A case of bullous dermatitis artefacta possibly induced by a deodorant spray

Dermatitis artefacta is one of a spectrum of factitious diseases etiologically responsible for skin lesions denied by patients. These factors often make it difficult to identify the causative agents of the condition. Herein, we report a case of bullous dermatitis artefacta in a 12-year-old girl, for which a deodorant spray was suspected as the probable cause. Pathological examination revealed subepidermal blistering with full-thickness necrosis of the epidermis, suggesting a thermo- or cryo-induced injury. Psychological testing demonstrated her immaturity and dependence. In searching for the causative agent, we suspected a deodorant spray as a blister-inducing agent. We succeeded in reproducing a similar blister lesion on the volunteer's healthy skin using the same spray. Psychiatric involvement significantly complicates the treatment of factitious diseases, including dermatitis artefacta. Cooperation among dermatologists, psychiatrists and the patient's family members is required for ensuring a favorable prognosis.     

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.     

A vesicular variant of pseudoverrucous papules and nodules in the genital area of an incontinent 4‐year‐old

Irritant contact dermatitis is a common cause of chronic vulvitis in patients wearing diapers and incontinence garments. In most cases the diagnosis is obvious; however, atypical presentations may mimic more serious dermatoses. We present a 4‐year‐old girl who presented at birth with cloacal atresia corrected surgically and resulting in chronic incontinence requiring full‐time diapers. She presented with crops of herpetiform vesicles and bullae on a base that ranged from normal skin to severe erythema and oedema. A histological examination revealed a well‐demarcated lesion showing a thickened epidermis with hyperkeratosis and parakeratosis, acanthosis and an abrupt transition to pallor of the upper half. Focal full thickness epidermis necrosis and small areas of spongiosis, acantholysis and apoptotic keratinocytes were seen. Immunofluorescence was negative. The lesions improved with the treatment of secondary infection and minimal topical therapy with an emollient only. This case represents an unusual vesicular variant of pseudoverrucous papules and nodules, which has been reported only once previously.     

Multifaceted dermatitis artefacta caused by garlic

Dermatitis artefacta is a self inflicted dermatosis without a precise and rational motive. A 19 year old patient presented with a peculiar multiform eruption induced by local application of garlic. The disorder of garlic dermatitis artefacta is discussed.     

Erythema multiforme‐like eruption associated with plant‐induced allergic contact dermatitis in a pediatric patient: A case report

An 11‐year‐old boy presented to the emergency department 5 days after playing in the forest. His initial eruption, consistent with allergic contact dermatitis to poison ivy, progressed into target lesions involving his extremities, palms, upper trunk, and face, consistent with an erythema multiforme‐like eruption. This report details the case and reviews the literature concerning this atypical and potentially underreported complication of plant‐induced allergic contact dermatitis.     

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.     

Recalcitrant granulomatous periorificial dermatitis with good response to low‐dose oral isotretinoin

Granulomatous periorificial dermatitis is a clinical variant of periorificial dermatitis. We present the case of an 18‐year‐old girl with several reddish papular lesions in the perioral, perinasal, and periorbital regions unresponsive to conventional therapy. After 6 months of therapy with low‐dose oral isotretinoin, the lesions fully remitted.     

Dermatitis artefacta unter dem Bild einer Lichtdermatose

Dermatitis artefacta is a form of a self-injury due to psychiatric disorders or internal conflicts. Delayed diagnosis often leads to unnecessary treatments. A 17-year old girl was referred with a putative photodermatosis presenting with erosions on an erythematous base on the face and forearms. The unusual rapid onset of new lesions following phototesting and in particular a reaction induced after a simulated light exposure substantiated the diagnosis of dermatitis artefacta. Faced with the diagnosed the patient admitted she had induced the lesions and was referred for psychiatric care.     

水芹致接触性皮炎1例

报告１例水芹致原发刺激性接触性皮炎。患者男性,２３岁,因用水芹捣碎贴敷于肩、背、双膝后,出现与贴敷部位一致的水肿性红斑,其上有大疱,部分皮肤以烫伤样表皮剥脱,自觉剧烈灼热、刺痛,无痒感。经抗炎治疗７天后痊愈出院。     

Annular lichenoid dermatitis of youth – a further case in a 12‐year‐old girl

Annular lichenoid dermatitis of youth was first described by Annessi et al. in 2003. Clinical criteria are persistent erythematous macules and annular lesions with a red‐brown edge and a central hypopigmentation usually found on the flanks and groins of children and adolescents. Histologically, the disease is characterized by a lichenoid interface dermatitis with necrotic keratinocytes at the tip of the rete ridges. In our case a 12‐year old girl developed annular red‐brown macules with papules at the borders in an inframammary location. The histology of the lesion's border showed a lichenoid lymphocytic infiltrate with apoptotic keratinocytes at the tip of rete ridges. The lesions cleared with 0.03% tacrolimus ointment. Annular lichenoid dermatitis of youth is probably a new entity in the group of lichenoid dermatoses.     

Annular lichenoid dermatitis of youth—Recurrent case of rare skin disease treated with cyclosporine

Annular lichenoid dermatitis of youth (ALDY), first described in 2003, represents an uncommon entity whose etiopathogenesis is still debated. Futhermore, the optimal treatment for ALDY is yet to be established. We report a 9‐year‐old girl who presented with annular and oval erythematous lesions mostly on her trunk, with several lesions on the neck, groin, flanks, and upper extremities. The lesions had histological and immunohistochemical features characteristic for ALDY. Treatment with H1‐antihistamines, topical corticosteroid, and UVB therapy was unsuccessful, while systemic treatment with cyclosporine induced complete remission.     

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.     

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.     

Dermatitis artefacta of the breast: a retrospective analysis of 27 patients (1976–2006)

Background Dermatitis artefacta (DA) is defined as all dermatological, self‐inflicted skin lesions, where the patient denies having produced the lesions. Objectives The purpose of this study is to make a single‐centre retrospective clinical review of patients diagnosed as DA of the breast. Materials and methods During a 30‐year period (1976–2006), patients diagnosed as DA of the breast, seen in the Department of Dermatology of the Virgen Macarena Hospital in Seville, were recorded. Clinical and epidemiological features are described. Results A total of 27 women with a mean age of 34.33 years were selected representing 13.43% of the total of DA patients recorded (n = 201) in this period. The most frequent clinical forms were: excoriations (nine patients, 33.33%) and ulcers (nine patients, 33.33%), followed by burns (six patients, 22.22%), blisters (one patient, 3.70%), contact dermatitis (one patient, 3.70%) and haematomas (one patient, 3.70%). Ten of the cases were located exclusively on the breasts, whereas 17 had also other locations such as face in seven cases, arms in five cases, abdomen in five cases and the entire body in two cases. Cutaneous lesions were treated with occlusive bandages using zinc paste or plaster splint when necessary. Conclusion To our knowledge, this is the major series of DA of the breast studied. This complicated psychodermatological condition requires a correct diagnosis, appropriate management and psychiatric assessment.     

Are obsessive‐compulsive disorders and personality disorders sufficiently considered in occupational dermatoses? A discussion based on three case reports

Hand dermatitis is relatively common in the general population. Among work‐related diseases, it is the most common form of occupational skin disease. Irritant hand dermatitis is the most frequent type. Besides wet work and direct contact to irritating occupational substances frequent hand washing can damage the barrier function of the skin facilitating the manifestation of hand dermatitis that frequently occurs chronically. According to own observations the role of obsessive‐compulsive washing as part of an anxiety disorder or personality disorders may not be considered sufficiently. A possible pathogenetic relation between hand dermatitis and psychogenic disorders is discussed in a 22‐year old physician's assistant, a 50‐year old male nurse working in intensive care, and a 54‐year old cleaner. All three patients complained about feelings of revulsion, fear of contamination and a high frequency of hand washing. These cases may encourage dermatologists to consider psychological aspects of hand dermatitis e.g. obsessive compulsive washing, overcome their inhibitions and consider these aspects in an integrated way when planning patient's therapy.     

Psycho-cutaneous disorders: an epidemiologic study

Background and aims  Psycho-dermatology addresses the interaction between mind and the skin. Effective management of at least one third of the patients attending the skin department depends, to some extent, upon the recognition of emotional and psychologic factors. The aim of this study was to provide epidemiologic data about common psycho-dermatoses and their prevalence in dermatologic patients in Iran.
Materials and methods  Patients suspicious to have psychocutaneous problem with primary dermatologic chief complaint were included. After detailed dermatologic evaluation, all patients were visited by an expert psychologist to determine prevalence of DSM-IV disorders in each psychocutaneous category including delusion of parasitosis, trichotillomania, dermatitis artefacta and neurotic excoriation.
Results  A total of 178 patients including 78 (43.8%) males and 100 (56.2%) females entered the study. The commonest psychocutaneous disorder was neurotic excoriation followed by trichotillomania, delusion of parasitosis and dermatitis artefacta. Mood disorder was the commonest DSM-IV disorder in our patients, then anxiety disorder and drug-induced symptoms.
Conclusion  According to our results, it seems that all psychocutaneous disorders but delusion of parasitosis are commoner in females. Mood and anxiety disorders were common in patients with dermatitis artefacta, as patients with neurotic excoriation. In trichotillomania, obsessive compulsive disorder was the commonest disorder. Drug abuse is a major background of delusional parasitosis.

Conflicts of interest

None declared.     

Irritant bullous contact dermatitis caused by a rove beetle: An illustrated clinical course

A 26‐year‐old Australian female traveller in Sierra Leone presented with an irritant bullous contact dermatitis consistent with paederus dermatitis. The lesions were treated with a potent topical corticosteroid with good effect. The affected area resolved in 6 weeks and hyperpigmention persisted for months until complete resolution. This dermatitis occurs when beetles of the genus Paederus (rove beetles) are crushed on the skin, releasing pederin. The same dermatitis ensues with Australian Paederus species. Serial clinical photographs are presented which will aid Australian dermatologists in the diagnosis of this dermatitis, which presents in regional Australian patients and returned overseas travellers.     

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.     

Cutaneous manifestation of IgG4-related disease mimicking dermatitis artefacta

Dermatitis artefacta is a self-inflicted cutaneous disease presenting as sharply delineated ulcers, usually in accessible sites such as the head and neck. IgG4-related disease (IgG4-RD) is a recently recognised immune-mediated condition causing a fibroinflammatory process, resulting in the formation of tumefactive lesions in various organs, rarely presenting primarily in the skin. We report a case of cutaneous IgG4-RD clinically presenting as dermatitis artefacta.     

Allergic contact dermatitis to phenylephrine eye drops in an infant

Ophthalmic medications used for diagnostic or therapeutic purposes are common causes of allergic contact dermatitis around the eyes. We report a case of periocular allergic contact dermatitis due to tropicamide and phenylephrine eye drops in a 1‐year‐old infant.