Dermatitis artefacta: Keloids and foreign body granuloma due to overvalued ideation of acupuncture

Introduction

Dermatitis artefacta is defined as the deliberate and conscious production of self-inflicted skin lesions to satisfy an unconscious psychological or emotional need. In women, it is regarded as a "cry for help," especially when the patient is faced with psychosocial stressors. ^[1] There is a marked female preponderance, with the ratio of female to male varying from 8:1 to 4:1. ^[2],[3] Various psychosocial conflicts and unconscious motivating factors have been held responsible for this self-destructive activity. ^[4] The patient typically denies their self-inflicted nature. ^[2] The various methods of producing the skin lesions are highly imaginative and depend on the patient′s background and education. ^[5] Lesions may be produced by a variety of mechanical or chemical means, including fingernails, sharp or blunt objects, burning cigarettes and caustic chemicals. Skin lesions in dermatitis artefacta are mainly confined to the areas located within easy reach of the patient′s hands. ^[6],[7],[8] We are reporting an unusual case of dermatitis artefacta in the form of self-inflicting keloids and foreign body granuloma due to overvalued ideation of acupuncture.

Case Report

A 42-year-old illiterate, female patient, housewife by occupation, was referred to us from the Orthopaedic department for asymptomatic solid raised scar-like lesions over the extremities for 1-2 years. The patient had vague complaints like weakness, joint pain, pain in both the eyes and pain in the abdomen for 2-3 years. The patient was not giving any history of trauma at the site of skin lesions. She was not able to describe the evolution of the skin lesions. On examination, the patient had multiple atypical and unusual skin lesions in the form of cotton threads buried under the skin, with both ends open on the skin surface involving the right knee, upper abdomen and back [Figure - 1]. Buried cotton thread over the upper abdomen was associated with crust formation. The patient also had multiple hyperpigmented keloidal lesions and hypopigmented atrophic scars involving the abdomen in a bizarre pattern [Figure - 2]. Both knees and lower third of the thighs revealed hyperpigmented keloidal lesions in a circular and horizontal line pattern, respectively [Figure - 3]. The dorsum of the feet and both the upper eyelids also revealed keloidal lesions with normal intervening skin at all the sites. Skin over the forehead and the dorsum of the hand revealed multiple ice pick scars. With the vague history and varied morphology and distribution pattern of the skin lesions, diagnosis of any specific dermatoses was not possible. Just to see if any specific morphology of skin lesions, we thought that might be seen under the sticking plaster applied over the right supraclavicular region, we removed the plaster. We were surprised to see a rusted pin pricked through the skin in that region. With this finding, the diagnosis of dermatitis artefacta (self-inflicting injuries) was made and a specific history was then taken retrospectively to determine the facts.

Initially, the patient denied the self-inflecting cause for all the skin lesions but on repeated questioning, the patient confessed that she produced the lesion by pricking the pins in the skin and at some sites inserted the cotton thread with the needle to get rid of the pain. The patient was then transferred to the skin ward. Psychiatric opinion was taken, which revealed the vague, varied nature of the pain with changing sites that exacerbated specifically when she was burdened with the stressful events of her family. On mental status evaluation, she had coherent speech, markedly depressed mood, was indifferent to pain, overvalued ideations about acupuncture being able to relieve her pain, anhedonia, ideas of helplessness, worthlessness and suicidal ideations without feeling of acting on it, with marked sociooccupational and interpersonal dysfunction. She used to insert the pins randomly in different parts of the body thinking that it would alleviate her pain. This belief had taken the precedence over all other ideations now and her entrenched behavior continued.

We removed the rusted pin and cotton threads in the skin ward. Injection tetanus toxoid was given. Topical and systemic antibiotics were given for the skin lesions for 1 week. Skin biopsy from the crusted lesion over the abdomen was performed, which revealed foreign body granuloma on histopathological examination. The patient was then transferred to the psychiatric ward. She was put on 40 mg of fluoxetine and 1 mg of risperidone per day for 2 weeks. Her Hamilton Depression Rating scale (HDRS) score on admission was 29. After 2 weeks, her depressive symptoms came down to 11 on HDRS; however, her pin pricking behavior continued. She was indifferent to pain during her stay in the ward and showed a rather marked reluctance and hostility when suggested to stop pinning her body by the treating team. She was considered for couple therapy but she requested for discharge. On first follow-up she was still found to be pinning herself.

Discussion

Skin is well recognized as an important somatic mirror of one′s emotion and a site for the discharge of one′s anxieties. Female predominance is observed in many studies and reports of dermatitis artefacta. ^[4],[9],[10] For the diagnosis of dermatitis artefacta, there are some diagnostic clues, ^[11],[12] like denial, amnesia or indifference to the symptoms or how these lesions have occurred. The history may be vague cited by Lyell as hallow. ^[7] Patients are typically unable to describe as to how the lesions evolved. ^[13] The patients often deny their self-inflicted nature. ^[2] Certain characteristic features are noted about cutaneous lesions of dermatitis artefacta, like clearly circumscribed lesions with normal intervening skin, a geometrical or bizarre pattern that is rarely seen in organic disease and the lesions are confined to areas of easy access by the patient. ^[6],[8] Precipitating factors range from simple anxiety to severe personality disorders, including attention-seeking traits, obsessions, compulsions, depression and psychotic disturbances. In our patient, all the characteristic findings were noted right from female gender ^[2],[3] to typical history ^[2],[7],[13] to skin lesions and associated psychological factors, ^[1],[4] which has been mentioned in various studies and reports for the diagnosis of dermatitis artefacta. The cause for self-infliction of skin lesions in our case is either psychosocial factors like family dysfunction and inadequate family support that lead to marked depression or overvalued ideations of acupuncture to get rid of pain. After 2 weeks of antidepressant drugs, her depressive symptoms came down but her pin pricking behavior continued, and on first follow-up, she was still found to be pinning herself. Thus, it is the overvalued ideations of acupuncture that led to self-inflicting injuries in our patient, but the triggering factor for this is the family dysfunction that led to severe depression and symptoms of vague pain in her. To satisfy her psychological or emotional need, it is the deliberate and conscious production of self-inflicted skin lesions through overvalued ideations of acupuncture on her part.

Except in mild transient cases triggered by an immediate stress, the prognosis for cure is poor. The condition tends to wax and wane with the circumstances of the patient′s life. ^[14] Long-standing cases may be secondary to underlying anxiety or depression, emotional deprivation, an unstable body image or a personality disorder with borderline features. Prognosis of dermatitis artefacta is poor but recovery seems to occur when the patient′s life circumstances changes, rather than as a result of treatment. ^[9]