A case of dermatitis artefacta during a pandemic.

Dear Editor,

The beginning of the coronavirus disease 2019 (COVID‐19) pandemic was associated with extreme measures taken by different countries to prevent and contain its spread: Italy was among the first countries that decided to set up travels bans and policies in order to limit the burden of the disease.

The implications of this crisis have been associated with adverse psychological outcomes in the general population: as a matter of fact, individuals who were already at risk had to endure additional psychological trauma because of the loss of their loved ones, unemployment and the need to be isolated or quarantined.

A 68‐year‐old woman, who had been affected by mood and anxiety disorders for many years, presented during the COVID‐19 lockdown period with self‐inflicted skin lesions on several part of the body.

On physical examination, she had numerous pruritic circular erythematous lesions on the extensor surfaces of her forearms (Figures 1 and 2). A biopsy of the lesioned skin was performed and it showed an excoriated epidermis with pseudoepitheliomatous hyperplasia (pruritic eczema‐like findings). Furthermore, the superficial dermis was characterized by small proliferating capillary vessels indicating a chronic process. Laboratory routine investigations were normal.

FIGURE 1

Circular erythematous lesions on the extensor surfaces of the forearms of a 68‐year‐old woman

FIGURE 2

Dermatitis artefacta: three circular lesions with an erythematous outer portion and a yellow core on the arm the of a 68‐year‐old woman

All in all, given the clinical picture of the patient, a diagnosis of dermatitis artefacta was made and the patient was sent to the psychiatry department of our hospital for a consultation.

The diagnosis was confirmed by the psychiatrist as well: in fact, he reported that the patient injured her skin in a compulsive way and could not avoid it, although aware of the risks underlying this behavior. In previous distressing conditions of her life (a conflicting relationship with her adopted child, breast cancer and chemotherapy at 58 years, and pituitary gland surgery), the patient had never injured her skin producing dermatitis. Nevertheless, she experienced depression and anxiety. During the recent period, the fear of a possible COVID‐19 infection, reinforced by media information, the lockdown condition and staying at home all day for several weeks produced an increased anxiety state with severe emotional distress.

The patient was prescribed oral tablet sertraline (100 mg/d) and oral tablet alprazolam (1 mg/d); in addition, she was given additional appointments to follow‐up her psychological status.

Emollient creams were applied on the lesions, improving the pruritus and the appearance of the erythematous areas.

She reported significant improvements in her psychological and dermatological symptoms at 2‐week follow‐up (Figure 3).

FIGURE 3

Arms of the patient at 2‐week follow‐up showing the improvement of the cutaneous lesions

Dermatitis artefacta, which is also referred to as factitious dermatitis, is a frequently unrecognized clinical entity associated with self‐injury behavior, in which conscious or unconscious manipulation causes skin lesions. , The self‐inflicted damage is likely to be found in areas of the body that are easily reachable and it stems from an attempt to shift the focus from psychological and/or social conflicts to a tangible entity like the skin. Factitious dermatitis is a psychocutaneous disorder which is more prevalent among women and it is frequently associated with a variable degree of psychological distress and a history of psychiatric disorders.

There is a plethora of skin lesions which may be associated with dermatitis artefacta and they are often endowed with nonspecific pathophysiological findings as in the case of our patient. The diagnosis can be challenging because of the dearth of unequivocal diagnostic tools, , hence it is made by exclusion of other skin diseases. The conditions that should be included in the differential diagnosis are vascular disorders, allergic contact dermatitis and prurigo nodularis. , Typically, the latter presents with dome‐shaped lesions on the extensor surfaces of the limbs on the background of a preexisting chronic pruritic condition. On the other hand, dermatitis artefacta is usually associated with lesions that are heterogeneous in appearance and are produced to fulfill a subconscious need to be seen as vulnerable : in this case, the pruritus is a consequence of the disease and not a preceding factor.

We decided to report this case because in this patient dermatitis artefacta seems to be related to and appeared in coincidence with the COVID‐19 emergency and lockdown. Moreover, we believe that there will be an increase of dermatitis artefacta incidence in the near future resulting from the ubiquitous effects of the COVID‐19 emergency.

CONFLICT OF INTEREST

The authors declare no conflicts of interest.

AUTHOR CONTRIBUTIONS

Ganiyat Adenike Ralitsa Adebanjo: The author took part in diagnosis, patient care, follow‐up, literature review, writing and preparation of the manuscript. The author reviewed the manuscript, and was involved in photography and literature review. Francesca Romana Parisella: The author took part in literature review, writing and preparation of the manuscript. The author reviewed the manuscript, and was involved in photography and literature review. Andrea Cittadini: The author is the primary physician of the patients and supervisor of the process. The author reviewed the manuscript, and was involved in data collection and follow‐up. Fabiola Luzi: The author took part in literature review, writing and preparation of the manuscript. The author reviewed the manuscript, and was involved in photography and literature review. Antonella Tammaro: This author is the primary physician of the patient and supervisor of the process. The author created the idea, reviewed the manuscript and was involved in photography, data collection and follow‐up.