Things Invisible to See

presented by David Elpern MD

Williamstown, MA,USA

on June 21, 2001

The patient is a 22-year-old woman who presented for treatment of acne. She had seen another dermatologist for about a year and had been prescribed various
topical therapies as well as doxycycline and minocycline. Both of the latter made her light-headed, so she stopped taking them. She states that she hates her skin and is very self-conscious. She won't let her boyfriend rub acne medications on her back; she doesn't want anyone touching her back.

On closer questioning, she expresses humiliation with her body. She is embarrassed because she is short and feels that she is fat. She goes to the gym and looks at the thin women exercising and wishes she could be anorexic but says she wouldn't "hurt myself."

Her mother has told her she is on the heavy side and to just accept it.

The patient has been on birth control pills (Demulen) since age 14 to regulate her menses, which were infrequent and painful.

This shows a neat, attractive, well-groomed, articulate woman. She does not appear clinically depressed. She is 5 foot tall and weighs 115 lbs. She has scattered small erythematous papules, few in number, on the forehead, cheeks and chin. Similar small lesions are also present on the upper back and upper chest. The lesions are monomorphous. They can be seen in good light and with magnification, but are barely noticeable clinically.


Laboratory studies:

Mild inflammatory acne with possible Body Dysmorphic Disorder (BDD).

I have seen patients like improve after Accutane, but realize that the disorder is much more complicated. I am aware of the literature linking Accutane with depression, but have found that most patients who are depressed about their skin do better emotionally with this medication. In addition, I will pursue a psychiatric opinion, since a cognitive behavioral or psychopharmacologic approach may be more appropriate if the patient is willing to pursue this avenue.

Definition: Body Dysmorphic Syndrome, BDD, is a distressing or impairing preoccupation with a nonexistent or slight defect in appearance. Importantly, the individual's rating of the body feature (skin) does not fit with that of an objective observer, who may not see anything unattractive or unusual about the feature, or who may note some minimal problem (i.e., mild acne on the skin). The preoccupation causes distress or impairment in social, occupational, or other important areas of functioning that severely interferes with the individual's existence.

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