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Self-inflicted Dermatoses
Table 1: Differential Diagnoses of Main Self-inflicted sometimes producing a trichobezoar, a compaction of hairs in the
Skin Lesions in Infancy
gastrointestinal tract that is potentially life-threatening.
10
Trichobezoars can increase in size due to the aggregation of non-
Differential Diagnosis
absorbable food. Symptoms include pain, nausea, bilious vomiting,
Neurotic Excoriations
haematemesis, weight loss and abdominal mass. Some patients eat
Dermatitis herpetiformis
or suck just the roots of hairs. Clinically, trichotillomania presents
Arthropod infestation (scabies, bedbugs)
with an unusual pattern of hair loss and the presence of hairs of
Folliculitis (bacterial, fungal)
multiple lengths, and involves the scalp, eyelashes, eyebrows and
Organic cause of generalised pruritis (HIV,
renal disease, lymphoma)
pubic hair. The treatment of trichotillomania is often frustrating.
Atopic dermatitis
Psychological counselling, hypnotherapy and habit reversal
Dermatitis Artefacta
treatment have been shown to have some usefulness.
11
With regard
Autoimmune bullous disease (pemphigus,
to pharmacological intervention, fluoxetine,
12
olanzepine
13
and
pemphigoid, etc.)
paroxetine
14
have demonstrated favourable clinical responses
Pyoderma gangrenosum in adult patients.
Vasculitis
Connective tissue disease
Neurotic Excoriations
Folliculitis (bacterial, fungal)
Neurotic excoriations clinically consist of papules with erosions and
Granulomatous infection (mycobacterial, deep fungal)
crusts as result of a compulsive need to scratch and pick the skin
Trichotillomania
(see Figure 3). As result of an obsessive–compulsive disorder, the
Tinea capitis
patient produces these lesion unconsciously. In the variant named
Alopecia areata
acne excoriee, patients manipulate real or perceived acneic lesions. A
Folliculitis decalvans
peculiarity of this variant is that patients usually are not affected by
specific psychopathology and are often aware of their compulsion to
Figure 1: Trichotillomania in a Six-year-old Patient
manipulate the skin. Lesion tends to heal as scars or show
post-inflammatory hyper/hypopigmentation. The treatment of
neurotic excoriations usually consists of both pharmacological and
behavioural intervention.
15
Dermatitis Artefacta
Dermatitis artefacta must be distinguished from the other factitial
dermatoses, as the patients manipulate and damage their skin
consciously but deny this behaviour. Moreover, patients deny pain
or discomfort in relation to these lesions. This condition, which is
more common among females, usually underlines psychological
dysfunctions such as anorexia or body dysmorphic disorder.
The lesions are localised in easily accessible areas and show a
peculiar morphology, consisting of erosions, ulcerations or burns.
No primary lesions are observable, since the final morphology
Figure 2: Trichotillomania in a Seven-year-old Patient
appears fully formed.
The history of the appearance of the lesions is defined as a ‘hollow
history’. Patients with medical exposure or medical knowledge are
more prone to developing this kind of behaviour, in particular those
with chronic diseases due to a heavy stress burden. Injuries can be
produced using different methods.
Physical injuries can be produced with a great variety of instruments,
limited only by the imagination of the patients; lesions caused by
sand-paper, screwdrivers, nail brushes, the sharp point of
geometrical compasses and pumice stones have been described.
16
Lesions can also be self-inflicted using chemicals and, in this case,
consist of irritant dermatitis or burns. An example of this is the
application of battery acid, causing a deep eschar. A psychological
approach is necessary, but should be complemented with drugs such
evaluation of a hair-pulling habit. Sometimes, instead of pulling on as antidepressants or antipsychotics. The application of pigment in
their hair, some patients may use tools such as scissors or razors to order to resemble erythema or other skin disease has also been
cut or shave it. This condition is named trichotemnomania.
9
Hairs described, usually with a head and neck localisation.
removed can be then used to express further psychiatric disability.
They can be eaten or hidden so as not to draw the attention of A classic example of thermal damage is the cigarette burn, but a great
relatives. Thrichophagia is the habit of eating the removed hairs, thus variety of thermal methods have been described, including the use of
30 EUROPEAN DERMATOLOGY
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