Self-Inflicted Lesions in Dermatology: A Management and Therapeutic Approach – A Position Paper From the European Society for Derma­tology and Psychiatry

Abstract

The classification of self-inflicted skin lesions proposed by the European Society for Dermatology and Psychiatry (ESDaP) group generated questions with regard to specific treatments that could be recommended for such cases. The therapeutic guidelines in the current paper integrate new psychotherapies and psychotropic drugs without forgetting the most important relational characteristics required for dealing with people with these disorders. The management of self-inflicted skin lesions necessitates empathy and a doctor-patient relationship based on trust and confidence. Cognitive behavioural therapy and/or psychodynamic and psychoanalytic psychotherapy (alone, or combined with the careful use of psychotropic drugs) seem to achieve the best results in the most difficult cases. Relatively new therapeutic techniques, such as habit reversal and mentalization-based psychotherapy, may be beneficial in the treatment of skin picking syndromes.

Factitious disorders in children: clinical and therapeutic considerations

“…Most pediatric patients who inflict self-harm reveal quite a frequent history of stressful life events. They were frequently mentally or sexually abused or neglected in childhood [19,30]. There are several case reports of self-inflicted skin lesions after serious bullying at school [28].…”

“…The treatment strategies for patients with FD in general have been only based on single studies, with more recent emphasis given in the last few years. More recently, the ESDaP [30] published a position paper to compile the knowledge available on self-inflicted skin disorders and proposed a therapeutic approach and management guideline. However, there are few studies on FD specifically in children addressing the subtleties of their management.…”

“…In children, the prognosis of FD seems to be better and they may be easier to manage and have a better response to treatment [42,30]. However, further studies are required to determine the differences between the adults and children regarding proper approach and suitable strategies.…”

“…The ideal scenario would be that the patient was first observed in a multidisciplinary team [24,40,45], such as in a psychodermatology unit, but if this does not happen, it is important to point out that it is not recommended to automatically refer the patient to a psychiatrist or a psychologist in the first visit. For example, if the first doctor who sees the patient is a dermatologist, that will make the patient feel his doctor does not believe he has a «true» skin disease and, instead, that the patient is responsible for the skin lesions [30] and, as a consequence, the patient will not accept to be seen by a psychiatrist or a psychologist and will not follow up with the same dermatologist [24,43]. Some authors have reported that this may worsen psychopathology connected with the FD, worsening the denied self-inflicted behavior [29].…”

“…FD are considered an expression of a psychological stress and a way of calling for help [30,45]. All the patients with FD have psychiatric comorbidities [24].…”