A screening questionnaire for body dysmorphic disorder in a cosmetic dermatologic surgery practice.

BACKGROUND: Dermatologic surgeons frequently see patients with body dysmorphic disorder, a distressing or impairing preoccupation with a nonexistent or slight defect in appearance. Recognition of this disorder is essential to avoid unnecessary and generally unsatisfying surgical outcomes, but no screening tools are available for use in a dermatology setting. OBJECTIVE: To develop and validate a brief self-report questionnaire to screen for body dysmorphic disorder in dermatology settings. METHODS: A questionnaire was developed and its sensitivity and specificity determined in 46 subjects, using a reliable clinician-administered diagnostic interview for body dysmorphic disorder. The interrater reliability of a defect severity scale was also determined (n = 50). RESULTS: The self-report questionnaire had a sensitivity of 100% and a specificity of 93%. The interrater reliability (ICC) of the defect rating scale was.88. CONCLUSIONS: This brief questionnaire was a highly effective screening tool for body dysmorphic disorder in a cosmetic dermatology setting. Use of this questionnaire may help identify patients with this syndrome.

Electrosurgery, pacemakers and ICDs: a survey of precautions and complications experienced by cutaneous surgeons.

BACKGROUND: Minimal information is available in the literature regarding the precautions implemented or complications experienced by cutaneous surgeons when electrosurgery is used in patients with pacemakers or implantable cardioverter-defibrillators (ICDs). The literature pertinent to dermatologists is primarily based on experiences of other surgical specialties and a generally recommended thorough perioperative evaluation. OBJECTIVE: To determine what precautions are currently taken by cutaneous surgeons in patients with pacemakers or ICDs, and what types of complications have occurred due to electrosurgery in a dermatologic setting. METHODS: In the winter of 2000, a survey was mailed to 419 U.S.-based members of the American College of Mohs Micrographic Surgery and Cutaneous Oncology (ACMMSCO). RESULTS: A total of 166 (40%) surveys were returned. Routine precautions included utilizing short bursts of less than 5 seconds (71%), use of minimal power (61%), and avoiding use around the pacemaker or ICD (57%). The types of interference reported were skipped beats (eight patients), reprogramming of a pacemaker (six patients), firing of an ICD (four patients), asystole (three patients), bradycardia (two patients), depleted battery life of a pacemaker (one patient), and an unspecified tachyarrhythmia (one patient). Overall there was a low rate of complications (0.8 cases/100 years of surgical practice), with no reported significant morbidity or mortality. Bipolar forceps were utilized by 19% of respondents and were not associated with any incidences of interference. CONCLUSIONS: Significant interference to pacemakers or ICDs rarely results from office-based electrosurgery. No clear community practice standards regarding precautions was evident from this survey. The use of bipolar forceps or true electrocautery are the better options when electrosurgey is required. These two modalities may necessitate fewer perioperative precautions than generally recommended, without compromising patient safety.

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.

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.

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.

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 vermilionectomy were all clinically effective. All 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.

An intraoperative skin-stretching device to close wounds in Mohs defects.

BACKGROUND: A skin-stretching device takes advantage of the viscoelastic properties of the skin by exerting incremental traction to aid in closing complex wounds. OBJECTIVE: To evaluate the effectiveness of a skin-stretching device and determine the cosmetic results available when this device is used in Mohs surgery. METHODS: We applied a skin-stretching device to seven patients, each of whom had a large, complex wound defect following Mohs surgery. All of the patients had basal cell carcinomas. In one patient the carcinoma was on an upper extremity, and in the others the carcinoma was located on broad facial surfaces, including the temple and forehead. RESULTS: Complete primary closure was accomplished in six patients. A maximum of three cycles of tissue stretching were applied during the period of tissue processing between Mohs layers. In one patient the defect was reduced in size by more than 75%, with final healing by secondary intention. In two patients minor complications developed: focal wound dehiscence occurred in one patient and in the second patient, an inconsequential hypertropic scar developed. In both cases, the problems resolved with acceptable cosmetic results. The remaining patients experienced no complications and the cosmetic results were excellent. CONCLUSION: The skin-stretching device accomplishes effective primary closure of large skin defects by dramatically reducing the size of the defect. It allows a simpler closure where a full-thickness graft or local flap would have otherwise been utilized. The device is convenient to use with minimal complications, reduces operative time, and aids greatly in preserving tissue integrity.

Xylene substitutes in frozen sections.

BACKGROUND: Toxic exposure to xylene may occur during routine histopathologic staining procedures. Safer xylene substitutes have been available for over a decade, however, a 1991 survey of 25 Mohs training programs revealed that only 56% were using xylene substitutes. OBJECTIVE: The purpose of this study was to compared xylene to xylene substitutes in the histologic preparation of frozen sections with respect to staining quality, clarity, cellular detail, and tissue distortion. METHODS: Xylene and xylene substitutes were used as the final clearing agent in the routine histologic preparation of fresh frozen horizontal sections. The slides were evaluated by a dermatopathologist and a Mohs surgeon in a blinded manner. RESULTS: No difference between xylene and the xylene substitutes were noted. CONCLUSION: In light of the improved safety profile and efficacy of the xylene substitutes, they should replace xylene in the Mohs laboratory.

Carbon dioxide laser treatment of pitted acne scarring.

Laserabrasion has been shown to have limited application in the treatment of acne scarring. Focal laserabrasion used to treat individual pitted acne scars may have broader clinical application. We present 8 patients with pitted acne scars who were treated with either conventional continuous wave carbon dioxide (CO2) laser, or with the superpulsed CO2 laser, or both. Cosmetically acceptable results were attained, particularly in the patients treated with the superpulsed laser.

Carbon dioxide laser treatment of chronic actinic cheilitis.

The carbon dioxide laser in both conventional and superpulsed modes was used to treat 13 patients with chronic actinic cheilitis. The procedure was well tolerated. Focal, but not functionally restricting, scarring developed in three patients. The cosmetic result was otherwise excellent. No recurrences have been noted.

Childhood bullous lichen planus.

A child with previous lichenoid lesions had bullae refractory to antistaphylococcal antibiotics. Biopsy of a bulla showed histologic changes of bullous lichen planus. Indirect immunofluorescence using the patient's serum on a perilesional bulla biopsy showed positive staining for IgA and IgG in the stratum granulosum and stratum corneum, confirming the diagnosis. The lesions resolved with dapsone treatment.