Self-induced dermatoses: A great imitator

Self-provoked oral illness: When the mouth mirrors the soul

BACKGROUND

Factitious disorder imposed on self (FDIS), also known as Munchausen's syndrome, is a psychological disorder characterized by falsification of physical or psychological symptoms without an obvious external incentive. Oral presentations of FDIS are infrequently reported, and diagnosis might be challenging because affected patients often have impressive skills in fabricating symptoms and deceiving healthcare professionals.

AIM

To describe the diagnostic dilemma and management challenges in a female patient who presented with tooth ache and oral ulcers.

CASE DESCRIPTION

A 53-year-old female presented with complex medical history, vague symptoms and confusing dental history regarding persistent toothache and generalized oral ulcers. She underwent extensive investigations and multiple dental and oral surgical procedures without reaching a confirmed diagnosis or achieving symptomatic improvement. Thorough review of her medical records revealed multiple admissions to various hospitals across the country and abroad for various reasons, and failed to find any laboratory, clinical, or radiographic evidence of her "claimed" symptoms.

CONCLUSION

Oral healthcare professionals should suspect FDIS in patients presenting with vague and complex history that is not explained by clinical or radiographic findings. Consultation with psychiatric department and hospital administration might be needed to confirm diagnosis and plan appropriate management of the case.

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.

Miscellaneous annular diseases

Annular lesions represent a unique macro-morphologic pattern in various skin disorders that may be found in pityriasis rotunda, elastosis perforans serpiginosa, subacute nodular migratory panniculitis, keratolysis exfoliativa, neutrophilic eccrine hidradenitis, hemophagocytic lymphohistiocytosis, and intentionally induced annular lesions. This group is highly heterogenous and variable in clinical presentation. Whereas some are benign self-limiting disorders like pityriasis rotunda, others such as hemophagocytic lymphohistiocytosis follow a chronic course or have a potential of being life-threatening. Epidemiology, pathogenesis, histopathology, clinical presentation and diagnosis, differential diagnosis, and treatment are discussed.

Update on Diagnosis and Management of Onychophagia and Onychotillomania

Onychophagia (nail biting) and onychotillomania (nail picking) are chronic nail conditions categorized as body-focused repetitive behavior (BFRB) disorders. Due to a limited awareness of their clinical presentations, embarrassment on the part of patients, and/or comorbid psychiatric conditions, these conditions are frequently underrecognized and misdiagnosed. This article reviews the prevalence, etiology, diagnostic criteria, historical and physical exam findings, and treatment options for these conditions. The PubMed/MEDLINE database was searched for relevant articles. Onychophagia and onychotillomania are complex disorders necessitating a detailed patient history and physical examination and a multidisciplinary treatment approach for successful diagnosis and management. Due to the dearth of clinical trials for treatment of nail biting and nail picking, large clinical trials are necessary to establish standardized therapies.

Nail-Associated Body-Focused Repetitive Behaviors: Habit-Tic Nail Deformity, Onychophagia, and Onychotillomania

Habit-tic nail deformity, onychophagia (also referred to as nail biting) and onychotillomania (also referred to as nail picking) are body-focused repetitive behaviors that can involve the nails and periungual skin. Patients with habit-tic nail deformity are typically unaware that repeatedly using their nail, often the adjacent index finger, to rub the proximal nail fold and its underlying matrix - usually of one or both of their thumbnails - is the cause of the longitudinal depressed groove that extends along the entire the nail plate. Nail biters usually bite multiple nails - most commonly on the digits of the hands - and the patient is cognizant of their behavior. However, the term onychophagia is a misnomer and onychodaxia would be a more appropriate nomenclature. Nail pickers also often realize that their dystrophic nail results from using other nails or tools to pick, pull, or excessively manicure the affected nail. Individuals with habit-tic nail deformity or onychophagia or onychotillomania may concurrently have other repetitive behaviors involving the skin or the hair or both. Three patients with a nail-associated body-focused repetitive behavior are described who not only presented with dystrophy of their nails but also abnormalities of the adjacent nail apparatus: a 36-year-old woman with habit-tic nail deformity and dermatodaxia, a 64-year-old man with biting of both the nails and the skin, and a 63-year-old man with nail picking and skin picking. The nail dystrophy and concurrent skin biting or skin picking were not the issues that prompted the reported patients to seek evaluation by a physician; the body-focused repetitive behaviors of the nails and skin were incidental findings during their cutaneous examination. The management of nail-associated body-focused repetitive behavior may include non-pharmacologic treatments (such as physical modalities and behavior modifications) and/or pharmacologic agents. The reported woman with habit-tic nail deformity was willing to consider an attempt to modify her repetitive behavior by using paper tape as a physical modality to cover the area on her thumbs that she would unconsciously rub. However, similar to the men in this report with onychophagia and onychotillomania, many of the patients with nail-focused repetitive behaviors do not want to initiate any interventions that might decrease or eliminate their nail condition.

Obsessive-compulsive disorder in children and adolescents: epidemiology, diagnosis and management

Obsessive-compulsive disorder (OCD) can be found in about 4% of the general population and is characterized by various compulsions and obsessions that interfere with the person's quality of life from a mild to severe degree. The following discussion reflects on current concepts in this condition, including its epidemiology and etiologic underpinnings (behavioral, neurological, immunological, gastroenterological, as well as genetic). The interplay of PANS and PANDAS are included in this review. In addition, the core concepts of OCD diagnosis, differential diagnosis, and co-morbidities are considered. It is stressed that the quality of life for persons with pediatric OCD as well as for family members can be quite limited and challenged. Thus, principles of management are presented as a guide to improve the quality of life for these persons as much as possible.