Evaluation of cutaneous body image dissatisfaction in the dermatology patient

Abstract

Cutaneous body image (CBI), defined as the individual's mental representation of his or her skin, hair, and nails, is an important clinical factor in dermatologic disorders and often the primary consideration in deciding whether to proceed with cosmetic procedures or institute treatment in some skin disorders such as acne. CBI is a highly subjective construct that can be significantly confounded by cultural, psychosocial, and psychiatric factors. Assessment of CBI in the dermatology patient is best accomplished using a biopsychosocial model that involves (1) evaluation of concerns about the appearance of the skin, hair, and nails, (2) assessment of comorbid body image pathologies, especially body dysmorphic disorder, and (3) assessment of other psychiatric comorbidities such as major depressive disorder that can confound the presentation of the CBI complaint. Depending on the psychiatric comobidities, an assessment of suicide risk may have to be done, and if necessary, a referral made to a mental health professional. The clinician should consider the patient's developmental stage (eg, body image concerns are likely to be much greater in the adolescent patient independent of his or her dermatologic disorder) and sociocultural background (eg, a desire for lighter skin in some ethnic groups), factors that can also have a major effect on CBI.

Introduction

Body image, defined as the mental representation of the body and its organs, is an important clinical construct in disorders that are cosmetically disfiguring or alter the appearance of the patient.¹ Cutaneous body image (CBI) refers to the individual's mental perception of the appearance of his or her integumentary system (ie, skin, hair, nails).² CBI dissatisfaction can contribute to significant morbidity in dermatologic disorders and is often the primary consideration in deciding whether to proceed with some cosmetic procedures or institute treatment in some skin disorders such as acne. Assessment of CBI has important clinical implications, because it can significantly affect the patient's quality of life. CBI dissatisfaction can increase the overall morbidity in dermatologic disease and has been associated with intentional self-injury, such as self-induced dermatoses,1., 3. and suicide.4., 5. In some cases of stress reactive dermatoses, such as psoriasis and atopic dermatitis, the psychosocial stress caused by the social stigma, cosmetic disfigurement, and body image concerns resulting from the dermatologic condition can in turn cause flare-ups of the primary dermatologic disorder.⁶

Poor CBI has been shown to be an important factor in adherence to treatment in chronic disorders such as psoriasis,⁷ where patients with more severe and more visible disease were less adherent to dermatologic therapies because the greater psychosocial burden might have caused patients to lose confidence in the treatments.⁷ Greater body satisfaction, a construct that measures satisfaction with the way the body looks, was more likely to be associated with thorough skin self-examination performance for melanoma screening,⁸ especially among women.

During the last 2 decades, the number of men and women seeking cosmetic treatments and procedures has significantly increased.⁹ It is important to assess underlying CBI concerns in patients seeking cosmetic procedures to rule out body image pathologies, such as body dysmorphic disorder (BDD), before starting dermatologic therapies, because BDD patients are often not satisfied with treatment outcome.10., 11. BDD patients who undergo cosmetic procedures have been reported to experience no change or even worsening of their symptom or to develop a preoccupation with another imagined flaw.¹⁰ CBI is a highly subjective construct, and body image perception in dermatology can vary across the life span, depending on the patient's developmental stage, and be significantly confounded by cultural, psychosocial, and psychiatric factors.