• Users Online: 705
  • Print this page
  • Email this page


 
  Table of Contents  
CASE REPORT
Year : 2012  |  Volume : 3  |  Issue : 2  |  Page : 141-143  

Dermatitis artefacta


Department of Dermatology, PSG Hospitals, Coimbatore, Tamil Nadu, India

Date of Web Publication29-May-2012

Correspondence Address:
Reena Rai
Department of Dermatology, PSG Hospitals and PSGIMSR, Coimbatore - 641 004, Tamil Nadu
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5178.96720

Rights and Permissions
   Abstract 

Dermatitis artefacta (DA) is a psychocutaneous disorder where the skin lesions are self self-induced to satisfy an unconscious psychological or emotional need. We report a case of DA where we video recorded the patient self-inducing the lesions.

Keywords: Dermatitis artefacta, psychocutaneous, factitious


How to cite this article:
Kumaresan M, Rai R, Raj A. Dermatitis artefacta. Indian Dermatol Online J 2012;3:141-3

How to cite this URL:
Kumaresan M, Rai R, Raj A. Dermatitis artefacta. Indian Dermatol Online J [serial online] 2012 [cited 2020 Oct 31];3:141-3. Available from: https://www.idoj.in/text.asp?2012/3/2/141/96720


   Introduction Top


Dermatitis artefacta (DA) is a factitious dermatological disorder with many forms of presentation that may involve any part of the body. In women, it is regarded as a "cry for help'', especially when the patient is faced with psychosocial stress. A high index of suspicion is required to diagnose the condition as the history is often vague as patients dissociate while they self-abuse. [1] Herein, we report a case of DA.


   Case Report Top


A 11-year year-old boy presented to us with multiple linear excoriations and erosions on the forearm, leg, face and dorsum of the hand of 11 months duration. The child and the parent were unable to explain the evolution of lesions. He gave a history of sudden onset of the erosions over the body. Lesions disappeared with post inflammatory pigmentation within 10 days. There was no pain or itching over the lesions. He was evaluated in many hospitals for dermatitis and investigated extensively. On examination, there were multiple, linear, well well-defined excoriations and erosions with crusting and scab formation of varying sizes over the forearm, face, legs and dorsa of the hands [Figure 1] and [Figure 2]. Lesions were more frequent on the left side of the body. Only the accessible parts of the body were involved and inaccessible parts such as the midline of the back were spared. Routine hematological and biochemical investigations were within normal limits. Histopathology of the skin lesions was non-specific. With the above history and the clinical findings, we made a provisional diagnosis of DA. The child was admitted in the ward and was put under close circuit camera surveillance without his knowledge. Video recording showed the child picking on his skin and presenting with erosions and excoriations. Video recording was shown to the parents to convince them about the diagnosis. On careful history and multiple sessions of counselling with the help of a psychiatrist, the child confessed to self-inducing the lesions. The reason behind his act was the parental attention being given to his elder sister, and he tried to draw attention by self-inducing the skin lesions. Detailed psychiatric evaluation was done and the child was advised counselling without any medications, following which he improved. He was followed up for a period of 6 months without any recurrence.
Figure 1: Linear erosions over the face

Click here to view
Figure 2: Multiple, linear, healed erosions over the forearm

Click here to view



   Discussion Top


DA is a psychocutaneous disorder where the patient self-inflicts to create skin lesions to satisfy the internal psychological or emotional need. Patients intentionally create lesions to assume the sick role and typically deny the self-inflicted nature of the injury. [2] Patients frequently have an impulsive personality disorder. [3] This disorder is seen more commonly in women (male to female ratio of at least 1:4), and has a broad and variable age of onset (9-73 years), with the highest frequency during adolescence and young adulthood. The prevalence is about 0.3% among dermatology patients. [3]

Skin lesions are always self self-inflicted and the morphology varies widely depending on the mode of injury: cutting, abrasion, burning, applying chemicals, and injecting various products. Bizarre lesions with sharp geometric borders surrounded by normal skin is characteristic of DA. [4] The various methods of producing the skin lesions are highly imaginative and depend on the patient's background and education. [5] Lesions may be produced by a variety of mechanical or chemical means, including fingernails, sharp or blunt objects, burning cigarettes and caustic chemicals. [5] In the right right-handed person, the left side is usually involved and the accessible body parts are usually involved than inaccessible part like midline of back, [6] as in our case. Recurrent excoriation produces inflammation and lichenification of the skin; the resultant irritation and pruritus leads to further self self-trauma and chronic dermatitis. [3] Patients are unable to explain the evolution of these lesions, since they dissociate themselves while self-inflicting. Indifference to symptoms is also commonly encountered. Precipitating factors for DA range from simple anxiety to severe personality disorders, including attention-seeking traits, obsessions, compulsions, depression and psychotic disturbances. [5] Histopathological features are non specific and usually show features of acute inflammation with increased polymorphonuclear leucocytes and scattered erythrocytes. There may also be areas of necrosis with areas of healing and fibrocystic reaction. [7]

This diversity makes it particularly difficult to diagnose DA. Except in mild transient cases triggered by an immediate stress, the prognosis for cure is poor. [5] The condition tends to wax and wane with the psychosocial circumstances of the patient's life. [8] Long-standing cases may be secondary to underlying anxiety or depression, emotional deprivation, an unstable body image or a personality disorder with borderline features. [5] Many use their lesions to obtain attention, maintain contact with others and fill their emotional emptiness. [9] The visible skin lesions can be understood as an attempt at non-verbal communication subserving an appeal function. [9]

Patients with DA are particularly sensitive when confronted by medical practitioners, to which they react with renewed self-mutilation. [10] The condition must be distinguished from neurotic excoriations and Munchausen's syndrome, as the psychopathology, and therefore the treatment, is different in each case. [11] Patients with neurotic excoriations usually have depression or anxiety with obsessive-compulsive features; those with Munchausen's syndrome have a sociopathic personality, while patients with dermatitis DA are most commonly diagnosed with the borderline personality disorder. [11] The need for psychiatric referral should be balanced against the fact that the patient will interpret this referral as a rejection, which can intensify the self self-mutilation. [3] Follow-up studies have shown that most patients with DA improve significantly with changes in life situation and maturation than as a result of psychiatric treatment. [3]

Psychotropic medication, including antipsychotics, might be helpful in certain clinical situations, but is unnecessary for all cases. [1] The antipsychotics like pimozide, aripiprazole and risperidone are the drugs of choice, and aripiprazole has an advantage in that it also has antidepressant properties. Appropriate referral to other community resources with expertise in assisting patients who self-abuse, including self-help groups available in some communities is an important adjunct to treating these skin lesions.

 
   References Top

1.Lent B, MacLean C, Willing JA. Treating dermatitis artefacta. Can Fam Physician 1997;43:1204-5.  Back to cited text no. 1
[PUBMED]  [FULLTEXT]  
2.Tamakuwala B, Shah P, Dave K, Mehta R. Dermatitis artefacta. Indian J Psychiatry 2005;47:233-4.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.Murray AT, Goble R, Sutton GA. Dermatitis artefacta presenting as a basal cell carcinoma--An important clinical sign missed. Br J Ophthalmol 1998;82:97.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Gupta MA, Gupta AK, Haberman HF. The selfinflicted dermatoses: A critical review. Gen Hosp Psychiatry 1987;9:53-7.  Back to cited text no. 4
    
5.Choudhary SV, Khairkar P, Singh A, Gupta S. Dermatitis artefacta: Keloids and foreign body granuloma due to overvalued ideation of acupuncture. Indian J Dermatol Venereol Leprol 2009;75:606-8.  Back to cited text no. 5
[PUBMED]  Medknow Journal  
6.Sneddon I, Sneddon I. Self inflicted injury: A follow up of 43 patients. Br Med J 1975;1:527-30.  Back to cited text no. 6
    
7.Antony SJ, Mannion SB. Dermatitis artefacta revisited. Cutis 1995;55:362-4.  Back to cited text no. 7
    
8.Koblenzer CS. Dermatitis artefacta. Clinical features and approaches to treatment. Am J Clin Dermatol 2000;1:47-55.  Back to cited text no. 8
[PUBMED]  [FULLTEXT]  
9.Krishna K. Dermatitis artefacta. Indian J Dermatol Venereol Leprol 1995;61:178-9.  Back to cited text no. 9
[PUBMED]  Medknow Journal  
10.Gardner AR. Self mutilation, obsessionality and narcissism. Br J Psychiatry 1976;127:127-32.  Back to cited text no. 10
    
11.Koblenzer CS. The current management of delusional parasitosis and dermatitis artefacta. Skin Therapy Lett 2010;15:1-3.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2]


This article has been cited by
1 Unklare Effloreszenzen bei einem 17-jährigen Jungen
R. Savva,H. Ott,L. Haftel,M. Endmann
Monatsschrift Kinderheilkunde. 2018;
[Pubmed] | [DOI]
2 Dermatitis Artefacta in Childhood: A Retrospective Analysis of 44 Patients, 1976-2006
Sara Alcántara Luna,Begoña García Bravo,Antonio Rodríguez Pichardo,Francisco M. Camacho Martínez
Pediatric Dermatology. 2015; 32(5): 604
[Pubmed] | [DOI]



 

Top
 
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
   Introduction
   Case Report
   Discussion
    References
    Article Figures

 Article Access Statistics
    Viewed2233    
    Printed109    
    Emailed0    
    PDF Downloaded383    
    Comments [Add]    
    Cited by others 2    

Recommend this journal