Dermatitis artefacta-a ‘focal suicide’

R Mariyath, P Kumar

 Department of Skin and STD, Kasturba Medical College Hospital, Attavar, Mangalore-575 001, India

Correspondence Address:
P Kumar
Department of Skin and STD, Kasturba Medical College Hospital, Attavar, Mangalore-575 001
India

Introduction

Dermatitis artefacta is an artefactual skin disease produced entirely by the actions of the fully aware patient. There is no rational motive for this behaviour.[1] There is a marked female preponderance, the ratio of female to male very from 4:1 to 8:1. It is associated with a variety of psychiatric disorders and can be produced by different methods.

Case Report

A 17-year-old female was brought to the skin OPD by her mother with multiple, painful erosions with crusting on the right side of the body of 2 weeks duration. According to her mother erosions started first on the dorsal aspect of right foot and gradually ascended upwards to reach the right side of the abdomen. Patient used to get four erosions every day above the previous lesions. Erosions appeared suddenly at a particular time of the day.

Cutaneous examination revealed multiple, crusted erosions of almost uniform size and shape over the anterior aspect of right lower limb and right side of abdomen, arranged in a horizontal and parallel pattern [Figure - 1]. There were four fresh erosions below the right costal margin. Skin in between the erosions was normal.

Diagnosis of dermatitis artefecta was suspected and patient was admitted for observation. She developed multiple fresh erosion of three consecutive days following admission. Skin biopsy showed ulcerated epidermis and dense inflammation of dermis. Patient was observed continuously for next 3 days with her hands immobilized. No fresh lesions appeared thereafter. On repeated questioning patient confessed that she produced the lesion by pinching. Psychiatric evaluation did not reveal any major psychiatric disorder and the psychiatrist found no stresses or secondary gain.

Discussion

Dermatitis artefacta describes cutaneous lesions that are wholly self inflicted, however the patient typically denies their self inflicted nature.[2] It is a form of ′focal suicide′.[3] Dermatitis artefacta has been associated with severe personality disorders, dissociative disorders, sexual abuse, child abuse, obsessive compulsive disorder, depression, psychosis and mental retardation.[4] However in the vast majority of patients obvious evidence of secondary gain is not present.[4]

Characteristic clinical features are ′hollow history′[1] i.e. sudden appearance of complete lesions without prodrome, lack of history of progression of lesions, strenuous denial by the patient of inflicting the lesions and patient can forecast the site and timing of lesions. Patient appears indifferent towards her disease - ′la belle indifference.[1] Lesions are bizarre with sharp angulated, geometric borders and surface necrosis, do not correspond to any known dermatosis and confined to areas accessible to the dominant hand.

Diagnosis can be confirmed when so fresh lesions appears when patient is under total surveillance 24 hours a day and when no lesions appear in an area totally protected. Diffferential diagnosis vary greatly because of the various methods used for inflicting the lesions.

In cases where skin involvement is mild and patient is relatively healthy psychologically, supportive and symptomatic therapy is adequate. Severe cases with borderline personality need long term and intensive psychotherapy. Psychotic patients are best referred to a psychiatrist.[5]

Thus the visible symptoms of dermatitis artefecta serve as a non verbal communication - a ′cry for attention and help′ from a patient incapable of meaningful verbal communication.

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