Volume 5 Issue 13 Jan 2015
Consultation- Liaison Psychiatry Focus: Dermatology
Dermatitis artefacta belongs to the category of factitious disorders in which the patient manifests a self-harming behaviour without being directly linked to suicidal ideation or intent. More specifically, it is a dermatosis caused by the deliberate action of a fully aware patient on skin or appendages. It includes intentional simulation of signs or symptoms in order to assume the sick role in the absence of any external incentives. Dermatitis artefacta by proxy is a form of abuse in which the patient creates lesions on a child for secondary gains or to satisfy a deep psychological need.
Dermatitis artefacta is more commonly seen in adolescents or young adults with a female preponderance but can be seen in children too. Adult patients may have associated neurosis, depression, or paranoid personality disorder. Affected children may have associated anxiety disorder, history of dysfunctional parental relationship, bullying, sexual, and substance abuse.
The most common sites of involvement are the areas that are easily accessible such as face, back of hands and forearms. The lesions are bizarre, clearly demarcated from the surrounding normal skin, angulated, and with a tendency for linear arrangement. Self-inflicted chemical burn may show a “drip sign” and punched-out necrotic areas or uniform circular blisters or erosions suggest cigarette burns. Firm swellings with bumpy appearance occur secondary to injection of foreign bodies like milk, oil, or grease into breasts, thighs, abdomen and penis. Another common presentation is chronic, non-healing infected wounds.
The features that should raise the dermatologist’s index of suspicion include the repeated hospital visits with ineffective treatments, negative findings on investigation, in addition to bizarre skin lesions, shallow history, and the affect of patient and family. The treating dermatologist should avoid immediate confrontation regarding the suspicion that the lesions are self-inflicted. Instead symptomatic treatment of skin lesions followed by gradual identification of nature and extent of psychological problem and adopting non-confrontational ‘narrow escape’, ‘quasi-confession’, ‘recovery’, ‘face-saving’ or ‘escape with honour’ strategies form the ideal management.
Department of Dermatology, AIIMS Delhi
