Body dysmorphia in common skin diseases: results of an observational, cross-sectional multicentre study among dermatological outpatients in 17 European countries.

BACKGROUND: Body dysmorphic disorder (BDD) is a common psychiatric disorder associated with high costs for healthcare systems as patients may repeatedly ask for different, often not effective, interventions. BDD symptoms are more prevalent in patients with dermatological conditions than in the general population, but there are no large sample studies comparing the prevalence of BDD symptoms between patients with dermatological conditions and healthy skin controls.
OBJECTIVES: To compare the prevalence of BDD symptoms between patients with different dermatological conditions and healthy skin controls and to describe sociodemographic, physical and psychological factors associated with BDD symptoms to identify patients who may have a particularly high chance of having this condition.
METHODS: This observational, cross-sectional, comparative multicentre study included 8295 participants: 5487 consecutive patients with different skin diseases (56% female) recruited among dermatological outpatients at 22 clinics in 17 European countries, and 2808 healthy skin controls (66% female). BDD symptoms were assessed by the Dysmorphic Concern Questionnaire. Sociodemographic data and information on psychological factors and physical conditions were collected. Each patient was given a dermatological diagnosis according to ICD-10 by a dermatologist. The study was registered with number DRKS00012745.
RESULTS: The average participation rate of invited dermatological patients was 82.4% across all centres. BDD symptoms were five times more prevalent in patients with dermatological conditions than in healthy skin controls (10.5% vs. 2.1%). Patients with hyperhidrosis, alopecia and vitiligo had a more than 11-fold increased chance (adjusted Odds Ratio (OR) > 11) of having BDD symptoms compared with healthy skin controls, and patients with atopic dermatitis, psoriasis, acne, hidradenitis suppurativa, prurigo and bullous diseases had a more than sixfold increased chance (adjusted OR > 6) of having BDD symptoms. Using a logistic regression model, BDD symptoms were significantly related to lower age, female sex, higher psychological stress and feelings of stigmatization.
CONCLUSIONS: Clinical BDD symptoms are significantly associated with common dermatological diseases. As such symptoms are associated with higher levels of psychological distress and multiple unhelpful consultations, general practitioners and dermatologists should consider BDD and refer patients when identified to an appropriate service for BDD screening and management.

Yasmin Nikookam,1 Sabba Chaudhry,2 Dijon Millette 2 and Anthony Abdullah2

Queen’s Hospital, Romford, Barking and Havering NHS Trust, London, UK; and Corbett Outpatient Centre, Dudley Group NHS Trust, Dudley, Birmingham, UK

There is an ongoing concern regarding patients on biological therapy and their increased susceptibility to severe COVID‐19 infection. The British Association of Dermatologist’s guidance on continued care of the clinically extremely vulnerable, last updated in November 2020, advised that those on immunosuppressive therapies (including biologics) have a ‘sufficient to significantly increased risk of infection’ and were therefore recommended to shield and are now considered for primary third booster vaccines in light of this risk. This advice is evidenced based on the poor outcome this cohort of patients experienced during the pandemic. However, there have been minimal studies performed to evaluate the risk patients on biologics have when compared with the wider population. The authors believe this is an important topic to address as it may provide a consensus into risk stratification for this cohort of patients. The clinical characteristics of 15 patients under dermatology care on biologics and COVID‐19‐positive (confirmed by polymerase chain reaction) were reviewed retrospectively between November 2020 and March 2021. A 20‐item tool was used to collect quantitative data. This encompassed demographics, skin disease, biologic, hospitalization, intensive care admission, the severity of disease (as determined by oxygen therapy, imaging and symptoms), and the presence of long COVID. Patients included ranged in age from 37 to 75 years; 12 were white, one was Asian and one was South‐East Asian, with one unknown. Patients were on a range of biologics including tralokinumab (n = 1), dupilumab (n = 1), ustekinumab (n = 3), adalimumab (n = 5), risankizumab (n = 2) and secukinumab (n = 3). The majority of patients included had multiple comorbidities (73%), of which 21% had a respiratory condition. Approximately a third of patients required hospitalization (33%) and oxygen (29%). However, none required intensive care or noninvasive ventilation, and the chest X‐ray findings from all participants were clear, illustrating no scarring or evidence of long‐COVID clinical changes. This study has shown that exposure to biologics did not appear to increase the susceptibility of patients to COVID‐19. Although being a significant comorbid group, outcomes following infection with COVID‐19 were good and did not seem to affect the clinical outcomes or mortality in this cohort. This suggests that biologics for dermatological conditions could be used continuously during the COVID‐19 pandemic. However, larger multicentre case series assessing the treatment efficacy of biologics vs. nonbiological therapy in those with skin disease and COVID‐19 infection is warranted.