Year : 2006 | Volume
: 51 | Issue : 1 | Page : 39--41
Dermatitis artefacta: Three case reports
Dept. of Dermatology & STD, Military Hospital, Secunderabad, India
N S Walia
Department of Dermatology & STD, Miliatary Hospital, Secunderabad, Trimulgherry, Secunderabad - 500 015
Three cases of dermatitis artefacta are reported for their varied presentation, diagnostic indicators and complex management. A 21-year-old soldier had multiple painful erosions on dorsum of both forearms of three weeks duration normal with inbetween skin. By occlusive bandaging dressing lesions healed without recurrence. A 28-year-old mechanic had recurrent blisters with non healing wounds on the right knee without surrounding inflammation. Histopathology was nonspecific. A young soldier had multiple asymphomatic nodular lesion in linear distribution on right forearm of two years induration. Biopsy showed features of scar. Psychiatric evaluation and follow-up was essential in all cases.
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Walia N S. Dermatitis artefacta: Three case reports.Indian J Dermatol 2006;51:39-41
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Walia N S. Dermatitis artefacta: Three case reports. Indian J Dermatol [serial online] 2006 [cited 2022 Aug 17 ];51:39-41
Available from: https://www.e-ijd.org/text.asp?2006/51/1/39/25189
Factitial dermatitis or dermatitis artefacta is a psychocutaneous disorder produced by or perpeturated by the patient's own actions. It encompasses a large heterogeneous group of skin lesions and may form part of a braod spectrum of artefactual disease which can affect any organ and present to any discipline. Differential diagnoses may vary greatly depending on the methodology and type of skin lesions produced by the individual. The various methods of producing the skin loesions are highly imaginative and depend on the patient's back ground and education. The patient usually denies any role in producing these skin lesions. The condition is more common in adolescent females.
A 21-year-old soldier presented with multiple painful erosions on dorsum of both forearms of three weeks duration. The lesions were sudden in onset, recurring every few days, not associated with injury, insect bite or intake of drugs. Cutaneous examination revealed multiple linear erosions on the dorsal aspect of both forearms of uniform size and shape slightly tapering towards the periphery. The skin in between the lesions was normal [Figure 1]. A diagnosis of dermatitis artefacta was suspected and the patient admitted for observation. It appeared that the excoriations had been caused by application of irritants or abrasive substances. Topical 1% framycetin was applied after a saline wash to prevent secondary bacterial infection. Occlusive bandage dressing was used to cover the affected limb. The cutaneous lesions healed within a week with no recurrence. Psychiatric evaluation did not eveal any disorder. The patient denied any role in producing the lesions despite questioning. In view of absence of any underlying psychopathology, the individual was counseled, rendered psychotherapy and advised regular OPD review. However, in three months follow up there was no recurrence of lesions or any other complaints requiring medical intervention.
A 28-years-old mechanic was referred to the dermatologist with a three month history of recurrent blistering and non healing wounds on the right knee. The patient complained of numbness on the affected area but repeated objective examination did not reveal any sensory deficit. The bullae were firm, non-tender, without signs of inflammation of surrounding skin [Figure 2]. No specific causative factor could be identified. Detailed general physical and systemic examination was normal. Culture from the bullae fluid was sterile. Routine laboratory tests were normal. Skin biopsy showed intra-epidermal cleft of non-specific aetiology. He was treated with topical antibiotics under close supervision and lesions healed in two weeks. Psychiatric evaluation revealed marital discord with his spouse. He was ofered psychotherapy, anti-depressants and partner counseling. No recurrence of lesions was seen on a six month follow up.
A young soldier sought consultation for multiple asymptomatic nodular lesions on the right forearm of two years duration. He gave a history of progressive appearance of lesions on the affected limb of which only a few had healed. The mode of onset could not be explained. Dermatological examination revelaed multiple scars in linear distribution on the dorsal aspect of right forearm [Figure 3]. A skin biopsy was done to rule out sporotrichosis but only revealed findings suggestive of hypertrophic scars. He was treated with occlusive/intralesional steroids over a three-month peiod with fare response. Repeated psychiatric assessment disclosed a neurotic propensity. A colleague claimed that the individual had initially produced these lesions in a party by using burning cigarette ends. No motive could be identified for producing these lesioins over this length of time. He was placed under regular therapy and observation under the care of apsychiatrist.
The clinical characteristics observed in our cases were quite similar to that reported elsewhere. None of the men were posted to a war zone or on rigorous army duties at the time of presentation. Liaison with the individual's unit was undertaken in every case to exclude malingering and Munchausen's syndrome. The presence of lesions on extremities rather than the face can be explained by the gender of the patients, as females have higher facila involvement. It varied from case reports from western world whose patients have more access to drugs and chemicals leading to diverse presentations. The hollow history and the bizarremorphology of the lesions not fitting into known dermatoses and confined to areas accessible to the dominant hand lead to the diagnosis. The disappearance of lesions under occlusive dressing was the decisive conclusive test. Skin biopsy was only done where necessary. The issue of etiology was sidestepped after the initial hospitalization because confrontation is often counter productive. Creaing an accepting, empathetic and nonjudgmental environment and close supervision of dermatologic therapy lead to the regressino of the cutaneous lesions. An underlying psycho-pathology could be identified only in one case and the patient was offered therapy. Unfortunately, the dermatological diagnosis or injury mode did not offer a clue to the principle psychological condition, reasons for injury or presentation to the hospital.
Dermatitis artefacta is a form of focal suicide. Various psycho-social conflicts and unconscious motivating factors have been held responsible for the self destructive activity. The reason for self-mutilation goes beyond that of malingering as cure of the dermatoses is less desirable than the disease itself. The management of these patients has to be gentle, non-confrontational and flexible and involves building a mutual trust and rapport between patient and doctor. It is imperative that we follow an integral approach and treat these patients as a bio-psychosocial individual incorporating their thoughts and manipulations without being judgment. Follow-up is essential in these cases as the future prognosis is uncertain in these individuals. More studies are necessary to document more accurately the cause, treatment outcome and prognosis for this group of patients.
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