Dermatitis Simulata: A Curious Case of Photodistributed Facial Rash.

Dear Sir,

Psycho-cutaneous disorders are an under-recognized group of diseases in clinical practice. They can mimic various dermatoses and a high index of suspicion is usually required for its diagnosis.[1] Herein, we report a case of dermatitis simulata in a young woman clinically resembling a photosensitive rash.

A 24-year-old female patient on imatinib therapy for chronic myelogenous leukemia (CML) was referred to dermatology services for the evaluation of an asymptomatic intermittent rash involving her face. She attributed her current complaints to imatinib as they developed soon after its initiation three years ago. She also complained of photosensitivity and occasional joint pains but denied fever, oral ulcers, Raynaud's phenomenon, and muscle weakness. The referring hematologist had considered the differentials of imatinib-induced photosensitive rash and connective tissue disease-associated malar rash.

On examination, well-defined pink patches were noted over both cheeks and peri-ocular area [Figure 1a]. In addition, similar pink patches in a linear distribution were seen over the abdomen and legs [Figure 1b-d]. On dermatoscopic examination, pinkish-red exogenous pigment deposits, over perifollicular and eccrine gland openings were observed. A clinical possibility of dermatitis simulata was considered. The lesions were rubbed with an alcohol swab with which the artificial color was easily wiped off [Figure 2 and inset]. On further questioning, the patient initially denied the application of cosmetics but later on she admitted to have self-inflicted the lesions using lipstick. However, the intention behind this behavior was not clear. She was referred for further psychiatric evaluation and they have advised for projective personality testing but the patient refused to participate in the test and didn’t follow up.

Figure 1

A case of dermatitis simulata in a young female showing well-defined pink patches over both cheeks and peri-ocular area (a), similar pink patches arranged in a linear distribution is present over the abdomen (b), left leg (c) and right leg (d)

Figure 2

Complete clearance of the lesions after wiping with spirit swab. Inset showing pink pigment laden spirit swab

Dermatitis artefacta or factitial dermatitis is a psychocutaneous disorder in which the patient intentionally self-inflicts the signs of a dermatosis in an attempt to satisfy a conscious or unconscious desire to assume the sick role.[2] Lesions are inflicted by sharp objects and irritant chemicals, producing erythematous, ulcerative, and gangrenous lesions that show a bizarre geometric pattern. These lesions are often located over accessible sites with the surrounding skin being unaffected. Dermatitis simulata is a related entity, where apparent skin disease is produced using an external disguise and there is no significant damage to the skin.[3] Some of the external agents used by patients of dermatitis simulata include cosmetics, to induce skin discoloration which can be easily removed by spirit swabs, crystallized sugar to simulate keratin crusts that can be dissolved in water.[4] In these patients, a detailed psychiatric evaluation is necessary to exclude malingering as a cause in which the patient may have a secondary material gain.

Imatinib, a tyrosine kinase inhibitor is a cornerstone for the treatment of CML. A plethora of cutaneous adverse effects to imatinib have been reported including photosensitive rash and pseudoporphyria.[5] The apparent photo-distributed rash in our patient clinically mimicked malar rash and drug-induced photosensitive eruption. However, a close examination and a detailed history revealed dermatitis simulata as the underlying cause.

The knowledge of psycho-cutaneous disorders among other specialties, namely family physicians and internist is limited leading to diagnostic delay or missed diagnosis. With the increasing ease of access to medical knowledge by the layman, patients are being more proficient in disguising signs and symptoms. The predominance of lesions over accessible sites, linear or punched out lesions, bizarre and angulated morphology, gaps in patient history, and lesional evolution are certain red flags, which point towards dermatitis artefacta. A non-confrontational approach by the dermatologist and allowing the patient to have the freedom to express their difficulties in a passive confidential environment by a psychiatrist will help towards exploring the complex personality and behavioral derangement that underlies this condition.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.