Dermatitis artefacta: revisión

Self-mutilation: a systematic review

Self-mutilation lesions can represent a clinical diagnosis challenge for healthcare professionals, as patients do not admit to self-mutilation. This leads to failed diagnoses due to the similarity of this condition to other diseases. Searches on the subject were carried out at the PubMed, Periódicos Capes, Scopus, Science Direct and WoS databases, according to the following inclusion criteria: articles in English, Portuguese or Spanish, published from 2018 to June 2023, encompassing case reports, case series and literature reviews. Men are slight more affected by self-mutilation injuries, also presenting the most serious lesions. Self-mutilation injuries are reported globally, mostly in the Asian and American continents. Clinical presentations are varied, but morphology is, in most cases, associated to the form/instrument used for self-mutilation. Greater evidence of diagnosed mental disorders in women and underreporting of these cases in men due to low demands for specialized treatment are noted. A higher prevalence of self-mutilation lesions was verified for men, affecting a wide age range, with the highest number of cases in the USA. The most affected body areas are arms and external genitalia, mostly due to knife use. An association between self-mutilation injuries and mental disorders is clear, with most cases being previously undiagnosed.

Dermatitis Artefacta: A Retrospective Descriptive Study on 46 Patients

INTRODUCTION

Self-induced dermatoses are self-inflicted skin lesions, whose occurrence patient denies responsibility for.

OBJECTIVES

The aim of this study was to retrospectively investigate all the clinical records of dermatitis artefacta (DA) in order to put special focus on: a) epidemiological aspects; b) location, shape and additional features of the lesions; c) availability of psychiatric details in the records.

METHODS

A retrospective observational descriptive study on 46 patients affected by dermatitis artefacta was conducted from January 2015 to March 2021. The only inclusion criterion was clinical or histological diagnosis of DA in patients for which we had clinical images.

RESULTS

The most frequent type of lesions were erosions/excoriations and ulcers (14/46, 30.4% and 13/46, 28.3% respectively) followed by ecchymoses (9/46, 19.5%), vasculitis-like lesions (5/46, 10.9%), crusted plaques (3/46, 6.5%), scales (1/46, 2.2%) and erythema (1/46, 2.2%). Thirty-three percent of the medical records generically referred to the presence of psychiatric disorder, but none of them included a specific psychiatric diagnosis.

CONCLUSIONS

In our study the main dermatologic lesions observed in DA were represented by excoriations and ulcers and that the shape and location of the lesions are essential for a correct diagnosis.

The Role of Sex and Gender in Dermatology - From Pathogenesis to Clinical Implications

BACKGROUND

Sex and gender have increasingly been recognized as significant risk factors for many diseases, including dermatological conditions. Historically, sex and gender have often been grouped together as a single risk factor in the scientific literature. However, both may have a distinct impact on disease incidence, prevalence, clinical presentation, severity, therapeutic response, and associated psychological distress.

OBJECTIVES AND PROJECT DESCRIPTION

The mechanisms that underlie differences in skin diseases between males, females, men, and women remain largely unknown. The specific objectives of this review paper are:To highlight the biological differences between males and females (sex), as well as the sociocultural differences between men and women (gender) and how they impact the integumentary system.To perform a literature review to identify important sex- and gender-related epidemiological and clinical differences for various skin conditions belonging to a range of disease categories and to discuss possible biological and sociocultural factors that could explain the observed differences.To discuss dermatological skin conditions and gender-affirming treatments within the transgender community, a population of individuals who have a gender identity which is different than the gender identity they were assigned at birth.

FUTURE IMPACT

With the rising number of individuals that identify as non-binary or transgender within our increasingly diverse communities, it is imperative to recognize gender identity, gender, and sex as distinct entities. By doing so, clinicians will be able to better risk-stratify their patients and select treatments that are most aligned with their values. To our knowledge, very few studies have separated sex and gender as two distinct risk factors within the dermatology literature. Our article also has the potential to help guide future prevention strategies that are patient-tailored rather than using a universal approach.

Factitial dermatitis in the hospital setting

Factitial Dermatitis (FD) is a notoriously difficult disease to diagnose, as patients produce self-induced cutaneous lesions and provide an inadequate or inaccurate history. We performed a cross-sectional study, querying an inpatient consultation database of all patients admitted to the Ohio State University Wexner Medical Center from 2012 to 2017 with a dermatologic ICD as a discharge diagnosis. Our exhaustive keyword search produced 189 candidates. Consult notes were thoroughly examined, and 32 patients were found to meet case definition of FD. Our analysis of this cohort revealed a significantly greater proportion of cases in the female population. Lesions were more often found to involve the skin on the upper extremities. Isolated secondary skin changes such as erosions, ulcers and excoriations in the absence primary morphologies were also significant in our cohort. As FD is difficult to identify, further understanding of its presentation pattern will decrease time to diagnosis and improve both hospital resource allocation and patient care.

Clinical characteristics and comorbidities of the most common atypical wounds in Northern Finland in 1996-2019: A retrospective registry study

Background and Aims

Atypical wounds comprise about 20% of all chronic wounds. Their diagnosis and treatment are challenging and require multidisciplinary cooperation. More knowledge is needed about the clinical characteristics and comorbidities of atypical wounds to enhance the treatment of these wounds.

Methods

We studied clinical characteristics and comorbidities of the atypical wounds by using the patient data retrieved from the Oulu University Hospital patient database from the year 1996 to the end of 2019 with the following International Classification of Diseases codes: L88, L95.0, L95.8, L95.9, and L98.1.

Results

In our data, there were 135 patients with atypical wound, more commonly seen in females (N = 84, 62.2%) than in males (N = 51, 37.8%) (p < 0.05). The mean age of patients at the time of diagnosis was 57.3 years; those with pyoderma gangrenosum (PG) and factitious wounds were the youngest (53.1 and 53.0 years, respectively). The majority of subjects (N = 126, 93.3%) were diagnosed with comorbidity at the time of the diagnosis. The most common type of wound was PG (N = 49/135, 36.3%), followed by vasculitis and factitious wounds. The prevalence of inflammatory bowel diseases and rheumatoid arthritis in PG patients was high (18.4% for both). All patients with Martorell hypertensive ischemic leg ulceration/calciphylaxis had a diagnosis of hypertension and diabetes mellitus. Psychiatric diseases were more common in patients with factitious wounds than in other types of wounds, whereas patients with vasculitis wounds had more commonly hypertension, obesity, and diabetes mellitus; however, these did not reach statistical significance.

Conclusion

Specific comorbidities associated with atypical wounds, such as high psychiatric comorbidity in factitious wounds. There is a female predominance in atypical wounds and patients are typically younger than patients with other types of wounds. Recognition of the typical clinical picture and comorbidities of atypical wounds may help in identifying these patients and thus also improving their treatment.

Flagellate dermatitis in bleomycin chemotherapy: a causality?

Flagellate dermatitis is a relatively rare reaction to toxicity. It appears as skin lesions with erythematous patches or papules of linear, multiple, flagellate structures. Flagellate dermatitis can be triggered by several causes, which are most commonly associated with bleomycin. This paper reports two cases of flagellate dermatitis, one in a patient with germ cell carcinoma and another in a patient with osteosarcoma who were both diagnosed with flagellate dermatitis after the administration of bleomycin.

Purpura with regular shape in an adolescent: Beware of dermatitis artefacta

BACKGROUND

Purpura is common in pediatric patients, mostly diagnosed as IgA-related vasculitis (Henoch-Schönlein purpura), idiopathic thrombocytopenic purpura (ITP), and thrombotic thrombocytopenic purpura (TTP). However, in some cases, for example, cases with dermatitis artefacta, it could puzzle a physician or pediatrician for a long time, with great challenges in diagnosis.

CASE PRESENTATION

We present the case of a 13-year-old boy with recurrent painful purpura on both upper limbs. The physical exam was unremarkable, except for right blepharoptosis and scars from burns. The diagnostic tests were normal. Through repeated communication, the patient was finally diagnosed as having dermatitis artefacta, accompanied by underlying psychological problems.

CONCLUSIONS

Before dermatitis artefacta was diagnosed, we spent a lot of money and effort on the diagnosis. Therefore, in order to determine the diagnosis as soon as possible and save on unnecessary medical expenses, we propose a rapid process for the diagnosis of purpura of dermatitis artefacta in children.

Gaslighting in alleged assault ascertained as Munchausen syndrome transcending to malingering in highly counterintuitive self inflicted acid burns

A factitious disorder leading to the self-infliction of highly counter-intuitive burns was diagnosed in a middle-aged female. The injuries were otherwise alleged to have been sustained by assault inflicted upon her by an unknown person. The case was diagnosed by medico-legal interpretation of injuries, in spite of a highly deceptive and concocted history by the patient and her husband. The entity was unique in being associated with magnificent primary, secondary and tertiary gains. The exploitation of the morbid sequel to malinger by the patient, and the involvement of the husband for the prolongation of the illness of his wife for financial gains as gaslighting was highly unusual. The self-infliction of injuries over hands is seen in factitious disorder. However, a combination of a guarded self-immersion of the hands and feet in a corrosive by an illiterate female, followed by malingering to earn livelihood is unprecedented in factitious disorders. The delayed presentation which required amputation of all the limbs to save the life of the patient is a glaring highlight of this case.

[Self-inflicted lesions in the context of hidradenitis suppurativa: Pathomimicry]

BACKGROUND

Factitious disorders constitute a complex pathology for the dermatologist. Although a diagnosis is often indicated, it is difficult to confirm and treatment is complicated. Dermatitis artefacta is the somatic expression of an often serious psychiatric disorder consciously created by patients on their own cutaneous-mucosal surfaces but the motivation is unconscious and no secondary benefits are sought (in contrast to simulation). Pathomimicry represent a specific entity: the provocation of outbreaks of a known disease, triggered by voluntary exposure to a causative agent. Herein we report on a case of pathomimicry in a context of hidradenitis suppurativa.

PATIENTS AND METHODS

A teenage girl whose main previous medical history consisted of grade-2 obesity and an episode of pubic abscess was seen at our clinic for axillary lesions. She presented in a state of negligence, was suspicious and aggressive, and refused to undress. After gaining her trust, clinical examination revealed prominent ulcerations (each with a granulated base) at a distance from the folds in the axillary areas, as well as typical hidradenitis lesions of Hurley Grade 2 with purulent openings and rope-like scars from the inguinal folds. Hospitalization was recommended and a positive outcome was achieved under antibiotic therapy with doxycycline, topical alginate and hydrocellular dressings. A psychiatric evaluation concluded that the patient was presenting dysmorphophobic narcissistic weakness, probably in reaction to recurrent harassment at school since childhood. Once she developed trust with us, which was difficult to establish, the patient admitted to having caused the lesions herself. Given the history and clinical data, as well as the negative laboratory tests, a diagnosis of pathomimicry was made.

DISCUSSION

Several cases of dermatological pathomimicry (sustainment by the patient of an ulcer with a known cause, contact with an allergen found in eczema, or renewed use of a medication implicated in toxiderma) or systemic disease (insulin injection in a diabetic patient) have been reported. To the best of our knowledge, this is the first description of pathomimicry associated with hidradenitis suppurativa. Regarding therapy, aftercare should be multidisciplinary. Confessions should not be forced and confrontations, which risk serious psychiatric collapse, should be avoided. A reassuring attitude enables psychiatry to be applied once trust has been sustainably established, hence the crucial role of the dermatologist.

Dermatitis artefacta

Dermatitis artefacta, also known as factitial dermatitis, is a condition whereby self-induced skin damage is the means used to satisfy a conscious or unconscious desire to assume the sick role. It is particularly common in women and in those with an underlying psychiatric diagnosis or external stress. The diagnosis is one of exclusion, and it is often difficult to confirm, with patients rarely admitting their role in the creation of their lesions. Treatment can be challenging, and management should adopt a multidisciplinary team approach composed of dermatologists and mental health professionals. We present a literature review of dermatitis artefacta, highlighted by a case report of a patient with bilateral ulcerations to the legs, which after thorough investigation represented dermatitis artefacta.

Psychocutaneous disease: Clinical perspectives

Psychocutaneous disease, defined in this review as primary psychiatric disease with skin manifestations, is commonly encountered in dermatology. Dermatologists can play an important role in the management of psychocutaneous disease because patients visit dermatology for treatment of their skin problems but often refuse psychiatric intervention. This review describes common psychocutaneous syndromes, including delusional, factitious, obsessive-compulsive and related, and eating disorders, as well as psychogenic pruritus, cutaneous sensory (pain) syndromes, posttraumatic stress disorder, and sleep-wake disorders. The updated classification of these disorders in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition is included. Strategies for management are reviewed.

Dermatitis Artefacta Mimicking Borderline Personality Disorder: Sometimes, Skin Could Be Misleading

Dermatitis artefacta lies in a gray zone, between the specialities of psychiatry and dermatology. The condition could mimic a number of other lesions and therefore is a source of much confusion in clinical practice. Here, we describe a case of dermatitis artefacta in an 11-years old girl, which resembled self-harming behavior in Borderline personality disorder. We then discuss how the two could be differentiated and why this becomes imperative while dealing with such cases.

Dermatitis Artefacta in Childhood: A Retrospective Analysis of 44 Patients, 1976-2006

BACKGROUND

Dermatitis artefacta (DA) consists of self-inflicted skin lesions that the patient denies having produced.

OBJECTIVES

To conduct a single-center retrospective clinical review of children and adolescents diagnosed with DA.

METHODS

From 1976 to 2006, data were collected on children diagnosed with DA who were seen in the Department of Dermatology in our hospital. Clinical and epidemiologic features are described. Forty-four children (mean age 12.9 yrs) were selected, representing 21.9% of the total patients with DA recorded (n = 201) during this period.

RESULTS

The most frequent clinical forms were excoriations (16 [36.4%]) and ulcers (10 [22.7%]), followed by blisters (7 [15.9%]), burns (3 [6.8%]), contact dermatitis (3 [6.8%]), hematomas (2 [4.5%]), panniculitis (1 [2.3%]), cheilitis (1 [2.3%]), and hyperpigmentation (1 [2.3%]). Sixteen were located exclusively on the face and neck, whereas 28 also had other locations (upper limbs, n = 10; lower limbs, n = 9; thorax, n = 5; abdomen, n = 4). Cutaneous lesions were treated with occlusive bandages using zinc paste or a plaster splint when necessary.

CONCLUSION

To our knowledge, this is the largest reported series of DA in childhood. This complicated psychodermatologic condition requires correct diagnosis, appropriate management, and psychiatric assessment.

Photoletter to the editor: Bullous dermatitis artefacta induced with a hot spoon

A 22-year-old female presented to the dermatology department with a 8-month history of blistering lesions over the left forearm and face. Most of the bullae and erosions were perfectly round and of nearly the same size. In absence of any obvious etiological, precipitating or aggravating factor, a provisional diagnosis of dermatitis artefacta (self-inflicted dermatological lesions) was made. A detailed anamnesis revealed that stress caused by her ex-boyfriend's threats and apprehension of consequences prompted her to create the lesions using a hot spoon. The patients of dermatitis artefacta usually present to dermatologists as their pathology manifests as unexplained and variable cutaneous lesions which may go undiagnosed for a long time. It is important for the dermatologist to have a high index of suspicion to recognise the underlying psychopathology.