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More Than Skin Deep: Exploring the Intersection of Body Dysmorphic Disorder and Dermatological Conditions

By Duncan MacIntyre, BS, and Peter A. Lio, MD

 

 

Introduction

In an era where technology has reshaped how we perceive ourselves and how others view us, the impact of skin health on self-image has become increasingly apparent, with profound effects on mental well-being. Social media and the sudden proliferation of virtual meetings during the COVID-19 pandemic have given rise to phenomena like “Zoom dysmorphia,” where constant exposure to one’s image in digital mirrors amplifies insecurities and distorts self-perception.1 Central to this is body dysmorphic disorder (BDD), a condition characterized by an overwhelming fixation on perceived physical imperfections. Li et al. recently published a review article shedding light on the increasing prevalence of BDD in dermatology, illustrating how visible skin conditions wield immense psychological power.2 This brief review highlights some key concepts and studies that showcase the importance of understanding BDD in dermatology, even outside of strictly cosmetic-focused practices.

Understanding Body Dysmorphic Disorder(BDD)

BDD is characterized by an intense preoccupation with perceived physical flaws. These imperfections are often minor or unobservable to others and lead to significant impairment in social, occupational, or daily functioning. Insight into these beliefs varies, ranging from recognition of their inaccuracy to complete delusional conviction.3 BDD is not uncommon, with a prevalence of 2–3% of the population. It affects nearly as many men as women despite common misconceptions that the disorder is more prevalent in women.4

Studies have demonstrated that BDD is associated with psychological distress, perceived stigmatization, and notable psychosocial impairment, with behaviors such as excessive checking of perceived physical defects exacerbating appearance-related preoccupations and contributing to anxiety and depressed mood.5 The preoccupations with one’s appearance experienced in BDD can become intrusive and uncontrollable, often resulting in significant social and occupational functioning difficulties.6 Recognizing and effectively treating BDD is critical due to its link to suicidal ideation, suicide attempts, and completed suicides, underscoring the urgent need for early diagnosis and comprehensive management to mitigate these severe risks.7

BDD in Dermatology Patients

Understanding the link between BDD and dermatological conditions is essential, as skin issues are physical manifestations that influence how individuals perceive themselves and believe others perceive them. Individuals with BDD are most frequently preoccupied with the skin (73%), hair (56%), and nose (37%). Any area of the body can become a focus, however, with an average lifetime concern involving five to seven different body parts.8 The intersection of BDD and dermatology spans a wide range, as BDD is reportedly 4.9% to 36% more likely to be experienced among dermatology patients than among the general population.9

Approximately one-third of the global population is affected by at least one dermatological condition, highlighting the significant prevalence and impact of skin diseases.10 Conspicuous dermatological diseases such as psoriasis, vitiligo, and acne vulgaris often carry a heavy burden of negative emotions, including depression and anxiety, which are critical considerations in managing these patients.10,11 An observational, cross-sectional, comparative multicenter study found that individuals with dermatological conditions were five times more likely to exhibit BDD symptoms compared to those with healthy skin.12 This highlights the important role of dermatologists in recognizing the psychological impact of visible skin conditions and adopting a comprehensive approach to care that addresses physical symptoms, which can significantly improve mental health, particularly in patients with BDD.

The Role of Dermatologists

Dermatologists and dermatology healthcare practitioners are critical in addressing the psychological and social aspects of skin diseases and their potential intersection with BDD. In many cases, dermatologists serve as the first point of contact for patients with BDD, as cosmetic intervention is sought by 33–76% of these individuals.2,4 Patients with hyperhidrosis, alopecia, and vitiligo were more than 11 times more likely to exhibit symptoms of BDD compared to people with healthy skin.12 Additionally, individuals with atopic dermatitis, psoriasis, acne, hidradenitis suppurativa, prurigo, and bullous diseases were more than six times as likely to experience BDD symptoms.12 These patients often present with dermatological complaints such as acne, scars, or thinning hair and may exhibit compulsive behaviors like spending hours in front of mirrors or attempting excessive grooming to address their perceived flaws.13 Recognizing these signs is essential for dermatologists to guide patients toward appropriate psychological and dermatological interventions.

The perception of beauty is fluid within society and can shift based on cultural practices, societal interactions, and exposure to social media, all of which can influence BDD by intensifying preoccupation with perceived physical appearance flaws.14 Dermatologists play a critical role in recognizing the influence of these trends, counseling and educating patients on unrealistic beauty standards, adequately treating any underlying conditions with physical manifestations that may contribute to a negative self-image, and reinforcing these unrealistic concerns that patients may have. Patients may be influenced by heavily edited images and filters that can be found on social media, contributing to dissatisfaction with their appearance and unrealistic beauty ideals.14 The emotional distress and social withdrawal often associated with BDD can further complicate treatment adherence. BDD patients may avoid follow-up appointments or fail to disclose critical information about their condition, such as the use of over-the-counter treatments or harmful practices, like the excessive use of cosmetic products.12 Poor adherence to prescribed dermatological treatment regimens is another issue, as BDD patients may either disregard medical advice or prematurely discontinue therapies when immediate results are not achieved.15 The unhealthy perceptions that are caused by BDD can also complicate the management of skin conditions. It was found that individuals with BDD were more prone to engage in behaviors such as excessive skin picking, which can lead to secondary skin lesions, infections, and scarring, further exacerbating their preoccupation with perceived flaws.16 This highlights the responsibility of dermatologists in identifying red flags, such as fixation on perceived flaws and frequent dissatisfaction with previous treatments, and referring BDD patients to appropriate professionals to provide adequate treatment for their mental health.17

Despite the significant impact BDD can have on the management of dermatological conditions, many dermatologists may hesitate to address these issues. This hesitation can be attributed to a variety of factors, such as a lack of training in psychiatric diagnosis and treatment, combined with uncertainty about how to manage these conditions effectively within the scope of their practice.18 This reluctance often leaves a critical gap in care, as addressing the psychological aspects of dermatological conditions can significantly improve patient outcomes.19 Although dermatologists shouldn’t be expected to manage BDD directly, having an open discussion with patients could increase the likelihood of patients seeking treatment and help reduce the stigma a patient may be experiencing.

Multidisciplinary Approaches to Diagnosis and Treatment

In BDD, identifying and treating potential underlying causes like skin conditions is crucial, as these factors may exacerbate distress and contribute to the severity of the disorder. Given the high risk of suicidality in BDD patients, where up to 24% report lifetime suicide attempts, early recognition and intervention are essential to improving outcomes.20 Cognitive behavioral therapy (CBT) is the first-line treatment for BDD, with selective serotonin reuptake inhibitors (SSRIs) also shown to reduce the significantly impaired dysfunction associated with appearance-related distress, anxiety, and depression.4,21

Although the efficacy of combined treatment versus monotherapy has not been fully studied, combining pharmacotherapy with CBT is particularly recommended for patients with severe BDD, as initial improvement with medication may help facilitate participation in CBT.4 For patients with treatment-refractory BDD, addressing common issues such as inadequate SSRI dosing, insufficient trial duration, or poor CBT adherence is essential, with a combination of medication and evidence-based CBT often proving effective. More intensive treatment options like partial hospitalization or residential programs may also be considered.4

When there is a high suspicion of BDD, a dermatological practice-specific tool can be used for identification. The Body Dysmorphic Disorder Questionnaire (BDDQ ) is a validated self-report screening tool with high sensitivity and specificity designed to identify individuals with body dysmorphic disorder.22 A screening tool specific to dermatology, the BDDQ–Dermatology Version (BDDQ-DV) is a self-administered screening tool based on DSM-5 criteria that takes up to five minutes to complete that has proven to provide a rapid, comprehensive evaluation of BDD using a Likert scale.23 This tool allows for the effective detection of BDD and the opportunity for referral to a mental health practitioner along with discussion before pursuing potentially unnecessary or unsatisfactory treatments.

Future Research Directions

Research should aim to understand better the long-term impact of BDD on dermatological treatment outcomes and psychosocial well-being through more longitudinal studies. Further exploring the effectiveness of combined therapeutic approaches like CBT and SSRIs may provide insights into improving care for patients with BDD. Lastly, investigating the implementation of screening tools like the BDDQ-DV into routine dermatological practice could provide evidence demonstrating early detection and reduction of unnecessary treatments to improve mental health and dermatological outcomes for patients with BDD.

Conclusion

The high prevalence of BDD among dermatology patients, combined with its profound impact on mental health, like depression, anxiety, and heightened risk of suicide, underscores the vital role dermatologists and dermatology health professionals play in helping patients mitigate these risks. It is imperative that the signs of BDD are identified by those within dermatology, given their unique position as frontline providers for patients who may present with this condition.

By fostering open communication with patients and addressing unrealistic beauty expectations, dermatologists can help destigmatize psychiatric concerns and encourage patients to seek appropriate mental health support. Tools like the BDDQ-DV enable clinicians to efficiently identify at-risk patients and refer them for early intervention, reducing the likelihood of unnecessary or unsatisfactory treatments. Early identification not only facilitates timely referral to mental health professionals but also improves the outcomes of dermatological care by addressing the psychological factors that can complicate treatment adherence and overall patient wellbeing. The ability to recognize and address BDD by dermatologists can transform the patient experience, reinforcing the critical intersection of dermatological and mental health care.

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ABOUT THE AUTHORS
Duncan Macintyre, BS, is a fourth-year medical student at the University of Illinois Chicago.

Peter A. Lio, MD, is a Clinical Assistant Professor of Dermatology and Pediatrics at Northwestern University Feinberg School of Medicine and a partner at Medical Dermatology Associates of Chicago in Chicago, IL.

DISCLOSURES
Duncan MacIntyre, BS, reports no disclosures.

Peter A. Lio, MD, reports being on the speaker’s bureau for AbbVie, Arcutis, Eli Lilly, Galderma, Hyphens Pharma, Incyte, La Roche-Posay/L’Oreal, Pfizer, Pierre-Fabre Dermatologie, Regeneron/Sanofi Genzyme, and Verrica. He reports consulting/advisory boards for Alphyn Biologics, AbbVie, Almirall, Amyris, Arcutis, ASLAN, Astria Therapeutics, Boston Skin Science, Bristol-Myers Squibb, Burt’s Bees, Castle Biosciences, Codex Labs, Concerto Biosci, Organon (Dermavant), Eli Lilly, Galderma, LEO Pharma, Lipidor, L’Oreal, Merck, Micreos, MyOR Diagnostics, Pelthos Therapeutics, Regeneron/Sanofi Genzyme, Sibel Health, Skinfix, Soteri Skin, Stratum Biosciences, Sun Pharma, Theraplex, Thimble Health, UCB, Unilever, Verdant Scientific, Verrica, and Yobee Care. Dr. Lio has stock options with Alphyn Labs, Codex Labs, Concerto Biosci, Soteri Skin, Stratum Biosciences, Thimble, Yobee Care, and Verdant Scientific. In addition, he has a patent pending for a Theraplex product with royalties paid and is a Board Member and Scientific Advisory Committee Member emeritus of the National Eczema Association.

This research received no funding.

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