Dermatitis Artefacta


Article Author:
Veena Chandran


Article Editor:
George Kurien


Editors In Chief:
Wanda Wright
Cynthia Oster


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Carrie Smith
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James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
3/16/2019 1:30:42 PM

Introduction

Dermatitis artefacta or factitious dermatitis is a psychocutaneous disorder in which the patients consciously create lesions in skin, hair, nail, or mucosae to satisfy a psychological need, attract attention, or evade responsibility. The patients usually hide the responsibility for their actions from their doctors. Dermatitis artefacta should enter the differential diagnosis of every chronic, puzzling, and recurrent dermatoses.[1][1][2]

Etiology

Unlike malingering, there is no direct benefit sought from induction of the skin lesions. The patient induces the lesions to satisfy an internal psychological need, which is often the need to be noticed or to receive care. Various psychosocial conflicts, emotional immaturity, unconscious motivations, and disturbed interpersonal relations have been implicated as the etiological factors.[3][4]

Epidemiology

In general, there is female preponderance (female-male ratio reported to vary from 20:1 to 4:1), with the highest incidence of onset in late adolescence to early adult life. [5]No age group is exempt, and onset in older age, as well as the occurrence of the condition in children as young as eight years old, has been documented in the literature.[6] The condition used to be more common in people with a background of medical knowledge. This bias is less obvious in a modern and well-informed society that has more access to media and the internet.

Pathophysiology

Adults with the disease may have associated neurosis, personality disorders, impulsiveness, or depression. The patients may assume a sick role which may allow avoidance of adult responsibilities. There may be associated self-hate and guilt. Children may have associated anxiety or immature coping styles to various psychosocial stresses. The fictitious illness may symbolize anger or conflict with authorities, for example, a school phobia.

History and Physical

The typical presentation includes cutaneous lesions which are bizarre and mimic many of the known inflammatory reactions in the skin[7]. The fabricated history that follows is usually “hollow," and there is no complete description of the genesis of individual skin lesions which appear suddenly and fully formed on accessible sites. More emphasis is given to describing the complications and failure to heal. The patients typically have a “la belle indifference” towards their predicament, showing a lack of concern, but their relatives may be angry and frustrated.[8][9][10][11]

The lesions may be circular blisters or erosions, burns, cryodamage, excoriations, urticarial lesions, hemorrhages, indurations, or necrosis. These may be consequences of an application of foreign bodies or chemicals.[12] Traces or evidence of these is noticeable on close examination of crude dermatitis. Any part of the body can be affected, but the most common site in all age groups is the face, followed by dorsum of hands and forearm of the non-dominant limb. The patients also may present with nonhealing postsurgical wounds.

Classic location of dermatitis artefacta includes the following:

  • Face, most common
  • Lower extremity, second most common
  • Hands and forearm, third most common
  • Trunk
  • Upper arm and shoulder
  • Scalp
  • Neck

Types of lesions seen in dermatitis artefacta:

  • Abrasions or erosions
  • Alopecia
  • Crusted lesions
  • Discolored macules
  • Erythematous papules
  • Excoriations
  • Nail deformity
  • Petechiae or purpura
  • Scars in chronic cases
  • Ulcerations

Most patients have more than one skin lesion. On the physical exam, the healthcare worker must differentiate the disorder from trichotillomania, excoriation disorder dermatitis neglecta. Sometimes the skin lesions may be severe and mimic a T cell lymphoma, hemophilia, and porphyria cutanea tarda.

Evaluation

The clinical presentation, including distribution and physical characteristics, are almost diagnostic. The typical presentation in the context of a psychiatric constellation differs from that of neurotic excoriations, delusional disorders, malingering, and Munchausen syndrome (hospital hoppers who fake illness without motivation by external incentives). The differential diagnoses to be considered for crusted, blistering lesions include ecthyma and herpes simplex. Others may simulate porphyria cutanea tarda, epidermolysis bullosa acquisita, amyloidosis, vasculitis, pyoderma gangrenosum, cutaneous lymphoma, drug eruptions, or loxoscelism.

Treatment / Management

The skin lesions may need treatment with topical antibiotics, but in some cases, one may need oral antibiotics if there is evidence of a severe infection.

The underlying mental health disorder must be addressed and treated. The usual drugs include antipsychotics, antidepressants, and sedatives. NSAIDs may be prescribed, but opiate and other prescription analgesics should be avoided for fear of inducing addiction and physical dependence.[13][14][15][16]

If the individual has evidence of depression, then reports indicate that SSRIs should be the drugs of choice. Tricyclics also are helpful for patients with itching and insomnia. Tricyclics also help relieve pain and depression.

Prolonged use of antipsychotics should be avoided because they also have potent side effects. However, in patients with delusional and psychotic features, antipsychotics can be beneficial.

The patient's denial of psychological distress and negative feelings aroused in healthcare personnel make management difficult. The doctor should create an accepting, empathic, and non-judgemental attitude and avoid confrontation. Close supervision and good symptomatic care of skin lesions permit the development of a therapeutic relationship in which psychological issues may gradually be introduced, which may occasionally permit a psychiatric referral. When the patient refuses a psychiatric referral, the use of psychotropic drugs by dermatologists is helpful and appropriate[17]. The upper dose range of SSRIs or low-dose atypical antipsychotic agents may be effective. Except in mild transient cases triggered by an immediate stress, the prognosis for cure is poor. The condition tends to wax and wane with the circumstances of the patient's life. Lesions can be kept to a minimum, and the patient can be protected from unnecessary and intrusive studies with ongoing supervision and support and regular outpatient reviews.

Dermatitis artefacta is a long-term disorder, and patients need regular follow up with a dermatologist and a psychiatrist because relapses are common. Many patients are noncompliant with treatment and often fail to follow up.

Prognosis

For patients with mild cases of dermatitis artefacta associated with common stressors like pressure, anxiety or depression, the prognosis is good. However chronic cases of dermatitis artefacta that are associated with medical problems and chronic skin damage usually have a guarded outcome. These people usually cannot be cured, and relapses are very common. When the condition is left untreated, it can lead to severe self-mutilation and poor aesthetics with disfiguring scars. Tragically, suicide is also a real potential outcome in some of these patients.

Enhancing Healthcare Team Outcomes

The diagnosis and management of dermatitis artefacta is complex and best done with a multidisciplinary team that includes the primary care provider, nurse practitioner, psychiatrist and dermatologist. While the skin lesions may need treatment, the underlying mental health disorder must be addressed and treated. The usual drugs include antipsychotics, antidepressants, and sedatives. NSAIDs may be prescribed, but opiate and other prescription analgesics should be avoided for fear of inducing addiction and physical dependence.

The patient's denial of psychological distress and negative feelings aroused in healthcare personnel make management difficult. The doctor should create an accepting, empathic, and non-judgemental attitude and avoid confrontation. Close supervision and good symptomatic care of skin lesions permit the development of a therapeutic relationship in which psychological issues may gradually be introduced, which may occasionally permit a psychiatric referral.

Dermatitis artefacta is a long-term disorder, and patients need regular follow up with a dermatologist and a psychiatrist because relapses are common. Many patients are noncompliant with treatment and often fail to follow up. The prognosis for most patients is poor- leading to self injury, scarring and poor cosmesis.[18][19]


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Dermatitis Artefacta - Questions

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A 17-year-old female presents with new onset oval, yellowish skin defects on her right hand. They are an average of 3 x 3.5 centimeters in diameter and have an erythematous, clearly defined border surrounded by erythematous, painful skin resembling pyoderma gangrenosum. What is the most probable diagnosis?

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A 35-year-old woman presented with six years of history of ulcerated lesions over the chest and abdomen. She was living with her elderly mother. She gave a vague history of the evolution of symptoms and said that an insect bite triggered the lesions. There was no history of diabetes mellitus or any other systemic illnesses. On examination, she was systemically well. There were large ulcerated lesions on the affected areas that were tender. Poor personal hygiene was noted, and there was a possibility of self-neglect. Which among the following makes one think about the possibility of dermatitis artefacta?



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Dermatitis Artefacta - References

References

Dermatitis artefacta. Clinical features and approaches to treatment., Koblenzer CS,, American journal of clinical dermatology, 2000 Jan-Feb     [PubMed]
Pradhan S,Sirka CS,Dash G,Mohapatra D, Dermatitis Artefacta in a Child: An Interesting Morphological Presentation. Indian dermatology online journal. 2019 Jan-Feb;     [PubMed]
Lavery MJ,Stull C,McCaw I,Anolik RB, Dermatitis artefacta. Clinics in dermatology. 2018 Nov - Dec;     [PubMed]
Mohandas P,Ravenscroft JC,Bewley A, Dermatitis artefacta in childhood and adolescence: a spectrum of disease. Giornale italiano di dermatologia e venereologia : organo ufficiale, Societa italiana di dermatologia e sifilografia. 2018 Aug;     [PubMed]
Krooks JA,Weatherall AG,Holland PJ, Review of epidemiology, clinical presentation, diagnosis, and treatment of common primary psychiatric causes of cutaneous disease. The Journal of dermatological treatment. 2018 Jun;     [PubMed]
Wong JW,Nguyen TV,Koo JY, Primary psychiatric conditions: dermatitis artefacta, trichotillomania and neurotic excoriations. Indian journal of dermatology. 2013 Jan;     [PubMed]
Tittelbach J,Peckruhn M,Elsner P, Histopathological patterns in dermatitis artefacta. Journal der Deutschen Dermatologischen Gesellschaft = Journal of the German Society of Dermatology : JDDG. 2018 May;     [PubMed]
Persad L,Salim S,Motaparthi K, Factitious Dermatitis Due to Thermal Burn With Histologic Features Simulating Fixed Drug Eruption. The American Journal of dermatopathology. 2017 Aug;     [PubMed]
Gupta MA,Pur DR,Vujcic B,Gupta AK, Suicidal behaviors in the dermatology patient. Clinics in dermatology. 2017 May - Jun;     [PubMed]
Lee HG,Stull C,Yosipovitch G, Psychiatric disorders and pruritus. Clinics in dermatology. 2017 May - Jun;     [PubMed]
Chatterjee SS,Mitra S, Dermatitis Artefacta Mimicking Borderline Personality Disorder: Sometimes, Skin Could Be Misleading. Clinical psychopharmacology and neuroscience : the official scientific journal of the Korean College of Neuropsychopharmacology. 2016 Aug 31;     [PubMed]
Gupta MA,Jarosz P,Gupta AK, Posttraumatic stress disorder (PTSD) and the dermatology patient. Clinics in dermatology. 2017 May - Jun;     [PubMed]
Sarin A,Ummar SA,Ambooken B,Gawai SR, Dermatitis Artefacta Presenting with Localized Alopecia of Right Eyebrow and Scalp. International journal of trichology. 2016 Jan-Mar;     [PubMed]
Patra S,Sirka CS, Attention deficit hyperactivity disorder presenting as dermatitis artefacta. Journal of pediatric neurosciences. 2016 Jan-Mar;     [PubMed]
Saha A,Seth J,Gorai S,Bindal A, Dermatitis Artefacta: A Review of Five Cases: A Diagnostic and Therapeutic Challenge. Indian journal of dermatology. 2015 Nov-Dec;     [PubMed]
Mohandas P,Bewley A,Taylor R, Dermatitis artefacta and artefactual skin disease: the need for a psychodermatology multidisciplinary team to treat a difficult condition. The British journal of dermatology. 2013 Sep;     [PubMed]
Rogers M,Fairley M,Santhanam R, Artefactual skin disease in children and adolescents. The Australasian journal of dermatology. 2001 Nov     [PubMed]
Verraes-Derancourt S,Derancourt C,Poot F,Heenen M,Bernard P, [Dermatitis artefacta: retrospective study in 31 patients]. Annales de dermatologie et de venereologie. 2006 Mar     [PubMed]
Jacobi A,Bender A,Hertl M,König A, Bullous cryothermic dermatitis artefacta induced by deodorant spray abuse. Journal of the European Academy of Dermatology and Venereology : JEADV. 2011 Aug     [PubMed]

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