Neurotic excoriations and dermatitis artefacta

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.

Primary psychiatric conditions: dermatitis artefacta, trichotillomania and neurotic excoriations

Primary psychiatric conditions encountered in dermatology include dermatitis artefacta, trichotillomania (TTM) and neurotic excoriations. For these disorders, the primary pathologic condition involves the psyche; therefore, any cutaneous findings are self-induced. Herein, we review common primary psychiatric conditions in dermatology – dermatitis artefacta, neurotic excoriations and TTM – and examine their epidemiology, clinical presentation, differential diagnosis and treatment strategies. For all primary psychiatric disorders, the most effective underlying strategy is to first establish a strong therapeutic rapport with the patient. Various pharmacologic and non-pharmacologic therapies can then be attempted afterwards to successfully manage these patients.

Clinical, epidemiologic, histopathologic and molecular features of an unexplained dermopathy

BACKGROUND

Morgellons is a poorly characterized constellation of symptoms, with the primary manifestations involving the skin. We conducted an investigation of this unexplained dermopathy to characterize the clinical and epidemiologic features and explore potential etiologies.

METHODS

A descriptive study was conducted among persons at least 13 years of age and enrolled in Kaiser Permanente Northern California (KPNC) during 2006-2008. A case was defined as the self-reported emergence of fibers or materials from the skin accompanied by skin lesions and/or disturbing skin sensations. We collected detailed epidemiologic data, performed clinical evaluations and geospatial analyses and analyzed materials collected from participants' skin.

RESULTS

We identified 115 case-patients. The prevalence was 3.65 (95% CI = 2.98, 4.40) cases per 100,000 enrollees. There was no clustering of cases within the 13-county KPNC catchment area (p = .113). Case-patients had a median age of 52 years (range: 17-93) and were primarily female (77%) and Caucasian (77%). Multi-system complaints were common; 70% reported chronic fatigue and 54% rated their overall health as fair or poor with mean Physical Component Scores and Mental Component Scores of 36.63 (SD = 12.9) and 35.45 (SD = 12.89), respectively. Cognitive deficits were detected in 59% of case-patients and 63% had evidence of clinically significant somatic complaints; 50% had drugs detected in hair samples and 78% reported exposure to solvents. Solar elastosis was the most common histopathologic abnormality (51% of biopsies); skin lesions were most consistent with arthropod bites or chronic excoriations. No parasites or mycobacteria were detected. Most materials collected from participants' skin were composed of cellulose, likely of cotton origin.

CONCLUSIONS

This unexplained dermopathy was rare among this population of Northern California residents, but associated with significantly reduced health-related quality of life. No common underlying medical condition or infectious source was identified, similar to more commonly recognized conditions such as delusional infestation.

Pediatric psychocutaneous disorders: a review of primary psychiatric disorders with dermatologic manifestations

Psychocutaneous disorders (PCDs) are conditions that are characterized by psychiatric and skin manifestations. Classifications of PCDs and their nomenclature are matters of debate. For the purpose of this review, we adopted the classification that distinguishes primary dermatologic disorders with psychiatric co-morbidity (PDDPC) from primary psychiatric disorders with dermatologic manifestations (PPDDM). PDDPC includes the psychophysiologic disorders such as atopic eczema, psoriasis, vitiligo, and alopecia areata. PPDDM includes impulse control disorders, obsessive-compulsive disorders, factitious disorder, factitious disorder by proxy, self-mutilation, delusions of parasitosis, psychogenic purpura/Gardner-Diamond syndrome, and cutaneous sensory disorders. Diagnosis and treatment of PCDs are challenging and require that the underlying psychopathology be addressed. A specific PCD may have different underlying psychopathologies and, at times, multiple overlapping psychopathologies may coexist. Most often, both non-pharmacologic management and psychopharmacologic treatment are necessary. The choice of psychopharmacologic agent depends on the nature of the underlying psychopathology (e.g. anxiety, depression, obsessive-compulsive disorder, psychosis). This article reviews the spectrum of PPDDM in children.

Factitial dermatoses in children

PURPOSE OF REVIEW

Factitial skin diseases are characterized by unusual patterns of skin lesions that do not conform to any known dermatologic condition and that are consciously or subconsciously fabricated by the patient. This review summarizes the current literature regarding the diagnosis and management of factitial dermatoses in children.

RECENT FINDINGS

Neurotic excoriations, acne excoriee and trichotillomania are the most common factitial skin diseases seen in children. Dermatitis artefacta is also seen in children, but is less common. In many cases, the development of factitial skin disease is associated with a comorbid psychiatric condition or identifiable psychosocial stressor. With regard to the management of factitial dermatoses in children, it is of paramount importance for the clinician to establish an appropriate physician-patient-family relationship. Although controlled studies in children are lacking, pharmacologic and/or nonpharmacologic adjunctive therapy can be helpful in the treatment of these difficult conditions.

SUMMARY

The diagnosis and management of factitial skin diseases in children is a challenge. Clinicians caring for children should be able to recognize the common factitial dermatoses that are seen in the pediatric population. The conveyance of support and acceptance by the physician is essential to the treatment process. Both psychotherapy and psychopharmacology can be important adjunctive treatments.

The Emotional Impact of Chronic and Disabling Skin Disease: A Psychoanalytic Perspective

This article discusses some major early factors that influence the evolving psychologic development, which in turn helps determine the emotional impact that chronic or disabling skin disease may have on patients' lives. If the emotional environment, encompassed by the infant-caretaker relationship, is less than optimal, the stability of the body image may be compromised, self-esteem diminished, and affect less well handled and the somatic expression of emotional content may ensue. Each of these is important in dermatology, as is the nature of the disease and the capacity of families and of society to adapt. Psoriasis, atopic dermatitis, and acne are used as examples.

A neuropsychiatrist's perspective on selected dermatoses

Many neuropsychiatric diseases present with concomitant dermatologic manifestations. These manifestations may help the clinician formulate a correct diagnosis when it is otherwise unclear. In this article, we present six cases with clinical photographs of associated skin findings discussed from a neuropsychiatrist's perspective. Each case will be followed by a discussion and a brief review of the associated neuropsychiatric and dermatologic aspects of the disease.

Self-induced nasal ulceration

BACKGROUND

Nasal ulcerations have many causes. Ulcerations that are self-induced are difficult to diagnose and treat. Two rare conditions with self-induced nasal ulceration are trigeminal trophic syndrome (TTS) and factitious disorder (FD). Trigeminal trophic syndrome is characterized by trigeminal anesthesia, nasal alar ulceration, and facial paresthesia. Appearance of the nasal ulcer after trigeminal ablation for neuralgia is diagnostic. Self-induced nasal lesions that occur in FD are primarily distinguished from those in TTS by the presence of normal trigeminal nerve function and frequent patient denial of lesion manipulation.

OBJECTIVES

To increase physician awareness of the disorders leading to self-induced nasal ulceration and to discuss management issues in our patient series.

DESIGN

A retrospective review of 7 cases in which the patients presented for reconstructive consultation between March 1985 and October 1997 and were found to have self-induced nasal ulcerations.

SETTING

Tertiary university medical center.

RESULTS

Five patients were identified with TTS and underwent nasal reconstruction an average of 43 months (range, 4-72 months) after nasal ulcer presentation. Four of the 5 patients developed ulcer recurrence between 1 and 58 months after reconstruction; secondary reconstruction resulted in recurrence in 2 of these patients. Two patients were identified with FD and self-induced nasal ulceration. One of these 2 patients underwent total nasal reconstruction 15 months after ulcer occurrence and developed recurrence 2 weeks after surgery.

CONCLUSIONS

Self-induced nasal ulceration remains a difficult condition to diagnose and treat. Readily treatable conditions should be excluded, and diagnostic workup should include tissue biopsy and laboratory studies. Patients with TTS may have associated ocular findings, and those who do should be referred for ophthalmologic consultation. Surgical reconstruction can be considered in the highly motivated patient with TTS; however, delayed ulcer recurrence is common. Patients with FD should be treated primarily with local wound care and referred for psychiatric intervention. We strongly recommend nasal prosthetic devices as the primary means of aesthetic correction and discourage surgical repair in the patient with FD.

Neurotropic and psychotropic drugs in dermatology

Several psychotropic and neurotropic agents are useful in treating patients with skin diseases such as obsessive compulsive skin manipulation, delusions of parasitosis, generalized pruritus, and post-herpetic neuralgia. The mechanism of action of these agents is based on their interaction with central and peripheral neuronal receptors. The medications discussed in this article include the tricyclic antidepressants, serotonin reuptake inhibitors, naltrexone, pimozide, and gabapentin. The pharmacology, mechanism of action, adverse effects, drug interactions, and monitoring guidelines are outlined for each of these drugs.

Dermatitis artefacta. Clinical features and approaches to treatment

In dermatitis artefacta, the patient creates skin lesions to satisfy an internal psychological need, usually a need to be taken care of. The clinical presentation is characteristic, and differs from that of neurotic excoriations, delusional disorders, malingering, and Munchausen's syndrome. Munchausen's syndrome by proxy is a form of dermatitis artefacta. Except where disease is mimicked, lesions that do not conform to those of known dermatoses are shrouded in mystery, appearing fully formed on accessible skin, within the context of a characteristic psychological constellation. The patient is friendly but bewildered, and the relatives, angry and frustrated. Because of lack of diagnostic stringency, quoted female-to-male ratios range from 3:1 to 20:1, with the highest incidence of onset in late adolescence to early adult life. Most patients have a personality disorder; borderline features are common. The patient's denial of psychic distress, and negative feelings aroused in healthcare personnel, make management difficult. Limit-setting for the protection of both the physician and patient; creation of an accepting, empathic, and nonjudgmental environment; and close supervision of symptomatic dermatologic care will permit development of a therapeutic relationship in which psychological issues may gradually be introduced, that may occasionally permit psychiatric referral. Issues of etiology should be sidestepped because confrontation is counter productive. When psychiatric referral is refused by the patient, the use of psychotropic drugs by dermatologists is helpful and appropriate. The upper dose range of selective serotonin reuptake inhibitors (SSRIs), or low dose atypical antipsychotic agents, may be effective. 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. Lesions can be kept to a minimum, the patient can be protected from unnecessary and intrusive studies, and society can be protected from escalating and unnecessary expenditure of medical resources if, rather than discharging the patient, the dermatologist continues to see the patient on an ongoing basis for supervision and support, whether or not lesions are present. Research studies are necessary to document more accurately the expectable cause, treatment outcome, and prognosis for this group of patients.

Dermatitis artefacta: A review of 14 cases

BACKGROUND

Dermatitis artefacta (DA) is a self-inflicted dermatologic injury sometimes produced for secondary gains. Laboratory investigations, including histologic examination of lesional tissue biopsy, are usually negative and do not give a clue to the correct diagnosis.

PATIENTS AND METHODS

Over a five-year period, 14 patients were diagnosed with DA at King Fahad Hospital (KFH) in Al Baha during routine outpatient and inpatient dermatologic consultations. The diagnoses were based on vagueness of history given by the patients, and the presence of bizarre skin lesions distributed over sites accessible to the patientsA centAA hands. Investigations excluded the possibility of other diseases. In some cases, consultant psychiatric assessment was sought in order to identify possible underlying psychopathologic factors. Seven patients were hospitalized while the rest were managed as outpatients.

RESULTS

The 14 patients comprised 12 females and two males aged 12 to 71 (mean 25.9) years. All except one were Saudis. DA in the males was probably caused for secondary gains. The females, four of whom were married and eight single, were aged 12-36 (mean 21.8) years. Nine of the females (64%) had identifiable severe emotional or psychiatric problems. The remaining two were unmarried and had no identifiable underlying factors.

CONCLUSION

This study reveals that the presentation of DA in Saudi Arabia is essentially similar to what has been reported from other parts of the world. It brings into focus a medical problem which needs to be recognized, as greater awareness may bring about earlier correct diagnosis and treatment.