Dermatitis artefacta: A diagnostic dilemma

ABSTRACT

Dermatitis artefacta (DA) is a rare psychological disorder in which patients self-inflict cutaneous lesions to satisfy an emotional need. Here, we describe a case of DA initially misdiagnosed as pemphigus. This case represents the importance of the timely recognition and treatment of DA to prevent its progression like in our case scarring alopecia.

CASE REPORT

An 18-year-old woman presented with raw areas over the scalp for 15 days associated with profuse bleeding [Figure 1]. A history of lice is present. No history of self-harm was reported. On examination, there were yellow-crusted erosions over the vertex and forehead. Therefore, she has been diagnosed with pediculosis with a secondary bacterial infection. The patient denied any history of psychiatric illness. The hematological and biochemical investigation was normal. There was no resolution of lesions even after 2 weeks, and hence, a biopsy was done, which showed acantholytic cells [Figure 2]. On clinicopathology, she was treated for pemphigus with corticosteroids for 1 month with no improvement, and hence, the diagnosis was revised to dermatitis artefacta (DA) with psychiatric reference. At this time, she was treated with an occlusive dressing [Figure 3] of the scalp and the patient was followed every alternate day with 90% improvement for 1 week [Figure 4]. She was referred to the psychiatric department for further management.

Figure 1.

Superficial hemorrhagic crusted erosion present over the vertex

Figure 2.

Histopathology showed a crust, perifollicular infiltrate, and secondary acantholytic cells

Figure 3.

Clinical image showing a sterile occlusive dressing over the scalp

Figure 4.

Posttreatment photograph showing cicatricial alopecia over the scalp

DISCUSSION

Introduction

DA or factitious dermatitis is a psychocutaneous disorder in which patients consciously create lesions in skin, hair, nail, or mucosae to satisfy a psychological need, attract attention, or evade responsibility. They usually hide the responsibility for their actions from their doctors.[1,2] Various etiological factors have been implicated such as psychosocial conflicts, emotional immaturity, unconscious motivations, and disturbed interpersonal relations.[3,4] In general, there is female preponderance (female-to-male ratio reported to vary from 20:1 to 4:1), with the highest incidence of onset in late adolescence to early adult life as seen in our case[5] Adults with the disease may have associated neurosis, personality disorders, impulsiveness, or depression. Children may have associated anxiety or immature coping styles with various psychosocial stresses. The typical presentation includes cutaneous lesions, which are bizarre and mimic many of the known inflammatory reactions in the skin.[6,7] The classic location of DA includes the following: face, most common, lower extremity, hands and forearm, trunk, upper arm and shoulder, scalp, and neck. The types of lesions seen in DA are as follows: abrasions or erosions, alopecia, and crusted lesions. The differential diagnoses to be considered for crusted, blistering lesions include ecthyma and herpes simplex. Others may simulate porphyria cutanea tarda, epidermolysis bullosa acquisita, amyloidosis, vasculitis, pyoderma gangrenosum, cutaneous lymphoma, and drug eruption. Treatment includes treating the underlying psychiatric illness with antipsychotics and counseling. Dermatological treatment includes oral and topical antibiotics.[8-10] The patient’s denial of psychological distress and negative feelings aroused in healthcare personnel make management difficult as seen in our case. The doctor should create an accepting, empathic, and nonjudgmental 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.

In dermatologic practice, it is important to take note of patients with persistent chronic conditions that do not respond to treatment and denial of the psychiatric illness by the patient. Conditions that have atypical presentations should be questioned even further. In this case, specifically, the presence of chronic ulcers that were resistant to treatment and no confirmed diagnosis should prompt further investigation to decrease misdiagnosis of DA and prevent progression to permanent scarring.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.