Dermatitis artefacta

Published on 19/03/2015 by admin

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Dermatitis artefacta

Jillian W. Wong Millsop and John Y.M. Koo

Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports

image

Dermatitis artefacta is a rare, psychiatric condition in which patients self-induce a variety of skin lesions to satisfy a conscious or unconscious psychological need. However, patients will invariably deny responsibility for their injuries. The method used to inflict the lesions is typically more elaborate than simple excoriations. The appearance of the lesions depends upon the manner in which they are created, and can range from minor cuts to large areas of trauma, but is usually characterized by peculiarly shaped injured areas surrounded by normal-looking skin on parts of the body easily reachable by the dominant hand. Chemical or thermal burns, injection of foreign materials, circulatory occlusion, and tampering with old lesions, such as existing scars or prior surgical incision sites, are some common methods of self-injury. More serious wounds can result in abscesses, gangrene, or even life-threatening infection. A large proportion of patients with dermatitis artefacta manifest borderline personality disorder. Interestingly, when the patient is asked about the manner in which the skin condition evolved, he or she is often vague, generally unmoved, and cannot provide sufficient detail, an unique aspect of the illness termed the ‘hollow history.’

Management strategy

It is first important to rule out malingering as the etiology of the skin lesions. If the lesions were made deliberately for secondary gain, such as disability or insurance benefits, the case is no longer considered psychiatrically based, since it is then a criminal act and may eventually need to be dealt with legally. On the other hand, if the lesions are created for no material or other personal gain, then the condition is considered an illness, and medical/psychiatric intervention is warranted.

Most treatment for dermatitis artefacta is symptomatic and supportive. Protective dressings, such as an Unna boot, can occlude the involved areas and protect against further self-injurious behavior.

Antidepressant medications, such as selective serotonin reuptake inhibitors (SSRIs), may be helpful for patients with dermatitis artefacta who have primary or secondary depression. If there is clinical evidence of a psychotic process, pimozide could be considered. There have also been recent case reports of patients responding to the atypical antipsychotic olanzapine when other modes of therapy, including anti-depressants and other anti-psychotics, have failed.

Importantly, physicians should be aware that patients presenting with dermatitis artefacta have a psychiatric illness, and the skin lesions are often an appeal for help. However, suggesting that the illness is psychiatrically based often has a negative effect on patient rapport. Direct confrontation should be avoided if possible, and instead, a supportive environment and a stable physician–patient therapeutic alliance should be fostered, often initially through short (so as not to ‘burn out’ the dermatologist), but frequent (so as to satisfy the patient) office visits. The clinician should be non-judgmental, empathize with the pain, discomfort, and restrictions imposed by the skin lesions, and potentially explore events and possible stressors in the patient’s life. In the case of an adolescent, the clinician should encourage the parents to become involved in identifying psychosocial stressors and helping to modify their environment to meet his or her needs. Some parents may be resistant to this diagnosis and can be angry and critical toward the clinician, so great tact is advisable. If there is a palpable antagonism (‘power struggle’) between the adolescent patient and the parents, it may be advisable to see the patient alone, without the parents, to optimize the possibility of developing therapeutic rapport with the patient. Once the patient establishes trust in the physician by means of a stable relationship, the physician may help the patient recognize the psychosocial impact of the disorder and recommend consultation with a psychiatrist or psychotherapy. This should be attempted, however, only if the clinician feels that the therapeutic rapport is strong enough to give such an intervention a likely possibility of success rather than being taken negatively and defensively by the patient.

Most patients with dermatitis artefacta have a chronic, waxing and waning course. Thus, even when the condition is under control, the physician should still follow the patient at regular intervals to ensure that the self-destructive behavior does not reinitiate. Regular visits, whether or not lesions are present, will help the patient feel cared for and diminish the need for self-mutilation as a call for help.

Specific investigations

First-line therapies

image Occlusive dressings D
image Psychotropic agents D
image Psychotherapy (even if only supportive) D
image Management of secondary cutaneous complications D

Self-inflicted skin diseases. A retrospective analysis of 57 patients with dermatitis artefacta seen in a dermatology department.

Nielsen K, Jeppesen M, Simmelsgaard L, Rasmussen M, Thestrup-Pedersen K. Acta Derm Venereol 2005; 85: 512–15.

This retrospective analysis of 57 patients reported the following findings: when self-infliction was suggested as the potential cause of illness to patients (n = 30), only one patient agreed to see a psychiatrist and two-thirds denied self-infliction or discontinued treatment. Ten patients had a psychiatric diagnosis. The most common subjective complaints were ‘pain’ (59%) and ‘itching’ (37%). The three most common lesion types were skin ulcers (72%), excoriations (46%), and erythema (30%). Of the 57 patients, 61% were treated with anxiolytic or antidepressant medications. In 32 patients, occlusive dressings were administered, and the lesions showed improvement except in two cases.

[/level-membership-for-dermatology-category][not-level-membership-for-dermatology-category]

Dermatitis artefacta

Jillian W. Wong Millsop and John Y.M. Koo

Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports

image

Dermatitis artefacta is a rare, psychiatric condition in which patients self-induce a variety of skin lesions to satisfy a conscious or unconscious psychological need. However, patients will invariably deny responsibility for their injuries. The method used to inflict the lesions is typically more elaborate than simple excoriations. The appearance of the lesions depends upon the manner in which they are created, and can range from minor cuts to large areas of trauma, but is usually characterized by peculiarly shaped injured areas surrounded by normal-looking skin on parts of the body easily reachable by the dominant hand. Chemical or thermal burns, injection of foreign materials, circulatory occlusion, and tampering with old lesions, such as existing scars or prior surgical incision sites, are some common methods of self-injury. More serious wounds can result in abscesses, gangrene, or even life-threatening infection. A large proportion of patients with dermatitis artefacta manifest borderline personality disorder. Interestingly, when the patient is asked about the manner in which the skin condition evolved, he or she is often vague, generally unmoved, and cannot provide sufficient detail, an unique aspect of the illness termed the ‘hollow history.’

Management strategy

It is first important to rule out malingering as the etiology of the skin lesions. If the lesions were made deliberately for secondary gain, such as disability or insurance benefits, the case is no longer considered psychiatrically based, since it is then a criminal act and may eventually need to be dealt with legally. On the other hand, if the lesions are created for no material or other personal gain, then the condition is considered an illness, and medical/psychiatric intervention is warranted.

Most treatment for dermatitis artefacta is symptomatic and supportive. Protective dressings, such as an Unna boot, can occlude the involved areas and protect against further self-injurious behavior.

Antidepressant medications, such as selective serotonin reuptake inhibitors (SSRIs), may be helpful for patients with dermatitis artefacta who have primary or secondary depression. If there is clinical evidence of a psychotic process, pimozide could be considered. There have also been recent case reports of patients responding to the atypical antipsychotic olanzapine when other modes of therapy, including anti-depressants and other anti-psychotics, have failed.

Importantly, physicians should be aware that patients presenting with dermatitis artefacta have a psychiatric illness, and the skin lesions are often an appeal for help. However, suggesting that the illness is psychiatrically based often has a negative effect on patient rapport. Direct confrontation should be avoided if possible, and instead, a supportive environment and a stable physician–patient therapeutic alliance

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