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The skin is an organ that plays a special role in one’s relational life; it is visible, may be touched and is easily accessible. It is particularly associated with one’s emotional, socio-affective and psychological life. Commonplace emotional difficulties may be expressed through the skin such as when one blushes in public for example, but it may also be used to express more rare and serious psychological troubles, as in cases of self-mutilation.
The skin, therefore, is easily accessible and may be embellished, made to look younger, made up, or adorned. It may also be tattooed, pierced, or attacked. The attacks of individuals on their skin may be more or less serious both from a dermatological viewpoint (i.e. small, picked-at pimples versus deep mutilating sores) and from a psychological perspective (i.e. the desire to make an unsightly pimple disappear as soon as possible as opposed to uncontrollable behaviours that express a profound disquiet).
Dermatitis artefacta is part of this context: the patient feels compelled to produce lesions on his/her skin and to seek the help of various healthcare providers without admitting to them that the lesions are self-inflicted.
This type of behaviour is a sign of immense psychological suffering. The lives of patients are often marked by separation, rejection, mourning and patients may sometimes also suffer from a depressive disorder.
The treatment strategy must therefore comprise two facets, a dermatological one with a dermatologist capable of understanding the patient’s psychological suffering irrespective of how it is expressed, and a psychiatric one with a psychiatrist who is also a psychotherapist.
The psychological aspects of the disorder are treated primarily by psychotherapy. The psychological support provided by the dermatologist, the healthcare team, by social workers and sometimes by the family, is fundamental. Regular, more in-depth psychotherapeutic meetings with therapists trained in psychoanalysis, psychiatry or psychology are also indispensable.
Patients may sometimes also require treatment with chemical antidepressants when suffering from a depressive disorder.
Treating patients with factitious cutaneous disorders is often a long, difficult and hazardous process. Treatment can only be instituted and continued if the patient-healthcare provider relationship is trusting. It is well known that prognosis for the condition is better when the psychological treatment is implemented rapidly and when it is well coordinated with the dermatological treatment.
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