Dermatitis artefacta. Clinical features and approaches to treatment.

In dermatitis artefacta, the patient creates skin lesions to satisfy an internal psychological need, usually a need to be taken care of. The clinical presentation is characteristic, and differs from that of neurotic excoriations, delusional disorders, malingering, and Munchausen's syndrome. Munchausen's syndrome by proxy is a form of dermatitis artefacta. Except where disease is mimicked, lesions that do not conform to those of known dermatoses are shrouded in mystery, appearing fully formed on accessible skin, within the context of a characteristic psychological constellation. The patient is friendly but bewildered, and the relatives, angry and frustrated. Because of lack of diagnostic stringency, quoted female-to-male ratios range from 3:1 to 20:1, with the highest incidence of onset in late adolescence to early adult life. Most patients have a personality disorder; borderline features are common. The patient's denial of psychic distress, and negative feelings aroused in healthcare personnel, make management difficult. Limit-setting for the protection of both the physician and patient; creation of an accepting, empathic, and nonjudgmental environment; and close supervision of symptomatic dermatologic care will permit development of a therapeutic relationship in which psychological issues may gradually be introduced, that may occasionally permit psychiatric referral. Issues of etiology should be sidestepped because confrontation is counter productive. When psychiatric referral is refused by the patient, the use of psychotropic drugs by dermatologists is helpful and appropriate. The upper dose range of selective serotonin reuptake inhibitors (SSRIs), or low dose atypical antipsychotic agents, may be effective. Except in mild transient cases triggered by an immediate stress, the prognosis for cure is poor. The condition tends to wax and wane with the circumstances of the patient's life. Lesions can be kept to a minimum, the patient can be protected from unnecessary and intrusive studies, and society can be protected from escalating and unnecessary expenditure of medical resources if, rather than discharging the patient, the dermatologist continues to see the patient on an ongoing basis for supervision and support, whether or not lesions are present. Research studies are necessary to document more accurately the expectable cause, treatment outcome, and prognosis for this group of patients.