Pediatric dermatitis artefacta presenting as geographic ulcers on the face.

Abstract

A 3 year and 6 months old boy presented with irregular ulcers on his face which had progressed over the prior 2 month. The initial lesion presented as red papule in the nostril without itching and pain. The papule was umbilicated after scratching and disseminated to nasal tip and fused to ulcer with obvious pruritus. Topical antibiotics demonstrated partial effect on some new rash. On examination, there were multiple well-demarcated ulcers on the middle of the face. The ulcers had rolled edges and minimal surrounding erythema and crusts (Figure 1A). Systemic examination and laboratory data including blood routine examination, biochemistry, and immunologic tests were unremarkable. Skin biopsy specimens showed acanthosis and nonspecific inflammation with lymphocytes and neutrophils in the dermis. Several deformed keratinocytic nuclei can be seen in the skin pathology (Figure 2). PAS stain, tuberculosis stain, and gram stain were negative. Skin swabs of the superficial of the ulcers demonstrated Streptococcus Viridans and Coagulase Negative Staphylococci; no fungi were found through tissue culture. Family history revealed his father had the same manifestation on his face from 1 year old which disappeared at 10 years old. After 2 weeks of inpatient management included topical mupirocin, closely observation, combined with proper psychological education, the ulcers relieved rapidly (Figure 1B). The lesions were completely recovered with scars 1 month later (Figure 1C) and did not recur in the subsequent 6 months. Nonspecific clinical features and the remarked effect of symptomatic treatments suggest clues to explore the social history, which revealing his parent's separation and he was living along with his father who had a violent personality. We also learned from his mother that the patient hoped to see his mother through scratching himself. Thereafter, we made an early diagnosis of dermatitis artefacta. Dermatitis artefacta (DA) is a factitious disorder rarely reported in children where patients deliberately produce skin lesions to fulfill a conscious or unconscious desire to assume the sick role.1 DA is common in prepubertal children and adolescents with a clear female preponderance and often is underestimated clinically. To our knowledge, the youngest reported case was at 8 years old,2 while our case diagnosed at a 3 years of age. Ulcers, as the second most common presenting skin sign except excoriations and erosions, often have a bizarre morphology with stark linear appearance.3 Our case presented ulcers with geometric shapes which often masquerade as pyoderma gangrenosum (PG). DA is a diagnosis of exclusion and should be considered when the lesion atypical and poor curative effect and addressing underlying etiology. Although DA can have nonspecific histopathological characteristics, some characters, such as prominent epidermal damage, multinucleated keratinocytes, and deformed keratinocytic nuclei, as well as absence of stratum corneum without and substantial inflammatory urge consideration of the diagnosis DA.4 Deformed keratinocytic nuclei in our case gave us the clue for the possibility of DA. Based on why and how the lesion was caused, the final diagnosis of DA should be determined. Our patient illustrates the significance of identifying the psychological causes of DA and separating it from its imitators, including PG. Zhaoyang Wang contributed the clinical data collection and wrote the original manuscript. Zigang Xu involved in central idea and revised the manuscript. Yuan Liang involved in clinical data collection and revised the manuscript. All funding sources that supported the work: This study was supported by Beijing Natural Science Foundation (7174300), Special fund of the Pediatric Medical Coordinated Development Center of Beijing Municipal Administration (XTZD20180502). No conflict of interest disclosure. Written informed consent was obtained from the patient for publication of this case.