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.     

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.     

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.     

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.     

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.     

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.     

Managing the patient with psychiatric issues in dermatologic practice

Patients often communicate emotions through their bodies and physical symptoms; the skin commonly serves as a means of expression in the patient-doctor relationship. It is important for the dermatologist to be able to indentify psychological issues that manifest in the skin and the interplay between psychiatric and dermatologic conditions. Delusional parasitosis, dermatitis artefacta, trichotillomania, and somatoform disorders all represent dermatologic conditions with underlying emotional causes. Many chronic dermatoses, such as psoriasis, atopic dermatitis, and acne, modulate and are influenced by psychosocial factors. Special issues, including significant medication interactions and the treatment of the “difficult” patient, are reviewed.     

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.     

Reflex sympathetic dystrophy: description of a case with skin lesions

Reflex sympathetic dystrophy or algodystrophy is a poorly defined syndrome in which the patient develops pain disproportionate to the cause. It is included among the complex regional pain syndromes. The symptoms are triggered by some type of trauma, at times trivial, and consist of burning pain, edema, changes in skin color, alterations in vascularization, temperature changes, hyperhidrosis and skin disorders, which primarily consist of atrophic changes. Other less frequent cutaneous manifestations have been described in patients with this syndrome. These include papules, blisters, inflammatory lesions and reticulated hyperpigmentation. We discuss the case of a patient with reflex sympathetic dystrophy who presented with superficial ulcers on the affected limb, which mimicked dermatitis artefacta.     

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.     

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.     

The Girl Shedding Glass Pieces from Her Body Parts: Unfolding the Mystery Behind Dermatitis Artefacta

Patients presenting with unusual symptoms are uncommon. Unusual symptoms often catch the attention of the public including the health professionals. Atypicality in the symptoms is usually seen in patients with factitious disorder. In patients with factitious disorder, there occurs conscious production of symptoms with an unconscious motive, irrespective of the fact whether they are ill or not. Self-inflicted injuries to skin often give rise to typical skin lesions known as dermatitis artefacta, which many a times simulate other dermatological conditions. Patients with factitious disorder often have a narrow line of demarcation from malingering. We present a case of an adolescent girl presenting with spontaneous extrusion of glass pieces from her body parts with focus on diagnostic dilemma and management.     

Skin and treponemal diseases among Asian domestic house-helpers in northern Saudi Arabia

Background Asian domestic house-helpers in Saudi Arabia come from a different socioeconomic setting with a different disease pattern from that of their host country. This study reports the incidence of skin and treponemal diseases in this group seen at a referral hospital in northern Saudi Arabia. Methods The study was based on the analysis of the dermatologic and serologic examinations of 1520 domestic house-helpers during resident permit issue, and a retrospective study of clinical records of house-helpers with skin disorders. Results Routine examination revealed significant skin disease in 374 (24.6%) individuals, and the disease was transmissible in 126 (8.3%). Treponemal infection (5, 0.3%) and leprosy (1, 0.07%) were seen. Hand dermatitis and chicken pox were the most common causes of hospital attendance. Psychologic skin disorders included three cases of neurotic excoriations, two cases of delusion of parasitosis, and a case of dermatitis artefacta. Conclusions The prevalence of transmissible skin diseases in Asian domestic house-helpers is low compared with that in their home countries. Excluding individuals with stigmata of atopic dermatitis from employment as house-helpers, adequate counselling will reduce the incidence of hand dermatitis and psychologic skin disorders. There is a need for continuous surveillance to prevent the introduction of skin diseases not normally seen in the native population.     

Dermatitis artefacta with artefacta of patch tests

Three patients with dermatitis artefacta, who manipulated their patch tests, are described. This is an uncommon occurrence in the experience of our Contact Clinic, and has rarely been reported in the literature. The cases demonstrate once again the ingenuity of many patients with dermatitis artefacta, and the protean manifestations of this disorder.     

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.     

Dermatitis artefacta: revisión

Dermatitis artefacta is a rarely diagnosed disorder that is often a source of perplexity and anxiety for dermatologists because they know less about the cause of this self-inflicted condition than the patients themselves. It differs from other skin disorders in that diagnosis is made by exclusion rather than on the basis of histologic and biochemical findings and therefore involves a considerable investment of time and resources. Based on the findings of a study of 201 patients diagnosed with dermatitis artefacta between 1976 and 2006, we review the different clinical presentations of this skin disorder and discuss its diagnosis and treatment. The series analyzed comprised 152 women and 49 men (female to male ratio of 3.1:1) with a mean age of 31.2 years. The patients were mostly single and had a low educational level and few or no job qualifications or skills.     

Cutaneous lupus erythematosus: a personal approach to management

SUMMARY Skin disease in patients with lupus erythematosus may be subdivided into two broad categories - those lesions that when biopsied demonstrate interface dermatitis and those that do not demonstrate interface dermatitis. The skin lesions that are represented by the interface dermatitis include discoid lupus erythematosus, subacute cutaneous lupus erythematosus and acute cutaneous lupus erythematosus. Patients with these 'specific' manifestations have varying degrees of systemic involvement from rare systemic disease in patients with localized discoid lupus erythematosus to common and often severe involvement in patients with acute cutaneous lupus erythematosus. Patients who do not demonstrate interface dermatitis also may have systemic disease and in some instances the skin manifestations are linked to some of the more severe systemic manifestations. Many patients with cutaneous lesions characterized by the interface dermatitis can be controlled with 'standard' therapies including sunscreens, protective clothing and behavioural alteration, and topical corticosteroids with or without an oral antimalarial agent. This review presents a brief summary of each common cutaneous manifestation of lupus erythematosus, its relationship to systemic involvement and treatment issues to effectively deal with the lupus erythematosus patient who has skin disease.     

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.