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Dermatitis Artefacta

Editor: George Kurien Updated: 7/12/2022 12:47:22 PM

Introduction

Dermatitis artefacta or factitious dermatitis is a psychocutaneous disorder in which the patients consciously create lesions in skin, hair, nails, 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][2]

Etiology

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Etiology

Unlike malingering, no direct benefit is sought from the 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 adulthood.[5] No age group is exempt, and onset in older age and the occurrence of the condition in children as young as 8 years old have been documented in the literature.[6] The condition used to be more common in people with a medical knowledge background. This bias is less obvious in a modern and well-informed society with more media and internet access.

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 with 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 that 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 the application of foreign bodies or chemicals.[12] Traces of evidence of these are noticeable on close examination of crude dermatitis. Any body part can be affected, but the most common site in all age groups is the face, followed by the dorsum of the 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, 2nd most common
  • Hands and forearm, 3rd 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 1 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, is 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 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 opiates 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 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.

Differential Diagnosis

Differential diagnosis to consider and rule out regarding dermatitis artefacta include the following:

  • Alopecia Areata
  • Anagen effluvium
  • Bedbug bites
  • Delusions of parasitosis
  • Friction blisters
  • Impetigo
  • Insect bites
  • Irritant contact dermatitis
  • Onycholysis
  • Telogen effluvium

Prognosis

For patients with mild cases of dermatitis artefacta associated with common stressors like pressure, anxiety, or depression, the prognosis is good. However, chronic dermatitis artefacta 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

Diagnosing and managing dermatitis artefacta is complex and best done with an interprofessional team. 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 opiates 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]

References


[1]

Pradhan S, Sirka CS, Dash G, Mohapatra D. Dermatitis Artefacta in a Child: An Interesting Morphological Presentation. Indian dermatology online journal. 2019 Jan-Feb:10(1):72. doi: 10.4103/idoj.IDOJ_132_18. Epub     [PubMed PMID: 30775305]


[2]

Lavery MJ, Stull C, McCaw I, Anolik RB. Dermatitis artefacta. Clinics in dermatology. 2018 Nov-Dec:36(6):719-722. doi: 10.1016/j.clindermatol.2018.08.003. Epub 2018 Aug 16     [PubMed PMID: 30446194]


[3]

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:153(4):525-534. doi: 10.23736/S0392-0488.18.06019-4. Epub 2018 Apr 19     [PubMed PMID: 29683292]


[4]

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:29(4):418-427. doi: 10.1080/09546634.2017.1395389. Epub 2017 Nov 5     [PubMed PMID: 29052453]


[5]

Wong JW, Nguyen TV, Koo JY. Primary psychiatric conditions: dermatitis artefacta, trichotillomania and neurotic excoriations. Indian journal of dermatology. 2013 Jan:58(1):44-8. doi: 10.4103/0019-5154.105287. Epub     [PubMed PMID: 23372212]


[6]

Rogers M, Fairley M, Santhanam R. Artefactual skin disease in children and adolescents. The Australasian journal of dermatology. 2001 Nov:42(4):264-70     [PubMed PMID: 11903159]

Level 3 (low-level) evidence

[7]

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:133(3):235-8     [PubMed PMID: 16800172]

Level 2 (mid-level) evidence

[8]

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:16(5):559-564. doi: 10.1111/ddg.13504. Epub 2018 Apr 24     [PubMed PMID: 29689138]


[9]

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:39(8):622-624. doi: 10.1097/DAD.0000000000000840. Epub     [PubMed PMID: 28614838]


[10]

Gupta MA, Pur DR, Vujcic B, Gupta AK. Suicidal behaviors in the dermatology patient. Clinics in dermatology. 2017 May-Jun:35(3):302-311. doi: 10.1016/j.clindermatol.2017.01.006. Epub 2017 Jan 23     [PubMed PMID: 28511829]


[11]

Lee HG, Stull C, Yosipovitch G. Psychiatric disorders and pruritus. Clinics in dermatology. 2017 May-Jun:35(3):273-280. doi: 10.1016/j.clindermatol.2017.01.008. Epub 2017 Jan 22     [PubMed PMID: 28511824]


[12]

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:25(8):978-82. doi: 10.1111/j.1468-3083.2010.03861.x. Epub 2010 Oct 3     [PubMed PMID: 21740463]


[13]

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 31:14(3):311-3. doi: 10.9758/cpn.2016.14.3.311. Epub     [PubMed PMID: 27489388]


[14]

Gupta MA, Jarosz P, Gupta AK. Posttraumatic stress disorder (PTSD) and the dermatology patient. Clinics in dermatology. 2017 May-Jun:35(3):260-266. doi: 10.1016/j.clindermatol.2017.01.005. Epub 2017 Jan 22     [PubMed PMID: 28511822]


[15]

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:8(1):26-8. doi: 10.4103/0974-7753.179395. Epub     [PubMed PMID: 27127373]


[16]

Patra S, Sirka CS. Attention deficit hyperactivity disorder presenting as dermatitis artefacta. Journal of pediatric neurosciences. 2016 Jan-Mar:11(1):80-2. doi: 10.4103/1817-1745.181263. Epub     [PubMed PMID: 27195043]


[17]

Koblenzer CS. Dermatitis artefacta. Clinical features and approaches to treatment. American journal of clinical dermatology. 2000 Jan-Feb:1(1):47-55     [PubMed PMID: 11702305]


[18]

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:60(6):613-5. doi: 10.4103/0019-5154.169139. Epub     [PubMed PMID: 26677280]

Level 3 (low-level) evidence

[19]

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:169(3):600-6. doi: 10.1111/bjd.12416. Epub     [PubMed PMID: 23646995]

Level 2 (mid-level) evidence