INTRODUCTION

MATERIALS AND METHODS

This descriptive case study was conducted at the Dermatology Outpatient Clinic of Baghdad Teaching Hospital in Baghdad, Iraq, from 2014 to 2021. A consultant dermatologist-the first author-oversaw all patients with SISLs who visited the clinic. Fifteen patients who met the diagnostic criteria of compulsive skin biting were enrolled in the study, and one extra male patient from the Psychiatric Outpatient Clinic presented with serious DSH, totaling sixteen patients. After completing their dermatological examinations and checking medical records, a consultant psychiatrist subjected the patients to a semi-structured DSM-5 interview [11]. The included patients consented in writing to participate in the study and had their skin lesions photographed without revealing their identities. They received a full explanation of the study’s goal and were assured confidentiality and the freedom to approve or disapprove their pictures. Formal approval was obtained from the research committee attached to the Iraqi Council of Medical Specialization. A complete physical examination further confirmed the dermatological findings. Patients with skin pathologies related to medical diseases were excluded. Psychiatric assessments were carefully conducted to exclude psychotic disorders, primarily schizophrenia, and organic causes, such as acute brain syndrome, substance abuse, autism spectrum disorder, and intellectual disability (autophagia). A significant number of patients refrained from psychiatric referrals and denied having psychiatric issues. The assigned psychiatrist-the second author-visited the dermatological setting to encourage a positive attitude toward treatment. Two registrars assisted both authors-the consultant dermatologist and consultant psychiatrist-in the multidisciplinary team at the dermatology clinic.

RESULTS

Fifteen patients with a median age of twenty years, ranging from 14 to 45 years, were diagnosed with dermatophagia by the consultant dermatologist and psychiatrist-the authors. Nine males and six females visited the dermatology outpatient clinic seeking treatment for skin lesions caused by self-picking and biting of their hands. Most of them visited the clinic concerned about their cosmetic appearance. All patients accepted responsibility for their illness. Seven patients (46.66%) presented with excessive nail-biting, consisting of five (71.4%) patients with linear nail dystrophy due to proximal nail fold biting (Fig. 1). Two (28.57%) patients harshly bit the distal part of all nail plates, causing whole nail deformities (Fig. 2a). Six patients (40%) presented with dome-shaped, pigmented nodules on the dorsal sides of both the hands, a single nodule in one patient and multiple in five patients (Fig. 2b). The other two patients (13.33%) had hyperkeratotic pigmented plaques affecting the dorsum of the hand in one patient (Fig. 2c) and scaly, dermatitis-like lesions affected the fingers in the second patient (Fig. 2d). Psychiatric assessments revealed that none of the patients had brain lesions, neurodevelopmental disorders, or intellectual disabilities. Psychotic or bipolar disorder features were absent and none of them had a history of substance abuse. Therefore, we examined the patient with DSH for comparison purposes. The patient with DSH who attended the psychiatric outpatient clinic for treatment was selected. His chief complaint was repeated, self-inflicted cutting with a sharp razor. He described his action as „killing the inner pain” and expressed the feeling of immediate relief after seeing his blood. He denied suicidal intents or attempts. An examination revealed large, surgical scars on both arms and other superficial skin lacerations. A detailed psychiatric assessment revealed symptoms of depression with characteristics of borderline personality disorder; there was no history of alcohol or substance abuse. He presented with a classical form of DSH with dangerous wounds and superficial laceration (Fig. 3).

	Figure 1: Linear nail dystrophy.
	Figure 2: (a) Complete nail dystrophy following nail destruction. (b) Multiple skin nodules. (c):Hyperkeratotic pigmented plaques affecting the dorsum of the hand.(d) Scaly hyperkeratosis.
	Figure 3: Deep wounds and lacerations (DSH).

DISCUSSION

Self-inflicted skin lesions in their variable clinical presentations are usually encountered by physicians, general practitioners, and dermatologists, who are aware that many people with such problems do not seek medical treatment. A number of studies have classified skin biting disorders as a form of OCD, while others have included them in the domain of DSH or disorders of impulse control. However, this classification is still debated, owing to variations and sometimes contradictory findings and psychopathology [12]. Skin biting, such as dermatophagia, gnawing, or eating skin debris, is an internationally underreported SISL. There are no available data from Iraq, apart from a case study by Sharquie et al. and a single case report [13,14]. Inconsistent with numerous psychocutaneous disorders such as dermatitis artefacta and trichotillomania, all fifteen patients in the present study with dermatophagia did not deny their role in the occurrence and exacerbation of their lesions, contrary to what has been reported in other studies [8,10,12–14]. In addition, some patients reported local infections preceding the skin lesions, while others showed calluses caused by chronic friction and accumulation of keratinocytes [15,16]. Patient 16 was a typical example of a severe and dangerous presentation of DSH. Simple forms of DSH mimicking SISL, such as superficial lacerations or burns, may be managed in a dermatology clinic; otherwise, it will be ignored and remain undetected. Therefore, a tactful empathetic approach is important for successful dermatological and psychiatric management [17]. Dermatophagia may occur in people with organic brain pathologies, such as Alzheimer;s disease, autism spectrum disorder, and intellectual disability [18]. Occasionally, intermittent dermatophagia may be associated with dissociation, parasuicide, and post-traumatic stress disorders [8,9]. In the same context, mental disorders may precipitate or exacerbate existing dermatological problems, and psychotropic medications may cause allergic dermatitis [8–10,19]. In the same context, psychiatric disorders may precipitate or exacerbate an existing dermatological problem, and psychotropic medications may cause allergic dermatitis [12]. On the other hand, most patients suffering from episodic forms of OCD do not fulfill the diagnostic criteria of classical OCD according to the DSM-5. They are more likely to be categorized between psychopathies (dermatitis artefacta) and DSH [19,20].

The treatment of patients with DSH includes symptomatic therapy, such as topical steroids for patients with skin-biting rash, and other supportive management. Psychiatric management begins with psychoeducation and rapport building, which play a significant role in drug compliance and follow-up. In our study, a typical antidepressant medication-selective serotonin reuptake inhibitors (SSRI)-was administered to patients who presented with symptoms of OCD, anxiety, and underlying depression, together with cognitive behavioral therapy in scheduled sessions run by the clinical psychologist during the follow-up process. Unfortunately, most patients were not ready to provide a detailed history of lesion onset and causative factors. However, the team administering treatment found that inner tension, bouts of anxiety, and depressive symptoms either predisposed individuals to or resulted from compulsive skin biting, which is similar to the results reported in developed countries, despite cultural differences[8,19,20]. This study calls for further, large-scale research on psychocutaneous diseases in Iraq to bridge the data gap and help engineer a specialized unit for better medical care.

CONCLUSION

Self-inflected skin lesions are emerging psychocutaneous disorders that are mostly treated by dermatologists without a psychiatric referral and many patients refrain from medical consultation. Fifteen patients with dermatophagia presented with diverse cutaneous manifestations, mostly nail dystrophy, skin nodules, and dermatitis-like features, limited to the hands. All patients were diagnosed and treated by the dermatologist and psychiatrist. All patients revealed symptoms of OCD with underlying anxiety and depression. Establishing a rapport and liaison management may help patients overcome psychiatric and skin problems and achieve healing. The lack of data mandates extensive future studies in Iraq and other countries.

REFERENCES

Notes