Skin disease, even in its mildest form, can alter the outward appearance of the skin and have negative effects on body image, self-esteem, and pysche.1 How a person perceives their physical attractiveness affects how they view themselves and it also influences their self-confidence, behavior towards others, and perception of social acceptance.1 Self-esteem problems in dermatology patients (however mild the disease) are well known, as are their effects on psyche and quality of life. Acne, for example, alters both physical appearance and body image, and in some cases can even lead to psychiatric disorders, such as body dysmorphic disorder (BDD).1–3 Acne and BDD are particularly prevalent in adolescents,4 and considering that the 2 conditions can coexist and feed on each other, it is important to diagnose BDD early. A diagnosis of BDD is often suspected in the dermatology office. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, lists 3 diagnostic criteria for BDD5:

A. Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive.

B. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in anorexia nervosa).

As dermatologists, we need training and sufficient knowledge in order to be able to treat patients who present with psychological problems. We also need to be alert to certain warning signs—impaired quality of life, psychological impact, stress as a trigger of the dermatologic disease being treated, altered body image, and even psychiatric disorders, such as depression, anxiety, BDD, and others—and to take a holistic approach to forge a doctor-patient relationship that will help identify the ideal approach for managing each case.

The authors of the article that follows describe a study that contains important learning points and highlights the need for training in this area.