Are You Confident of the Diagnosis?
There are six common sets of circumstances under which a patient may create lesions on his or her own skin: 1) Patients with neurotic excoriations, 2) patients with delusional beliefs about the skin, 3) wrist cutters, 4) malingerers, 5) patients with Munchausen’s syndrome, 6) patients with dermatitis artefacta. The clinical presentation and a careful history will draw the distinctions between each of these.
The patient with neurotic excoriations, or what has been termed “dermatitis para-artefacta,” fully acknowledges that the lesions are self-induced and that they result from an irresistible urge to pick or scratch the skin. This may be in response to intractable pruritus or to psychosocial stress.
Patients who have a delusional belief that they are infested with bugs or fibers also will acknowledge inducing lesions, but in this case it is an attempt to “dig” out the believed infesting agent.
Those who repeatedly cut the flexor aspect of the wrist acknowledge the activity. These patients most commonly are young women who have had, early inconsistent, or hostile parenting, and the, cutting serves to confirm body boundaries and, indeed, the very existence of the self.
By contrast, the malingerer will deny any role in creating lesions. The goal here is usually both material and obvious. It may be to achieve an expected financial gain or to avoid an unpleasant duty, such as military service or jury duty.
The patient with Munchausen’s syndrome will also deny any role in the creation of lesions. The presentation here is unique. The description of symptoms is very florid, and the history characterized by the three “p’s”: pseudologia fantastica, pathological lying and peregrination. Characteristically the patient has a psychopathic personality disorder and travels from hospital to hospital, and city to city, for ever more diagnoses and for ever more exotic treatments.
Dermatitis artefacta stands out from each of the above and has a quite characteristic presentation. The patient denies any part in creating the lesions. These may be extremely destructive, yet the patient is remarkably calm, unconcerned, and emotionally uninvolved. The parents or family members, by contrast, are anxious and often angry. They demand answers and feel betrayed by the medical profession.
What you should be alert for in the history
In dermatitis artefacta, it is often difficult to obtain a meaningful history. No description of the evolution of individual lesions can be evoked. These seemingly have appeared fully formed, overnight, or during a brief break during the day. This phenomenon has been called the “hollow history.”
Characteristic findings on physical examination
The lesions themselves do not resemble those of any known dermatitis. They are distributed on areas that are accessible and may be bilateral and symmetrical, or primarily within reach of the dominant hand. The face and breasts are especially common locations.
Lesions are surrounded by entirely normal skin and vary in shape depending upon the mode of creation (Figure 1). Any agent that comes to hand may be used. These include knives, scalpels, carpenter’s tools, lighted cigarettes, or indeed anything that one might think of. Lesions may be angular or geometric, the surface may be necrotic, crusted or cleanly granulating, or there may be linear streaks from caustic liquids or acids (Figure 2). Injections of saliva or pus are reported, or skin may be burned with, for example, deodorant spray. Ligatures may be applied to an extremity to produce swelling and discoloration (Figure 3).
Lesions such as leg ulcers, surgical scars, or lesions of an existing dermatosis may be perpetuated or simulated, or lesions of a known but absent dermatosis may be simulated afresh (Figure 4). Surgical wounds may be perpetuated, and biting of the mucosal surface of the labia or the buccal mucosa may be interpreted as pemphigus or bullous pemphigoid.
Whenever there is a characteristic hollow history, whenever lesions do not respond to treatment as one would expect, whenever the clinical picture does not correspond to the biopsy findings, or whenever the emotional response of the patient is not synchronous with the severity of the clinical picture, dermatitis artefacta must be ruled out.
Who is at Risk for Developing this Disease?
Common in the history is a close association with the healthcare field. This may be through a relative or close associate, or the patient him- or herself may have worked in some capacity with patients, or may have suffered a prolonged illness earlier in life. Many patients are retired nurses.
Dermatitis artefacta-by-proxy occurs when artefactual lesions are produced on another individual, such as a child. This too is likely to occur at the hand of someone closely associated with the healthcare field who has dependency needs.
There are few reliable controlled studies of dermatitis artefacta, and undoubtedly many cases are never diagnosed. One study suggests that 2% of patients in a clinical dermatology unit have a factitious disorder, but it is not clear which particular artefacts have been included in the study, and the percentage quoted would seem to be somewhat high.
The onset is most commonly in adolescence or early adult life. Prior to adolescence the sex ratio is essentially equal, but in adolescence and early adult life, the female:male ratio is quoted as anywhere from 3:1 to 20:1, while there is a group of significantly older patients in whom males predominate.
Patients with dermatitis artefacta most commonly have had inconsistent or hostile parenting in early life, and a history of physical or sexual abuse is not uncommon. This has led to instability of identity and body image, with insecure boundaries and a profound need to be taken care of. Anxiety, depression and eating disorders are common co-morbidities, as are somatizing disorders such as chronic fatigue syndrome and fibromyalgia.
While some patients are fully aware that they are producing lesions, in others, lesions may be produced unconsciously, in a dissociated state.
Dermatitis artefacta by proxy is usually perpetrated by the mother on her child, in a bid for attention. The patient is usually under 4 years of age, there may be a history of unexplained illness in other children in the family, and the mother most commonly has a personality disorder, with the history of a difficult childhood herself, and a difficult marital relationship. Frequently the father of the child is ineffectual and the mother powerful.
What is the Cause of the Disease?
Most commonly, patients with dermatitis artefacta have a personality disorder. This may be dependent or borderline in nature and is frequently associated with co-morbid depression and anxiety and the other somatizing disorders noted above.
Creation of lesions is triggered by psychosocial stress, and in addition to releasing tension, the unconscious goal for the patient, or the instigator if by proxy, is to be taken care of. Accordingly, the severity of the problem tends to fluctuate with the events in the patient’s life.
The pathophysiology is that of whatever ingenious mode the patient has selected for the creation of lesions.
Systemic Implications and Complications
There are systemic implications both in relation to the psychopathology and the physical pathology of dermatitis artefacta.
Psychologically co-morbid anxiety, depression, eating disorders and somatizing syndromes are common, and there is ongoing serious but unconscious anger caused by the childhood traumata.
Relationships are likely to be dysfunctional, with difficulties in the workplace, in marriage and in parenting. Many patients are unable to work, or may be confined to bed.
Embarrassment and social isolation are common, suicidal ideation and attempted suicides occur, as does legal action or violence against the attending medical staff, and even murders are reported.
Psychiatric referral would be the ideal approach, but unfortunately the suggestion of such a referral is treated with anger, hostility, and probable further doctor-shopping. Rather, the dermatologist would do well to find a psychiatrist with whom he or she can discuss the case, and the possible therapeutic approach.
Physical complications again depend on the mode by which lesions are produced.
Infection, tissue destruction, loss of function, blood loss with anemia are all possibilities. Bacterial and fungal cultures are important. Biopsies should be taken to rule out a primary dermatologic disorder, as should baseline lab studies. While interviewing the patient it is important to try to assess the emotional state: is the patient markedly anxious or depressed? Is anger prominent? Is there suicidal ideation?
Because of the unusual, unexplained and nonresponsive nature of the skin disease, patients with dermatitis artefacta generate much anxiety in the numerous non-psychiatric physicians whom they consult. In the search for answers, these patients undergo numerous and repeated unnecessary tests and biopsies and often receive a variety of inappropriate and expensive medications. Thus they consume a considerable proportion of available medical resources, to little avail.
Optimal Therapeutic Approach for this Disease
Treatment falls into three parts, of which the first is crucial if one is to progress to the second and third:
A careful history and complete physical examination must be undertaken. Because of the plethora of imaginative methods by which lesions may be created, any tests ordered must be based on the physical findings. In addition to baseline studies, cultures for both superficial and deep bacteria and fungi may be indicated, as may X-ray studies to determine any bony or deep soft-tissue involvement. The results of these tests should be taken at face value, and the tests not repeated again and again.
It is crucial that one develop rapport and that a meaningful doctor-patient relationship be allowed to evolve to ensure that doctor-shopping is not perpetuated. Frequent, perhaps seven weekly, though quite short, visits, even if quite short, are helpful.
Except in child cases, confrontation is contraindicated, as this can only arouse anxiety, which is often expressed as hostility and may lead to greater tissue destruction and further doctor-shopping. Instead, it is important to empathize with the patient about the negative impact of the patient’s condition on the quality of the patient’s life, and to stress the need for the patient to keep appointments and to carry out all the treatments prescribed.
Gradually, over time, as one learns of, and empathizes with, the stress and the particular circumstances of the individual’s life, one may find a way to introduce the concept of the patient’s participation in producing lesions and, perhaps, gently to suggest the goal that the lesions are designed to achieve. This, in turn, may enable psychiatric referral to be recommended.
In child cases, after having taken a careful history and undertaken a thorough physical examination, it is often helpful to interview the patient separately from the parents, when a more frank discussion can perhaps take place. If one can achieve an atmosphere that is non-threatening, confrontation may reap rewards.
Because the skin is overvalued in this disorder, topical treatment is very important. The specific mode is determined by the nature of the lesions in each case.
Compresses and gentle debridement are helpful and give the patient positive activity to replace the prior destruction. Compresses, twice daily for 10 minutes may contain table salt (one teaspoon to one pint of water), betadine or Clorox, and these may be followed by a topical antibiotic ointment (triple antibiotic or mupuricin) as indicated.
Deep ulcers may be packed with gauze and a protective dressing applied. Agents such as 10X sugar may be applied to open surfaces to stimulate granulation tissue, or necrotic tissue may be treated by enzymatic debridement with agents such as, for example collagenase (Santyl Ointment). If the necrosis is of greater proportion, surgical debridement may be indicated.
Occlusive dressings are often applied as a protective measure, and as a means to demonstrate to the patient in a non-threatening way, that if there is no access, lesions can heal. Unfortunately, however, this measure may simply lead to the appearance of new lesions in a different location.
Dermatitis artefacta by proxy is a form of child abuse. When this is suspected it is important to separate the child from the parent. Unfortunately the maternal pathology is such that confrontation raises intense rage, and medico-legal issues may become a factor. Discussion with local authorities may be necessary.
Oral antibiotic or anti-fungal agents are determined by culture. It is important to remember that dermatitis artefacta represents the expression in the skin of a problem that is primarily psychiatric. Anxiety and depression are most often comorbid, and the medications outlined below offer a reasonable approach to treatment.
It is important to discuss major possible side effects and also to explain to the patient that the suggested medications are not approved by the Food and Drug Administration (FDA) for this particular disorder. One may profess ignorance as to why the medications are effective, explain that experience teaches that they can be so, or alternatively evoke cytokines or neuropeptides as a possible explanation.
The treatment of choice for anxiety currently is one of the specific serotonin reuptake inhibitors (SSRIs), which are also the drugs of choice for treatment of depression. Sertraline is usually well tolerated and less sedating than fluoxetine or paroxetine; it usually also has fewer sexual side effects–50mg once daily can be increased by 50mg every 3 to 5 days up to 200mg once daily, as tolerated.
The SSRIs, however, do not become fully effective for several weeks, and so a benzodiazepine may be prescribed concurrently with the SSRI (clonazepam 1.0 to 2.0mg at bedtime, or alprazolam 0.25mg to 1.00mg up to 4 times daily) for the first month, until the SSRI takes effect. The benzodiazepine should then be withdrawn by tapering the dose gradually, as these drugs are potentially habit-forming.
An alternative anxiolytic is buspirone, which can be started at 10mg once daily at bedtime and increased by an increment of 10mg each week, to a total of 10mg 3 times daily. Buspirone is not commonly prescribed as an antidepressant, but like the SSRIs, the therapeutic effect of buspirone may not occur for several weeks.
Patients with dermatitis artefacta are commonly depressed. The drugs of choice to treat depression currently are the SSRIs, and if one drug in this class is ineffective or not tolerated, another drug in the same class may be prescribed. Sertraline is usually well tolerated and may be prescribed as described above.
Alternative SSRIs are paroxetine 10mg, increasing to 20mg in 5 to 7 days, or citalopram 10mg, increasing to 20 mg in 5 to 7 days. In neither of these drugs have higher doses been shown to have a significant advantage. Possible side effects include gastric intolerance, cholinergic effects, decreased libido, and weight gain. There is also the possibility of suicidal ideation or attempted suicide in children, adolescents and young adults; one must be alert to possible signs that such ideation may be present.
Another option is duloxetine, a serotonergic and norepinephrine re-uptake inhibitor. This drug has not only antianxiety and antidepressive action, it also helps to relieve both pain and itching, through action on the peripheral nerves. A dose of 20 mg can be increased by increments of 20 mg weekly, to a total dose of 60 mg twice daily.
To prevent recurrence of depression, it is suggested that antidepressant medication be continued for 4-6 months before attempting to taper the dose. It should never be discontinued abruptly, and frequently the drug is maintained for a year or even long-term.
If the steps described above do not lead to the healing of current lesions and the prevention of new lesions, and if psychiatric referral has not been possible, then the addition of a small dose of an antipsychotic may reduce the self-destructive behavior. Risperidone 1 to 2mg at bedtime or pimozide 1 to 2mg once daily are usually effective.
In these low doses, side effects are minimal but may include sedation, fatigue and accommodation disturbance. Because of possible interaction, the prescribing of SSRI antidepressants together with drugs like pimozide are sometimes questioned, however, the effective dose of the antipsychotic is so small that side-effects are not reported. Cardiac side effects are unlikely in a dose less than 10 mg each day, and tardive dyskinesia is not convincingly reported in the dermatologic literature.
It is important to keep in mind, however, that a drug that has been effective at first, may lose that capacity over time. Usually, however, it can be replaced by another drug in the same family.
In order to demonstrate caring and ensure that the treatment regimens described above are being followed, it is important to continue to see the patient frequently, regardless of whether lesions are present or not. While the condition is active, weekly visits are in order, but these may be reduced to monthly visits, or even three-monthly, if things continue well.
It is important constantly to be alert to signs of deepening depression and also to any evidence that the patient may be softening in his or her resistance to psychiatric referral.
Whereas remissions are possible if things in the patient’s life go well, recurrences are always around the corner, and dermatitis artefacta may be considered to be a life-long condition.
Unusual Clinical Scenarios to Consider in Patient Management
Be aware that the patient’s mental stability is uncertain, and certainly until a meaningful and trusting relationship has developed, the risk of arousing the patient’s unconscious anger is substantial. It is very important for the physician not to allow the patient’s hostility and rage to arouse his or her own anger or defensiveness, as this will surely create a major conflict and drive the patient away, or worse, drive the patient to violence.
One must always be alert to the possibility that deepening depression, or life’s everyday difficulties, may trigger the creation of further serious damage or may precipitate suicidal thoughts. If the approaches described above prove ineffective, it is helpful for the physician, him or herself, to consult a friendly neighborhood psychiatrist.
What is the Evidence?
Abhijit, Saha. “Dermatitis Artefacta: A Review of Five Cases. A Diagnostic and Therapeutic Challenge”. Indian j. Dermatol. vol. 60. 2015. pp. 613-615. (This paper presents five good clinical examples of DA, giving different ways of creating lesions, typical personality presentation, and rather common failure on the part of patients to follow through.)
Amin, SM, Yelamos, O, Martinez-Escala, ME. “Epidermal necrosis with multinucleated keratinocytes: a possible diagnostic clue for dermatitis in children”. J Eur Acad Dermatol Venereol. 2015 Sep 15.
Gutierez, D, Schowsler, MK, Piliang, MP, Fernandez, AP. “Epidermal multinucleated keratinocytes: a histologic clue to dermatitis artefacta”. J. Cutan. Pathol. 2015, Jun 2. (Two above papers approach the diagnosis from the dermatopathology angle, which is quite unusual, and very interesting.)
Harth, W, Taube, K-M, Gieler, U. “Factitious disorders in dermatology”. J Disch Dermatol Ges. vol. 8. 2010. pp. 361-72. (This paper gives a clear and comprehensive overview of the different types of factitious disorder that one sees in dermatology.)
Gattu, S, Rashid, RM, Khachemouri, A. “Self-induced skin lesions: a review of dermatitis artefacta”. Cutis. vol. 84. 2009. pp. 247-51. (A review of the literature that stresses the association with the borderline personality disorder and the very important association with anorexia nervosa.)
Rodriguez-Pichardo, A, Hoffner, MV, Garcia-Bravo, B, Camacho, FM. “Dermatitis artefacta of the breast: a retrospective analysis of 27 patients (1976-2006)”. J Eur Acad Dermatol Venereol. vol. 24. 2010. pp. 270-4. (These 27 women with breast lesions represented 13.43% of the total number of patients with dermatitis artefacta — a reminder to do a full-body examination.)
Van Moffaert, M, Koo, JYM, Lee, CL. “The spectrum of dermatological self-mutilation and self-destruction including dermatitis artefacta and neurotic excoriations”. Psychocutaneous medicine. 2003. pp. 169-89. (This chapter gives a very clear distinction between the different forms of self-mutilation. Dr Van Moffaert also gives guidance about creating a therapeutic relationship and the psychological aspects of treatment.)
Koblenzer, CS. “Dermatitis artefacta. Clinical features and approaches to treatment”. Am J Clin Dermatol. vol. 1. 2000. pp. 47-55. (A concise clinical description and approach to treatment of what currently is specifically defined as dermatitis artefacta.)
Sneddon, I, Sneddon, J. “Self-inflicted injury: A follow-up of 43 patients”. Br Med J. vol. 3. 1975. pp. 527-32. (A classic paper. A 22-year follow-up of 43 patients, reporting incidence, psychologic aspects and outcome.)
Lee, CL, Koo, JHY, Koo, JYL, Lee, CL. “The use of psychotropic medications in dermatology”. Psychocutaneous medicine. 2003. pp. 427-51. (An excellent review of psychotropic drugs for the non-psychiatrist.)
Joe, EK, Li, VW, Magro, CM, Arndt, KA, Bowers, KE. “Diagnostic clues to dermatitis artefacta”. J Am Acad Dermatol. vol. 63. 1999. pp. 209(Clear and concise description of clinical and histopathologic pointers to a diagnosis of a group of often very difficult patients.)
Burns, T, Breathnach, S, Cox, N, Griffiths, C. “Psychocutaneous Disorders, in Rook's Textbook of Dermatology, 8th Edition 2010”. pp. 64.35-4. 54. (These are the relevant pages of a very comprehensive but concise chapter. These pages cover the topic clearly and accurately from both a psychiatric and a dermatologic viewpoint.)
Mohandas, P, Bewley, A, Taylor, R. “Dermatitis artefacta and artefactual skin disease: the need for a psychodermatoloy multidisciplinary team to treat a difficult condition”. Br J Dermatol. vol. 169. 2013 Sep. pp. 600-606. (This paper describes a chart review of 28 patients with dermatitis artefacta treated by a multidisciplinary team. Reportedly, with both psychiatric and dermatologic input, 93% of patients achieved remission. This is a remarkable response, and the authors rightly stress the great importance of psychiatric participation — a participation that is still not common.)
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