By definition, the dermatologic manifestations of BDD are minor, if not absent, in comparison to the level of preoccupation and distress related to the perceived defect. Patients with BDD frequently report concerns with the face, but concerns can involve any body area [1]. Skin color dissatisfaction can lead to harmful attempts to lighten or darken skin in all ethnic groups [7]. Patients often spend many hours at tasks intended to correct the perceived defect. Poor insight is characteristic of BDD, with children and adolescents having less insight than their adult counterparts. In addition, adolescents with BDD have higher rates of suicide attempts when compared to adults [8]. There is high co-morbidity with major depressive disorder, obsessive-compulsive disorder, social phobia, and substance use disorders [9]. Adolescence is a developmental period during which peer groups become increasingly important, and negative body image may lead patients with BDD to become socially isolated. Social isolation can lead to further impairment in development of social skills, education, and overall quality of life [1, 7, 10].

The most critical aspect of management of BDD is establishing rapport with the patient. It is vital to understand the underlying nature of the complaint without invalidating concerns.

Once a patient feels more comfortable, there are many diagnostic instruments that can be used in addition to the structured interview. The Body Dysmorphic Disorder Questionnaire has been validated in dermatologic settings [10]. The Cosmetic Procedure Screening Questionnaire can be used to screen for symptoms and to track symptoms over time [4]. The Yale-Brown Obsessive Compulsive Scale Modified for BDD also rates symptom severity [10]. In addition to screening for BDD, it is imperative to screen for comorbidities.

Assessing how the perceived defect has affected a patient’s life will help the doctor grasp a more comprehensive view of the problem. Suicide rates are high in this population, so a safety assessment should also be considered [1, 8].

Treatment options should start with referral to a mental health professional for both treatment of BDD as well as further exploration of underlying psychiatric co-morbidities. A multidisciplinary approach to treating patients with BDD is recommended, involving psychiatry and dermatology.

Cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) are well supported, first-line therapies for BDD in adults and are accepted as first line for children and adolescents [8]. CBT including exposure and response prevention (ERP), anxiety management training (AMT), and mindfulness-based cognitive therapy have been shown to be efficacious in case reports. Engaging the family in treatment and maintaining a positive therapeutic alliance with the patient and family are also recommended.

Though some SSRIs are FDA approved for OCD in children and adolescents, evidence for their usefulness in BDD is lacking. Case reports and one case series provide support for SSRIs particularly fluoxetine (Prozac) and sertraline (Zoloft). High doses are generally needed for OCD and are recommended for BDD as well [8–10]. See Table 25.2.

Signs secondary to starvation include lanugo-like body hair, asteatosis, carotenoderma, acrocyanosis, acrodermatitis, and changes with hair and nails [12]. Lanugo-like body hair is fine, soft hair that lacks pigment and is present on the arms, back, and abdomen. This type of hair is frequently seen on newborns, but is also seen in patients who are malnourished. Asteatosis (dry, scaly skin) is often seen by the fourth week of starvation, though it may be present earlier. Starvation leads to a decreased production of sebum and an altered composition of sebum, and asteatosis is seen in approximately 70 % of patients with anorexia [12]. Low body mass index (BMI) is a risk factor for acrocyanosis, making this condition more prevalent in patients with AN than in the general population. Low BMI also correlates with reported pruritus, likely due to multiple pathophysiologic mechanisms including endocrine dysfunction and impaired hepatic, renal, and thyroid function. Eczema is more frequent in AN, as are hair and nail fragility, nail pitting, and periungual erythema.

Carotenoderma, or yellowed pigmentation of the palms, soles, and nasolabial folds is common in patients with AN and is thought to be due to a diet rich in carrots and yellow vegetables though it may also be related to changes in lipid metabolism [13]. Vitamin deficiencies of zinc, biotin, and fatty acids can lead to acrodermatitis. An excess of vitamin A can lead to hair loss [12].

Signs secondary to repeated vomiting (“purging”) in BN include salivary gland enlargement (though this sign is non-specific and is also seen in other medical conditions). Recurrent purging lowers the pH of saliva, which contributes to loss of tooth enamel [12]. “Russell sign” is a callus found on the dorsal knuckles of the patient’s dominant hand, caused by self-induced vomiting.

Signs secondary to laxative or diuretic abuse are associated with the side effects of the specific drug used. Thiazide diuretics are associated with increase in photosensitivity. Urticaria is seen in phenolphthalein laxatives, and clubbing on the fingers is seen in patients using senna [12].

Treatment of skin signs in AN and BN involves treatment of the underlying disorder, as most signs resolve with weight gain or cessation of harmful behaviors. As eating disorders affect multiple organ systems, a multidisciplinary approach is best, including psychiatric care. Once an eating disorder is suspected, referral to a psychiatrist is recommended, as early intervention including therapy is likely to improve prognosis. If there is concern that the patient’s malnourishment is life-threatening, inpatient hospitalization may be required. Criteria for consideration of hospitalization include a heart rate near 40 bpm, orthostatic blood pressure changes, a blood pressure less than 80/50 mmHg, hypokalemia, hypophosphatemia, hypomagnesemia, refusal to eat, a body weight less than 85 % of healthy body weight, or suicidal ideation.

Factitious skin disorder is rare in children; emergence often begins in adolescence or adulthood [16]. The history does not match the physical examination, and is often accompanied by bewilderment from the patient as to how the lesion arose [1, 14]. Lesions are most frequently seen on the side of the body contralateral to the dominant hand and are on the most accessible areas of the body. Lesions vary significantly, based on the method used, and morphology differs from recognizable dermatitis [17]. Methods used include cutting, applying heat, suction, dyes, caustic substances, pressure, and injection of substances including chemicals or bodily secretions [17]. Lesions are often geometric, with well-defined borders surrounded by healthy skin. Purpura may be created by suction, with the size of the lesion corresponding to the shape of the object used [18].

Histopathology from a biopsy of the skin is not specific or diagnostic, though in the case of injection, foreign body giant cells may be seen [16]. Factitious skin disorder in children may be associated with neglect or abuse. Patients who suffer from factitious skin disorder may also suffer from other psychiatric co-morbidities, including body image disorders and personality disorders [14, 16].

Factitious skin disorder by proxy also presents with varied lesions with no specific histopathology. The individual producing the lesions may be highly involved in the patient’s care, and may keep close record of the patient’s diagnostic studies and procedures, and may have a personal or family connection to the healthcare field [15].

Screening for other signs and symptoms such as reactions caused by medications, metabolic abnormalities, fever, diarrhea, and vomiting should be done, as falsification of symptoms may extend beyond cutaneous manifestations [16].

Malingering presents similarly to factitious disorder in the sense that there are various methods used to produce the lesion. The history presented by the patient may be inconsistent with the dermatologic presentation [14, 16].

Early recognition of factitious disorders can limit the illness [15]. It is vital to rule out infections, cancer, or other illness that could be causing the lesions, and to discuss these findings with the patient. This may open a discussion of what is causing the lesion. Accusatory confrontation is rarely helpful, and often leads to patients leaving the office and refusing to return. Instead, clinicians should work to build a strong doctor-patient relationship characterized by empathy for the patient’s suffering [7, 17]. Treating the lesion symptomatically with mild ointment and an occlusive dressing will help the lesion heal quickly and protect the skin from further damage [16]. Due to the association of factitious disorder with depression and PTSD, selective serotonin reuptake inhibitors (SSRIs) may help alleviate the unconscious psychological need and may be helpful in alleviating psychiatric symptoms. Supportive therapy or dialectical behavioral therapy may be helpful in this population [16]. Referral to psychiatry and psychology is recommended, though this should be done cautiously and only after doctor-patient rapport has been well established [4].

In the case of a factitious disorder by proxy, a multidisciplinary team should be involved, including a child psychiatrist and Child Protective Services [15, 19].