acceptable result. In contrast, psychiatric treatment, serotonin-reuptake inhibitors and cognitive-behavioral therapy, often are effective. This clinically focused review describes the clinical features and prevalence of BDD, the disorders treatment response, how to recognize and diagnose BDD, and practical suggestions for primary care physicians who encounter these often difficult-to-treat patients.

Multiple antithrombotic agents increase the risk of postoperative hemorrhage in dermatologic surgery

BACKGROUND Studies show that holding single antithrombotic agents perioperatively increases the risk of acute thrombotic events and does not significantly decrease the risk of bleeding complications in dermatological surgery. Recent data suggest that selected patients may benefit from combination therapy in preventing acute thrombotic events. OBJECTIVE We sought to evaluate postoperative bleeding complications in patients who underwent Mohs micrographic surgery while using multiple agents perioperatively compared with patients using a single agent or none at all. METHODS We conducted a retrospective chart review of patients treated in one academic Mohs micrographic surgery department during 1 year. RESULTS Patients taking two or more agents at the time of surgery were more likely to bleed than those taking one agent or none at all (P = .0016, Fishers exact). LIMITATIONS Small sample size and retrospective nature were limitations. CONCLUSION Perioperative use of more than one antithrombotic agent increases postoperative bleeding risk.

Treatment of squamous cell carcinoma in situ: a review.

BACKGROUND Squamous cell carcinoma in situ (SCCIS) is thought to be a precursor to squamous cell carcinoma. It should be treated before invasive cancer develops, especially in transplant recipients, who may develop more aggressive skin cancers. Treatment can involve surgical and nonsurgical methods. OBJECTIVE To review the evidence available in the English medical literature for different treatment options of SCCIS on nongenital skin and evaluate the efficacy of each option. METHODS AND MATERIALS A Pubmed search of articles describing the treatment of SCCIS was conducted. Keywords were “treatment,” “Bowens disease,” and “squamous cell carcinoma in situ.” Articles describing the use of surgical excision, curettage and electrodesiccation, cryotherapy, 5‐fluorouracil, imiquimod, radiation, photodynamic therapy, lasers, and rarer methods were reviewed. RESULTS No single treatment can be said to be superior for any one situation. Most studies are small, limiting the power of each. Further studies are needed to clarify optimal treatment protocols for nonsurgical methods such as cryotherapy, photodynamic therapy, and topical chemotherapy. CONCLUSION There are many methods available to treat SCCIS. Physicians should consider each patients situation while keeping in mind that treatment protocols have not been fully defined for most options. The authors have indicated no significant interest with commercial supporters.

Incidence of and Risk Factors for Medical Malpractice Lawsuits among Mohs Surgeons

BACKGROUND Despite rising medical malpractice costs, little is known about the factors associated with claims filed against Mohs surgeons. OBJECTIVE We sought to define the scope of medical malpractice claims filed against Mohs surgeons and to identify salient factors associated with the filing and disposition of those claims. METHODS A comprehensive survey was mailed to 599 physicians with US addresses listed in the 2003 directory of the American College of Mohs Micrographic Surgery and Cutaneous Oncology. RESULTS Of the 300 completed surveys returned, 33 (11%) reported ever having been sued. Physicians who practiced Mohs surgery for a longer period of time were more likely to have been sued for malpractice. Physicians reported the wrong site and functional outcome as the most frequent causes of malpractice lawsuits.

Body dysmorphic disorder and cosmetic dermatology: more than skin deep

Body dysmorphic disorder (BDD) is relatively common in cosmetic practise, yet it remains under‐recognized.

Preoperative methicillin-resistant Staphylococcus aureus screening in Mohs surgery appears to decrease postoperative infections.

BACKGROUND Colonization with methicillin‐resistant Staphylococcus aureus (MRSA) places patients at risk for postoperative MRSA wound infections. OBJECTIVE To determine the effect of a decontamination and prophylaxis protocol on postoperative MRSA wound infections in patients with nasal MRSA. METHODS & MATERIALS Wound cultures over a 23‐month period were reviewed before and 11 months after implementation of a screening and decontamination protocol. After preoperative MRSA screening with nasal swabs, carriers were instructed to use intranasal mupirocin for 5 to 7 days before surgery and 5 to 7 days of trimethoprim‐sulfamethoxazole starting the day before surgery. RESULTS During the 23 months before prescreening evaluation, we performed 3,633 Mohs surgical cases, and 12 postoperative MRSA wound infections (0.3%) occurred. Subsequently, 963 patients underwent screening for MRSA, and 23 MRSA carriers were identified (2.4%). Of the 22 who underwent the decontamination and treatment protocol, none developed postoperative wound infections. One MRSA carrier did not receive preoperative treatment and subsequently developed a MRSA wound infection. There were no other MRSA infections. CONCLUSION Preoperative MRSA screening and implementation of a decontamination protocol appears to decrease postoperative MRSA wound infections after Mohs surgery. Although an interesting observation, controlled studies of clinical and cost effectiveness are required before general implementation. The authors have indicated no significant interest with commercial supporters.

Seasonal presentation of keratoacanthomas in Rhode Island

Seasonal presentation of skin cancers has been previously described, but the seasonal presentation of keratoacanthomas is less well documented. Pathology reports and dermatology clinic visits were examined from the Roger Williams Medical Center, the major dermatopathology service in Rhode Island. U.S.A., from 1990 to 1992. Seasonal presentation was defined as the ratio of keratoacanthomas during the summer months (June–September) to the number diagnosed during the winter months (December–March). A peak incidence of keratoacanthomas was noted in the summer and early autumn months. The summer/winter ratio (1.38) was statistically significant (P=0.002).The summer/winter ratio of office visits was smaller at 1.12. but also significant (P< 0.001). There appears to be a seasonal presentation of keratoacanthoma in southern New England. This suggests that ultraviolet radiation has an acute effect on the development of keratoacanthoma.