PracticeUpdate Dermatology May 2019

AAD 2019 23

physically threatened, and 10% received legal and violent threats. Thus, a missed diagnosis of BDD can have consequences for both provider and patient alike. What can we do as physicians? Identifying patients with BDDmay allow early treatment of this disorder (and prevent suicidal acts/ completion) and avoid unnecessary proce- dures with unsatisfied patients. In practice, physicians may add validated screening questionnaires to intake forms (which may include patient expectations, spe- cific defect, impact of perceived defect on social life/work/ADLs, and suicidality). Tak- ing pre-procedure (and post-procedure, if applicable) photos is highly recommended. Signs of BDD • There is preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others. • At some point during the course of the disorder, the individual has performed repetitive behaviors (eg, mirror checking, excessive grooming, skin picking, reas- surance seeking) or mental acts (eg, comparing appearance with that of others) in response to the appearance concerns. • Preoccupation causes clinically signif- icant distress or impairment in social, occupational, and other important areas of functioning • Appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms

― ― Second-level tests include: SPEP/ immunofixation to look for evidence of a paraprotein; C3 and C4 levels, which may be low in urticarial vasculitis or sys- temic lupus and signal more significant systemic involvement; ANCAs, which are strongly suggestive of ANCA-as- sociated vasculitis, cryoglobulins Treatment • Most cases are minimally symptomatic and self-limited. Therefore, aggressive immunosuppression is generally not advisable. Dr. Micheletti does not use prednisone in most cutaneous-only cases. Instead, his recommendations include rest and elevation; compression stockings; and topical steroids for itch relief. • Systemic therapy is indicated if severe, intractable, or recurrent (8% to 10% become chronic). Unfortunately, there is a dearth of high-quality data – only one small randomized controlled trial for colchicine and case reports and expert opinion on dapsone, azathioprine, and others. IgA vasculitis • Prognosis is favorable, but it depends on the severity of renal disease; lasts up to 6 months in one-third of cases. • Those patients with hematuria or pro- teinuria should be carefully followed with frequent urinalysis with micro and blood pressure monitoring for at least 6 months. Renal involvement usually develops within 1 month. • There is no benefit to prophylactic ster- oids, but steroids are indicated if renal complications develop. Body Dysmorphic Disorder – Protecting Your Patients and Yourself – Evan Rieder, New York University While prevalence of body dysmorphic dis- order (BDD) in the general population is 1% to 2%, it is much more common in derma- tology settings (12.65%, and not cosmetic patients in particular). About 25% of BDD patients have suicidal ideation, often with high rates of completion. There are two vali- dated questionnaires to screen for BDD: the Dysmorphic Concern Questionnaire (DCQ) and the Body Dysmorphic Disorder Ques- tionnaire – Dermatology Version (BDDQ). Repercussions of treating BDD patients include unsatisfied patients (the majority of studies report poor outcomes after pro- cedures) as well as threats to the treating physicians. In a survey of 265 aesthetic surgeons and BDD patients, 29% of sur- geons were legally threatened, 2% were

meet the diagnostic criteria for an eating disorder

Dermatologic Surgery Pearls: Managing Postoperative Pain – Andrew Shors • Whilemost dermatologic surgery patients do not need aggressive pain control, surgery on sensitive areas such as the lip, nose, ear, and scalp may require special attention. For patients who need more aggressive pain control, consider bupivacaine; however, remember that bupivacaine toxicity (2 mg/kg) is additive with lidocaine (5 mg/kg) or lidocaine with epinephrine (7 mg/kg) toxicity. • Ibuprofen 400 mg with 1000 mg of acetaminophen has been shown to be as effective for acute pain as oxycodone 5 mg with 325 mg of acetaminophen. For healthy patients, maximum doses should be 2.4 g for ibuprofen and 3 g for aceta- minophen. Typical dosing is ibuprofen 400 mg/acetaminophen 1000 mg three times daily. ― ― Ibuprofen is associated with low rates of postoperative bleeding complications. ― ― Celecoxib 200/400 mg periopera- tively, followed by 200 mg twice daily, can be used in patients on anticoagu- lants or with gastrointestinal disease. ― ― Scar dysesthesias lasting longer than 4 weeks may respond favorably to peri-incisional botulinum toxin 10 to 30 U. www.practiceupdate.com/c/80923

VOL. 3 • NO. 2 • 2019