Description, Causes and Risk Factors:
Dermatitis artefacta is a form of factitious disorder in which patients will intentionally feign symptoms and produce signs of disease in an attempt to assume the patient role. It is also self-inflicted skin damage, most commonly from prolonged deliberate scratching, but sometimes by means of sharp instruments or another agency.
It is a rare condition, more common in women than in men. There may be a psychological basis to the disease such as attention seeking because of loneliness, or it may underlie an attempt to secure industrial compensation. Often, no satisfactory explanation can be found.
The pathophysiology of dermatitis artefacta is poorly understood. Multifactorial causes include genetics, psychosocial factors, and personal or family history of psychiatric illness. People with dermatitis artefacta usually have an underlying psychological problem. It can be caused by stress and drugs (particularly methamphetamine or "crank"). Abuse and Munchausen's Syndrome by Proxy are other causes of what may seem to be self-infliction of injuries, at first glance.
It is reasonable to assume that this condition represents a psychological abnormality although the patient may not be known to have a psychiatric illness. Coexisting psychiatric disorders are wide-ranging and include anxiety, depression, personality disorders, psychotic illness and dissociative disorders.
Other Risk Factors:
There is a strong association with eating disorders - the condition occurring in approximately a third of patients with anorexia or bulimia.
Onset or relapse of dermatitis artefacta is often precipitated by definable psychosocial stressors, varying according to age and life situations.
Many patients also have an associated chronic medical or dermatological condition.
Stress and post-traumatic stress disorder (PTSD) may be involved.
The prevalence of dermatitis artefacta in the pediatric population is 1 case in 23,000 persons. It is more common than is typically thought because it is poorly recognized and underreported.
Presentation is variable. Exposed areas are common sites. The lesion is often bizarre and of an unusual angular or geometric shape. Substances such as caustic soda may be applied to the skin or finger nails, and hair may be damaged or removed. Inappropriate interest and persistence of the lesion away from inpatient care are important clues.
Skin injuries and diseases are quite well defined, so the cause of a skin injury or defect can be determined by how it looks, by certain details in the patient's description of the injury, and by microscopic examination of skin biopsies.
There is no investigation that is specific for the disease. Swabs may be taken if secondary infection is suspected. If applicable, tests may be used to exclude other diseases such as skin biopsy. There is almost certainly some psychiatric pathology that will merit investigation at some stage.
Close supervision and symptomatic care of skin lesions will hopefully lead to a doctor-patient relationship in which psychological issues may gradually be introduced. Regularly review suicide and self-harm risk.
Palliative dermatological measures such as occlusive bandages, ointments or placebo drugs, as well as admission to hospital that includes bathing and massaging by nurses, can have a therapeutic impact on the psychiatric problem by symbolizing the medical attention and care for which the dermatitis artefacta patient is craving. Improvement of lesions under protective dressings is supportive of the diagnosis.
Antidepressants may be of value. Selective serotonin reuptake inhibitors (SSRIs) are often preferred although the tricyclic antidepressants may have some antipruritic effect and sedation can be beneficial. If the patient is motivated, cognitive and behavioral therapy (CBT) may be helpful as part of a package of care, although evidence is currently lacking. Atypical antipsychotics such as olanzapine may also be helpful. Inevitably, patients with different psychiatric illnesses require different approaches.
Dermatitis artefacta is a challenging condition that requires dermatologic and, often, psychiatric expertise. Early consideration of the diagnosis is important to avoid unnecessary and potentially harmful investigations and treatments.
NOTE: The above information is for processing purpose. The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition.
DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.
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