We have all seen lonely, housebound, elderly patients who have leg ulcers that never seem to heal. Somehow compliance with instructions never seems to be achieved, bandages have been loosened and legs constantly in use despite advice to keep them up. These patients' only company may be when the district nurse calls to do the dressings, but as a nurse's time is valuable, it is important to consider alternative stimulation and company for the patient.
Bizarre, well-demarcated lesions that may be linear or geometric in shape are produced by action of the patient. Lesions appear overnight and may be made by the fingernails or chemical agents. They may be raw, crusted areas or blisters complicated by secondary infection. A psychological condition almost certainly underlies this. Patients respond badly to confrontation, but with empathy and a topical preparation to ease discomfort it may be possible to ascertain the underlying distress and offer support.
Lichen simplex occurs as the result of repeated rubbing and scratching of localised areas of skin. Common sites are the back of the neck, wrists or the outside of the lower leg or ankle. It is most common in adults. The urge to scratch may initially be due to an insect bite or other stimulus but the habit develops often in stressed and anxious patients.
Resolution of the problem is not always easy to achieve and potent topical steroids, sometimes under occlusion, may be required to ease symptoms and help to change the habit. The anxieties of the patient may also need to be discussed.
Trichotillomania is the name given to self-induced alopecia. This may be by pulling, twisting or, as in this case, cutting the hair and can occur at any age from childhood to adult life. It is sometimes seen in association with the chronic tics seen in Tourette's syndrome. Most patients are unaware of what they are doing. In some it appears to be related to underlying tension, anxiety or obsessional behaviour. Management of the condition may be to help discourage bad habits and in some psychological help is effective. The prognosis in young children is good but in adults recovery is unusual.
Self-harm is often a cry for help. A patient seen in the surgery with old scars from previous damage will often alert one to the fact that the patient has been unstable at some time in their life. It is a problem that should be taken seriously, as approximately 15 per cent of those who self-harm are actually intending suicide.
Self-harm is most common between the ages of 11 and 25, but others at particular risk are the elderly, single or divorced, unemployed, those who misuse drugs or alcohol and those with an underlying psychiatric illness.
Some patients are convinced that they are infected with mites. Their fears are confirmed by itching and the feeling of something crawling under the skin. They commonly present with a matchbox full of the 'proof'. However, when examined under the microscope, only skin fragments are found. Delusional parasitophobia is a form of delusional psychosis that is difficult to help and patients can be reluctant to seek psychiatric advice.
If the patient seems to be depressed, antidepressant therapy may help. Pimozide or olanzapine may be prescribed by a specialist.
Debate about the effects of cannabis continues. After using the drug patients may be unfit to drive or operate machinery. A single dose can lead to panic attacks or paranoia. Longer term risks include psychosis, delusions and hallucinations that may simulate schizophrenia in those predisposed to it. Regular use of cannabis can have long-term effects on cognitive performance. Finding a tattoo such as this would suggest that cannabis features in the patient's life and gives us the opportunity to warn of the dangers and recommend cessation.
Confidence and acceptance by peers are important and this is helped by appearance. Unfortunately, the formative years are often marred by acne. Not only is the presence of pustules offensive but severe lesions may leave scars. When treating such patients we need to be aware of these fears, which may very occasionally lead to suicidal attempts.
Much can be done in the way of treatment to avoid these consequences and we must be ready to refer severe, persistent cases and cases of cystic acne to a dermatologist for consideration of isotretinoin to help to avert problems.