Dermatitis Artefacta: A Review of Five Cases: A Diagnostic and Therapeutic Challenge.

Dermatitis artefacta (DA) is a self-inflicted dermatological condition where the underlying motive is to assume a sick role. The act of self-harm is to discharge the inner sense of isolation and emotional distress, which is too great to endure. We, hereby, report five interesting cases of DA with varied presentations, using diverse and innovative means for inflicting injury/injuries. Rarity may be attributed to masquerading presentation, leading to misdiagnosis and paucity of awareness among the physicians. Lack of proper identification of the underlying psychiatric disturbances may be the major cause of the loss of follow-ups. Here, we were fortunate enough to identify the emotional need of most of the patients. A flexible, nonconfrontational yet strong therapeutic rapport is required to improve the therapeutic outcomes.

What was known?

DA is a psychocutaneous disorder produced by the patient's own action, with a female preponderance.

Introduction

Dermatitis artefacta (DA) is a rare self-induced psychocutaneous disorder where the patient denies his/her role in its causation. Mechanical and chemical devices are most commonly used to produce such injuries. Laboratory investigations, including histopathological examination, are usually nonspecific and do not give a correct clue to diagnosis. Here, we report five cases of DA with varied presentations.

Case Reports

Case 1

A 32-year-old woman presented with multiple painful erosions with some pustules and scarring over her accessible body parts [Figures 1a–c]. There was no evidence of insect bite, or drug or food allergy. She denied any self-inflictive nature of her injury such as scratching or rubbing with any object. The lesions were bizarre, with a tapering end at various stages of healing, and were not compatible with any known dermatological disorder. Gram stain and Tzanck smear were found to be negative from the pustules. Her histopathological findings were nonspecific. Her psychiatric evaluation revealed marital discord. Treatment with occlusive therapy completely healed the lesions within 2 weeks. She did not turn up for further follow-ups.

Figure 1

(a) Erosions and scarring in a linear distribution over both forearms (b) Similar type of lesions over the dorsa of both feet (c) Closeup view showing scarring, pustules, and erosion

Case 2

A 15-year-old woman had multiple asymptomatic erythematous plaques in a linear distribution with longitudinal alignment on the flexor aspect of both forearms, the cause of which she could not explain [Figure 2]. She refused to discuss her problem. She appeared sad and depressed; after repeated interviews with a psychiatrist, it was found that she had dropped out of school in the seventh standard due to poor academic/scholastic performance and constant criticism by her teachers and friends. The routine investigations were normal. When confronted about the self-inflictive nature of her injury, she left against medical advice and did not come up again.

Figure 2

Erythematous plaques in a linear distribution with longitudinal alignment on flexor aspect of both forearms

Case 3

A young man presented with patterned hypopigmented lesion with scarring and erosions at places over his face [Figure 3]. The morphology of the lesion hardly fits with that of any dermatological disease. He was referred to the psychiatric department. On psychological evaluation, we learnt that it was a classic example of overvalued ideation where he used carbolic acid to get rid of his pain of parotitis. No history of any psychiatric illness or behavioral disorder in his family could be elicited.

Figure 3

Patterned hypopigmented lesion with scarring and erosions at places over the face

Case 4

A 48-year-old lady sought consultation for multiple skin lesions having features of chemical burn over her face, back, inframammary region, arm, and abdomen [Figure 4]. She gave a hollow history regarding the causation. Complete amnesia or indifference to the presenting symptoms was noted. She is now under the observation of the psychiatric department.

Figure 4

Lesion over the back, resembling chemical burn

Case 5

A 12-year-old boy had multiple linear scarring, with intervening normal skin at the angles of his mouth and below the lower lip [Figure 5]. He was depressed, withdrawn, and unwilling to discuss his problems. On psychiatric evaluation, we came to the conclusion that interpersonal conflict with his parents was the most probable cause. His histopathology was nonspecific. Unfortunately, we lost follow-up of the case.

Figure 5

Multiple linear scarring with intervening normal skin at the angles of mouth and below the lower lip

Discussion

DA is a type of factitious disorder produced by deliberate action of the patient to satisfy some deep-seated interpsychiatric need. Denial regarding the self-inflicted nature of injury/injuries is a common finding,[1] consistent with our cases. Therefore, confrontation to explore the underlying psychosocial conflicts should be strongly discouraged;[2] rather, a gentle, nonjudgmental, and empathetic approach often works. A sense of hesitancy and difficulty in making eye contact are useful clues of such strange behavior. By definition, external incentives whether economic, legal, or related to body image are typically absent. Pathophysiology is still an enigma. Several factors such as delayed developmental milestones, marital dispute, loss of close relatives in the recent past, self-guilt, disturbed parent-child relationship, bipolar personality disorders, and sexual and substance abuse are implicated as the precipitating factors,[345] similar to our cases. The ultimate objective is to assume a sick role to fulfill unconscious psychological need for dependency and to form stable body image and boundaries. In spite of the underlying psychiatric disturbances, the patient appears to be cooperative, unconcerned about his/her painful and puzzling lesions, or somewhat bewildered. On the contrary, anxiety and frustration of the accompanying family members and inquisitiveness about the evolution of the lesions is noteworthy. According to the literatures, this practice is more common in females, with onset during or after adolescence.[36] Several creative methods and means are stated to be used, starting from burning with cigarettes to the use of caustic chemicals to inflict injury, as reflected in our observation too. The physician often notices that the patient enters the examination room with a stack of investigative reports and a bag of medications. He/she might have fair knowledge about the medical field (s). During the interview session, constant rubbing or picking of the lesions with a Mona Lisa smile is not uncommon. Except amnesia about the act and the Mona Lisa smile, other signature signs are bizarre-shaped lesions with various stages of healing; involvement of approachable body parts, most commonly the face and the dorsum of the hand; normal intervening skin; nonspecific histology; normal blood test; and most importantly complete disappearance of the lesions under occlusion therapy. Basically, it is a disease of exclusion that masquerades as numerous dermatological diseases. Shape of the lesions indicates the mode of infliction to a great extent. Tendency of linear configuration points toward chemical burn, as in our case 4, whereas circular ulcer(s) or blister(s) may be associated with cigarette burn. A prudent physician may even predict the potential sites for the reappearance of lesions in future visits.[7] Important dermatological differentials are necrotizing vasculitis,[8] pyoderma gangrenosum, and cutaneous T-cell lymphoma. The Munchausen syndrome should be considered as an important psychiatric differential, characterized by flamboyant males who feign multiple symptoms and shifting complains not limited to only the skin, just to draw attention.[9] Malingerers inflict injury on themselves for some secondary gain. Malingering is considered to be a crime as malinger is not mental illness.

Initial strong therapeutic alliance with the patient, in terms of mutual trust and rapport, is very crucial for a better outcome as prognosis of the disease is not good with frequent waxing and waning.[9] Antidepressants in the form of selective serotonin reuptake inhibitor and[8] behavioral therapy[10] are the mainstay of treatment. Dermatological care with bland emollient, topical antibiotics, and occlusive dressing should not be underestimated as the patients tend to be emotionally attached to their skin.

Conclusion

DA is often a challenge for the clinicians because of its rarity, vague history, bizarre and polymorphic morphology, lack of decisive diagnostic tests, and poor therapeutic outcomes.

What is new?

In contrast to the existing literature, facial involvement was found to be more common in male patients in the present case series.