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Self-inflicted Dermatoses
Self-inflicted Skin Lesions in Infancy
Anna Belloni Fortina
1
and Edoardo Zattra
2
1. Head and Senior Consultant; 2. PhD Student, Dermatology Unit, Department of Paediatrics, Medical School, University of Padua
Abstract
Self-inflicted skin lesions, also called factitial dermatoses, constitute both a diagnostic and a therapeutic challenge. Making the right
diagnosis requires both experience and skill. Establishing a satisfactory relationship with the parents of a patient can play a pivotal role in
achieving successful management of the problem. This article aims to review briefly the available literature on the subject. Pictures of a
few striking cases from our own experience are provided.
Keywords
Self-inflicted, skin lesions, factitial dermatoses
Disclosure: The authors have no conflicts of interest to declare.
Received: 2 March 2009 Accepted: 19 March 2009
belloni@pediatria.unipd.it
Factitial dermatoses are a dermatological expression of a factitious manipulation, for either healing or ritualistic purposes, is a potential
disorder, a formal Diagnostic and Statistical Manual of Mental Disorders confounder (see Table 1).
5
For example, the practice of coin rubbing
IV (DSM-IV) mental health diagnosis.
1
These lesions consists of self- with essential oil, common among the population in Vietnam, can
inflicted lesions produced by the patient to satisfy a psychological easily be misdiagnosed as child abuse or factitial dermatoses.
need of which he or she is not completely aware.
2,3
Self-inflicted
lesions in childhood are an under-recognised phenomenon. The Trichotillomania
incidence of such lesions has been estimated to be one per 23,000,
4
The term ‘trichotillomania’ is of Greek origin, resulting from the
with a peak of greater frequency in adolescence and females being combination of the words ‘trich’ (hairs), ‘tillo’ (pull) and mania, and
affected five to seven times more often than males. was coined by Hallopeau in 1889.
6
Trichotillomania is a poorly
understood disorder characterised by repetitive hair pulling that leads
Diagnosing self-inflicted skin lesions requires experience and skill, to noticeable hair loss, distress and social or functional impairment. It
since cutaneous fabricated lesions are extraordinarily varied and can most frequently affects the scalp, but can involve any other site of the
be peculiar and bizarre in shape and in physical distribution. These body, notably eyelashes, eyebrows, pubic hair, body hair and facial
lesions are usually linear or geometric, and the evolution is not hair. Clincally, it consists of hair loss with geometric patterns and the
gradual but unexpected at the onset, often during the night, and co-existence of hairs of different lengths (see Figures 1 and 2).
appear mainly on skin areas accessible to the hands. The diagnosis
of factitial skin disease remains a diagnosis of exclusion. Main This condition is more prevalent among females and the mean age of
factitial dermatoses in children are trichotillomania, neurotic onset is 10 years. One to four per cent of the general population is
excorations, acne excoriee and dermatitis artefacta. Less common estimated to be affected by clinically relevant hair pulling.
7
The
self-inflicted lesions are factitial porpora and bleeding, factitial underlying psychological disorder could be a lack of impulse control
onychodystrophy, factitial panniculitis and factitial cheilitis. driven by the need to reduce underlying tension by performing a
specific action.
Factitial dermatoses must be differentiated from numerous skin
conditions. Neurotic excoriations can resemble dermatitis Trichotillomania is considered differently at different ages. In infants,
herpetiformis, arthropod infestation such as scabies or bedbugs, this behaviour usually represents a self-limited habit response
folliculitis (both bacterial and fungal), organic causes of generalised without an underlying psychological component, and often manifests
pruritis and atopic dermatitis.
4
Dermatitis artefacta must be as thumb-sucking. In children, it is usually associated with stress, but
differentiated from autoimmune bullous disease such as pemphigus co-morbid psychiatric disease is not common. Older children and
vulgaris, bullous pemphigoid, chronic bullous disease of childhood, adolescents affected by trichotillomania are usually affected by
pyoderma gangrenosum, vasculitis, various connective tissue obsessive–compulsive disorder and can also show other
disease, folliculitis (bacterial, fungal) and granulomatous infection compulsions such as nail-picking and skin-picking. In some cases,
(mycobacterial, deep fungal). Trichotillomania can be misdiagnosed trichotillomania could be a sign of child abuse.
8
Such an eventuality
as tinea capitis alopecia areata or folliculitis decalvans. Ethnic skin highlights the necessity of appropriate screening during the
© TOUCH BRIEFINGS 2009 29
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