Munchausen syndrome as dermatitis simulata.

Psychiatric comorbidity is associated with many dermatological disorders. It may be the cause for skin problem or may be the effect of a skin problem as skin being a visual organ. A 28-year-old female presented with multiple red lesions on the skin with unusual morphology and was diagnosed as dermatitis simulata. She gave history of multiple episodes of similar illnesses with admissions in various hospitals and being evaluated and dropping off in between treatments. After detailed psychological evaluation, patient was diagnosed as case of Munchausen syndrome.

INTRODUCTION

Factitial dermatitis or dermatitis artefacta is a psychiatric disorder in which the patient intentionally feign symptoms or inflict signs of disease on skin in an attempt to assume a sick role in order to elicit sympathy, escape responsibility, or collect disability insurance.[1] Dermatitis simulata is type of factitial dermatitis where the patient inflicts lesions which do not significantly damage their skin.[2] Munchausen syndrome is a variant of factitial disorder in which symptoms and signs are produced to satisfy the need of receiving medical attention.[3]

CASE REPORT

A 28-year-old housewife admitted with reddish tender lesions all over the body of 2-day duration. There was no associated fever or other systemic complaints except for severe body pain and pain over the lesions. There was no history of prolonged sun exposure or drug intake prior to onset of lesions. There was history of four similar episodes in 9 months with admission in different hospitals each time and dropping out half way while on treatment. On examination, lesions were reddish brown macules all of similar size and morphology all over the body predominantly over thighs and legs with fewer lesions on chest, abdomen, face, and total sparing back of trunk [Figures 1–3]. On scrubbing with alcohol, some lesions showed fading of color. During all the episodes, patient had same type of lesions without significant damage to the skin; hence, a diagnosis of dermatitis simulata was made and patient was investigated to rule out other possible differential diagnosis of dermatological conditions like fixed eruptions, vasculitis, or generalized lichen aureus. Nothing significant was detected from routine blood and urine examination and skin biopsy. Patient was treated with only placebos. Condition was not revealed to patient or relatives and no such history was probed to find out nature of infliction of lesions as same would lead to patient hopping. No new lesions appeared and all lesions started fading in about a week. Later, detailed psychiatric evaluation was done, according to which patient did not have any perceptual abnormalities. Psychiatric evaluation could not elicit any external incentive for act like fear, avoiding duties, or financial gain. Both patient and bystanders gave inconsistent history. Since the past nine months, patient is being admitted in different hospitals four times, each time developing lesions suddenly. All the episodes occurred when the husband was away from home. She would get admitted to hospital and while the investigations are being done, abscond from hospital once the false nature has been identified. With the history and clinical finding, diagnosis of Munchausen syndrome presenting as dermatitis simulata was made. Skin lesions cleared completely in 2 weeks. Patient is under regular psychiatric follow-up with no new episodes since past six months.

Figure 1

Lesions on the face patient wincing due to pain

Figure 3

Back of trunk showing total sparing

Lesions of similar morphology on lower extremity

DISCUSSION

Richard Asher first used the term Munchausen syndrome to describe a hospital hopper who presented with untruthful story of illness.[3] Munchausen was an extravagant liar who narrates false stories. Essential features of disease are recurrent nature of illness, similarity in pattern of presentations and visiting different hospitals with same complaint, and dropping off treatment once deception has been discovered. Usually, they present with neurological or abdominal complaints. Dermatological manifestations are rare.[2] Dermatitis artefacta is a factitial disorder in which skin lesions are self inflicted to attain sick role. Lesions are often seen in accessible areas and show bizarre geometric pattern. Surrounding skin is normal. Lesions show unrevealing histology.[1] Lesions are often produced with sharp objects or chemicals. Lesions may mimic dermatological diseases; usually, erythematous, ulcerative, or gangrenous. Rarely, subcutaneous emphysema or lymphedema may be the presenting lesion. Complications like secondary infection and septicemia can occur. Dermatitis simulata is the name given to similar type of lesions where the patient inflicts lesions without significant damage to skin.[4] Munchausen's, by proxy, is a condition in which illness is fabricated by perpetrator, usually to children.[5] Management of dermatitis artefacta is symptomatic and supportive initially. Dermatologic local therapy is to be initiated first. Immediate revealing of false nature of illness to the patient or relatives by enthusiastic dermatologist may end up in patient dropping off treatment. Skin biopsy may be done to rule out dermatological mimics.[6] Spectrometry of biopsied specimen may be done if injection of foreign material is suspected.[2] In dermatitis simulata, patient uses external disguise to simulate a skin disease.[4] These patients do not cause major damage to skin. Make up, crystallized sugar, and glue printing dyes are used to induce discolouration.[2] These can be easily removed by alcohol swabs. Sugar crusts dissolved in water keratin crust are not soluble in water. After gaining confidence of patient, detailed psychiatric evaluation is to be done to rule out malingering where malingerers have specific goals like insurance payment, avoidance of jail term, and escape from duties.[7] Usually, they are short term and opportunistic.[8] Somatoform disorder must also be ruled out which is caused by unconscious or symbolic factors where the infliction of lesions is unintentional.[9] In Munchausen syndrome, the simulated illness may be esoteric and rare with patient often presenting dossier to the doctors.[8] Internet is a rich source for expansive personality of Munchausen patient.[10] Dermatological complaints are uncommon.[1] Simulated porphyria or connective tissue disorders are reported. Munchausen falsification is chronic and persistent.[7] There is no external incentive as in malingering, but there is internal incentive to assume sick role but conscious one. Early diagnosis of illness and nonconfrontational approach initially by dermatologist and allowing patient to have freedom to express their difficulties in a passive confidential environment by psychiatrist will help to change the behavior of the patient to a great extent as in our case.