Dermatitis artefacta in pediatric patients: experience at the national institute of pediatrics

Factitious dermatitis in children and adolescents is highly comorbid with psychiatric disorders

OBJECTIVE

Factitious dermatitis (FD) is a psychocutaneous disorder characterized by self-induced skin lesions. FD is related to mental illness, but the correlation is poorly defined in the pediatric population. Our study aims to investigate the risk of psychiatric disorders diagnosed after the FD diagnosis in children and adolescents.

METHODS

We conducted a retrospective cohort study over a seven-year period (2016-2022) to measure the incidence and risk ratio of psychiatric disorders in patients under age 19 years. The FD cohort was defined as patients with FD (International Classification of Diseases, ICD-10-CM: L98.1); the control cohort was defined as patients who attended a regular dermatology visit by applying a diagnostic code of disease of the skin and subcutaneous tissue (ICD-10-CM: L00-99).

RESULTS

A total of 453 patients were identified for analysis. We found that FD patients were more likely to be diagnosed with anxiety disorder (Relative risk [RR] 7.63; P < 0.001), obsessive-compulsive disorder (RR 6.20; P < 0.001), attention-deficit hyperactivity disorder (RR 4.90, P < 0.001), depression (RR 2.27; p = 0.02), sleep disorder (RR 2.23; P = 0.01), impulse disorder (RR 2.20; P = 0.04), and conduct disorder (RR 2.14; P = 0.04) within 1 year following the diagnosis of FD.

CONCLUSION

FD is highly comorbid with psychiatric disorders. Though some practitioners believe FD could result from experimental or recreational behavior in children and adolescents, possible underlying psychiatric disorders should never be overlooked.

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.

A review of the diagnosis and management of pediatric psychodermatologic conditions: Part II

Pediatric psychodermatologic conditions encompass both primary dermatologic conditions with psychiatric comorbidities and primary psychiatric conditions with self-induced dermatologic manifestations. Detection, diagnosis, and management of primary psychiatric conditions with dermatologic manifestations are challenging due to patient-perceived stigma and lack of educational opportunities for dermatology providers. This two-part series highlights the most up-to-date evidence-based data and management techniques of some of the more common dermatoses of primary psychiatric conditions in children. Part I includes trichotillomania, skin picking disorder, and onychophagia, and part II covers dermatitis artefacta, body dysmorphic disorder, and delusions of parasitosis by proxy, with special considerations for family dynamics.

Purpura of the chin: Two consecutive cases

Two healthy children, a 10-year-old boy and a 13-year-old girl, both with no previous medical history, unrelated, presented with pinpoint purpura of the chin and the upper lip. It had appeared 2 days before and extended from the chin to the lower lip. Neither had fever or recent trauma, nor had they taken any medication. Their vital parameters and physical examination were normal. Their peripheral blood cell counts and coagulation parameters were normal. A week later, upon the follow-up consultation, the purpuric lesions had disappeared and both children reported they had played the glass game.

[A stereotypical clinical presentation of childhood linear purpura of the arms: Analysis of six cases]

Among causes of childhood purpura, other- or self-induced mechanical purpura, such as factitious purpura, needs to be considered. This cause is unfamiliar to pediatricians, usually compromising early diagnosis. We report on the cases of six children, seen between 1998 and 2014 at the Toulouse and Bordeaux Departments of Dermatology, presenting with a stereotypical linear purpura on the arms. All were females, aged 6-14 years. One patient had a psychiatric history, whereas the others were undergoing a stressful time period. All had several relapses and diagnosis was delayed in all. The patients presented with multiple oval or square purpuric macules, forming a discontinuous linear band. Some patients reported functional discomfort such as pain or pruritus. Lesions were always located on the arms and sometimes on other areas of the body. Biological assessments were normal and there was no vasculitis at skin histology. We retained the diagnosis of induced mechanical purpura. Psychological support was offered to four patients. One of them declared that the lesions were induced by classmates using suction. Another child declared that she caused the lesions herself, without explaining the mechanism. Outcome was favorable in five children (one was lost to follow-up), 1-4 years after diagnosis. In conclusion, induced mechanical purpura in children, although rarely described in the medical literature, must be kept in mind. Investigations should be carried out in cases with uncertain diagnosis. Underlying psychological distress should be sought.

Dermatitis Artefacta

Background:

Dermatitis artefacta (DA) is difficult to diagnose by clinical findings alone. Histopathologic analysis may rule out organic disorders and in some cases establish, in conjunction with microanalytic techniques, a definite diagnosis.

Objective:

We report a young woman with DA in the form of recurrent abscesses whose diagnosis was aided by the identification of subcutaneous foreign material through histologic and microanalytic methods.

Methods:

Histologic examination showed foreign body giant cell reaction with polarizable material, which was identified as cellulose by energy dispersive x-ray analysis and Fourier transform infrared spectrometry.

Results:

Self-injection of exogenous matter was suspected. Referral to an expert in psychodermatology resulted in the diagnosis of multiple psychiatric comorbidities commonly associated with DA. Initiation of antidepressants resulted in marked improvement in her skin disease, as well as her mood and affect.

Conclusion:

We emphasize the importance of interdisciplinary collaboration between dermatologists, dermatopathologists, and mental health professionals in the management of DA.

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.

Life events and quality of life in female patients with dermatitis artefacta: a comparative study with siblings and controls

BACKGROUND

If the severity of dermatitis artefacta (DA) is accepted by most authors, few published studies have sought to clarify its etiology and impact. It is in this context that this work aimed to compare Life Events (LE) and quality of life (QoL) scores in patients with DA, in their siblings and in control patients with other chronic dermatological diseases.

METHODS

This is a descriptive and comparative cross-sectional study carried out in the dermatology department of Farhat Hached hospital in Sousse, Tunisia. Thirty female patients diagnosed with DA according to DSM-IV criteria were retrospectively recruited. For each patient with DA, one of her sisters, the closest in age, was enrolled in the siblings group. The control group consisted of thirty female patients with other chronic dermatological diseases, matched with DA patients for age and duration of disease progression. Assessment was based on Paykel inventory for LE and on SF-36 for QoL.

RESULTS

Compared to both control groups, DA patients reported more LE with more objective negative impact of these events and had a lower score and more often impaired mean global score of QoL.

CONCLUSIONS

LE would have a role in the pathogenesis of DA which seems to alter the QoL of patients. These results could help to improve the understanding of DA and incite clinicians to focus not only on the diagnosis and treatment of DA but also on the impact of this disease.

[Dermatitis artefacta in a young girl]

Dermatitis artefacta is a self-inflicted skin disease during which the patient denies having produced and is not conscious of the psychological need he or she needs to satisfy through the lesions. Suggestive clinical features often include bizarre, linear, or geometric outlines of accessible parts of the body and an ambiguous history of the lesions. Dermatitis artefacta in children is often associated with familial dysfunction and/or problems at school. We report a case of acute linear purpuric lesions of the upper right limb in a 12-year-old girl.

Dermatitis artefacta in a child

The high visibility of dermatologic diseases and their easy accessibility make the skin a primary and direct target for dysfunctional behaviors. Self-harm tendencies can frequently be expressed through dermatologic lesions, and dermatitis artefacta falls within this clinical frame. The occurrence of this cutaneous manifestation in children is very rare, with a peak of greater frequency in adolescence. We describe the characteristics of a multidisciplinary intervention-dermatologic and psychologic. Our pediatric patient displays a dermatologic picture that has no etiologic confirmation. The source of this disorder must therefore be found in socio-relational difficulties within the family and school environments, which lead the patient to self-harm behaviors that have a high communication value.

Dermatitis artefacta unter dem Bild einer Lichtdermatose

Dermatitis artefacta is a form of a self-injury due to psychiatric disorders or internal conflicts. Delayed diagnosis often leads to unnecessary treatments. A 17-year old girl was referred with a putative photodermatosis presenting with erosions on an erythematous base on the face and forearms. The unusual rapid onset of new lesions following phototesting and in particular a reaction induced after a simulated light exposure substantiated the diagnosis of dermatitis artefacta. Faced with the diagnosed the patient admitted she had induced the lesions and was referred for psychiatric care.

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.

Úlceras genitales artefactas de aparición simultánea en pareja

Genital ulcers may be due to a number of causes, with the most frequent ones being of infectious, tumorous and physical etiology. The coexistence of genital lesions in a couple makes it necessary to rule out sexual transmission as a first option, as it is not always the cause. We present the case of a 78 and 73-year-old couple, both of whom presented with genital ulcers which had been developing for months and which began to manifest simultaneously. The negative results in the tests performed, the exclusion of other likely causes and the favorable evolution of the lesions suggest self-inflicted ulcers as a probable diagnosis, an infrequent form of presentation of "folie à deux". Despite its infrequent occurrence, dermatitis artefacta is a cause that should always be included in the differential diagnosis of any skin lesion, as it often goes unnoticed because of its many clinical presentations.

Factitious buccal lesion secondary to bruxism in a child with cerebral palsy

Children with cerebral palsy are at greater risk of a whole range of oral conditions than their peers. These include bruxism (tooth grinding), oral skill dysfunction, gross malocclusion due to effects of the abnormal orofacial muscle tone on tooth eruption, drooling of saliva, and poor oral hygiene. A challenging case of a painful buccal lesion in a 2 year old girl with cerebral palsy (CP) that did not respond to antifungal, antiviral or antibiotic treatment is presented as a factitious lesion. The recognition and significance of self-injurious behaviour and factitious lesions in children are discussed.