Dermatitis artefacta: growing awareness.

Sir,

This article is regarding the current understanding and awareness about the multiple aspects of psychodermatology.[1] It is of extreme importance that adequate awareness and skills should be imparted to post-graduates and stress is laid upon the teaching of the psychodynamic aspects of the dermatological lesions, also regarding the primary psychiatric conditions like dermatitis artefacta that present to a dermatologist, which when present to the OPD are often missed, inadequately managed or lost to follow-up. In the same league, we wanted to discuss briefly a case of 14-year-old girl who presented to us with complaints of multiple circumferential and linear clearly demarcated, hyperpigmented scars over the forearms uniform in shape, which were slightly tapering towards the periphery, over the left leg, and on the thighs for 2 months [Figure 1 and 2]. The lesions were sudden in onset, recurring every few days and were in different stages of healing, were not associated with injury (as per patient), insect bite or intake of drugs; also, there was no history of fever, cold and cough, or any medical or surgical history of any kind. All her investigations including blood investigations — Human immunodeficiency virus antibodies test and venereal disease research laboratory test were non-reactive. Skin biopsy was done, which revealed traumatic pathology. Due to the unusual nature of her lesions as well as suggestive biopsy report, diagnosis of dermatitis artefacta was suspected; however, the patient denied any role in producing the lesions despite questioning. Although detailed psychological evaluation did not reveal any specific psychiatric disorder, the personality work up revealed attention-seeking behaviour, la belle indifference, poor impulse control, and poor coping styles in the patient. Patient was started on a holistic treatment approach and was followed up for observation. It appeared that the lesions had been caused by application of an abrasive substance. Occlusive bandage dressing was used to cover the affected limb. The cutaneous lesions healed within a week with no recurrence. The psychological interventions included psycho education to patient and more importantly her family members and were advised regular OPD review. Also, individual psychotherapy was planned for patient.

Figure 1

Dermatitis Artefacta — self-inflicted linear scar mark on the wrist

Figure 2

Multiple old and new linear burns with scarring over non-dominant hand

Increasingly, the psycho-dermatology is starting to get its due attention and is being called as an exciting field, which deals with the close relationship that exists between dermatological and psychiatric disorders.[2] Dermatitis artefacta, also known as factitial dermatitis, is a disorder of self-injurious behaviour and one of the primary psychiatric conditions to dermatologist with no exact prevalence known, but definite female predominance documented.[345] A number of case reports have been previously described with each emphasizing on the unusual and varied presentation of lesions.[6789] Unconscious motivating factors and psychological need or hypochondriacal tendencies drive the patient towards self-destructive behaviour, where the psychological needs are taken care of by assuming the role of the sick patient.[310]

The most crucial and aspect of DA is managing or treating the case, where the recommended approach is bio-psycho-social approach, incorporating the thoughts and manipulations of the patients without being judgemental.[11]

With the growing knowledge and literature of psychocutaneous lesions and the basic underlying psychological cause for it, the current focus should be to create awareness and formulate better protocols of educating and dealing with the disorder.