Self-Inflicted Skin Disorders: Diagnosis and Management

Self-inflicted disorders, or factitious diseases, can be observed in all branches of specialist medicine and represent one of the most challenging problems in clinical medicine. Among them, self-induced dermatoses are inflicted using multiple different means (physical, chemical, or biotic in nature), for various different purposes. In the great majority of cases, the simulation of cutaneous disorders is dictated by psychiatric problems; sometimes, however, simulators are motivated by an illicit intent. Self-inflicted cutaneous disorders are due to excessive manipulation of the skin and appendages, hair, and nails. The anomalous behaviour is typically repetitive, and it is this reiteration that generally leads to chronic damage. Manipulation of the skin can cause a de novo disease, or else complicate the course of a primary dermatological disease, as in the case of pre-existing acne, psoriasis, or other itchy skin conditions. Skin artefacts in subjects with psychiatric disorders, without any venal intent, are described as “pathomimic”; instead, artefact skin disorders caused with illicit intent, aiming to gain various advantages, are true simulations (“malingering”). In both cases, affected subjects deny or deliberately hide their anomalous behaviour. Apart from these cases, there is also a group of body-focused repetitive behavioural disorders (“impulsive-compulsive disorders”) that are inflicted by aware subjects who, in most cases, are very ready to confess their urge to induce self-inflicted lesions. Generally, the lesions are localized on easily accessible areas (face, back of the hands, forearms). Except in situations where the patient wishes to perpetuate or mimic a known dermatosis, the lesions do not show the characteristics of known dermatological afflictions. In all cases of primary self-inflicted skin afflictions, the various laboratory tests are within normal limits; instrumental diagnostic investigations also yield negative results. All these patients need both psychiatric and dermatological treatments.