'Juicy' lips and BDD

Denver - On the final day of the 72nd Annual Meeting of the American Academy of Dermatology, one expert shared clinical pearls regarding how to treat patients with body dysmorphic disorder.

When a patient has body dysmorphic disorder (BDD), says Neelam Vashi, M.D., it’s very unlikely that the aesthetic treatment being sought will improve the patient’s quality of life. In this regard, a study has shown that less than 5 percent of dermatology patients with BDD experience symptom improvement with following an aesthetic procedure (Sarwer DB, Spitzer JC. Aesthet Surg J. 2012;32(8):999-1009). To steer clear of problematic patients, she recommends asking during the screening process whether or not the aesthetic defect - be it real or perceived - impacts the patient’s ability to function.

For such patients, she says, the most effective psychological interventions include cognitive behavioral therapy and antidepressants. In the latter area, Dr. Vashi says, options include fluoxetine, citalopram and selective serotonin reuptake inhibitors (SSRIs). Among these categories, “SSRIs have the best response rate - between 63 percent and 83 percent.” If patients’ self-insight is weak or patients refuse to see a mental health professional, she adds, “One may pulse-start the medication to help them feel less distressed. Referral may be possible later as insight improves.”

Unfortunately, Dr. Vashi says, many dermatologists must expand their comfort zone relative to psychiatric medications. In a recent study, only 11 percent of dermatologists reported feeling comfortable starting patients on antidepressants; only 3 percent were comfortable starting antipsychotics (Gee SN, Zakhary L, Keuthen N, et al. J Am Acad Dermatol. 2013;68(1):47-52).

Patients with BDD seen by Dr. Vashi included a 46-year-old male with midface volume loss who stated during consultation that he wished to look like Denzel Washington. Dr. Vashi said that initially, she did not recognize his BDD and ultimately performed two filler treatments. Over time, however, she noted his constant preoccupation with a small pocket mirror, and she declined to treat him further. She later found out he went to another dermatologist for additional fillers.

Conversely, a female patient who requested “juicy lips” reported crying daily and being unable to ride a bus due to concerns over her appearance. “I tried to reassure her” her lips looked fine as is, Dr. Vashi says. But after the initial consultation, this patient never returned.

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