Dermatitis Artefacta Research Articles

Facial ulcer treated with olanzapine

A 69-year-old woman presented with a nonhealing ulcer on her right cheek. On histological examination of a biopsy, no evidence of granuloma formation or malignancy was found, and the overall picture was felt to be consistent with dermatitis artefacta (DA). The patient was referred to a joint psychodermatology clinic, where treatment with risperidone was started. However, at follow-up the ulcer remained unchanged, and treatment was changed to olanzapine 2.5 mg twice daily. Within 10 months, the large facial ulcer, which had been refractory to treatment for several years, had completely healed. Anxiolytics, antidepressants and low-dose antipsychotics have been shown to be helpful in the management of DA. Successful treatment with olanzapine has been described. The good clinical response to olanzapine may be attributed to its anti-impulsive effect, antihistaminic properties and low risk of parkinsonian side-effects.

Bullous Dermatitis Artefacta

Bullous artefactual dermatoses are rare and may be induced by various techniques, including chemicals, heat, or electrical current. Proving a factitial etiology and identifying the mechanism of injury may be difficult. We describe the clinical features and histopathology of 2 patients with bullous disease induced by electrical current or heat. Physical examination in both patients demonstrated geometrically shaped tense bullae. Skin biopsies revealed epidermal necrosis overlying a pauci-inflammatory subepidermal cleft, with homogenization of underlying superficial dermal collagen. In 1 of the 2 patients, there was prominent vertical elongation of keratinocyte nuclei and also of cytoplasmic processes. Direct immunofluorescence study of skin plus testing of serum by indirect immunofluorescence and enzyme-linked immunosorbent assay for BP180 and BP230 antibodies revealed no evidence for immunobullous disease in either patient. Vertical elongation of keratinocyte nuclei, often attributed to a polarization effect of electrical current, is characteristic of electrical burn but also may be induced by thermal injury. These 2 patients highlight the importance of histopathology in confirming a diagnosis of bullous dermatitis artefacta.

Multinucleated giant cells in factitial dermatitis

Multinucleated giant cells in factitial dermatitis

A difficult case of dermatitis artefacta requiring surgical intervention

Funding sources: none. Conflicts of interest: none declared. Madam, Dermatitis artefacta (DA, also called dermatitis factitia) refers to skin lesions produced in secret by the patient to satisfy an internal psychological need, usually a need to be taken care of.1 DA is often difficult to diagnose and treatment requires an empathic, multidisciplinary approach. A 44‐year‐old woman was referred to our care in 2010 with a 3‐year history of recurrent lesions affecting the face and neck, which had initially improved with oral antibiotics. At presentation she was tearful, describing a painful scalp wound. She did not recall how the lesions had developed, except that they started around the time of the death of her nephew. She admitted to feeling depressed and acknowledged that her condition was worsened by stress. She had no other comorbidities and was taking doxycycline, temazepam and ibuprofen (up to 4000 mg per 24 h) for pain. Examination revealed a deep midline ulcer on the forehead, exposing bone, and multiple atrophic irregular scars on the face and neck. Blood tests demonstrated marked iron‐deficiency anaemia (haemoglobin 7·6 g dL−1, mean corpuscular volume 71·2 fL, ferritin 3 μg L−1) attributed to chronic gastritis due to excessive self‐medication of ibuprofen. DA was considered. A skin biopsy from a right cheek ulcer, taken at another centre, was reviewed. This demonstrated well‐demarcated ulceration with dermal fibrosis, vascular proliferation and a chronic dermal inflammatory infiltrate with foreign body giant cells around birefringent material. This was felt to be consistent with DA.

Primary psychiatric conditions: Dermatitis artefacta, trichotillomania and neurotic excoriations

Primary psychiatric conditions encountered in dermatology include dermatitis artefacta, trichotillomania (TTM) and neurotic excoriations. For these disorders, the primary pathologic condition involves the psyche; therefore, any cutaneous findings are self-induced. Herein, we review common primary psychiatric conditions in dermatology – dermatitis artefacta, neurotic excoriations and TTM – and examine their epidemiology, clinical presentation, differential diagnosis and treatment strategies. For all primary psychiatric disorders, the most effective underlying strategy is to first establish a strong therapeutic rapport with the patient. Various pharmacologic and non-pharmacologic therapies can then be attempted afterwards to successfully manage these patients.

Incidental Focal Acantholytic Dyskeratosis in the Setting of Rosacea

Dear Editor: Focal acantholytic dyskeratosis (FAD) was first described by Ackerman1 in 1972 as a distinct histopathological pattern associated with various cutaneous conditions, and with classic histopathological findings including suprabasal clefting, hyperkeratosis and parakeratosis, and the presence of acantholytic and dyskeratotic cells at the epidermis. While FAD can be observed in many various cutaneous lesions including benign and/or malignant epithelial lesions, fibrohistiocytic lesions, inflammatory lesions, melanocytic and/or follicular lesions2-4. These histopathological findings may also extend into the surrounding tissues, which often appear to be clinically normal. A 42-year-old woman was presented to our department with multiple erythematous pruritic papules and tiny vesicles on her face. The lesions had been present for several years and aggravated 7 days ago. Physical examinations revealed multiple 2 to 3 mm, slightly spongiotic-appearing papules and tiny vesicles with serous crusts on the face (Fig. 1). Laboratory tests obtained at that time were within normal limits. A skin biopsy of an erythematous papule on the nose was also performed, and histopathological results revealed focal suprabasilar clefting and acantholytic keratinocytes in the epidermis, dense inflammatory infiltrates and vascular dilatation with solar elastosis in the dermis, and a negative direct immunofluorescence (Fig. 2). In the serial sections, we observe the same findings. Differential diagnosis for the possibility of polymorphous light eruption, systemic lupus erythematosus, contact dermatitis, and dermatitis artefacta should be considered. But given these clinical and histopathological features, a diagnosis of rosacea with FAD was reached. The patient was then admitted to hospital for treatment with doxycycline 100 mg and antihistamines. After one week, the lesions had remarkably improved. The patient was then discharged, and continued on the same therapeutic regimen for an additional month, bythe time all lesions were nearly resolved. Fig. 1 (A) Multiple erythematous papules and tiny vesicles on the face, especially on the nose area. (B) Nose with diffuse erythema, multiple erythematous papules and tiny edematous vesicles. A biopsy was performed at the site of the erythematous papule indicated ... Fig. 2 Hyperkeratosis, acantholysis with suprabasilar clefting, with dermal vascular dilatation and inflammatory infiltrates (A; H&E stain, ×40). Epidermal hyperkeratosis and suprabasilar clefting, with scattered acantholytic (full lined arrow) ... To date, the etiology of FAD has been attributed to numerous sources including hormones, viral infection, various immunologic factors, tobacco use, physical stimuli although the exact causative mechanism of this finding remains unknown. Other researches have suggested that sunlight and/or ultraviolet radiation may lead to the development of FAD5. In our case, we propose that the acantholytic dyskeratosis occurred secondarily to ultraviolet radiation exposure, given the lesion's location on the nose, a chronically sun-exposed area. Furthermore, chronic physical irritations may also have influenced, as the patient complained of severe pruritus limited to the affected area, the resulting excoriations which possibly lead to acantholytic dyskeratosis. To the best of our knowledge, there have not been any prior reports of FAD associated with rosacea. We also contended that UV exposures combined with consistent physical irritation (i.e. excoriation) which represent two prime etiological factors contributing to the development of FAD in our patient. Therefore we report herein a case of FAD associated with rosacea and this report may provide additional explanation of pathomechanism in incidental FAD in the setting of rosacea.

Self-Inflicted Lesions in Dermatology: Terminology and Classification – A Position Paper from the European Society for Dermatology and Psychiatry (ESDaP)

The terminology, classification, diagnosis and treatment of self-inflicted dermatological lesions are subjects of open debate. The present study is the result of various meetings of a task force of dermatologists, psychiatrists and psychologists, all active in the field of psychodermatology, aimed at clarifying the terminology related to these disorders. A flow chart and glossary of terms and definitions are presented to facilitate the classification and management of self-inflicted skin lesions. Several terms are critically discussed, including: malingering; factitious disorders; Münchausen's syndrome; simulation; pathomimicry; skin picking syndrome and related skin damaging disorders; compulsive and impulsive skin picking; impulse control disorders; obsessive compulsive spectrum disorders; trichotillomania; dermatitis artefacta; factitial dermatitis; acne excoriée; and neurotic and psychogenic excoriations. Self-inflicted skin lesions are often correlated with mental disorders and/or patho-logical behaviours, thus it is important for dermatologists to become as familiar as possible with the psychiatric and psychological aspects underlying these lesions.

Dermatitis artefacta

A 27-year old lady presented to our department with multiple erosive lesions over extremities, which had a very bizarre pattern and was only over accessible parts of body. A thorough history was taken and a diagnosis of dermatitis artefacta was made. We present this interesting case for its rarity and future reference.

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.

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.

Emotional regulation, dissociation, and the self-induced dermatoses: Clinical features and implications for treatment with mood stabilizers

The self-induced dermatoses (such as trichotillomania, pathologic skin picking or neurotic excoriations, dermatitis artefacta, onychophagia and onychotillomania), which are caused as a result of excessive manipulation of the skin, hair, and nails by the patient, can contribute to significant morbidity and can even complicate the course of a primary dermatologic condition such as acne (eg, in acne excoriée) and some pruritic dermatoses. Reports on the self-induced dermatoses in the past decade have tended to focus upon the specific motor behaviors involved in self-inducing the lesions (ie, skin picking or hair pulling) rather than address the common psychopathologic factors underlying the self-injurious behaviors. In the current psychiatric nosology (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision) the self-induced dermatoses are classified as Impulse Control Disorders and Stereotypic Movement Disorders, and this classification does not adequately consider the fact that in most patients with self-induced dermatoses, the frequency and severity of the self-injurious behaviors are directly related to acute or chronic problems with emotional regulation and dissociation. This may be part of the reason that there is a relative paucity of effective treatments for these disorders. The skin and its appendages are well innervated with a dense network of afferent sensory nerves and efferent autonomic nerves, and the integumentary system is frequently the focus of tension-reducing and emotion-regulating behaviors, especially during states of autonomic nervous system hyperarousal. This factor is important in the pathogenesis of the self-induced dermatoses. Mood-stabilizing agents, such as lithium carbonate, that are used to treat disorders of emotional regulation have not been adequately studied in the management of the self-induced dermatoses and may prove to be very helpful in the management of these disorders.

Dermatitis Artefacta: Facts for a Facial Plastic Surgeon

Objective: 1) To report a large scalp lesion secondary to dermatitis artefacta, requiring reconstruction. 2) To emphasize the need for a multidisciplinary approach involving dermatologist, psychiatrist, and facial plastic surgeon for optimizing outcome. 3) To highlight specific issues in the patient’s care in the perioperative period. Method: Case report of a 44-year-old white female patient who presented to our combined dermatology–facial plastic surgery clinic with a large lesion on her scalp and a known diagnosis of dermatitis artefacta. Results: The scalp lesion had gradually increased in size over 4 years. Prior to this she was being followed up by the dermatologists for this and other multiple, bizarre ulcerating areas on her face; the patient had associated depression. A diagnosis of dermatitis artefacta was made by the dermatologists and supported by the psychiatrists. She was treated with antibiotics for the excoriating lesions and local dressing for the scalp wound initially. Regional reconstruction of scalp was subsequently carried out to achieve closure of the scalp defect, with the active involvement of the dermatology and psychiatry teams. Conclusion: 1) Close monitoring is required postoperatively, as these patients can be passively noncompliant with treatment, inducing self-harm repeatedly because of lack of insight in causing skin damage. 2) Prompt discussion in a multidisciplinary setting with earlier input from facial plastic surgeons will potentially minimize the extent of reconstructive surgery required.

Dermatitis artefacta manifesting as genital scars: a result of an unusual behaviour pattern

A 25-year-old man, diagnosed previously with borderline personality disorder, presented with curvilinear genital scars. A meticulous history and examination led to a diagnosis of dermatitis artefacta with an atypical behaviour pattern.

A cry for help, do not omit the signs. Dermatitis artefacta – psychiatric problems in dermatological diseases (a review of 5 cases)

SummaryBackgroundDermatitis artefacta (DA) is a dermatologicopsychiatric illness that is a conscious self-infliction of lesions to accessible regions of the body. The lesions usually do not resemble those of any know skin disease and there are no specific diagnostic tests to recognize them. This makes dermatitis artefacta a very slow, challenging and expensive disease to diagnose.Case ReportWe present 5 different clinical cases of dermatitis artefacta treated in the Department of Dermatology, Venereology and Allergology, Medical University of Gdańsk in 2011. Detailed anamnesis and physical examination were performed at the day of admission. All patients had biochemical and hematological blood tests, skin biopsies and swabs for bacteriological examination, and photographs were taken. Psychiatric consultation was recommended in all cases.Clinical symptoms before diagnosis lasted from 1 to 10 years. The female-to-male ratio is 1:0.7, with age range of 57–62 years. Of our patients, only 2 refused a psychiatric consultation. Three out of 5 patients denied self-mutilation (2 of those 3 patients finally admitted to self-manipulations). Lesions were usually within the reach of the dominant hand. Two patients have other personality disorders. In 4/5 cases visible improvement after treatment with occlusive dressings were observed.ConclusionsWe discuss and attempt to depict issues associated with collaboration between dermatologists and psychiatrists, reasons for poor recognition of the disease, very long diagnosis and high costs. To conclude, we found that close collaboration between dermatologists and psychiatrists is important in diagnosing and treating DA patients.

Dermatitis artefacta

Dermatitis artefacta (DA) is a psychocutaneous disorder where the skin lesions are self self-induced to satisfy an unconscious psychological or emotional need. We report a case of DA where we video recorded the patient self-inducing the lesions.

P-850 - The meaning of the dermatitis artefacta through beliefs and culture

Dermatitis artefacta or factitious dermatitis is a quite rare kind of psychiatric disorder which has been always a challenge for psychiatrists and dermatologists. The patient impulsively or as a result of primary or secondary gain makes deliberate scars with his hand or needle, pin, razor and … on his body. Based on kind of spread, shape, margin, and recognition of basic conflict, these scars can be differentiated from other dermatological ones. What makes this disorder a challenge is not its diagnosis but its treatment, and what is important in treatment understands its meaning by its patient. The researchers in this study introduce a married 45 years old woman, with Dermatic artefacta, whose scars are limited to her feet. In order to understand the meaning of this disorder, the following question is asked: Why the scars are just seen in her feet? We try to answer this question with the focus on childhood history, Iranian culture, worldwide common beliefs, literature, and idioms.

Trichotillomania and Dermatitis Artefacta: A Rare Coexistence

A 24-year-old pregnant female patient presented with complains of bilateral lower limb swelling and fever for 1 month. On examination, blood pressure was 144/94 mmHg along with pitting pedal edema. She had bizarre skin lesions, aligned longitudinally and distributed over the approachable site of the body with tapering ends and in various stages of healing. Lower limbs examination also revealed similar lesions with signs of cellulitis. Her scalp had short and distorted hair suggesting pulling and plucking. These skin lesions and the denial of self-infliction by the patient made us reach the diagnosis of dermatitis artefacta with trichotillomania. Psychotherapy was advocated along with conservative management of skin lesions. The patient improved and is under our follow up.

Recurrent Deep Ulcers Resembling Rare Cancers as a Form of Factitious Disorder

Factitious disorders are defined as acts of self-harm that directly or indirectly result in clinically-relevant injury. They are typically performed in secret and without direct intention of suicide (1, 2). The patient’s initial goal is hospital admission and receiving medical treatment to confirm the severity of their state (3). Current prevalence ranges of factitious disorders is between 0.05 and 2.0%, with women being 4–20-fold more likely to be affected than men (1, 4–8). Contemporary psychodermatology classifies these disorders as: 1) dermatoses of primary psychiatric genesis (emotional/psychiatric disorders); 2) dermatoses with a multifactiorial basis, of which the course is subject to psychiatric influences (psychosomatic disease); or 3) secondary psychiatric disorders due to serious or disfiguring dermatoses (somatopsychic disease) (9). Mood swings, anxiety, impulsive behavior and somatization disorders are common among patients with dermatitis artefacta (5, 10–12).

Bullous cryothermic dermatitis artefacta induced by deodorant spray abuse

Dermatitis artefacta belongs to a broad spectrum of factitious diseases of lesions usually self-induced by patients. Here we report a surprisingly effective induction of blisters and thermic dermatitis by excessive abuse of common deodorant sprays. We evaluated the clinical course and outcome in three patients with dermatitis artefacta induced by deodorant spray. A 12-year-old boy only admitted the abuse of deodorant spray after psychiatric intervention. Two adults (21-year-old and 37-year-old women) had borderline personality disorder and frankly reported the urge to induce pain by spraying for at least 100 s at a short distance. Bullous dermatitis was the acute presenting sign in all patients. The bullae were found on the extensor surfaces of the extremities, with a distribution of older lesions showing erosions and scarring and fresh lesions with intact bullae with a diameter of 3-15 cm. After searching for the causative agent and removal of the deodorant spray, clinical outcome showed a healing without and with scars. Cryo-damage by abuse of common deodorant sprays seems to become a popular mechanism by which an impressive bullous dermatitis can be artificially induced. Dermatologists and psychiatrist should be aware of this method of injury.

Pathomimie cutanée chez une jeune fille

Dermatitis artefacta is a self-inflicted skin disease during which the patient denies having produced and is not conscious of the psychological need he or she needs to satisfy through the lesions. Suggestive clinical features often include bizarre, linear, or geometric outlines of accessible parts of the body and an ambiguous history of the lesions. Dermatitis artefacta in children is often associated with familial dysfunction and/or problems at school. We report a case of acute linear purpuric lesions of the upper right limb in a 12-year-old girl.