7.2.2 Dermatitis Artefacta
Grading & Level of Importance: C
Artefactual dermatitis; self-inflicted skin disorder.
1:23 000 in paediatric populations. Commonest in late adolescence and early adulthood. F>M 8:1.
A skin condition with no underlying organic cause where skin changes are self-inflicted. The patient invariably denies being the cause.
Aetiology & Pathogenesis
Dermatitis artefacta is a cutaneous manifestation of a primary psychiatric disorder. The skin lesions may convey secondary (unconscious) gain for the patient (e.g. attention-seeking). Patients with dermatitis artefacta generally do not want to be hospitalised in order not to be observed during the evolution of the lesions.
Signs & Symptoms
The symptoms are highly variable: atypical skin lesion, ranging from excoriation (scratch) to ulcer to extensive skin damage or loss. May mimic organic diseases. The way the lesions are created may include self-manipulation, or the use of tools or chemical substances.
The disease has a predilection for sites of the body that are easily reached. Locations which cannot be reached are usually spared.
Laboratory & other workups
Although medical tests are sometimes required to exclude organic disease (e.g. swab for atypical organisms), unnecessary tests should be generally avoided.
The histological findings are highly variable according to the mechanism of injury to the skin.
The disease has a chronic course, even with psychological treatments.
Secondary infections and scarring of different degrees up to functional disabilities. Unnecessary or inappropriate medical treatments may cause complications.
Primarily clinical: bizarre-looking lesions in easily reached locations. However, potential organic causes always should be considered and excluded first. Careful psychological evaluation is required. It should be noted that patients with psychological disease may also have concurrent organic diseases.
Many possibilities, depending on appearance. Consider pyoderma gangrenosum (including superficial forms). Also consider factitious disorder imposed on self, where there is a conscious gain in the self-harming behaviour.
Prevention & Therapy
It is unclear whether confronting the patient with the clinical diagnosis is counter-productive or not. A psychological review with therapeutic intervention is often helpful. Occlusive dressings or hospital admission (making further manipulation difficult) may help to confirm the diagnosis or provide treatment.
Analogously to Münchhausen syndrome, dermatitis artefacta may rarely occur by proxy i.e. the lesions on the patient may be induced by someone else.
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