INTRODUCTION
Artefactual skin disorder (ASD), formerly known as dermatitis artefacta (DA), is a psychodermatological disorder defined by self-inflicted skin lesions that the patient denies producing. This condition is uncommon, and particularly challenging to diagnose and manage. Positioned at the intersection of two distinct medical specialties, dermatology and psychiatry, this condition is further complicated by patients frequently denying their involvement in the development of skin lesions.
If the self-inflicted dermal injuries cause considerable distress and result in excessive thoughts or behaviors related to health concerns, they may overlap with somatic symptom disorder (SSD) criteria [1]. In the past, DA had been interchangeably used with factitious dermatitis or dermatitis factitia but the 2013 position paper from the European Society for Dermatology and Psychiatry (ESDaP) suggested using “factitious disorders in dermatology” for all those conditions [2]. The International Classification of Diseases (ICD) from the World Health Organization (WHO) issued the 2019 version ICD-10 which categorized dermatitis artefacta under code L98.1 “factitial dermatitis” together with neurotic excoriation and factitious disorders of dermatology [3, 4]. However, the January 2025 revised version of ICD-11 for Mortality and Morbidity Statistics from WHO classifies dermatitis artefacta under the code ED00 with the new name “artefactual skin disorder”, which is defined as self-inflicted skin injuries caused by mechanical trauma or chemical agents [5]. Factitious disorders are now recognized as a separate category [6].
EPIDEMIOLOGY AND ETIOLOGY
The prevalence of ASD is about 0.3% among dermatology patients with the highest frequency during adolescence and young adulthood [7], however there are studies which report that it represents approximately one-third of psychiatric patients who visit dermatological clinics each year [8]. Other research studies suggest that the percentage incidence of ASD among psychodermatology patients could be almost 7% [9], so it begs the question if this condition is underdiagnosed and these discrepancies could be primarily due to diagnostic difficulties (e.g. individuals with extreme dissociation may not recognize that their lesions are self-inflicted).
This disorder is more commonly observed in women, with a male-to-female ratio of at least 1 : 4 [10], particularly among individuals from lower socioeconomic background [11]. Case reports have also indicated that ASD may be influenced by occupation [12], cutaneous IgG4-related disease [13], and social isolation during the COVID-19 pandemic [14].
Although the specific origin is uncertain, ASD is associated with psychosocial stress and underlying mental diseases. Approximately 46.2% of patients with ASD have comorbid psychiatric conditions [15], among which the literature indicates a prevalence rate of 33% in patients diagnosed with anorexia and bulimia, or personality disorders – here including especially a strong association with borderline personality disorder (BPD) [16]. It is also associated with post-traumatic stress disorder (PTSD) [17], alcohol dependency and drug abuse [18], depression, anxiety, dissociative disorders [19], psychosis [20] or Munchausen’s syndrome [20]. Many patients report major life stressors that can trigger or exacerbate their condition, contributing to chronicity [15]. Consequently, such patients are often mislabeled as malingerers [20], with the assumption that they create lesions to satisfy psychological needs, most often a desire for medical attention [7, 21]. In fact, most individuals with ASD report experiencing stressful circumstances such as toxic relationships, emotional distress related to bereavement, family divorce, or histories of sexual, physical, or emotional abuse [22].
PATHOPHYSIOLOGY AND PSYCHOPATHOLOGY
The underlying pathology and mechanisms of action in ASD remain unclear as the processes involved are complex and on a case-by-case basis [23]. To date, serotonin pathway involvement in self-injurious behavior remains a consistently recognized neurobiological finding, which is why selective serotonin reuptake inhibitors (SSRIs) are often considered effective in its treatment [24]. However, this is undoubtedly an area that requires further research as such efforts could significantly enhance our understanding of the behaviors exhibited by these patients. Also, an interesting clue may lie in the condition’s pathophysiology as patients often use their lesions as a means of communication to seek attention that addresses their unmet emotional needs [11]. Currently, there is no clear consensus regarding the personality type associated with artefactual skin disorder. Nevertheless, it is often assumed that patients with ASD tend to exhibit features of borderline personality disorder, even though the association is mostly related to the impulse control disorder and obsessive compulsive disorder (OCD) [11]. One of studies indicates that the most common personality type associated with ASD in men is paranoid, whereas in women it is hysterical [25].
CLINICAL MANIFESTATIONS AND DIAGNOSIS
The clinical presentation of ASD varies depending on the type of manipulation employed as artificially induced symptoms can, in principle, mimic any skin condition. The lesions often present with atypical characteristics, mainly in the approachable body parts (most commonly the face and the dorsum of the hand [26]). However, we should remember that patients are frequently unable to provide specific details regarding their onset or duration and that is why the patient’s medical history often contains notable omissions or unexplained gaps. The harmful behavior typically occurs in secret, often during a dissociative state accompanied by amnesia, leaving the patient unable to recall their actions or comprehend the emotional state that triggered them [27].
Patients who are suffering from ASD frequently inject themselves to cause lesions, and they may exhibit erythema, swelling, tissue necrosis, fever, and sepsis as a result of injecting a variety of substances intracutaneously [28]. Some of the materials that have been reported include glass, air, gasoline, talc, turpentine, blood, bacteria, feces, saliva, and milk, highlighting the extreme nature of self-harm [28–30]. Then, conducting a thorough physical examination is clearly crucial as it may reveal the presence of a foreign object as the underlying cause. In turn, laboratory tests, including histopathological analysis, are usually nonspecific and do not provide a correct clue to diagnosis [26]. Unlike many other skin disorders, the diagnosis of ASD relies on a process of exclusion.
DETAILED DESCRIPTION OF SKIN LESIONS IN ARTEFACTUAL SKIN DISORDER
Lesions in ASD can appear bizarre, often with sharp geometric borders surrounded by normalappearing skin [20]. Some cases involve extensive scarring or necrotizing lesions, as seen especially in patients misdiagnosed with other conditions [31]. ASD has been observed to closely resemble various dermatological conditions, including pyoderma gangrenosum, intertriginous and flexural erythema or baboon syndrome, and recurrent deep forehead ulcers resembling rare cancers [28, 32–34].
As a result, patients with ASD may exhibit various types of scars, including keloid scars, hypertrophic scars, and contracture scars resulting from self-inflicted burns, which reflect the end stage of a spectrum of self-induced skin lesions [28, 35]. Chandran and Kurien list the types of lesions seen in ASD as follows [36]: abrasions or erosions, alopecia, crusted lesions, discolored macules, erythematous papules, excoriations, nail deformity, petechiae or purpura, scars in chronic cases, ulcerations, and this seems to include the most common ones. Full-thickness skin loss, extensive self-inflicted lesions, and severe scarring can necessitate major medical interventions, such as reconstructive plastic surgery or even amputations, affecting up to 10% of patients [20].
DIFFERENTIAL DIAGNOSIS
Misdiagnosis is unfortunately rather common, highlighting the importance of meticulous and careful evaluation [31]. According to Chandran and Kurien as well as the new WHO classification, the differential diagnosis for ASD should include several conditions that must be considered and ruled out. These include [6, 36]: alopecia areata, anagen effluvium, bedbug bites, delusions of parasitosis, friction blisters, impetigo, insect bites, irritant contact dermatitis, onycholysis, telogen effluvium, factitious disorders.
Other sources report that ASD should be also distinguished from neurotic excoriation [37], in which patients are usually aware of their actions but still feel unable to control them. In some cases, the skin lesions can be severe enough to resemble serious conditions like T-cell lymphoma, hemophilia, or porphyria cutanea tarda [36].
PSYCHOLOGICAL MOTIVATIONS OF PATIENTS FOR SKIN SELF-INJURY
The psychological motivations underlying ASD involve complex emotional and mental health factors, where patients self-inflict skin injuries to fulfill various psychological needs. Emotional stressors, such as trauma or significant life changes, can exacerbate the condition, leading to self-injury as a coping mechanism [38]. This condition often manifests as a means to express underlying distress, with patients frequently unaware of their motivations. Many patients deny their role in the development of their lesions, further complicating diagnosis and treatment [39]. While the motivations for self-injury in ASD are often rooted in psychological distress, some argue [18, 38, 40] that societal pressures and stigma surrounding mental health may also contribute to the prevalence of such behaviors, emphasizing the need for broader awareness and understanding. Gaining insight into these impulses is crucial for effective diagnosis and management.
Patients with ASD may engage in self-harm to fulfill an unconscious need to adopt the “sick role”, which provides attention, care, and support from others [30]. The disorder is often interpreted as a subtle “appeal for help”, underscoring the importance of comprehensive evaluation and empathetic care [20].
THE INFLUENCE OF SOMATIC DISORDERS ON THE CHRONICITY AND TREATMENT OF THE DISEASE
ASD is classified in ICD-11 as a sensory or psychological disorder affecting the skin, rather than as a factitious disorder [5, 6]. Although ASD does not meet the criteria for factitious disorders, the relationship between them provides valuable insights into patient behaviors. As they involve the manifestation of physical symptoms driven by psychological factors, highlighting the complex interplay between mental health and physical health in these patients [40], we believe that ASD should be discussed in a much broader context. Obviously, it is essential to recognize that not all patients exhibit these characteristics. As previously mentioned, ASD is often linked to various psychiatric conditions, but most notably somatoform disorders, which present as physical symptoms without an identifiable medical cause. The characteristics of somatoform disorders co-occurring with ASD reveal a complex interplay between psychological distress and self-inflicted skin lesions.
It is possible that ASD could be classified as a form of somatization arising from an underlying psychiatric disorder, functioning as a pseudo-somatic condition [22]. Somatoform disorders result from a complex interplay of genetic predispositions, early life experiences, individual differences in interpreting bodily sensations, and responses to stressful events. Neuroimaging cases show alterations in the structure and function of brain circuits related to bodily sensation and emotion. Both conditions have been associated with genetics, risk factors, and responses to particular medications. These could represent a continuum within the ‘neurotic spectrum’ or ‘anxiety-depressive spectrum’, underpinned by shared neurobiological and psychological mechanisms [22].
ASD and somatic disorders are defined by psychological factors like dissociation, difficulty tolerating distress, and challenges in emotion regulation, which serve as key predictors of non-suicidal self-injury (NSSI). Certain presentations of ASD may therefore be regarded as variants of NSSI within this spectrum and could respond to similar psychological interventions. The influence of somatic disorders on the chronicity of ASD is considerable, as these conditions often exacerbate the persistence and complexity of self-inflicted skin lesions [15]. One-third of patients with ASD continue to produce new lesions and remain disabled 12 years after diagnosis, underscoring its significant chronicity. The condition tends to fluctuate with the patient’s life circumstances, further complicating long-term management [37].
While ASD is primarily viewed as a manifestation of psychological distress, it is essential to consider that not all skin conditions with psychological components are self-inflicted. Coexistent somatic disorders refer to physical symptoms arising from psychological factors, whereas ASD is a distinct condition in which individuals intentionally create skin lesions, often in the context of underlying psychiatric illness [23, 41].
PROGNOSIS
The prognosis of ASD depends on several factors, including the patient’s age at onset (pediatric patients diagnosed and treated early tend to have better longterm outcomes compared to adults [36]), the identification of triggering stressors, overall health status, and the presence of underlying psychological disorders [42, 43]. According to some studies, the clinical symptoms before diagnosis can last from 1 to 10 years [31], which only highlights the complexity of this condition.
For sure, ASD is a very difficult illness to cure. One of the main reasons, as noted, lies in the diagnostic process, which frequently depends on excluding other dermatological diseases.
MANAGEMENT OF ARTEFACTUAL SKIN DISORDER
Successful treatment requires a coordinated multidisciplinary approach, integrating dermatological and psychiatric expertise to address both the physical symptoms and the psychological roots of the condition. It is estimated that as many as 20–40% of patients reporting with dermatological symptoms have underlying mental health conditions which cause or complicate patient presentation [44]. In ASD, diagnosis is particularly challenging because such patients lack awareness of the potential psychogenic origin of their symptoms. The medical management of this disorder prioritizes wound healing, infection prevention, symptom alleviation, and the incorporation of psychotherapy.
Paradoxically, it is not the dermatological lesions themselves that represent the greatest therapeutic challenge, but rather the underlying psychiatric disorders. For dermatological management, recommended measures include gentle emollients, topical antibiotics (oral antibiotics if severe infection is suspected), antifungals, and analgesics, combined with appropriate occlusive dressings or bandaging, which effectively support wound healing [26]. Surgical intervention is rarely required for most patients, however, debridement may be beneficial in cases involving wound colonization or abscess formation [43, 45]. Nevertheless, the true origin of the condition remains psychological.
An effective approach to managing the patient’s concerns might involve shifting the focus away from the exact mechanisms behind the lesions and instead highlighting the role of stress in exacerbating the condition as this perspective may be more acceptable to the patient [43]. Recognizing that the condition itself can be a source of significant stress provides a foundation for introducing psychological therapy as a legitimate and supportive treatment option [43]. In general, an empathetic and non-confrontational approach is essential for building trust and motivating patients to engage with psychiatric services [46]. Psychodynamic therapy and cognitive behavioural therapy (CBT) provide the basis for treatment that offers a comprehensive approach to emotional and behavioural aspects [23].
Psychodynamic therapy focuses on uncovering hidden motives, analysing trauma and increasing selfawareness. In the case of ASD, the target is to identify unconscious conflicts and emotional needs underlying self-destructive behaviours [36]. Many patients with ASD have had difficult experiences or strong stressors, and such therapy would help them process the past and understand for themselves as it affects their current emotions and behaviours [36]. This allows patients to better manage their problems and reduce selfharm as a strategy for regulating emotions [47].
Cognitive behavioural therapy has three main goals: changing maladaptive thought patterns, using behavioural interventions, and developing coping skills. In ASD, exposure and response prevention are among the techniques used, as they can reduce selfdestructive behaviours [43, 47]. Moreover, they teach more effective ways of managing stress and difficult emotions, which often trigger such behaviours, so it can be said that CBT prepares patients for future experiences. It can also prevent relapses [36]. The literature emphasises also the importance of dialectical behaviour therapy (DBT). This is a modified form of CBT that focuses on emotion regulation and stress tolerance, however it is used less frequently [47].
A range of psychopharmacological treatment options is available, and the presence of additional psychological or psychotic symptoms plays a crucial role in guiding the choice of medication. These options include SSRIs, serotonin and norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), and antipsychotics [47].
In the study by Koblenzer [47], specific treatment dosages were proposed for various pharmacological agents. In cases of ASD with comorbid OCD, fluoxetine is typically used at target doses ranging from 60 to 80 mg/day. Sertraline may be required at doses up to 200 mg/day. Paroxetine is generally effective at target doses between 20 and 40 mg/day. Fluvoxamine is used at doses ranging from 200 to 300 mg/ day. Venlafaxine may also be considered, with target doses between 300 and 375 mg/day, however administered in divided doses with food. Among antipsychotics, pimozide may be required at doses up to 8 to 12 mg/day, although doses of 2 to 4 mg/ day are often sufficient. Risperidone has a target dose of 2 mg/day, though many patients respond well to lower dosages. Olanzapine is typically used at doses between 2.5 and 5 mg/day, with higher doses rarely needed. Bupropion, a dopaminergic antidepressant, may be used at doses up to 300 to 375 mg/day, administered in divided doses with meals; however, it is not indicated for the treatment of OCD. Buspirone, a partial serotonin 5-HT1A agonist, is typically used at target doses ranging from 5 to 15 mg/day.
Additionally, anxiolytics can be effective in alleviating anxiety-related skin conditions, and mood stabilizers may surely prove helpful for patients with mood disorders that manifest with dermatological symptoms. Benzodiazepines can be used: lorazepam (0.5 mg), alprazolam (0.25–1 mg), and clonazepam (0.25–0.5 mg) [47–49]. A frequently recommended group of drugs are aforementioned SSRIs because of their effectiveness in treating underlying psychiatric disorders like anxiety and depression, combined with their relatively low risk of adverse side effects [21, 46]. Unfortunately, the impact of medication in managing ASD remains a contentious issue, with studies providing conflicting evidence regarding its benefits and outcomes (e.g. sertraline was found to lack therapeutic efficacy in patients with ASD [50]). Particularly in cases where SSRIs are insufficient, it is claimed that low-dose atypical antipsychotic agents may also be beneficial [21]. Nonsteroidal anti-inflammatory drugs (NSAIDs) may be recommended, too, but the use of opioids or other prescription analgesics should be avoided due to the risk of addiction and physical dependency [36]. Pharmacotherapy can aid in symptom management, promoting wound healing and reducing the frequency of self-inflicted injuries [43].
CONCLUSIONS
Specialists should be always very attentive when the lesions are difficult to identify and they do not respond to standard treatments, the patient has a psychiatric disorder and the diagnostic interview is incoherent. The symptoms of ASD can closely resemble those of other skin disorders, further complicating early detection and proper diagnosis.
Effective management therefore requires close collaboration between dermatologists, psychiatrists, and psychologists as studies have demonstrated improved patient outcomes in multidisciplinary psychodermatology clinics [43]. Whilst dermatologists focus on diagnosing skin symptoms and treating physical damage, psychiatrists address the psychological issues driving self-inflicted skin injuries.
Even though ASD is a rare condition, it can serve as a telltale sign of a person suffering from mental or psychological issues. Unfortunately, the neuropathological mechanisms underlying ASD still remain unclear, and necessitate further research. The comprehensive understanding of the underlying pathophysiological mechanisms of ASD would be highly beneficial for healthcare providers, as it would enhance the patient care and management process.
Currently, treatment plans emphasize identifying underlying psychological causes while simultaneously addressing symptomatic issues using both pharmacological and non-pharmacological methods. Importantly, direct confrontation of patients regarding their role in lesion formation is often counterproductive, as it may lead to disengagement from medical care and eventual loss to follow-up [43].
