Body Dysmorphia in Common Skin Diseases

Results of an Observational, Cross-sectional Multicentre Study Among Dermatological Outpatients in 17 European Countries

Christina Schut; Florence J. Dalgard; Anthony Bewley; Andrea W.M. Evers; Uwe Gieler; Lars Lien; Francesca Sampogna; Sonja Ständer; Lucía Tomás-Aragonés; Nienke Vulink; Andrew Y. Finlay; Franz J. Legat; Geraldine Titeca; Gregor B. Jemec; Laurent Misery; Csanád Szabó; Vesna Grivcheva-Panovska; Saskia Spillekom-van Koulil; Flora Balieva; Jacek C. Szepietowski; Adam Reich; Bárbara Roque Ferreira; Andrey Lvov; Dmitry Romanov; Servando E. Marron; Tamara Gracia-Cazaña; Ake Svensson; Ilknur K. Altunay; Andrew R. Thompson; Claudia Zeidler; Joerg Kupfer


The British Journal of Dermatology. 2022;187(1):115-125. 

In This Article

Abstract and Introduction


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.


The skin is immediately visible,[1] and covering all of the body it influences a person's body image.[2] Appearance-related distress associated with visible skin diseases is an issue in dermatological conditions,[3,4] which can be associated with stigmatization.[5]

When persons have occasional negative thoughts about their appearance that do not interfere with daily functioning, these might be described as 'nonpathological body dysmorphic concerns'.[6] The prevalence of body dysmorphic concerns (BDC) has increased.[7] However, the diagnosis of body dysmorphic disorder (BDD) should be considered if a person is preoccupied by negative thoughts about minimal or not even obvious appearance-related flaws and their functioning in daily life is impaired. Both BDC and BDD may lead to repetitive behaviours such as mirror checking, avoidance of social events, and excessive camouflaging.[6,8] BDD is classified as an obsessive–compulsive disorder in the International Statistical Classification of Diseases and Related Health Problems[9] and the Diagnostic and Statistical Manual of Mental Disorders (DSM).[10]

BDD is a psychiatric disorder affecting about 2% of the general population.[11] Patients with BDD are often concerned about their skin,[12–18] but also their hair, nose and abdominal area.[12] BDD is of clinical relevance as it is associated with a lower quality of life, stress, depression, anxiety, suicidal ideation and suicidal attempts.[14,19–22] In addition, people with BDD may incur high costs for healthcare systems as they may repeatedly present for different usually ineffective interventions.[23] Besides, they often become dissatisfied with therapies and claim that any given therapy has worsened their appearance.[24]

Skin diseases can impose a high psychological burden on patients.[25] One of the aspects that contributes to this burden is change in appearance,[2] which is in contrast to the societal idea of flawless skin. People with these problems often experience increased self-consciousness,[26,27] skin-related shame,[28] feelings of stigmatization[29–31] and social anxiety.[32,33] It seems obvious that patients with skin conditions are more concerned about their appearance than people with healthy skin, and so might also experience symptoms of BDD more often than the general population.

There are studies investigating the prevalence of BDC and BDD in patients with dermatological conditions. However, most of these were single-centre studies, lacked healthy skin control groups and/or only included relatively small samples.[22,24,34–46] In addition, in previous studies factors such as age and sex were not always assessed,[11] even though they might be relevant in understanding the association between skin disease and symptoms of BDD. For example, a recent study[47] showed significantly higher appearance concerns in women than in men. In line with this, studies have reported higher prevalence of BDD in women than in men,[7,48] while others do not support these sex differences.[14,21,24]

After the first study by the European Society for Dermatology and Psychiatry (ESDaP), which primarily dealt with anxiety, depression and suicidality in dermatological patients and healthy controls,[25] the primary aims of this ESDaP Study II were to measure the prevalence of BDD symptoms in patients with different dermatological conditions and controls with healthy skin, and to investigate whether sociodemographic variables, physical factors such as body mass index and itch and psychological factors such as anxiety and stress are associated with the occurrence of BDD symptoms.