Published on 19/03/2015 by admin
Filed under Dermatology
Last modified 19/03/2015
This article have been viewed 1631 times
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
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.’
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
Treatment of Skin Disease Comprehensive Therapeutic Strategies 4e
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