The self-inflicted dermatoses: A critical review

doi:10.1016/0163-8343(87)90101-0

General Hospital Psychiatry

Volume 9, Issue 1, January 1987, Pages 45-52

https://doi.org/10.1016/0163-8343(87)90101-0 Get rights and content

Abstract

The self-inflicted dermatoses, namely dermatitis artefacta, neurotic excoriations, and trichotillomania, have been reported to be associated with various degrees of psychopathology in the dermatologic literature, but have received surprisingly little emphasis in the psychiatric literature. This probably reflects, firstly the fact that most of these patients initially deny any psychologic problems and hence may not receive psychiatric interventions, and secondly a lack of adequate collaboration between the psychiatrist and dermatologist. These disorders may be associated with serious sequelae, such as suicide and repeated major surgical procedures. Their treatment is also primarily psychiatric. This article critically reviews the literature and comments upon the salient clinical features and treatments for these disorders, which are relevant for the psychiatrist doing consultation-liaison work. Knowledge of these disorders is important in the evaluation of any psychiatric patient, as these disorders are essentially a cutaneous sign of psychopathology.

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We conducted a retrospective cohort study over a seven-year period (2016–2022) to measure the incidence and risk ratio of psychiatric disorders in patients under age 19 years. The FD cohort was defined as patients with FD (International Classification of Diseases, ICD-10-CM: L98.1); the control cohort was defined as patients who attended a regular dermatology visit by applying a diagnostic code of disease of the skin and subcutaneous tissue (ICD-10-CM: L00–99).
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Eating disorders (EDs) such as anorexia nervosa and bulimia nervosa have a plethora of skin manifestations. They can be categorized into skin signs of self-purging, skin signs of starvation, skin signs related to drug abuse, skin signs of psychiatric comorbidity, and miscellaneous signs. “Guiding signs” are valuable because they are pointers to the diagnosis of an ED. They include hypertrichosis (lanugo-like hair), Russell's sign (knuckle calluses), self-induced dermatitis, and perimylolysis (tooth enamel erosion). Practitioners should recognize such skin signs promptly, as this helps to diagnose early, which may improve the prognosis of ED. Management requires a multidisciplinary approach that focuses on psychotherapy combined with attention to medical complications, nutritional needs, and nonpsychiatric findings such as cutaneous manifestations. Psychotropic medications that are currently used in EDs include pimozide and atypical antipsychotic agents, such as aripiprazole and olanzapine, fluoxetine, and lisdexamfetamine.
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Skin picking disorder (also known as excoriation disorder or dermatillomania) is a common mental health disorder currently classified as an obsessive-compulsive and related condition. Despite being first described in the 1800s, very little is known about its phenomenology and clinical presentation. Most information about this disorder to date is based on online surveys rather than in-person assessments.
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This study sheds new light on the clinical presentation and phenomenology of skin picking disorder. Results highlight the need for further research into its clinical presentation, longitudinal course, and treatment approaches.
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Review forensic dermatology in cases of torture.
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Physicians who may encounter survivors of torture in community or specialist practice would benefit from basic training in forensic dermatology, whereas knowledge of common forms of torture and cultural practices in refugees' countries of origin is important when considering differential diagnoses of skin lesions.
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Psychocutaneous disorders are often attributed to stimulant medications, yet this relationship has never been fully elucidated. Literature on psychocutaneous disorders largely focuses on clinical presentation and treatment rather than disease etiology or exacerbation.
To determine whether patients presenting with psychocutaneous disorders display high rates of stimulant use and psychiatric comorbidity.
We undertook a retrospective cohort study of patients with psychocutaneous disorders presenting to a single center. It was hypothesized that these patients would have high rates of stimulant use and psychiatric comorbidity. Following analysis of baseline demographics, the patients were assigned to 1 of 2 groups: those with a psychotic disorder and those with a neurotic disorder.
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Citation Excerpt :
Dissociation can be associated with relative cutaneous analgesia and an increased threshold for pain perception.20 Patients with PTSD can use the integument as the focus of tension-reducing behaviors, which can manifest as body-focused repetitive behaviors (BFRB)21 (dermatitis artefacta, skin picking disorder, trichotillomania, onychophagia, onychotillomania); the BFRB, especially dermatitis artefacta,22 have been reported to be directly related to dissociative symptoms,21,22 and the moderately painful stimuli from the BFRB may in part serve to ground the dissociative patient.16 Some patients with BFRB who also experience dissociative amnesia (eg, in dermatitis artefacta) deny self-inducing their lesions and may be misdiagnosed as malingerers.
Dermatologic symptoms can be associated with posttraumatic stress disorder (PTSD) in several situations: (1) as features of some core PTSD symptoms, such as intrusion symptoms manifesting as cutaneous sensory flashbacks, as autonomic arousal manifesting as night sweats and idiopathic urticaria, and as dissociation manifesting as numbness and dermatitis artefacta; (2) the cutaneous psychosomatic effects of emotional and physical neglect and sexual abuse (eg, infantile eczema, cutaneous self-injury, and body-focused repetitive behaviors such as trichotillomania and skin picking disorder) and eating disorders, which can have dermatologic effects; (3) the direct effect of physical or sexual abuse or catastrophic life events (eg, earthquakes) on the skin; and (4) as a result of significant alterations in hypothalamic-pituitary-adrenal and sympatho-adrenal medullary axes, which can affect neuroendocrine and immune functions, and can lead to exacerbations of stress-reactive inflammatory dermatoses such as psoriasis, chronic urticaria, and atopic dermatitis. Elevated levels of inflammatory biomarkers and impaired epidermal barrier function have been reported in situations involving sustained psychologic stress and sleep deprivation. Some PTSD patients show hypothalamic-pituitary-adrenal axis hyporesponsiveness and higher circulating T lymphocytes, which can exacerbate immune-mediated dermatologic disorders. PTSD should be considered an underlying factor in the chronic, recurrent, or treatment-resistant stress-reactive dermatoses and in patients with self-induced dermatoses.

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^∗: Currently also with the Department of Psychiatry, University of Michigan, Ann Arbor, Michigan.

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The self-inflicted dermatoses: A critical review

Abstract

Psychosomatics

Compr Psychiatry

Pediatric Clin North Am

Compr Psychiatry

J Am Acad Dermatol

Compr Psychiatry

Behav Res Ther

J Behav Ther Exp Psychiatry

J Behav Ther Exp Psychiatry

J Behav Ther Exp Psychiatry

Behav Ther

Psychophysiological aspects of skin disease

Psychocutaneous disorders

Neurotic excoriations, a controlled psychiatric examination

Acta Psychiatr Scand

Psychiatric aspects of dermatitis artefacta

Br J Dermatol

Self-inflicted injury: A follow-up study of 43 patients

Br Med J

Deliberate disability

Br Med J

Neurotic excoriations: A personality evaluation

Cutis

Self-inflicted lesions

Dermatologica

Basic concepts in the production and management of the psychosomatic dermatoses I

Br J Dermatol

Basic concepts in the production and management of the psychosomatic dermatoses II

Br J Dermatol

Neurotic excoriations with report of cases

Arch Dermatol Syphilol

Neurotic excoriations

Arch Dermatol Syphilol

Itching in tension states

Br J Dermatol

Dynamically-oriented brief psychotherapy: Psychocutaneous excoriation syndromes

Psychosom Med

Tonsure trichotillomania

Br J Dermatol

Trichotillomania: Symptom and syndrome

Arch Gen Psychiatry

Trichotillomania, a clinicopathologic study of 24 cases

Arch Dermatol

Emotional aspects of cutaneous disease

Dermatitis factitia South Med J

Dermatitis artefacta in relation to the syndrome of contrived disease

Clin Expt Dermatol

Dermatitis artefacta and self-inflicted disease

Scot Med J