Attention deficit hyperactivity disorder presenting as dermatitis artefacta.

Dermatitis artefacta, a self-inflicted intentional dermatosis is a very rare diagnosis in childhood. In a large proportion, the underlying psychiatric disorders go unidentified due to lack of collaboration between dermatologist and psychiatrist. The underlying psychological reasons for childhood dermatitis artefacta include emotional distress and interpersonal conflicts. A multitude of psychosocial factors interact to precipitate this disorder. Here, we report a child with dermatitis artefacta who was diagnosed with attention deficit hyperactivity disorder during psychiatric evaluation. Parental expectations and sibling rivalry were further increasing the stress of the index child. Appropriate diagnosis and management lead to treatment compliance and functional improvement in the child.

Introduction

Dermatitis artefacta is a self-inflicted primary psychodermatosis of exclusive emotional origin. This enigmatic disorder often presents as symmetrical, bizarre shaped monomorphic skin lesions depending on the instrument used to inflict injury. While the dermatological diagnosis is relatively simple, the underlying psychiatric cause is difficult to find because patients look apparently normal and often deny inflicting the injury.[1] Prevalence is 0.5–5% of dermatological consultations and is even rarer in children.[2] Emotional disturbances, sibling rivalry and interpersonal conflicts have been reported to be underlying reasons in children.[345] Here, we describe a 12-year-old female child with dermatitis artefacta who was diagnosed with attention deficit hyperactivity disorder (ADHD) and managed with atomoxetine.

Case Report

RS, a 12-year-old female child was brought by her mother to dermatology outpatient department (OPD) with multiple monomorphic geometric erythematous lesions with sharp margins on anterolateral aspects of both her arms of sudden onset. There were no complaints of any pain or discharge from the lesions. There was no history of any physical or chemical injury. There were four lesions on both the arms at similar anatomical location with exactly similar morphological appearance [Figures 1 and 2]. The findings of histopathological examination were nonspecific. The lesions had appeared on 8–10 instances in last 1 year and had healed in 1–2 weeks time. The first episode had occurred, whereas the child was in school and she complained about this on coming back to home. She reported of utter ignorance about the cause of the lesions. Multiple medical consultations resulted in investigations such as hemogram, platelet count, fasting blood glucose, and all within normal limits. The nature of the lesions and course prompted a diagnosis of dermatitis artefacta and the child was referred to psychiatry OPD.

Figure 1

Right arm showing asymptomatic monomorphic erythmatous lesions

Figure 2

Left arm showing asymptomatic monomorphic erythematous lesion

The parents were reluctant for psychiatry consultation asking about the relation of skin disease with psychiatry. The initial barrier was overcome when the child and her parents were reassured that she had been asked for psychiatry consultation for the evaluation and management of “stress” which might be manifesting as a skin eruption.

RS was the younger daughter of a physics lecturer in a government college. Her elder sister was extremely bright in academics and preparing for board examinations. The father was engaged in teaching the elder sister as he had high expectations from her. He had little time left for RS. RS being a naughty child was not getting enough time and attention, her academic grades were persistently falling. RS was often rebuked by her father due to her poor scholastic performance which would make her extremely unhappy.

The birth history of RS was uneventful and developmental milestones were attained at age appropriate levels. RS talked of her difficulties in studies and feelings of loneliness and inadequacy on being scolded by her father for not performing well in studies. She talked about the difficulty in focusing on studies since her primary school days and inability to organize her tasks which would often result in late submissions of her work. The support which was provided by her father had also faded in the last 1 year which was adding to her problems. She denied pervasive feelings of sadness or anxiety. Her parents corroborated her difficulties. The child fulfilled criteria for ADHD, predominantly inattentive type as per Diagnostic and Statistical Manual of Mental Disorders Fifth Edition and with a total score of 32 on Vanderbilt ADHD diagnostic parent rating scale with positives on items about inattention.[67] She was prescribed with tablet atomoxetine 10 mg and is under regular follow-up.

Discussion

Patients with psychodermatoses deny any psychiatric problems and often due to stigma do not seek psychiatric treatment; hence, the primary psychiatric disorders remain undiagnosed. A supportive nonjudgmental approach from the treating psychiatrist is essential for initiating treatment.[1]

The dermatologic manifestation in our case is similar to superficial skin lesions in face and upper limbs as reported in literature.[8] Interpersonal conflicts with siblings and parent are often the underlying stressors as was in our patient.[45]

This is the first case of ADHD which has presented with dermatitis artefacta. The resulting scholastic impairment with high parental expectations was the cause of psychological distress to the child. The child expressed utter ignorance to the cause of her lesions demonstrating the fact that many a times patients dissociate while inflicting lesions.[9] Parents were ignorant of the condition as the lesions would appear, whereas the child would be in her school hence ruling out parental direct involvement.

The child has good response to medication and her difficulty in concentration has reduced dramatically. The core management of ADHD is pharmacotherapy and atomoxetine was chosen because of co-existing emotional problems. Behavior therapy is an evidenced-based treatment for ADHD which when added to pharmacotherapy improves patient outcome.[10] Parent training was initiated consisting of techniques of behavioral conditioning. Parenting skills training was imparted which included both positive and negative reinforcement techniques. Positive reinforcement techniques consisted of praise and rewards for desirable behavior and negative reinforcement techniques included ignoring unwanted behavior. The patient is also taught about identifying her negative emotional states and using relaxation exercises, distraction, and visual imagery as adaptive coping methods. The child is in regular follow-up with psychiatrist.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.