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  • Patients with dysmorphic syndrome regard their image as distorted in the eyes of the public; this becomes almost an obsession.

  • The patient with BDS does not generally consult a psychiatrist but a dermatologist or plastic surgeon. The typical patient with BDS is a single, female, young adult who is anxious.

  • Common dermatologic complaints are facial (wrinkles, acne, scars, hypertrichosis, and dry lips), scalp (incipient baldness, increased hair growth), genital (normal sebaceous glands on the penis, red scrotum, red vulva, and vaginal odor), hyperhidrosis, and bromhidrosis.

  • Management is a problem. One strategy is for the dermatologist to establish rapport; in a few visits, the complaint can be explored and further discussed.

  • If the patient and physician do not agree that the complaint is a vastly exaggerated skin or hair change, then the patient should be referred to a psychiatrist; this latter plan is usually not accepted, in which case the problem may persist indefinitely.


  • This rare disorder, which occurs in adults and is present for months or years, is associated with pain or paresthesia and is characterized by the presence of numerous skin lesions, mostly excoriations, which the patient truly believes are the result of a parasitic infestation (Fig. 24-1A).

  • The onset of the initial pruritus or paresthesia may be related to xerosis or, in fact, to a previously treated infestation.

  • Patients pick with their fingernails or dig into their skin with needles or tweezers to remove the "parasites" (Fig. 24-1B).

  • It is important to rule out other causes of pruritus. This problem is serious; patients truly suffer and are opposed to seeking psychiatric help.

  • The patient should see a psychiatrist for at least one visit and for recommendations of drug therapy: pimozide plus an antidepressant. Treatment is difficult and usually unsuccessful.

Figure 24-1

Delusions of parasitosis (A) Usually patients collect small pieces of debris from their skin by scratching with their nails or an instrument and submit them to the doctor for examination for parasites. In this case, pointed tweezers were used and the results are ulcers, crusted lesions, and scars. (B) Occasionally, this can progress to an aggressive behavior such as depicted in this case where the patient posed to demonstrate how she collects the "parasites" from her skin on a piece of paper. In the majority of cases, patients are not dissuaded from their monosymptomatic delusion.


  • Neurotic excoriations are not an uncommon problem, occurring more in females than in males and in the third to fifth decades.

  • They may relate the onset to a specific event or to chronic stress; patients deny picking and scratching.

  • The clinical lesions are an admixture of several types of lesions, principally excoriations, all produced ...

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