Psychological Approach in Cosmetic Dermatology

  • David Ernesto Castillo
  • Katlein FrançaEmail author
  • Torello Lotti
Living reference work entry
Part of the Clinical Approaches and Procedures in Cosmetic Dermatology book series (CAPCD)


Cosmetic psychodermatology is a new science that studies the psychological aspects of cosmetic patients. The complex relationship between mind and skin is the focus of study of psychodermatology and must be understood by cosmetic dermatologists. The patient’s mental status, expectations, background, and the possible presence of psychiatric comorbidities should be recognized and addressed prior to cosmetic procedures to obtain the best results. Cosmetic dermatologists must be trained to evaluate the psychological aspects of their patients. This chapter provides concepts of psychodermatology and its association to cosmetic dermatology, the common psychiatric disorders that can be seen in dermatology and advices to establish a good doctor-patient relationship.


Cosmetic psychodermatology Psychodermatology Cosmetic procedures Dermatologic procedures Psychiatric disorders Doctor-patient relationship Patient’s expectations Difficult patients Referring patients 


Psychodermatology is an integrative science that studies the interaction between skin and mind. The study of this complex cycle, in which mind and skin are linked and influencing each other, has expanded in the recent decades (França et al. 2013). This increasing interest, the recent advances in psychodermatology and the economic growth and, thereby growing interest in cosmetic procedures have led to the creation of a new science called “cosmetic psychodermatology .” According to França, this new science was created to understand the psychological aspects, emotions, and expectations of patients seeking cosmetic procedures (França 2016).

Epidemiological studies have shown that many patients with psychiatric conditions never receive appropriate treatment (Narrow et al. 1993; Kessler et al. 1999; Zimmerman et al. 2005). Thereby, in modern medicine, cosmetic psychodermatologists must be trained to deal with the psychological aspects of their patients. This involves learning skills to conduct a basic psychological evaluation to know the patient’s expectations, recent experience with procedures and outcomes, as well as the creation of an appropriate doctor-patient relationship , as the keystone for a good doctor-patient interaction (Goold and Lipkin 1999; França et al. 2015).

This chapter will discuss the concept of cosmetic psychodermatology and its application in modern medicine, the psychological aspects of dermatologic patients, including the most common psychiatric disorders, the patient’s expectation, how to deal with the difficult patient, and the importance of a good doctor-patient relationship.

Worldwide the demand for cosmetic procedures has expanded in the last decades (Sacchidanand and Bhat 2012). More and more patients are seeking esthetic procedures every year. In consequence, cosmetic dermatologists must develop skills to understand this diverse population. Even though adult females still account for the majority of patients seeking cosmetic therapy, dermatologists should be prepared to deal with patients of any sex or age as the interest for cosmetic procedures among young patients and males is increasing rapidly (França 2016). The increasing interest combined with an improved affordability and income of the population has driven the awareness for cosmetic procedures. There are several reason that may lead a patient to seek cosmetic procedures, and these include personal desire (embarrassment, vanity), society influence, and also psychiatric and psychodermatological disorders (Šitum and Buljan 2010; Sacchidanand and Bhat 2012).

Dermatologists that will perform a cosmetic procedure must consider the magnitude of the psychological aspect of the patient. There is a well-established relationship between mind and skin that must be taken into account (França 2016). Physicians should perform a psychological evaluation prior to the cosmetic procedure to identify those patients that will not benefit from the procedure. A thorough evaluation to explore the patient’s mental status, false expectations, doubts, and previous experiences will help the physician to recognize psychiatric disorders that will interfere with the procedure and that might worsen the patient’s condition. Thereby, basic knowledge about common psychodermatological disorders such as obsessive-compulsive disorders and body dysmorphic disorder is very useful for all physicians (Jafferany 2007). The dermatologist must provide clear information about possible outcomes and complications of esthetic procedures to avoid false expectations. This will increase satisfaction and prevent medicolegal complications.

Cosmetic Psychodermatology: A New Science

The scientific community has set a lot of interest on the interaction between mind and skin in the last decades. Psychodermatology was created to address the overwhelming evidence of the relationship between psychiatric conditions and dermatologic disorders. Physicians have placed special interest in developing this field of medicine combining concepts of dermatology and psychiatry (Koo 1995; França et al. 2013). Psychiatry focuses in the internal factors (psychic), while dermatology focuses in the external factors (the skin) (Jafferany 2007; Rodríguez et al. 2011; França et al. 2013). The complex interaction between mind and skin comes from their ectodermal origin and helps to explain the high incidence rates (30–60 %) of psychiatric disorders among these patients (Basavaraj et al. 2010).

In the last two decades, great scientific effort has been done to expand our knowledge about psychodermatology (França 2016). Recent advances in treatment combined with the increasing interest of patients in cosmetic treatment have driven concern about psychiatric disorder and its effects in dermatologic patients. More scientific information is being published every year about this specialty, increasing awareness among physicians (Jafferany and França 2016). Aspects such as mental evaluation, psychotherapy, and pharmacotherapy are of special interest, and close work between dermatologists and psychiatrists has been useful in the treatment of psychocutaneous disorders (Basavaraj et al. 2010).

The growing interest for cosmetic procedures and the new advances in psychodermatology have led to the development of a field named cosmetic psychodermatology (Sacchidanand and Bhat 2012; França 2016). According to França, this new subspecialty of psychodermatology originated from the combination of cosmetic dermatology and psychodermatology. Cosmetic psychodermatology involves the study of the social and psychological features of patients, their cultural background, expectations and experiences with previous cosmetic procedures, and the effects that these procedures produce on their lives (França 2016). In modern medicine, cosmetic dermatologists must be trained to provide a basic psychological evaluation and recognize psychiatric conditions in patients seeking cosmetic pro cedures (Scheme 1).
Scheme 1

Cosmetic psychodermatology: New science that studies the relationship between cosmetic dermatology and psychodermatology. Created to understand the psychological aspects of patients seeking cosmetic procedures and how it can affect the patient’s life. Information taken from (França 2016)

Knowing the Patient

Cosmetic dermatologists must know how important is to individualizing care for patients seeking esthetic procedures. These groups of patients are particularly seeking highest results. Thus, a good dermatologist must consider each patient’s background and personality, emphasizing the patient’s expectations, doubts, preferences, and goals to optimize care. Each patient must be treated with empathy and confidence in order to create a good doctor-patient relationship (França 2016). A pleasant conversation and a good relationship will allow an appropriate environment to gather the information needed to make a complete medical history. Personal, familiar, and psychological history must be collected carefully as many factors play a role on how the patient will respond to the procedure.

A dermatologist should have the ability to conduct a basic psychological evaluation. This evaluation will give an overview of the patient’s mental status and will allow the physician to resolve the patient’s doubts and fears about the procedure. Expectations, either real or false, negatively affect the outcomes of the procedure and need to be addressed immediately (Bowling et al. 2012). This is done by thoroughly evaluating the patient’s concerns, beliefs, cultural backgrounds, and experiences with previous procedures during the interview (Jhon 1992; Bowling et al. 2012). If false expectations are present, the dermatologist must clearly explain why they are unrealistic and provide accurate information about the procedure, real outcomes, and complications (França et al. 2014). Finally, doctors must remember the importance of the doctor-patient relationship spending enough time to ensure the patent’s welfare and understanding.

Common Psychiatric Disorders in Dermatology

Psychiatric disorders are relatively common disorders that can affect people of any age, culture, and income levels (França et al. 2014). They are defined as clinically significant behaviors or psychological patterns that cause distress and impair normal functioning (Stein et al. 2010; França et al. 2014).

Among the common psychiatric disorders found in the dermatologic practice, there is body dysmorphic disorder (Conrado 2009). Dermatologists should be trained to recognized this disorder prior to cosmetic procedures and promptly refer the patient for expert evaluation. Other common psychiatric conditions seen in practice are obsessive-compulsive disorder, anxiety, personality disorders, and eating disorders (Jafferany 2007). All of them will disrupt the patient’s overview about the procedure, and thus, these patients must be treated by a multidisciplinary group involving the dermatologist, psychiatrist, and psychodermatologist.

Body Dysmorphic Disorder

Body dysmorphic disorder is a chronic mental disorder frequently seen in cosmetic practice. It is characterized by excessive preoccupation with nonexistent or minimal defects in physical appearance (Bjornsson et al. 2010; Phillips 2004). These physical abnormalities are not perceived by others, and although it can focused on the whole body, it is more frequently focused on one specific part of it (Phillips 2004). The severity of the disorder varies among patients, ranging from a mild disease that might not interfere with daily activities to a severe condition that threatens life and can lead to suicide. Patients with body dysmorphic disorder see themselves as deformed and non-attractive, showing a marked discrepancy with their actual body appearance (Veale et al. 2003). These intrusive thoughts become obsessions which worsen when the patient’s feelings are under evaluation and become difficult to control (Conrado 2009).

In order to cope and dissimulate these obsessions, patients with body dysmorphic disorder resort to time-consuming compulsions (Crerand et al. 2006). These patients engage in behavioral acts such as excessive mirror gazing, grooming, applying makeup, and cloth changing, and they seek multiple dermatologic and cosmetic treatments (Conrado 2009; Jafferany and França 2015). Others engage on mental compulsions such as comparing one’s appearance with others (Jafferany et al. 2015). These behaviors are thought to reduce distress and impairment.

The estimated prevalence for body dysmorphic disorder in the general population is 1–2 %, and there is no gender difference (American Psychiatric Association 2000; Crerand et al. 2006; Conrado 2009). Even though body dysmorphic disorder first manifest during adolescence, it is often diagnosed later in life when patients seek cosmetic treatment (Veale 2004). These patients more often complains of their nose (size, shape), skin (excoriation, acne), and hair (baldness, excessive body hair) (Conrado 2009). The last two are of great importance because they are associated with pathologic behaviors such as skin picking and hair plucking (Phillips and Taub 1995). The dermatologist must know the difference between hair plucking in patients with body dysmorphic disorder and trichotillomania . While in body dysmorphic disorder hair plucking follows a specific reason (better appearance), in trichotillomania it does not (Conrado 2009). Body dysmorphic disorder is associated with higher rates of depression, anxiety, substance abuse, and personality disorders compare to other psychiatric conditions (Phillips et al. 2004; Crerand et al. 2006).

Among physicians, dermatologists are more likely to encounter patients with body dysmorphic disorder. The rate of this pathology for patients seeking dermatologic and cosmetic procedures ranges from 2.9 % to 16 % (Castle et al. 2004; Bellino et al. 2006; Vulink et al. 2006; Bowe et al. 2007; Taillon et al. 2013). Accordingly, the dermatologist must know how to recognize the disease to avoid cosmetic procedures in these patients, which will only worsen the psychiatric condition. It is also essential for the dermatologist to work closely with psychiatrists and psychodermatologists to provide prompt referral, prevent relapses, and achieve full compliance. Pharmacotherapy with selective serotonin reuptake inhibitors and cognitive behavioral therapy is the best approach (Phillips 2002; Crerand et al. 2006; Conrado 2009). The last one involves the use of behavioral exercises, cognitive techniques, and exposure therapy, which help to diminish the abnormal behavior and help the patient to integrate into society (Neziroglu and Khemlani-Patel 2002; Prazeres et al. 2013). Thereby, a good doctor-patient relationship based on trust and confidence is essential for appropriate management and to prevent multiple dermatologic visits and physician burnout.

Body dysmorphic disorder is classified in the spectrum of obsessive-compulsive spectrum disorders. To make the diagnosis, preoccupations cannot focus on noticeable defects or normal, non-pathological, appearance concerns (American Psychiatric Association 2013). The diagnostic criteria for body dysmorphic disorder from the 5th edition of the Diagnostic and Statistical Manual of Mental Disorder from the American Psychiatrist Association are listed below:
  • Preoccupation with imaginary defects: Patient’s concerns are not real or minimal and are not perceived by others. These preoccupations cannot be focused on real defects.

  • Engaging on repetitive behaviors: At some point of the disease, the patient engages on repetitive, compulsive behaviors in response to the physical defect. Patients can perform real on mental compulsions. Examples: excessive mirror gazing, grooming, and hair plucking.

  • Clinically significant: The preoccupation must cause clinically significant distress in social or occupational functioning.

  • Rule out eating disorder: If patient’s concerns are focused on body fat or weight and his/her symptoms meet diagnostic criteria for eating disorder, the eating disorder is the diagnosis and not body dysmorphic disorder.

  • Must specify if:
    1. (i)

      Muscle dysmorphia: the patient’s concerns are focused on having too small or insufficient muscle mass. This is true even if the patient is preoccupied with other body areas. This is associated with worse prognosis.

    2. (ii)

      Insight: Indicate the degree of insight regarding body dysmorphic disorder. This tells the doctor how convinced is the patient that his/her concerns are true. The patient may say, “I am ugly, I look deformed.”


Major Depressive Disorder

Major depressive disorder (MDD) is a common and recurrent mental disorder characterized by episodes of depressed mood and lack of interest associated with impaired neurovegetative functions (appetite, sleeping), cognition (guilt, feeling of worthlessness), psychomotor retardation or agitation, and suicidal thoughts (Fava and Kendler 2000). These episodes cause clinically significant distress in social and occupational functioning, and are not always precipitated by an external cause (Belmaker and Agam 2008). To make an appropriate diagnosis of major depressive disorder, the episodes of sadness cannot account for bereavement or be caused by the physiological effect of a substance or medical illness. Furthermore, physicians most recognized that patients with MDD might have signs and symptoms of mania, hence, meaning a diagnosis of bipolar disorder which implies a different diagnostic and treatment approach (Belmaker and Agam 2008).

The estimated lifetime prevalence of major depressive disorder in America is 16.2 % (Kessler et al. 2003). Moreover, the prevalence of depression in dermatologic patients is as high as 30 %, particularly for those with severe skin disorders such as psoriasis and rosacea (Filaković et al. 2008). Thereby, dermatologists must be prepared to face and diagnose this common and complex disorder. MDD usually begins during adolescence and adulthood life and most of these patients will have more than one episodes of MDD throughout their life, especially if the diagnose is made at young ages (Kessler et al. 2003; Kessler and Wang 2008). Several risk factors are identified for major depressive disorder, including gender (women), loss of interpersonal relationships, job loss, health problems, marital difficulties, history of sexual abuse (early in life), and poor parent-child relationship, among others (Kessler 1997; Fava and Kendler 2000). This is a highly comorbid disorder strongly associated with other psychiatric illness, being the most commonly identified anxiety disorders, substance abuse, and impulse control disorders (Kessler et al. 2003).

The treatment of major depressive disorder in dermatologic patients is complex and requires the conformation of a team involving the psychodermatologist and a psychiatrist in order to cover the aspects of both the mental and the somatic illness (Filaković et al. 2009). The pharmacotherapy of these patients should be based in the recent understanding of the role of the immune system by the release of pro-inflammatory cytokines and other immunomodulatory molecules in the development of both disorders (Katsambas and Stratigos 2001; Himmerich et al. 2006; Filaković et al. 2009). It is known that certain drugs such as selective serotonin reuptake inhibitors, that have proven to be very effective, have anti-inflammatory effects that help to improve the depressed mood and the skin disease, particularly if the skin disorder is related to an immune system alteration (Keshavan 1997; Szelėnyi and Selmeczy 2002; Filaković et al. 2009). Concomitantly, the psychotherapeutic approach must focus on interpersonal psychotherapy and cognitive behavioral therapy, which are as effective as pharmacotherapy for major depression disorder (Fava and Kendler 2000; Hollon and Dimidjian 2009). Other treatment therapies include atypical antidepressants (bupropion, mirtazapine, nefazodone, and trazodone), serotonin-norepinephrine reuptake inhibitors (venlafaxine), selective norepinephrine reuptake inhibitors (reboxetine), and electroconvulsive therapy (Fava and Kendler 2000).

The diagnostic criteria for major depressive disorder from the 5th edition of the Diagnostic and Statistical Manual of Mental Disorder from the American Psychiatry Association are listed below:
  1. (A)
    Five or more of the following symptoms have been present during the same 2 week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
    1. 1.

      Depressed mood most of the day, nearly every day. This might be an irritable mood for children and adolescents.

    2. 2.

      Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.

    3. 3.

      Considerable weight loss or weight gain (e.g., 5 % or more change of weight in a month). Can also be a significant increase or decrease in appetite. For children, no gain of the expect amount of weight.

    4. 4.

      Insomnia (difficulty falling or staying asleep) or hypersomnia (sleeping more than usual).

    5. 5.

      Psychomotor agitation or retardation. Observed by others.

    6. 6.

      Fatigue or loss of energy nearly every day.

    7. 7.

      Feeling of worthlessness or extreme guilty nearly every day (not about being ill).

    8. 8.

      Decreased ability to think or concentrate nearly every day.

    9. 9.

      Frequent thoughts of deaths or suicide (not just fear of dying) or attempt to suicide or specific plan for committing suicide.

  2. (B)

    These symptoms do not meet criteria for a mixed episode.

  3. (C)

    The symptoms cause clinically significant distress in social, occupational, or other areas of functioning.

  4. (D)

    The symptoms are not attributed to the physiological effects of a substance or medical condition.

  5. (E)

    The symptoms are not due to grief or bereavement after the death of a loved one and persist for more than 2 months or cause significant functional impairment, excessive preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.


Anxiety Disorders

Anxiety disorders are by far the most common psychiatric disorder (Kessler et al. 2005). These disorders are characterized by excessive worry that begin early in life and persist throughout it causing significant developmental, psychological, and functional impairment (Stein et al. 2014). Anxiety is a normal response to danger and is considered a very useful tool to deal with everyday life experiences (Staner 2003). However, when this response becomes pervasive, interfering with quality of life, cognitive and social functioning is considered pathologic (França et al. 2014). These common disorders are usually associated with other psychiatric and somatic disorders such as mood disorders and diabetes, creating a great burden for the patient and the society (Hettema et al. 2001; Koen and Stein 2011). Table 1 provides a list of the anxiety disorders, obsessive-compulsive related disorders, and trauma- and stressor-related disorders. It is important to highlight that in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorder from the American Psychiatry Association, the obsessive-compulsive and trauma- and stressor-related disorders were removed from the section of anxiety disorders and are now classified separately.
Table 1

List of anxiety disorders, obesessive-compulsive related disorders, and trauma- and stressor-relatd disorders. Information taken from (American Psychiatric Association 2013)

Anxiety disorders

Separation anxiety

Selective mutism

Specific phobia

Social anxiety disorder (social phobia)

Panic disorder

Panic attack


Generalized anxiety disorder

Substance-/medication-induced anxiety disorder

Anxiety disorder due to another medical condition

Unspecified anxiety disorder

Obsessive-compulsive and related disorders

Obsessive-compulsive disorder

Body dysmorphic disorder

Hoarding disorder

Trichotillomania (hair-pulling disorder)

Excoriation disorder (skin picking)

Substance-/medication-induced obsessive-compulsive and related disorder

Obsessive-compulsive and related disorder due to another medical condition

Other specified obsessive-compulsive and related disorder

Unspecified obsessive-compulsive and related disorder

Trauma- and stressor-related disorders

Reactive attachment disorder

Disinhibited social engagement disorder

Posttraumatic stress disorder

Acute stress disorder

Adjustment disorder

Other specified trauma- and stressor-related disorder

Unspecified trauma- and stressor-related disorder

As any psychiatric condition, anxiety disorders must be treated by physicians with expertise in these pathologies. The dermatologists must recognize these common disorders and promptly refer the patient for expert evaluation by a psychiatrist. A combination of psychotherapy, cognitive behavioral therapy, and pharmacotherapy with selective serotonin reuptake inhibitors is the most effective therapy for all anxiety disorders and anxiety-related disorders (Koen and Stein 2011; Stein et al. 2014).

Personality Disorders

Personality disorders are enduring patterns of experiences and behaviors deviated from the expectations of society (Livesley et al. 2001). These are maladaptive, inflexible, and pervasive patterns that cause significant distress and persist over time, and must be differentiated from personality traits that are repetitive patterns on how people perceive and think about oneself and the environment (Livesley et al. 2001). The severity of the disease ranges from a mild disease to a severe condition that causes functional impairment in all areas of life. Personality disorders are divided in three clusters, A, B, and C. A single individual may show one or many patterns of personalities (Zimmerman et al. 2005). A brief explanation of the most important personality disorders is provided in Table 2.
Table 2

Brief summary of personality disorders. Information taken from (Livesley et al. 2001; Angstman and Rasmussen 2011; American Psychiatric Association 2013)

Cluster and type

Important clinical features

Cluster A (odd, bizarre)

Associated with schizophrenia

Paranoid personality disorder

Pattern of pervasive distrust and suspiciousness. They are isolated from others as they negatively interpret people’s intentions and words and are constantly seeking clues to support these suspiciousnesses. Very sensitive to criticism. The most common defense mechanism is projection

Schizoid personality disorder

These patients do not desire or enjoy any form of social interaction and prefer engaging in solitary activities. Lack of close friends and show no interest in sexual relationships. Characterized by emotional coldness, flattened affect, and detachment from people including the family setting

Schizotypal personality disorder

Eccentric appearance, speech, beliefs, and magical thinking. These patients do not desire social interaction and many develop social anxiety. Interpersonal awkwardness and ideas of references are common. May present brief psychotic episodes

Cluster B (dramatic, emotional)

Associated with mood disorders and substance abuse

Antisocial personality disorder

Disregards and constant violation of social rules. These are very impulsive patients that lack guilt and pay no attention to the feeling of others. Very likely to commit crimes and to being in prisons. More common in male than females

Borderline personality disorder

Pattern of emotional instability and unstable interpersonal relationship. These patients are impulsive and have outburst of inappropriate anger. Feeling of emptiness and boredom. Engage self-mutilation and suicidal behaviors. More common in female than males. The major defense mechanism is splitting

Histrionic personality disorder

These are extremely dramatic persons that are constantly seeking attention and approval of others. They are overly concerned about their appearance and behave in a seductive and sexual manner. Relationships are usually superficial and lack honesty causing rejection of others. Thus, impairing social interaction as they are extremely sensitive to rejection and criticism

Narcissistic personality disorder

Characterized by grandiosity, self-entitlement, and arrogance. They need admiration and tend to demand special treatment. These patients lack empathy and usually exploit others. They feel underestimated and react bad to criticism with outburst of rage. People tend to see them as selfish, insensitive, and controlling

Cluster C (anxious, fearful)

Associated with anxiety disorders

Avoidant personality disorder

These patients are socially inhibited, see themselves as inept or inferior and are excessively concern about rejection and criticism. Feeling of inadequacy. Unlike schizoid PD they desire social interaction but will only establish a relationship if they are certain of being liked

Obsessive-compulsive personality disorder

Pattern of preoccupation with order, details, rules, organization, and schedules. Extremely perfectionist, which engage them in time-consuming behavior to increase productivity that limits social interaction. These persons are rigid, controlling, and demanding, interfering with interpersonal relationships

Dependent personality disorder

Characterized by a pervasive feeling of incompetence and lack of confidence. They cannot make decisions or assume responsibility. These patients are reluctant to take risk and do not show disagreement because of fear of being rejected

The estimated prevalence of personality disorders in general population is 9–14.9 % (Angstman and Rasmussen 2011). The most common personality disorders are avoidant, borderline, and obsessive-compulsive personality disorder (Zimmerman et al. 2005). There are some differences between genders. Dependant, passive-aggressive, and histrionic personality disorders are more common in females, rather obsessive-compulsive, schizotypal and antisocial personality disorders are more common in males (Maier et al. 1995; Zimmerman et al. 2001). Also, these disorders tend to appear at young ages and decline with time. Personality disorders are associated with substance abuse, anxiety disorders, sexual disorders, mood disorders, obsessive-compulsive disorder, and eating disorders (Angstman and Rasmussen 2011).

Many epidemiological studies have shown that most patients do not receive treatment for psychiatric conditions (Narrow et al. 1993; Kessler et al. 1999; Zimmerman et al. 2005). The mainstay of the treatment is individual and group psychotherapy, which is specific for each type of personality disorder (Angstman and Rasmussen 2011). Pharmacotherapy with antidepressants or antipsychotic drugs is reserved for patients with coexisting comorbidities (Angstman and Rasmussen 2011). Because suicidal ideations and attempts are common, extensive communication between the dermatologist and psychodermatologist is needed to create a safe environment and prevent negative outcomes.

The Patient and the Physician

Doctor-Patient Relationship

The doctor-patient relationship remains the keystone of medical practice (França et al. 2014). This interaction is the major medium by which the medical interview gathers information, diagnosis are made, compliance with treatment and care is accomplished, and must be guided by the bioethical principles of autonomy, justice, beneficence, and non-maleficence (França 2012; França et al. 2015). Susan et al. see the doctor- patient relationship as the major influence on practitioner and patient satisfaction, thereby contributing to practice maintenance, prevention of practitioner burnout and turnover, and it is the major determinant of compliance (Goold and Lipkin 1999).

The physician should begin the patient interview by greeting the patient, introducing himself, and using an open-ended question. The doctor must show empathy, respect, courtesy, and trust considered as “core conditions” to sustain an effective communication (França 2012). Furthermore, self-evaluation to enchase their communication skills, knowledge, and focusing on each patient as individual and unique is essential for an adequate doctor-patient relationship (Goold and Lipkin 1999). Following the initial approach, dermatologists must conduct a structured medical history including a comprehensive interview, physical examination, and appropriate closure to address patient questions and concerns (Ong et al. 1995).

The interaction between the physician and patients seeking cosmetic procedures is particular. These patients seek to correct imperfections in their physical appearance rather than heal a medical illness (França 2016). All cosmetic procedures must be explained clearly, including possible outcomes and complications to ensure patient satisfaction and prevent false expectations and medicolegal complications, even when the result is not the one expected (Sacchidanand and Bhat 2012).

A few tips to maintain an adequate doctor-patient relationship are listed in Table 3.
Table 3

Table 3 Tips to improve the doctor-patient relationship during the encounter. Information taken, modified from (França 2012, 2016; França et al. 2014)

Greet the patient

Be empathic, respectful, and friendly during the interview

Inquire about the patient’s concerns using open-ended questions and do not interrupt or rush the patient while speaking

Note the verbal and nonverbal communication signs showed by the patient

Keep eye contact during the interview and avoid crossing the arms

Touch the patient’s skin during examination

Make an appropriate closure: summarize the history, give a feedback if required, and ask about further patient concerns or questions

Patient Expectations

For dermatologist, the ultimate goal of providing therapeutics and esthetic procedures is to deliver a high-quality care to meet patient’s expectations. Expectations can be viewed as probabilities, in which expectations are the likelihood of future clinical outcomes or as a value, in which expectations are the patient’s desires, necessities, and attitudes (Chang 2012). Bowling et al. says in his review “The measurement of patient’s expectations for healthcare,” that expectations are the anticipation that given events are likely to occur during or as an outcome of healthcare (Bowling et al. 2012). It is the understanding and meeting of these expectations that increase patient’s satisfaction and compliance with the care provided. Furthermore, physicians should know the differences between real and false expectations and how to address them. A real or predicted expectation is the likelihood that an event will occur based mainly on previous expectations; it is expected by both the doctor and the patient (Bowling et al. 2012). Real expectations can be seen as the possible outcomes of a procedure known by the patient from trustful sources. Otherwise, false expectancies are hopes or desires regarding the procedure; they are ideals, based on beliefs and are usually seen in inexperienced patients influenced by doubtful sources (Bell et al. 2002). Expectations are difficult to evaluate as they are complex beliefs, perceptions based on previous experiences, cognitive processes, and social learning (Bowling et al. 2012). They are strongly influenced by cultural backgrounds, hopes, outcomes of previous procedures, and information acquired from different sources, such as internet, family, friends, etc. (Webb and lloyd 1994; França et al. 2014).

Cosmetic dermatologists must know that their patients have high expectations. Thus, cosmetic dermatologists must perform the cosmetic procedure as accurate and safe technically speaking in order to fill patient’s expectations and create a trustful relationship (França 2016). Physicians must know the patient’s experience with previous cosmetic procedures and their outcomes, backgrounds, and how the patient acquired information about the procedure (Šitum and Buljan 2010). The dermatologist can avoid unrealistic expectation by providing clear information regarding the procedure, including possible outcomes and complications, and solving the patient’s concerns and doubts about it (França et al. 2014). Finally, if false expectations are present, the dermatologist must calmly and directly explain how the patient is wrong.

The Difficult Patient

The difficult patient is a common figure of everyday care for physicians. These patients account for up to 15 % of all patients and are more likely to present mental disorders (Lin et al. 1991; Haas et al. 2005). Han et al. found that these patients are almost twice as likely to have a psychiatric diagnosis, such as somatoform disorder, anxiety, depression, and body dysmorphic disorder, compared to non-difficult patients. Factors such as patient’s expectations and cultural background might hinder the doctor-patient relationship as well as the doctor’s overwork, knowledge of mental disorders, and stress (Hahn et al. 1996).

Managing a difficult patient can be challenging for many doctors as physicians are not trained to provide a proper management of these patients during medical school and afterwards (França 2016). It can lead to physician frustration and burnout interfering with the doctor-patient interaction. The approach of a difficult patient should begin by doing a personal feedback, which includes ensuring own well-being, improving knowledge about mental disorders, and evaluating communication skills (Vanderford et al. 2001; Haas et al. 2005). It is essential to carefully listen to the patient, focusing on patient’s concerns and questions (Lang et al. 2000). This will help the physician to develop specific techniques to improve care of difficult patients. Some tips are listed in Table 4.
Table 4

Tips to improve management of difficult patients. Information taken, modify from (Haas et al. 2005)



What the physician can say or do

Show empathy

It will help patients to focus on solutions and not in problems

“I can imagine what you are going through,” “I can imagine your pain or frustration”

Listen carefully

Paying attention to the patient without interruptions will help the doctor to determine the patient’s real concerns, increasing patient collaboration and willingness to solve the problems

Do not interrupt the patient while speaking. Keep eye contact always.

Summarize the patient’s concerns

Focus on solutions and not in problems

Doctors should focus on finding different ways to solve problems. This will divert the discussion toward solutions and not problems

Keep a positive attitude. Encourage the patient to recognize and solve the problem

Improve partnership with the patient

Calmly point out that the relationship is not ideal, and offer ways to improve it

“Tell me how you feel about the care you are receiving from me.” “Do you have any problem with the care I am providing?”

Discuss the process of care

Establish why the patient is looking for care

State you are here to help him

Talk about expectations and if unrealistic address them

“I am here to help you.” “We will work together to find the best solution”

Referring the Patient

In the general medical practice, about 30 % of patients have a psychiatric disorder (Bronheim et al. 1998). Even though it is proven that these patients benefit from a referral to a psychiatrist or psychologist, many of them are reluctant to be referred. The difficulty of achieving a referral involves many factors; some of them are attributed to the patient and some to the doctor. When talking about the patient, social stigmatization is a factor of major concern. Psychiatric patients are usually considered embarrassing, distrusted, and worthless by society, thereby avoiding psychiatric aid not to be feared or disliked (Bursztajn and Barsky 1985).

Other factors that play a role in rejection of referrals are listed below (Bursztajn and Barsky 1985):
  • Impact on self-esteem: Patients believe that going to a psychiatrist means there is a defect that must be “fixed” on them. They see themselves as weak and disturbed.

  • The relationship between mind and physical: Patients do not believe that their physical symptoms can be related to psychological problem. These patients believe that there have to be a physical cause of their physical symptoms. Thus, they do not understand why they are being referred to a psychiatrist or psychologist.

  • Belief that referral means “rejection by the doctor”: For many patients, there is an implicit sense of “rejection” secondary to a referral. This misunderstanding can be intensified by the doctor attitude. A broken doctor-patient relationship strengthens this misconception.

  • Always refer to the same doctor: It is important to have a confident psychiatrist or psychologist. This allows a better understanding between the dermatologist, the psychiatrist, and the patient.

  • No training in psychiatric diagnosis: Doctor’s lack of knowledge about psychiatric condition tampers opportunity to a referral. Many doctors still think that for every physical sign or symptoms must be a physical cause and no psychic condition is allowed.

The doctor-patient relationship is the keystone to create a trustful relationship (França et al. 2014). This allows the patient to openly discuss his/her concerns and feelings about the referral. Physicians should propose the referral in a direct manner, clearly explaining the reasons and carefully listening to the patient’s response (Bursztajn and Barsky 1985). The best way to deal with social stigma is being empathic, acknowledging the patients concerns, and focusing in the patient’s most feared consequences, specially, if they come from family or friends as they can be addressed easier (Bursztajn and Barsky 1985). Also, doctors should clarify that referring the patient does not mean rejection, and reassure that the patient can still count on the physician.

Finally, a dermatologist trained in psychodermatology must be part of the cosmetic medical practice. It will make it easier to refer those patients that are reluctant to see a psychiatrist or psychologist due to the reasons described above. The psychodermatologist, when available, should be able to manage these cases.


The interest for psychodermatology and the new science cosmetic psychodermatology is rapidly growing. Several researches are being developed to better understand cosmetic patients. These patients are particular, they are looking to correct or improve their appearance rather than cure a medical illness, and many psychological and external factors influence how they perceive their psychical defects. Also, a number of psychiatric disorders have shown to be more common in the dermatologic and cosmetic practice than general medical practice. In such cases dermatologists must work closely with a physician with expertise in mental health care to provide the best care and avoid unnecessary and harmful cosmetic procedures.

The dermatologist must be trained to explore the psychological aspects of patients seeking cosmetic procedures, beginning with a pleasant and trustful conversation with the patient, devoting time to carefully listen to the patient’s motivations, concerns, expectations, cultural backgrounds, and previous experiences with cosmetic procedures. Accordingly, dermatologist should not only be trained to perform the most accurate and safe cosmetic procedure, but to see each patient as unique, with its own fears and concerns, looking to be treated as a human being. This will create a good doctor-patient relationship, which is essential for the best medical practice and to achieve full satisfaction.

Take Home Messages

  1. 1.

    Cosmetic psychodermatology is a new science created to study the relationship of psychiatric conditions on patients seeking cosmetic procedures.

  2. 2.

    Cosmetic dermatologists must be trained to perform a brief psychological evaluation prior to cosmetic procedures in order to recognize psychiatric disorders in this diverse population.

  3. 3.

    The prevalence of psychiatric disorders is high in the dermatologic practice. Among them, body dysmorphic disorders are one of the most common disorders, and dermatologists must promptly recognize and refer these patients for appropriate treatment.

  4. 4.

    The doctor-patient relationship is the keystone of the general medical practice. Dermatologists must be trained to establish a good relationship when facing difficult patients. Prompt referral to a psychiatrist or psychodermatologist is essential for psychiatric patients.

  5. 5.

    A psychodermatologist must be part of the cosmetic medical practice. They will provide adequate treatment for patients seeking cosmetic procedures with psychiatric disorders.



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Copyright information

© Springer International Publishing AG 2016

Authors and Affiliations

  • David Ernesto Castillo
    • 1
  • Katlein França
    • 2
    • 3
    Email author
  • Torello Lotti
    • 4
  1. 1.Department of Dermatology and Cutaneous surgeryUniversity of Miami Miller School of MedicineMiamiUSA
  2. 2.Department of Dermatology & Cutaneous Surgery, Department of Psychiatry & Behavioral SciencesInstitute for Bioethics and Health Policy- University of Miami Miller School of MedicineMiamiUSA
  3. 3.Centro Studi per la Ricerca Multidisciplinare e RigenerativaUniversità Degli Studi “G. Marconi”RomeItaly
  4. 4.Centro Studi per la Ricerca Multidisciplinare RigenerativaUniversity of Rome G.MarconiRomeItaly

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