Autoaggressive dermatoses in the practice of a dermatovenereologist

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RELEVANCE

Pathomimia is a group of artificial skin injuries caused by patients with the aim of emotional discharge and weakening of painful sensations. As a rule, to exaggerate any existing symptom of dermatosis or to mimic a known skin disease. According to statistical data, self-harm of varying severity is observed in 5-30% of people [1, 2].

The frequency of occurrence of neurotic excoriations in the population, according to different authors, varies from 3.8% to 22%, at a dermatological appointment it is about 2% of all skin diseases. Women aged 20-30 and 40-50 years old are most often affected. Self-harm is applied in the evening and at night, after situations of psycho-emotional stress. After self-destruction, the level of anxiety and internal tension decreases, and a feeling of satisfaction appears for a short time. Patients injure the skin with their nails, tear off the already formed crusts, often use sharp objects, irritating chemicals (acids, alkalis, vinegar essence, celandine solution). A distinctive feature of self-harm is their linear nature and localization in accessible, and most importantly “convenient” places for the patient [3, 4].

The first mention of the relationship between the skin process and mental disorders dates back to the second half of the 18th century in the works of W. Falconer (1788) and until the end of the 19th century was of an empirical nature. In the XX century, psychosomatic pathology is already being studied on the basis of experimental studies. Alexander in his monograph "Psychosomatic Medicine" (1950) emphasized that the skin has the property of a specific organ predisposition to respond to stress, which includes not only a local focus, but also the patient's holistic mind. In Russia, many scientists of the 20th century considered many diseases, including skin diseases, from the point of view of I.M. Sechenov’s theory of nervism and  psychophysiological doctrine of I.P. Pavlov. The active use of psychocorrective methods, including medications, is a clear confirmation of this [5-7].

The skin is a unique organ that combines, in addition to barrier functions, many others, including, due to its anatomy and physiology, it is one of the sense organs and perceives all types of irritations. The innervation of the skin is carried out through the interaction of the central and autonomic nervous systems. The main nerve plexus is located in the deep parts of the hypodermis, branches extending from it form a superficial plexus at the level of the papillary dermis, innervating all layers of the skin and its appendages (sebaceous and sweat glands, hair follicles). Terminal free nerve endings reach the granular layer of the epidermis, exercising pain sensitivity, itching and burning sensations. In addition to free nerve endings, the skin contains encapsulated formations responsible for touch (Meissner bodies) or a certain type of irritation: cold and heat (Krause flasks and Ruffini bodies), pressure and vibration (Vater-Pacini bodies) [7-11].

Through the skin, the nervous system interacts with the environment, and this connection is not one-way. Mental status and emotional background have a significant impact on the condition of the skin and its appendages, regardless of the etiology of dermatosis. In turn, various skin pathologies, especially those that cause discomfort (itching, soreness) or affect the socialization of a person (with localization in open areas of the body, genitals, etc.), leave their mark on the patient's psycho-emotional state. Sometimes the severity of the skin process does not correspond to the strength of the experience. Breaking this "vicious circle" is possible only with the joint work of a dermatologist and a psychotherapist.

Artifical dermatoses can be provoked by auto-aggressive behavior, which is considered in psychiatry as one of the means of getting rid of internal tension and anxiety. Among self-harm, there are: 1) skin diseases or complaints about those that occur against the background of primary mental disorders (artificial dermatitis, neurotic excoriations, excoriated acne, dermatozoic delusions, hypochondria, including limited, obsessive-compulsive disorders with self-damage of the skin, trichotillomania, onycho- and cheilophagy, etc.); 2) skin diseases, the predictors of the development and / or exacerbation of which are psycho-emotional factors or accompanied by mental reactions to the aesthetic defect of the disease, painful itching, etc.; 3) uncontrolled psychophysiological reactions (tidal erythema, hyperhidrosis, etc.) [5, 12, 13].

Often, autoaggressive dermatoses imitate real skin diseases (hemorrhagic vasculitis, pemphigus, ulcerative pyoderma, lupus erythematosus, etc.), due to which they remain unrecognized for a long time. According to the analysis of the five-year visits to the I.M. Sechenov MMA Clinic for Skin Diseases, the prevalence of pathomimy was 2.3% of the total number of applied patients [12].

In the analysis of such clinical cases, the following draws attention:

- complaints of pain or itching at the site of the rash,
- linear, correct location of skin lesions in accessible areas of the body,
- the uniformity of damage and their spontaneous occurrence,
- low efficiency of dermatological treatment,
- the patient's inability to explain in what situation the damage occurred, a negative emotional reaction to the assumption of a psychogenic cause of the disease.

Therapy of such “difficult” patients is always accompanied by difficulties and diagnostic errors, because in the presence of persistent criticism of their condition, patients are embarrassed to seek psychiatric help, and in the absence of it, they do not consider themselves ill and do not see the need for such [14]. With a long absence of treatment, pathomimia takes a complicated course (the formation of purulent and cicatricial complications, persistent changes in the nails, the development of alopecia, etc., up to suicidal attempts).

DESCRIPTION OF CLINICAL CASES
Patient S., 34 years old. I went for a consultation about scars on the skin, which I would like to get rid of. For 3 years, he notes the appearance of ulcers on the skin, and draws attention to their “sudden occurrence”, does not connect them with anything. She did not go to the doctor about this before, she independently lubricated the elements with a solution of brilliant green, hydrogen peroxide, ointments containing antibiotics (Levomekol, tetracycline ointment). Allergy anamnesis is calm, heredity is not burdened, chronic diseases are denied. Married for 5 years, husband is healthy. Gynecological history: menstruation since the age of 13, regular, no pregnancies, undergoing examination in order to prepare for IVF. Emotionally labile. Answers questions about the cause of the disease evasively. In addition, during the survey, she noted weakness and sleep disturbance.

On examination: the pathological skin process is represented by numerous abrasions, round-oval ulcers up to 2 cm in diameter with hemorrhagic and purulent-hemorrhagic crusts on the surface, multiple atrophic scars and single hyperpigmented spots at the sites of resolved elements. Rashes are located on the skin of the face, chest, upper back, outer surface of the shoulders, front of the thighs. The intactness of the surrounding skin is noteworthy (Fig. 1-3).

On the assumption of the self-destructive nature of the damage, a negative emotional reaction was noted on the part of the patient.
Presumptive diagnosis: artificial (artificial) dermatitis (neurotic excoriations), L98.1?
The patient was prescribed vitamin therapy, externally - Oflomelide ointment. Consultation with a psychotherapist is recommended.

When re-examined after 14 days, the healing of old and the appearance of several fresh excoriations was noted. During the conversation, the patient admitted that she causes skin damage on her own and unconsciously against the background of constant emotional stress (conflicts with her husband due to her "infertility"). A consultation with a psychotherapist was again recommended to prescribe the appropriate treatment, dermatological therapy was continued to heal the existing elements, the patient was explained that the aesthetic correction of cicatricial changes is not possible until the appearance of fresh rashes completely stops.

Patient N., 46 years old. Entered the venereology department with a diagnosis of Latent syphilis (MP 4+, ELISA sums. 4+). Satisfactory condition, clear consciousness, emotionally labile. Abuses alcohol.
When examining the patient, specific rashes on the skin and mucous membranes were not revealed, but atrophic scars on the skin of the face, located symmetrically mainly in the cheek area, surrounded by telangiectasias, attracted attention (Fig. 4-5).

The patient explains the occurrence of these scars by self-treatment from "subcutaneous mites". About 3 years ago, reddish rashes periodically began to appear on the skin of the face, itching of the skin of the face appeared. He did not seek medical help. After reviewing the Internet data (mainly blogs and advice using "folk" remedies), the patient diagnosed himself with demodicosis, deciding to get rid of the parasites with the help of cauterizing agents. Taking the advice with "cauterization" literally, he used smoldering cigarettes as a treatment, leaving burns in the places of rashes. According to the patient, the "treatment" was a success.

Patient I., 32 years old. He turned to a dermatologist with complaints of recurrent warts that occur spontaneously in various parts of the body and are not amenable to any treatment. As evidence, the patient provided "wart roots", which he extracts on his own after removing the "wart" with a solution of super celandine (Fig. 6-7). During the conversation, the patient is sociable, sociable, was in high spirits, proudly showed damage to the skin and a container with “wart roots” removed from the skin.

On examination: rashes are localized exclusively on the anterior-lateral surfaces of the upper extremities. They are represented by deep ulcers up to 2 cm in diameter (demonstratively, the patient could immerse the entire distal phalanx of the index finger into the defect). Ulcers have a rounded shape, surrounded by an infiltration roller, the bottom is covered with granulation tissue, scanty serous-hemorrhagic discharge, some are covered with crusts. In addition to ulcers, many scars (from atrophic to hypertrophic) are found on the skin.

The patient was prescribed symptomatic dermatological treatment (local antibacterial and wound-healing drugs: Oflomelid ointment), as well as consultations with a neurologist and a psychotherapist regarding the diagnosis: neurotic excoriations (dermatozoic delirium?).

DISCUSSION
In all three described clinical cases, certain patterns are revealed that indicate the self-destructive nature of dermatosis: localization on easily accessible areas of the skin, uniformity of lesions, spontaneous and unreasonable appearance of new rashes (appearance of secondary elements in the absence of primary ones), reduced criticism of one's condition. In addition, all patients had characteristic personality traits: emotional lability, instability, anxiety, impulsiveness, and sometimes demonstrative behavior.

Dermatological treatment in all cases is symptomatic, and the cause of the disease must be looked for much deeper. For a complete diagnosis in such situations, an integrated approach should be used, including a histological examination of the skin in lesions, ultrasound to determine the depth of damage, as well as a psychological conversation using a questionnaire to obtain a complete picture of the influence of psychological factors on the process of autodestruction.

CONCLUSION
Injuries that the patient inflicts on himself are often a way of psycho-emotional discharge, switching his attention from an internal conflict to experiencing physical pain. The state of panic that precedes self-harm is replaced by a sense of satisfaction.
In such cases, dermatological treatment can only be secondary and symptomatic, while the primary role should be given to psychological correction in order for the patient to realize his involvement in the skin lesion and understand his responsibility in its occurrence. The ultimate goal of psychotherapy is to return the patient to balance and harmony, love for himself.
A patient with auto-aggressive behavior can meet at the reception of any specialist. With the provision of timely and competent assistance, the prognosis for the treatment of pathomimia remains favorable.

About the authors

Vera V. Ryabova

Kirov State Medical University

Email: ryabova.vv@gmail.com
ORCID iD: 0000-0002-6594-6652
SPIN-code: 5573-6747

MD, Cand. Sci. (Med.), PhD, assistant of the Department of Dermatovenereology and Cosmetology

Russian Federation, K. Marx str., bldg 112, 610027, Kirov

Anna L. Evseeva

Kirov State Medical University

Email: jls0105@icloud.com
ORCID iD: 0000-0001-6680-283X
SPIN-code: 2409-6034

Senior Lecturer, Department of Dermatovenereology and Cosmetology

Russian Federation, K. Marx str., bldg 112, 610027, Kirov

Sergei V. Koshkin

Kirov State Medical University; Kirov Regional Dermatology Hospital

Author for correspondence.
Email: koshkin_sergey@mail.ru
ORCID iD: 0000-0002-6220-8304
SPIN-code: 6321-0197

MD, Dr. Sci. (Med.), Professor, MD, Associate Professor, Head of the Department of Dermatovenereology and Cosmetology

Russian Federation, K. Marx str., bldg 112, 610027, Kirov; Semashko str., bldg 2a, 610000, Kirov

References

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