Dermatitis artefacta (a type of self-harm)

Dermatitis artefacta (DA) is a skin condition caused entirely by the actions of the patient on the skin, hair, nails or mucosae. The patient has full insight, but hides the responsibility for their actions. Deliberate self‐harm differs from dermatitis artefacta in that patients will often take responsibility.

This chapter is set out as follows:

• Physical causes are more common than chemical, although the exact aetiology may not come to light 

• In adults there is a female preponderance, with estimates of the ratio of female to male varying from 20:1 to 4:1

• The majority of cases begin in adolescence and in young adults, although there is an important subgroup whose age of onset is significantly older - patients in this group are more likely to be male (male to female ratio 2:1), produce more subtle skin lesions and may have a past history of somatising illness

• The history is of particular importance:
• The patient often describes the sudden appearance of complete (ie fully formed) and often grouped lesions, sometimes on waking, with little or no prodrome and no story of the lesions developing further
• There is often a detailed description of the complications and the failure to heal

• There may be a history of psychiatric or personality disorders, or unexplained illness

• Patients are more often passive than aggressive, even though they have a widespread disfigurement. However, considerable anger is ­commonplace from family and carers

• If a child is involved, after the initial consultation it is then worth speaking separately to the parents and child

• Ask yourself - are there social difficulties or is there anything to gain by the patient having DA?

Distribution

• ​Mainly accessible areas of skin

• The commonest site is the face, particularly the cheeks, representing over half the presentations in children

• The dorsa of the hands are the next commonest site, then the forearms, most frequently of the non‐dominant limb. There is a particular covert pattern on covered skin where the clothes hide significant mutilation of the breasts, abdominal areas and sometimes the genitalia

• Involvement of the breasts or genitalia should increase the suspicion of sexual abuse 

Morphology

• Shape - lesions can be polymorphous, circular, linear, angulated or bizarre patterns that do not conform to recognised skin disease morphology

• The pattern of the dermatitis artefacta lesions may vary as follows:
• Superficial erosion (50%)
• Hyperpigmented macule or purpura (30-42%)
• Excoriation (17%)
• Deep necrosis, ulceration (17%) 
• Irritant dermatoses (17%) 
• Papules (17%)
• Crusts (8%)
• Scars - pinpoint, star-shaped, atypically shaped (8%)
• Onychodystrophy (nails)
• Other - keratosis, tattoo-like

• Except for the skin immediately around the lesions, skin at other sites should not show any inflammatory change 

The Compulsive Skin Picking disorder 

One pattern of DA is the compulsive skin picking disorder.  People with this condition may repeatedly pick, pull, or tear at healthy skin, spots, or scabs. It is more common in women than men, and as with other cases of DA patients may deny they are traumatising the skin. Symptoms most often develop during adolescence and adulthood, and include:

• Developing recurring skin lesions or open wounds due to picking
• Engaging in skin picking despite multiple attempts to address the behaviour
• Periods of remission alternating with periods of greater symptom intensity
• Significant psychological, physical, or social impairment as a result of skin picking, which often leaves scars

People may pick their skin for assorted reasons. Some may feel compelled to remove perceived imperfections, while others pick in response to stress, boredom, or out of habit. Current evidence demonstrates that the condition is more common in individuals with obsessive-compulsive disorder and their parents, siblings, or children than in the general population, suggesting that there is a genetic predisposition to the condition. 

Trichotillosis

Trichotillosis is a behavioural disorder characterised by compulsive hair pulling associated with an increase in tension prior to the pulling and a sense of relief when the hair is pulled out. For more information refer to the chapter Alopecia - an overview.

Exclude organic or psychotic disease

The diagnosis is usually not very difficult to make, although it is essential to exclude organic or psychotic disease:

• If the patient is complaining of itch refer to the chapter Pruritus

• Psychotic disorders such as Delusions of parasitosis (in which the patient is convinced that the lesions are caused by a parasite in the skin) and Morgellon's syndrome (in which patients report fibres coming out of the lesions)

DA subgroups

There appear to be a number of different patient groups with DA, groups 3-5 are of more concern and it is important to explore for the possibility of abuse:

1. Experimental: will soon resolve
2. Social: may get a kick from it
3. Coping strategy: underlying anxiety or unhappiness
4. Physical defence: often a cry for help
5. Mutilating: demonstrates self-loafing, self-punishment 
   

Groups 1&2 often settle without too much intervention. Others may require long-term psychological support by way of a multidisciplinary team approach, which may include a dermatologist (ideally a psychodermatologist), psychiatrist or other mental health worker in order to try and determine why the patient is self-harming, and to help manage the condition.

Key features of management 

• Establish the diagnosis early 

• Take a good history, which includes the skin problem as well as a social, family and psychological history. Examine the skin closely. Take skin swabs as there may be secondary infection

• Manage both the skin and psychological aspects of the condition, although the main focus must be on the latter

Managing the psychological aspects

• Explain to the patient that there is no apparent cause that can explain the skin changes 

• Although most patients will not admit to DA, it is important to be non-confrontational, never accuse the patient of knowingly damaging their own skin. If there are lots of excoriations / erosions some health professionals suggest to the patient that 'you may be scratching your skin subconsciously or when you are asleep'. The reality is that by this stage of the process most patients know that you know what the cause is 

• It is important to move the discussion over to the psychological aspects of management - this could be done by suggesting that 'this problem must be causing you a lot of stress'

• Patients must be allowed to have freedom to express their difficulties in a passive confidential environment, which of course is likely to take time and a number of consultations. In such an environment it may be possible to get to the root of the problem (eg bullying, pressure at school, abuse) 

• In terms of medications, some patients will benefit from either an SSRI or much less commonly a low dose of a psychotropic medication (eg risperidone). To improve compliance it is vital to explain that these treatments are used to help manage the stress associated with the skin problem, in addition to saying that such treatments can also help reduce any uncomfortable sensations that may be present in the skin

• In some cases referral for a psychological opinion (psychiatry or psychology) is necessary - to improve compliance (ie the patient agreeing to the referral) it is important to explain that this is just one part of management and can help with the stress and so forth

• A consistent management approach - the patient should not be referred repeatedly to different dermatologists looking for an alternative diagnosis

Habit reversal therapy

Several skin conditions can lead to behaviours such as scratching, rubbing, and/or picking as ways to try and cope. Eventually the behaviours can become habits. If a patient admits to damaging the skin then habit reversal therapy is a treatment programme that may help. The attached leaflet explains more. Unfortunately, therapy is not widely available.