A 22-year-old man comes to the office for evaluation of acne. The patient has seen several doctors over the past few years for his "huge pimples" and has tried multiple nonprescription acne preparations without benefit. He spends hours a day checking his skin in the mirror for new pimples and scars and researching the latest acne treatments. He avoids socializing and dating due to fears of being rejected based on his appearance. The patient purposely styles his hair to conceal his forehead and cheeks. He has no medical history. Vital signs are within normal limits. The patient is wearing a baseball cap and hesitantly removes it. Physical examination shows a small papule on his forehead and a few closed comedones on his nose that are noticeable only on close inspection. His skin is otherwise clear without scarring or hyperpigmentation. Which of the following is the most appropriate management for this patient?

Question

A 22-year-old man comes to the office for evaluation of acne.  The patient has seen several doctors over the past few years for his "huge pimples" and has tried multiple nonprescription acne preparations without benefit.  He spends hours a day checking his skin in the mirror for new pimples and scars and researching the latest acne treatments.  He avoids socializing and dating due to fears of being rejected based on his appearance.  The patient purposely styles his hair to conceal his forehead and cheeks.  He has no medical history.  Vital signs are within normal limits.  The patient is wearing a baseball cap and hesitantly removes it.  Physical examination shows a small papule on his forehead and a few closed comedones on his nose that are noticeable only on close inspection.  His skin is otherwise clear without scarring or hyperpigmentation.  Which of the following is the most appropriate management for this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d7ab_cc4c_bc81_2b2a07eceeaf_MD0003_00 This patient's preoccupation with a perceived defect in his appearance and time-consuming, repetitive behavior is consistent with body dysmorphic disorder (BDD). Common manifestations of BDD include disliking perceived appearance flaws in the following: Skin: as in this patient who is concerned about significant acne despite barely noticeable comedones with no scarring or hyperpigmentation Hair pattern: balding, too much hair Nose: size, shape Compulsions (eg, repeatedly checking one's appearance in mirrors) are characteristic. Patients with BDD typically have poor insight and often request unnecessary cosmetic and surgical treatments to correct perceived flaws. Treatment options for BDD include pharmacotherapy with selective serotonin reuptake inhibitors (SSRIs) (eg, escitalopram) and/or cognitive-behavioral therapy adapted for BDD. Pharmacotherapy typically requires significantly high doses of SSRIs, which have been shown to decrease symptoms of obsessional preoccupation, compulsive behaviors, and associated functional impairment. (Choice A) Oral isotretinoin is typically reserved for severe, treatment-resistant acne due to its teratogenicity and multiple adverse effects. It is not indicated for this case of very mild acne. (Choice B) Antipsychotic medications (eg, aripiprazole) are used primarily in psychotic and bipolar disorders and are not first-line treatments for BDD. Patients with delusions involving perceived appearance flaws are diagnosed with BDD rather than delusional disorder and may have varying degrees of insight (eg, BDD with absent insight/delusional beliefs, BDD with poor insight, BDD with good insight). SSRIs are first line in BDD, regardless of degree of insight. (Choice C) Reassurance and regular follow-up are important components of managing somatic symptom disorder, characterized by a preoccupation with physical symptoms (eg, leg pain, dizziness, bloating), and of illness anxiety disorder, characterized by fears of a specific illness (eg, cancer, lupus). In contrast, BDD is characterized by an excessive preoccupation with appearance flaws (eg, acne, hair pattern) accompanied by compulsions; it requires high doses of SSRIs. (Choice D) Patients with BDD are rarely satisfied with cosmetic, medical, or surgical interventions. This patient has already seen several physicians and has only mild symptoms that do not warrant the intervention of a specialist. Referral to a dermatologist is not indicated. Educational objective: Treatment of body dysmorphic disorder consists of selective serotonin reuptake inhibitors and/or cognitive-behavioral therapy. Cosmetic treatments and surgery should be avoided. References: Recent advances in understanding and managing body dysmorphic disorder. (http://www.ncbi.nlm.nih.gov/pubmed/28729345) New perspectives in the treatment of body dysmorphic disorder. (http://www.ncbi.nlm.nih.gov/pubmed/29636904)

A 22-Year-Old Man Comes to the Office for Evaluation of Acne