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3 Self-Inicted Skin Disorders: Diagnosis andManagement
Fig. 3.13 The same patient as Fig.3.12. (Reproduced with permission by Bonamonte etal. [7])
39
Fig. 3.14 Trichotillomania in a 15-year-old boy
Of course, in all cases histopathology testing is necessary to make a more certain
differential diagnosis from spontaneous clinical forms with the same morphology.
Depending on the type and duration of the artefact, various histological patterns can
emerge, some of which may mimic spontaneous disorders. It is therefore very
important that the clinician inform the histopathologist of the suspected artefactual
nature (based on clinical or medical history data) of the lesions. In general, the histological damage is to the epidermis: in fact, the most common pattern is epidermal
necrosis, with a modest inammatory process at the derma, that is the result of
exposure to thermal, chemical, or electrical aggression [110, 111].
Blisters are also common, induced by various attacks; clinically, they can mimic
immunobullous disorders, but the histopathological difference is the presence of
full-thickness epidermal necrosis, clearcut margins and a scarce inammatory
40
Fig. 3.15 Trichotillomania in a 52-year-old woman. (Reproduced with permission by Bonamonte
etal. [7])
G. Angelini et al.
Fig. 3.16 Trichotillomania in an adult woman
inltrate lacking eosinophils [112]. Immunouorescence will, of course, be negative. Intraepidermal or subepidermal blisters induced by electrical burns present
vertically elongated keratinocyte nuclei and homogenization of supercial dermal
collagen [113, 114].
The introduction of foreign material can cause the formation of a dermic or subcutaneous foreign-body granuloma, occasionally revealing polarizable material
3 Self-Inicted Skin Disorders: Diagnosis andManagement
Fig. 3.17 Tonsure-like trichotillomania in an adult man
41
Fig. 3.18 Tonsure-like trichotillomania in an adult patient
[115]. Other possible histopathological ndings include erosions, epidermal acanthosis, and neutrophilic inltrates [116, 117].
An infrequent reported histopathological nding, but suggestive of dermatitis
artefacta, is the presence of epidermal multinucleated keratinocytes, often comprising more than ve nuclei [110, 111, 118, 119]. The mechanism underlying the formation of these cells remains unknown: they could be due to chronic epidermal
irritation subsequent to exposure to corrosive substances or mechanical trauma,
which causes cell-to-cell fusion and the disruption of cytokinesis rather than mitotic
failure [111, 118]. Naturally, it is important to remember that epidermal multinucleated cells can be found in many other conditions, such as tumours, inammatory
42
Fig. 3.19 Tonsure-like trichotillomania in a woman
G. Angelini et al.
Fig. 3.20 Trichotillomania of the pubic area
disorders, acantholytic dermatoses, and herpetic infections, to name just a few.
Except in cases of HSV infections, multinucleated keratinocytes of dermatitis artefacta lack the typical bright grey-blue nuclei with marginalized chromatin [110,
111, 120].
3.4.5 Clinical Course
Skin artefacts usually resolve quite fast, except in clinical pictures characterized by
severe trophic disorders of the dermic-hypodermic tissues, such as ulcers, gangrene,
parafnoma. An unexpectedly slow improvement or healing and unpredictable
course of a lesion is in any case elements that can guide the diagnosis. However, it
3 Self-Inicted Skin Disorders: Diagnosis andManagement
Fig. 3.21 Trichotillomania and gured ulcerative lesion of the pubic area
43
is essential to stress that rapid resolution can only be obtained with occlusive dressing under strict medical and paramedical control.
True complications can sometimes arise, and even iatrogenic, that are possible
because a self-induced artefact can become chronic if not promptly diagnosed. The
infective nature of some artefacts poses a risk of septic complications, and even fatal
septicaemia [121]. Oedema and lymphoedema due to constricting bands can cause
lesions of the cortical bone (thickening) and subcutaneous brosis. Hideous scars,
cheloids, and retractions can also remain. The intentional aggravation of a postsurgical wound, if it goes undiagnosed, can lead to repetitive operative revisions,
that in turn legitimize the continuity of the artefact, followed by unexpected complications (osteomyelitis, stulae, and peritonitis) [122–124].
Only few follow-up studies of SISD have been reported in the literature. Haenel
and Coll investigated a large series of 81 patients with factitious skin lesions without external incentives: the follow-up conrmed the persistence of the problem in
39 cases [125, 126]. Of these, 25 (64%) referred a difcult family situation during
their childhood, 19 (48.7%) were under psychiatric treatment, and 23 (53%) suffered from a markedly depressive state. According to the authors, these patients did
not have sufcient psychological resources to overcome their problems. A similar
study of 43 patients followed up for many years showed that 33 of them continued
to present symptoms up to 12years after the rst manifestation of self-inicted skin
lesions [127]. In 20 cases, the symptoms improved over time as a result of new family situations, while some of these patients showed marked similarities to anorexia
patients.
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G. Angelini et al.
Table 3.2 Aetiological agents of self-induced skin disorders. (Modied, by Ref. [45])
A.Chemical agents
1. Acids (acetic, chromic, formic, hydrochloric, hot vinegar, trichloroacetic)
2. Alkalis (calcium oxide, caustic potash, chlorinated lime, sodium salt, potassium salt)
3. Solvents (boiling oils and liquids, petrol, propane gas, salt, turpentine oil)
B.Physical agents
Metal objects (forks, needles, paper knives, pins, pincers, scissors, tweezers, various tools),
cheese graters, ngernails, incandescent needles, haemostatic ligatures, lighted cigarettes,
pumice stone, small sandbags, wire brushes
C.Biotic agents
1. Animal (caterpillars, jellyshes, sea-anemones, salted sardines)
2. Plant (agave, cactus, ferula, g latex, nettle, primula)
3. Miscellaneous: substances used for injections (air, bacterial cultures from laboratories,
blood, faeces, foreign proteins, gasoline, industrial grease, liquid parafn, milk, saliva,
silicones, talc, urine)
3.5 Aetiological Agents
Causal agents can be of a physical, chemical, or biotic nature (Table3.2). Those in
the rst two categories are more frequently adopted [13, 44, 45, 98].
Among mechanical means, those produced simply by ngernails must also be
taken into account. The chemicals most commonly used are acids and alkalis.
Strong acids have a corrosive action, while weak ones tend to be astringent.
Hydrochloric acid provokes deep burns that may then form blisters. Sulphuric acid
carbonizes the skin forming ulcers that resolve very slowly. Nitric acid has a strong
oxidizing power and induces deep, intensely yellow burns. Other strong acids generally provoke ulcerative lesions with blurred margins. Strong alkaline solutions
cause extensive skin destruction, exerting a solubilizing action on the tissues and
causing the formation of hard escharotic lesions.
The mechanism of action of biotic agents is complex, and there are multiple
types, although essentially, they can be summarized as having a pharmacological
type of action that releases biochemical mediators and proteolytic enzymes.
In practice, identifying the aetiological agent can sometimes be difcult, due to
the obstinate reticence of the simulator. In such cases, the dermatologist needs to
rely on generic suggestive criteria: blisters are often due to vegetable agents, ecchymoses to mechanical agents, ulcers to chemical agents. However, the precise individuation of the culprit substance is sometimes impossible unless the simulator
confesses. The use of salted sardines, or propane gas from a lighter, for example, as
emerged in some of our cases, is difcult to image.
3 Self-Inicted Skin Disorders: Diagnosis andManagement
45
3.6 Concluding Diagnostic Remarks
The diagnostic criteria can be summarized as follows [7, 43, 44]:
Resumptive criteria. These serve to raise the suspicion of a self-inicted disorder
and are based above all on making as detailed as possible a diagnosis of the
development of the lesions. In cases of suspected occupational artefact dermatitis, it is also wise to enquire into the employment status (loss of work, reduced
working activity, and consequently reduced wages), and into possible disagreements with the employer.
Probability criteria. These are based mainly on the objective evaluation of clinical-
morphological ndings and on observation of the lesions over a period of time
and under occlusive dressings. In many cases, the morphology of the lesions
alone may provide sufcient grounds for the diagnosis of an artefact. The
diagnosis is more difcult when a simulator seeks to aggravate or to prolong and
perpetuate a pre-existing spontaneous dermatitis since this subject may know a
lot about its aetiology. In such cases, continued observation in the hospital may
be necessary to solve the diagnostic problem.
Certain criteria. These include the successful identication of residues of the agent
employed (chemical or biological) at the site of the lesions, and of partial or
complete admission of self-inicted harm. The latter can be achieved by means
of various reassuring, condential discussions, combined with persuading the
patient that it is useless to deny the factual evidence.
From the medico-legal standpoint, the problem is serious. It is important that the
physician who suspects a self-inicted disease should immediately share this suspicion with colleagues, fostering ample discussion and recruiting institutional management of legal services, in order to protect the physicians themselves from the
possible risks of isolation and persecution.
3.7 Management
3.7.1 Assessment
Patients affected by SISD need both psychiatric and dermatological assessment.
Because SISD are clearly correlated to mental disorders, the dermatologist needs
to have some familiarity with psychiatric issues, in order to ensure the best management of these patients, also as regards the basic elements involved in the treatment.
This is because most patients with factitious disorders do not believe in the possible
psychogenic origin of their symptoms and, in any case, are often reluctant to accept
any referral to a consultation of psychiatric type.
It must be borne in mind, moreover, that the effects of these diseases on the fam-
ily and social life of the patients may be very severe. Therefore, as well as
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G. Angelini et al.
psychiatric help and controlling patient compliance to medications, the dermatologist must inform the family members, who, where possible, can often be of great
aid. It should also be remembered that the diagnosis of a cutaneous artefact may
impair the doctor’s relationship with the patient. Besides, the dermatologist may
feel that he/she is being manipulated and may reect this feeling on the patient during the visit. Finally, the dermatologist must also check for the presence of comorbidities, such as eating disorders and dependence and/or abuse of non-addictive
substances, for instance, that are observed in a considerable percentage of cases [31].
Among the various dermatological diagnostic criteria, the clinical- morphological
aspects are undoubtedly the most important. The type of lesions, especially their
pattern and conguration, and the anatomo-functional conditions of the perilesional
skin, are elements with a considerable diagnostic value. However, this criterion
must not be overemphasized, given the possible occurrence of spontaneous dermatoses with equally bizarre congurations. Before diagnosing an artefact, therefore,
differential diagnosis must be made with all the possible spontaneous causes of the
afictions, based on clinical data, and also taking into account the possible unfavourable inuence of therapies applied before the dermatologist consultation. The
diagnosis of a skin artefact must not therefore be seen as the result of a process of
elimination but as a possible diagnosis among others. In cases of “irresponsible”
patients, the artefact must be accepted as the expression of strong mental suffering
of which the patient is unaware [67].
3.7.2 Treatment Approach
The simulation of skin artefacts not dictated by external incentives is perhaps one of
the most complex problems to treat in dermatology [67].
Since most patients with psychocutaneous disorders are rst, and perhaps only,
seen by a dermatologist, it is extremely important that the latter should stick to an
appropriate appointment schedule, limiting as much as possible the frequency of
phone calls [62]. The dermatologist must plan continual contact with the patient,
during frequent, not too brief (lasting at least half an hour) appointments. It will
often take many weeks and many meetings to establish an optimal relationship with
the patient. The physician must not become discouraged if progress is very slow and
there are frequent setbacks.
It is also absolutely essential to “save the patient’s face” and avoid the humilia-
tion of direct accusations of simulation and about the aetiology of the lesions. A
direct confrontation must be avoided at all costs because it is counterproductive
(owing to the risk of a necessary defensive strategy), and the approach to psychiatric
consultation and treatment must be introduced gently and rationally [62, 66,
128–132]. The patient may “open up” and recognize his/her behaviour only after a
variable series of interviews and some simple medical treatment [68]. These patients
must be visited in a quiet room, and not in the presence of many staff members or
students asking questions [133].
3 Self-Inicted Skin Disorders: Diagnosis andManagement
47
3.7.2.1 Dermatological Treatment
Hospitalization in a dermatological ward, in particular in serious cases, can help to
placate the conict between the patient and the surrounding environment. The
doctor- nurses team must act in symbiosis and establish an unvarying attitude.
Occlusive dressings are used both as a diagnostic tool and to prevent further self-
mutilation. However, it is important not to insinuate that these dressings are aimed
at preventing self-mutilation, nor to show triumph if the lesions heal after the use of
occlusive dressings. Moreover, it must be remembered that the patient may nd a
way to manipulate the dressing or may transfer the site of injury to another skin area.
3.7.2.2 Psychiatric Treatment
The main therapy is psychological and based on restructuring the patient’s personality and on psychotropic drugs. The former relies on analytical psychotherapy
adapted to borderline personalities and must be performed by a psychoanalyst with
specic experience in the eld. To make a precise diagnosis of the various personality disorders, many tools are publicly available: questionnaires are clinically validated and less “subjective” than a physician’s assessment [133–136]. In particular,
the treatment of psychocutaneous disorders should include psychoeducation, psychotherapy, psychotropic treatment, and, if necessary, psychobiotics [135, 137]. To
draw up an adequate therapeutic strategy, it is necessary to take into account the
type of disorder (psychophysiological, psychiatric with dermatological symptoms,
and dermatological with psychiatric symptoms), the type of comorbidity (anxiety,
depression, obsessive-compulsive or psychotic symptoms), and the severity of the
comorbidity, assessed with screening scales and questionnaires [135]. In practice,
the management of the various types of disorders must always include psychoeducation of the patient, by means of proper information and systematic knowledge
transfer of the dermatological and psychological problems involved, to allow the
patient to understand and face the situation, and to collaborate with a real expectation of success of the proposed treatment [137, 138]. This is particularly important
in cases of cutaneous sensory disorders (vulvodynia, burning mouth syndrome, for
example), that most physicians consider “medically unexplained”, thereby increasing the patient’s feelings of anxiety and depression [138]. Yet again, this highlights
the importance of the doctor-patient relationship; it may even be claimed that the
most important treatment the physician can prescribe is her or his complete attention [135, 139].
Psychotherapy (cognitive behavioural therapy, hypnosis) and psychotropics
(benzodiazepine, hydroxyzine, serotonin), must also be considered, depending on
the severity of the psychopathology (anxiety, depression) linked with the cutaneous
symptoms [62, 135]. In the management of psychocutaneous disorders, psychobiotics (Lactobacillus casei, Lactobacillus acidophilus, Bidobacterium bidum) are
also suggested, in view of their antidepressant and anxiolytic effect [140–143].
Finally, in psychodermatology it is essential to consider psychiatric risk assessment
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G. Angelini et al.
(prior suicide attempts, suicide plans, hopelessness, isolation, and loss of a relationship or a job) that once more highlights the absolute importance of relying on a
multidisciplinary team (dermatologist, psychiatrist, and psychologist). In fact, it
must be borne in mind that various suicides occur during severe depression and
anxiety, psychosis, and/or substances misuse, all comorbidities that can be observed
also in dermatology [144–151].
From what has been stated about the management of psychocutaneous disorders,
it is clear that it is essential to ensure a full awareness among dermatologists, psychiatrists, and psychologists of the problem of psychodermatology, to increase specic knowledge in the various sectors and so ensure a productive collaboration [152].
3.8 Conclusions
SISD are complex, multifactorial conditions that, on the one hand, are still in need
of standardized nomenclature and classication based on diagnostic criteria, and on
the other, of an individualized psychosocial approach.
Self-inicted skin diseases contribute signicantly to morbidity in the dermato-
logic patient and can also complicate the course of a spontaneous primary condition, such as acne and some pruritic dermatoses.
In the great majority of cases, self-inicted dermatoses are linked to acute or
chronic problems with emotional regulation and various levels of dissociation. The
skin and its appendages, hair, and nails are amply innervated with a dense network
of afferent sensory nerves and efferent autonomic nerves, and the skin is often the
target of tension-reducing behaviour, especially in cases of overexcitement of the
autonomic nervous system. For all these reasons, it is important that dermatologists,
psychiatrists, and psychologists, in particular, be well aware of SISD, in order to
ensure an optimal collaboration in the management of patients with psychodermatological problems.
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