Dermatitis artefacta.

A 27-year old lady presented to our department with multiple erosive lesions over extremities, which had a very bizarre pattern and was only over accessible parts of body. A thorough history was taken and a diagnosis of dermatitis artefacta was made. We present this interesting case for its rarity and future reference.

INTRODUCTION

Dermatitis artefacta (DA), also known as factitious dermatitis, is a condition in which skin lesions are solely produced or inflicted by the patient's own actions without any rational motive for this behavior.[1] Patients present with lesions that are difficult to recognize and do not conform to those of known dermatoses. Precipitating events range from simple anxiety to interpersonal conflicts and severe personality disorders, including compulsive behavior, depression, and psychotic disturbances. We present here a case of a 27-year-old lady with this rare and unusual disorder.

CASE REPORT

A 27-year-old lady presented to our OPD with a 6-month history of recurrent ulcers on extremities and upper back, the cause of which she could not explain. Her social and medical history revealed that her in-laws abandoned her after the death of her husband in a road traffic accident. On clinical examination, we found many symmetrical superficial excoriations on anterior aspect of both upper and lower extremities, which she claimed appeared overnight, interestingly many, as she narrated, appeared on her way to hospital. Almost all the lesions were similar in appearance (about 0.5 cm wide and 2.5 cm long), dimension and were positioned in a linear manner and all present only in accessible parts of body [Figure 1]. Though few were fresh erosions with little serous oozing, many were old marks indicating past healed-up lesions. Barring one or two over upper back and left flank [Figure 2], almost all the lesions were on anterior aspect of lower limb and extensor aspect of forearm. DA was suspected and the patient was hospitalized for further evaluation and treatment.

Figure 1

Lesions over accessible parts

Figure 2

Lesions sparing back

Physical examination and laboratory work-up were negative. Fresh symmetrical and identical skin lesions started appearing while she was in hospital. Interestingly, patient could tell the exact time when a particular lesion appeared. Only occlusion dressing was advised with systemic antibiotics and lesions healed in 2 to 3 days. After repeated interviews, it became obvious that she was depressed following death of her husband and was in conflict with her parents and confessed to having produced the lesions by own nail. A clinical diagnosis of DA was made. No fresh lesions appeared during two days of observation. She was referred to a psychiatrist and few sessions of psychotherapy produced marked improvement. She was discharged and was advised by the psychiatrist for further sessions. At follow-up visit two weeks later, the ulcers had recurred and were still present at two subsequent visits. She refused further admission and did not return for follow-up visits.

DISCUSSION

DA is a psychocutaneous disorder seen more by a dermatologist than a psychiatrist. It occurs more commonly in women than men and ratio vary from 4:1 to 8:1, with a broad and variable age of onset (9 to 73 years).[23] Usually, affected women are in their teens or early adulthood and tend to be emotionally immature or have psychosocial or interpersonal difficulty. It may also occur as a cry for help when emotional stresses become too great to endure.[4] It forms one of the spectrum of self-inflicted dermatoses and also represents one of the spectrum of obsessive compulsive disorders. It is reasonable to assume that this condition represents a psychological abnormality, although the patient may not be known to have a psychiatric illness. They tend to be emotionally immature or have psychosocial or interpersonal difficulty. Intelligence is variable. Stress and PTSD may be involved. The various methods of producing the skin lesions are highly imaginative and depend on the patient's background, including level and type of education. Fingernails, scarification, or cuts may cause deep excoriations by sharp instruments such as knives or pieces of glass, or burns with a cigarette, hot piece of metal, or cup of tea. However, in many a times, patients do not usually reveal how they produce the lesion.

The diagnosis of DA may be difficult if the clinician is unaware of its existence. It is based on vagueness of history, often in bizarre shapes with irregular outlines in a linear or geometric pattern, usually clearly demarcated from surrounding normal skin. Interestingly found on sites that are readily accessible and above all do not confirm to any known dermatoses and patient usually deny that the rash is self-induced. DA has also been reported as a result of willful or subconscious self-neglect through act of omission rather than commission.[5] Healing of the lesion following occlusive dressing to limit patients’ access is an additional clue that strengthens the diagnosis. But one should carefully evaluate all patients to identify any organic disease as highlighted by Cox and Wilkinson.[6]

DA is a form of focal suicide and various psychosocial conflicts and unconscious motivating factors have been held responsible for the self-destructive activity. The visible skin lesions can be understood as an attempt at non-verbal communication subserving an appeal function.[4] Management of DA has to be gentle, non-confrontational, and flexible and involves building a mutual trust and rapport between patient and doctor.[7] Intensive psychotherapy may be required in severe cases with borderline personality.[8] Close supervision and symptomatic care of skin lesions will hopefully lead to a doctor-patient relationship in which psychological issues may gradually be introduced. If appropriate, psychiatric referral may be recommended, although this is often refused. But in cases like ours, where patient is relatively healthy psychologically with very mild skin involvement, supportive and symptomatic therapy along with multiple counseling sessions is advisable. For these patients, a cure of the dermatoses is less desirable than the disease itself. What they seek is sympathetic management and understanding. It is best for the dermatologist to maintain a close relationship with the patient and provide symptomatic therapy and non-judgmental support. But most patients need some form of psychiatric evaluation and referral. 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-mutilation. Follow-up studies have shown that most patients with DA improve more significantly after changes in life situations and maturation than as a result of psychiatric treatment. It is imperative that we follow an integral approach and treat these patients as a bio-psychosocial individual incorporating their thoughts and manipulations without being judgment.[9] Antidepressants and low-dose atypical anti-psychotics have also been reported to be useful adjunctive therapies.[1011] Antidepressants may be of value. The SSRIs are often preferred although the tricyclic antidepressants may have some antipruritic effect and sedation can be beneficial.[12] High dose of selective serotonin reuptake inhibitors may also be beneficial.[13] The atypical antipsychotic, olanzapine, appears to have much potential.[11] Patients with different psychiatric illnesses require different approaches.[10] Resolution of the current underlying psychological problem facilitates a cure for the time at least but DA tends to be a chronic condition that waxes and wanes with events in the patient's life. To minimize damage, a patient should continue to see the doctor intermittently for supervision or support, whether or not lesions are present.[10] This condition requires further cooperative study, because there are still many more questions than answers.