Epidermal multinucleated keratinocytes: a histopathologic clue to dermatitis artefacta

Dermatitis artefacta is a psycho‐cutaneous disorder characterized by self‐inflicted cutaneous injuries, often in association with an underlying psychiatric disorder or as a response to external stressors. Cutaneous lesions suggestive of dermatitis artefacta are dependent on the means of injury and thus may be morphologically variable, but typically have geometric shapes, spare hard‐to‐reach anatomic areas, and are present in variable stages of evolution at any specific time. Although a dermatologist may be suspicious of dermatitis artefacta in a given patient, making a definitive diagnosis is extremely challenging. Patients often clinically evade questioning and deny creating skin lesions, and histopathologic evaluation of lesional biopsies usually reveals non‐specific epidermal and dermal changes and inflammation. Thus, identification of clues that lend support to a diagnosis of dermatitis artefacta would be welcomed by both clinicians and pathologists. Here we present a case of dermatitis artefacta with a unique, yet previously reported, histopathological finding of multinucleated keratinocytes within the epidermis. Although probably uncommon and dependent on the etiology of cutaneous injury, we believe this finding is important for dermatopathologists to be aware of as a potential diagnostic clue when evaluating biopsies in patients suspected to have dermatitis artefacta.     

Dermatitis artefacta in pediatric patients: experience at the national institute of pediatrics

Dermatitis artefacta is a factitious disorder in which there is deliberate conscious production of skin lesions. There are only a few reports that evaluate instances of dermatitis artefacta in the pediatric population. The aim of this retrospective study was to assess the characteristics of patients with this disorder who were seen at the National Institute of Pediatrics in Mexico City. The records of all patients diagnosed with dermatitis artefacta from January 1980 to December 1999 were analyzed. There were 29 patients (25 females, 4 males). The upper limbs and the face were the most commonly involved areas. Superficial erosions were the most frequent initial event, and residual lesions consisted of scars and crusts. Time taken to diagnosis was on average 10 months. Half of the patients were lost to follow-up. No correlation was found between the length of time from the disease onset to diagnosis, the type of lesions, and the clinical outcome. Twelve patients had an associated systemic disorder. The possible association with chronic disease has not been sufficiently stressed and demonstrates the importance of providing psychological support for these patients. Psychiatric diagnoses were anxiety, depression, and personality disorder. No correlation was found between the psychiatric diagnosis and the outcome of dermatitis artefacta. A young age at presentation, which has been considered important as a favorable prognostic sign, could not be demonstrated in our patients.     

Dermatitis artefacta

Dermatitis artefacta, also known as factitial dermatitis, is a condition whereby self-induced skin damage is the means used to satisfy a conscious or unconscious desire to assume the sick role. It is particularly common in women and in those with an underlying psychiatric diagnosis or external stress. The diagnosis is one of exclusion, and it is often difficult to confirm, with patients rarely admitting their role in the creation of their lesions. Treatment can be challenging, and management should adopt a multidisciplinary team approach composed of dermatologists and mental health professionals. We present a literature review of dermatitis artefacta, highlighted by a case report of a patient with bilateral ulcerations to the legs, which after thorough investigation represented dermatitis artefacta.     

Bullous cryothermic dermatitis artefacta induced by deodorant spray abuse

Background Dermatitis artefacta belongs to a broad spectrum of factitious diseases of lesions usually self‐induced by patients. Here we report a surprisingly effective induction of blisters and thermic dermatitis by excessive abuse of common deodorant sprays. Objectives We evaluated the clinical course and outcome in three patients with dermatitis artefacta induced by deodorant spray. Methods A 12‐year‐old boy only admitted the abuse of deodorant spray after psychiatric intervention. Two adults (21‐year‐old and 37‐year‐old women) had borderline personality disorder and frankly reported the urge to induce pain by spraying for at least 100 s at a short distance. Results Bullous dermatitis was the acute presenting sign in all patients. The bullae were found on the extensor surfaces of the extremities, with a distribution of older lesions showing erosions and scarring and fresh lesions with intact bullae with a diameter of 3–15 cm. After searching for the causative agent and removal of the deodorant spray, clinical outcome showed a healing without and with scars. Conclusions Cryo‐damage by abuse of common deodorant sprays seems to become a popular mechanism by which an impressive bullous dermatitis can be artificially induced. Dermatologists and psychiatrist should be aware of this method of injury.     

Dermatitis artefacta: unusual appearance in an older woman

Dermatitis artefacta is a rare and difficult condition for diagnosis and treatment, with the highest incidence of onset in late adolescence to early adult life. Most patients are young women who have a personality disorder; borderline features are common and the patient's denial of psychological distress makes management and treatment difficult. Patients use a variety of means to cause the skin changes. Clinical presentation of the skin lesions does not conform to those of known dermatoses and are located on easily reached parts of the skin. We report an unusual case of a 72-year-old woman with symmetrical changes under the breasts and in the right inguinal region. The lesions were composed partly of haemorrhagic round lesions and partly of scars. A skin biopsy was taken and consultations with the psychiatrist, internist and the patient's family led to the diagnosis of self-induced dermatitis. The skin lesions were covered by occlusion techniques and the lesions improved very rapidly. The patient was discharged from the hospital under psychiatric and family care.     

Dissociative identity disorder presenting as dermatitis artefacta

Dermatitis artefacta is a rare psychiatric condition characterized by rubbing of skin blisters and denial of self-infliction. Dissociation may be comorbid with self-injurious behavior. A background of emotional disturbances during formative years and in later life often results in feelings of isolation and insecurity, which can lead to dissociation as a primary defense mechanism used to overcome traumatic events. In this case report, we describe a female patient with dermatitis artefacta associated with dissociative identity disorder. The patient was a 14-year-old girl. Multiple large, deep ulcerations with unnatural shapes were seen on her left forearm. The ulcerations were thought to be self-inflicted. Psychiatric examination revealed that she had a different identity, and inflicted the lesions when this was assumed. This case leads us to suggest that patients with dermatitis artefacta might have comorbid dissociative experiences, which cannot be identified easily.     

Psychiatric aspects of dermatitis artefacta

Fifty patients with dermatitis artefacta were investigated psychiatrically over several years and twenty-six of these were seen independently by a clinical psychologist. The psychological investigations suggest a personality structure characterized by inward-looking self-centred attitudes leading to increasing isolation. The psychiatric investigations suggest a background of emotional disturbances during the formative years and in later life often resulting in feelings of isolation and insecurity. The onset of dermatitis artefacta is very frequently related to definable precipitating events which vary according to age and life situations. The visible skin lesions can be understood as an attempt at non-verbal communication subserving an appeal function. Therapeutic methods and prognosis are discussed in some detail.     

Dermatitis artefacta induced in a patient by one of her multiple personalities

A young woman suffered for 5 weeks with an inexplicable, severe dermatitis limited to her left arm. During hospitalization it was found that she had multiple personalities, one of whom had been applying the leaves of the poison ivy plant each night to her left arm, using 'his' gloved right hand. The factitial nature of the dermatitis was further documented by the fact that when the 'responsible personality' was cut off from supplies of poison ivy in the hospital, 'he' produced factitious haematomas by trauma to her left hand. Although this appears to be the first report of dermatitis artefacta associated with the multiple personality disorder, it is suggested that psychiatric study of other dermatitis artefacta patients might reveal the presence of unsuspected occult multiple personalities, responsible for skin lesions that patients cannot explain.     

Self-inflicted skin diseases. A retrospective analysis of 57 patients with dermatitis artefacta seen in a dermatology department

We analysed clinical symptoms, gender, age and social relations among 57 patients for whom a final diagnosis of dermatitis artefacta was established. The study is retrospective and the patients were seen in our department from 1982 to 2002. We observed that the diagnosis was 2.8 times more common in females than males. Symptoms were most common in the age group 18-60 years, median age 39 years. The skin lesions were 'multiple' among 88% of the patients. When self-infliction was suggested as the cause, two-thirds of patients initially denied it and only one patient agreed to meet with a psychiatrist. Only one-quarter had a job, the rest were unemployed or on sick leave. Many patients (61%) received medical treatment with anxiolytica. Ten patients (18%) had a psychiatric diagnosis. Among our 57 patients, 11 were deceased at the time of our study, but none because of suicide. Four had died before the age of 70, of whom two suffered from alcoholism and two had diabetes mellitus. Therapy should include an optimal nursing relationship with the patient so that social problems can be discussed. Psychological or psychiatric intervention appeared unhelpful because of patient denial.     

DERMATITIS ARTEFACTA AND SEXUAL ABUSE

Case 1 : This 16-year-old woman was referred for psychiatric management of her dermatitis artefacta that presented as superficial linear abrasions on her thighs and arms. During psychotherapy, the patient disclosed that her father had started sexually molesting her when she was about 8 years old. By age 10 years her father was having sexual intercourse with her. Initially, the patient confused her father's sexual advances with affection, but by age 10 years she became acutely aware of the abusive nature of their relationship. At this time, the father threatened to leave the family if the patient disclosed the sexual abuse. This was very threatening for the patient, since it would mean that her mother and her siblings would end up on welfare. The father then blamed the patient for “seducing him” and continued to abuse her sexually; the patient felt guilty and “bad.” The patient started making superficial linear abrasions on the anterior aspects of her thighs. She described that it helped her “release tension” because the pain helped her to cope with her guilt. The patient was essentially “punishing herself” by inflicting the lesions on herself. The patient also felt “very fat and ugly” and the scars on her body helped to validate this. During the course of therapy, the patient had much difficulty coping with the unresolved anger that began to surface as she acknowledged her feelings regarding the sexual abuse. Initially, she could cope with her anger only by cutting herself, and the symptoms of her dermatitis artefacta became worse. After about 1 year of psychotherapy she was able to acknowledge her feelings more effectively and became much more assertive. This was associated with a marked decrease in the frequency of her self-mutilative behavior. Case 2 : This 29-year-old woman was referred for psychiatric management of her dermatitis artefacta. The patient would typically present to her family doctor with rectangular abrasions on her forearms. The self-inflicted nature of the lesions was obvious on inspection, but the patient denied remembering that she caused the injury. The patient entered psychotherapy once weekly, and after approximately 6 months, she began to have flashbacks about being sexually abused regularly by an older brother when she was between ages 5–8 years. The patient described dissociative experiences when she was being subjected to the abuse. For example, she felt like “she was watching someone else being abused” and remembers “not feeling anything” while her brother was raping her. Over several months she was able to recognize that she would dissociate whenever faced with emotionally disturbing situations, especially those involving anger. During these dissociative states she would inflict the rectangular abrasions on herself. The patient experienced a significant improvement in the frequency of her dissociative experiences and her self-mutilative behavior as she acknowledged her anger toward her brother more directly. Chlorpromazine, 25 mg qid, prn, also proved to be a valuable adjunct in her therapy, as it helped her to cope with her very strong anger, and decreased the frequency of her dissociative reactions.     

Dermatitis artefacta in a patient affected by impulse control disorder: case report

Dermatitis artefacta is a disease characterized by self-inflicted skin lesions in fully aware patients. Mechanical and chemical devices are most commonly used to produce such injuries. Several psychological disorders like depression, obsessive compulsive disorders, hysteria, etc. are associated with this kind of disease. Most of the patients are young females aged between 15 and 30, but the diagnosis of dermatitis artefacta may even be made in pediatric patients or elderly people. Because of its rarity and the polymorphism of lesions, dermatitis artefacta is often a challenge for the clinicians. More difficulties might be due to the lack of cooperation in these patients, who usually refuse the dialogue with doctors and deny their primary role in damaging their skin. We present a case of an elderly woman who showed a peculiar pattern of deep excoriating lesions disseminated on the upper part of her body, with an evident state of depression. Diagnostic and therapeutic procedure, that is often long lasting and difficult in such cases, was made by teamwork of dermatologists, psychiatrists and psychologists, leading to steady control of impulses and full remission of cutaneous symptoms.     

Dermatitis Artefacta

Self-inflicted dermatoses mainly refer to psychiatric disturbances such as psychoses, mental retardation, and personality disorders. Diagnostic clues are found in the nature and the evolution of the lesions as well as in the ambivalent combination of dependency on doctors and hostility toward them revealed in the patient's medical history. Management of dermatitis artefacta patients means dealing with the complex emotional issue of a basic antagonism in the dermatologist-patient relationship. Both the dermatologist and the dermatologic nursing staff should show an understanding and nonaggressive attitude.     

Dermatitis artefacta as the presenting feature of auto-erythrocyte sensitization syndrome and naproxen-induced pseudoporphyria in a single patient

A female patient presented with two episodes of apparent dermatitis artefacta. Although it was clear that self-induced lesions were present on both occasions, there was also strong evidence in support of auto-erythrocyte sensitization syndrome on the first occasion and of naproxen-induced pseudoporphyria on the second occasion. The occurrence of two such rare disorders in a single patient is extremely unusual, and we discuss a possible pathogenetic link between them. The case emphasizes that patients with apparent artefactual lesions, or with a previous history of dermatitis artefacta, still require careful evaluation to identify organic disease.     

Dermatitis Artefacta

Abstract: Self-inflicted dermatoses mainly refer to psychiatric disturbances such as psychoses, mental retardation, and personality disorders. Diagnostic clues are found in the nature and the evolution of the lesions as well as in the ambivalent combination of dependency on doctors and hostility toward them revealed in the patient's medical history. Management of dermatitis artefacta patients means dealing with the complex emotional issue of a basic antagonism in the dermatologist-patient relationship. Both the dermatologist and the dermatologic nursing staff should show an understanding and nonaggressive attitude.     

Dermatitis artefacta

Dermatitis artefacta (factitious skin disorder) is a rare psychocutaneous disorder that poses a complex clinical challenge to clinicians. The hallmarks of diagnosis include self-inflicted lesions in accessible areas of the face and extremities that do not correlate with organic disease patterns. Importantly, patients are unable to take ownership of the cutaneous signs. It is essential to acknowledge and focus on the psychologic disorders and life stressors that have predisposed the condition rather than the mechanism of self-injury. The best outcomes are achieved via a holistic approach in the setting of a multidisciplinary psychocutaneous team addressing cutaneous, psychiatric, and psychologic aspects of the condition simultaneously. A nonconfrontational approach to patient care builds rapport and trust, facilitating sustained engagement with treatment. Emphasis on patient education, reassurance with ongoing support, and judgment-free consultations are key. Enhancing patient and clinician education is essential in raising awareness of this condition to promote appropriate and timely referral to the psychocutaneous multidisciplinary team.     

Self-induced dermatoses: A great imitator

The self-induced dermatoses represent about 2% of dermatology patient visits, and include the recurrent body-focused repetitive behaviors (BFRB) (skin-picking or excoriation disorder, trichotillomania, onychophagia and onychotillomania), dermatitis artefacta, and features of other psychiatric disorders, for example, secondary to excessive grooming in body dysmorphic disorder, skin picking in delusional infestation, or secondary to self-harm in depressive disease. Among the BFRBs, onychophagia and onychotillomania are most likely to be associated with lesions that mimic other dermatologic conditions (eg, nail psoriasis, lichen planus, vasculitis, onychomycosis, melanoma). Dermatitis artefacta (DA) describes lesions that are self-inflicted with the intention of assuming a sick role in the absence of obvious external rewards. DA lesions can be bizarre-appearing or may be created intentionally to mimic dermatologic disease (eg, Munchausen syndrome). The manipulation of the integument can have a focused obsessive-compulsive behavioral style which is more responsive to the standard behavior therapies, or an impulsive-dissociative style where patients have partial or no recollection of having self-induced their lesion; dissociative patients tend to have more severe BFRBs and DA, and greater psychopathology. Self-induced dermatoses may both imitate and co-occur with primary dermatologic disease, and may not be readily identified unless the clinician maintains an index of suspicion.     

Undiagnosed purpura: a case of autoerythrocyte sensitization syndrome associated with dermatitis artefacta and pseudo-ainhum

A 23-year-old young woman presented with recurrent episodes of painful bruising along with linear erosions on the accessible areas of the body of nine years duration with a pseudo-ainhum of her left nipple for the past three months. Her case history included repeated visits to various physicians at different centers and an extensive investigative profile. A diagnosis of autoerythrocyte sensitization was made on the basis of the clinical history, dermatological examination complemented by a positive autoerythrocyte sensitization test, psychiatric evaluation and absence of any organic cause for her ailment. She was placed on psychiatric management and has remained symptom-free after six months follow-up. The case is reported for its rarity, as well as for the association of autoerythrocyte sensitization syndrome with frank dermatitis artefacta and pseudo-ainhum, which to the best of our knowledge has not yet been reported in the literature.     

Dermatitis artefacta de localización periorbitaria y perioral

—Dermatitis artefacta, a part of the general spectrum of factitious conditions, is defined as a self-inflicted disorder in which the responsibility for the lesions is uniformly denied by the patient. A high index of suspicion is needed in the diagnosis, specially in patients presenting with unusual multisystem disease, bizarre skin lesions and recurrent hospital visits.We report the case of a 43-year-old woman with a 13-year rheumatological history, presenting with atypical crops of blisters and pustules, developing into excoriations and crusty lesions with an extremely symmetric distribution, located in periocular and perioral regions, of one year duration. She has already been admitted to hospital on five occasions. Laboratory tests showed no significant alterations. Histopathology was not specific. Occlusive dressings were the only partially effective treatment. Psychiatric assessment confirmed a diagnosis of factitious disease. Psychiatric relationship was established employing a supportive and empathic approach and avoiding direct confrontation.Therefore, liaison between dermatologists and psychiatrists is strongly advocated.     

Autoerythrocyte sensitization syndrome with vertigo and hemilateral auditory impairment

Autoerythrocyte sensitization syndrome (AES) is characterized by recurrent, painful purpura or ecchymosis. Testing for the reappearance of lesions after injection of the patient's own erythrocytes is usually useful for the diagnosis of AES, but the significance of this test is still controversial. As the lesions often appear in patients with psychiatric disorders, mental factors such as depression and stress are considered to be involved in the occurrence and exacerbation of AES. We report a 28-year-old woman who presented recurrent episodes of painful purpura with vertigo and hemilateral auditory impairment after difficulties at her workplace. After the diagnosis of AES, she was referred for psychiatric counselling, after which the symptoms disappeared. These findings suggest that treatment for psychological disorders is important in patients with AES.     

Dermatitis artefacta: retrospective study in 31 patients

BACKGROUND: The outcome for patients with dermatitis artefacta is not well known. The primary objective of this single-centre retrospective study was to describe the initial clinical aspects and the prognosis of the disease. The secondary objective was to describe the somatic and psychological management and long-term treatment of these patients. PATIENTS AND METHODS: Records of patients with dermatitis artefacta followed in the dermatology department over the 15 last years were reviewed independently by 2 dermatologists. Diagnostic criteria consisted of evocative clinical pictures and the exclusion of other forms of dermatosis. Data collection included: file analysis, photographs, review questionnaires sent to general practitioner or completed during a phone call to patients (follow-up data). RESULTS: Thirty-one patient files were selected: 23 women and 8 men, mean age 31 years (SD = 14.8). Clinical aspects included: erythema (50%), ulceration (37%), crust (23%) and blisters (17%). The main sites were the face (67%) and arms (43%). Topical treatment was prescribed in all cases and systemic treatment was prescribed in 23% of cases. Psychological support was offered to 65% of the patients and was accepted by 50%. A follow-up study was performed for 17 patients and showed serious complications in 4 cases consisting of psychosis (n=2) and/or severe self-mutilation (n=3) occurring over several years following diagnosis (5 years for one patient and 12 years for 2 patients). DISCUSSION: The results confirm the usual and characteristics of dermatitis artefacta such as predominance in young female patients, with lesions affecting visible areas (face, upper legs). In contrastwith published studies, no cases of attempted suicide were observed in our series, although severe dermatitis artefacta was evidenced in only a minority of patients.