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Dermatitis artefacta
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 (DA), also known as factitious dermatitis , is a rare psychiatric condition in which patients self-induce a variety of skin lesions. The motive for creating the lesions is often a conscious or unconscious psychological need to seek attention or play the ‘sick role,’ possibly due to childhood feelings of abandonment or neglect. DA is unique from psychogenic excoriation , a disorder characterized by excessive scratching or picking of one’s skin. While both DA as well as psychogenic excoriation can result in significant disfigurement and distress, psychogenic excoriation is used to describe superficial excoriations caused by nail or finger manipulation only. In contrast, DA is used to diagnose self-inflicted cutaneous wounds that are more severe than simple excoriations; it is often generated using sharp instruments, cigarette butts, or injecting feces into one’s skin.
Of patients presenting to dermatology with a primary psychiatric condition, 23% of them have DA. DA occurs in a four-to-one ratio of female-to-male patients, with an average age of onset of 12.5 years old. Certain populations, such as healthcare workers and those of lower socioeconomic class, exhibit greater prevalence of DA versus the general population. DA is associated with both childhood abuse and childhood psychiatric disorders. Recent studies suggest that a large proportion of patients with DA have comorbid anxiety, depression, or borderline personality disorder.
To diagnose DA, a detailed history is necessary to uncover any significant stressors, social issues, or underlying psychological diseases. When DA patients are asked about the nature in which their lesions developed, they will often be vague and deny any responsibility. Their disposition is classically described as inappropriately unconcerned or pleasantly detached, a unique feature termed hollow history .
Appearance of DA lesions is variable and depends on what tool or method is used to harm the skin, such as heat, boiling or ice-cold water, chemicals, injection of foreign materials, or tampering with old lesions, such as existing scars or surgical incision sites. Lesions can range in severity from tiny cuts to large areas of trauma, and may include ulcers, burns, erosions, bullae, purpura, hyperpigmentation, ecchymosis, excoriations, or lichenification. Significant disfigurement may result, with more serious lesions posing risk of abscess formation, gangrenous necrosis, or life-threatening infection. Signs of DA-related lesions are different stages of healing, surrounding normal-appearing skin, location in easy to reach areas, and irregular or bizarre morphology. Patients are often otherwise healthy.
The diagnosis of DA is one of exclusion that is difficult to verify, as patients seldom admit to their involvement in producing the lesions. It is important to have a broad differential diagnosis, as DA is capable of mimicking several conditions. First, it is important to consider malingering. If skin lesions are created deliberately for secondary gain, such as to obtain disability or insurance benefits, then the case is no longer considered psychiatrically-based, but instead an act of fraud. However, if skin lesions are created without an underlying material or personal gain, then it is considered an illness warranting medical and psychiatric intervention.
Second, it is important to consider Munchausen syndrome and Munchausen syndrome by proxy, which involves deceptively presenting one’s self or another (a victim), respectively, as ill or injured, without obvious external reward. While similar in presentation, Munchausen patients often have an embellished explanation for their condition, with an extensive history of hospital admits and other organ involvement. In Munchausen by proxy, mentally ill individuals make up or cause illness or injury to another, typically a child or even a baby, who are unable to speak for themselves. Finally, since DA frequently occurs in adolescents, it is important to have a low threshold for suspecting physical or sexual abuse in these patients.
Management Strategy
Management of DA can be challenging, with most therapeutic options symptomatic and supportive. Topical treatment is first line, and may include bandages, dressings, emollients, baths, or antibiotics. Protective dressings, such as an Unna boot, are used to occlude involved areas and protect against further self-injurious behavior.
The mainstay of DA treatment is addressing the patient’s underlying psychopathology and behavioral patterns, which could be done with different types of therapy, such as cognitive behavior therapy or psychotherapy. Psychotropic medications are useful in some cases, with appropriate agents depending on patients’ underlying psychological issues. Antidepressant medications, such as selective serotonin reuptake inhibitors , could be helpful for patients with DA and primary or secondary depression. If there is clinical evidence of a psychotic process, pimozide could be considered. There have also been case reports of patients responding to olanzapine, an atypical antipsychotic, after other therapies failed. A multidisciplinary approach to management, between dermatologists and mental health professionals, is often necessary.
Physicians should be aware that DA patients have a psychiatric illness, and the skin lesions are often a cry for help. However, suggesting the lesions are psychiatrically based often has a negative effect on patient rapport. Direct confrontation should be avoided, if possible, and instead, a supportive environment and stable physician–patient therapeutic alliance should be fostered. This is often done with short and frequent office visits.
With an adolescent patient, the clinician should encourage the parents to become involved in identifying psychosocial stressors and helping to modify the patient’s environment to meet his or her needs. Certain parents could be resistant to their child’s diagnosis and may become angry or critical toward the clinician. If there is intense antagonism between the adolescent patient and the parents, it may be advisable to see the patient alone to optimize the possibility of developing therapeutic rapport. Once the patient establishes trust in his or her physician, through a stable relationship, the physician may then help the patient recognize the psychosocial nature of their disorder and recommend psychiatric consultation .
Most DA patients have a chronic waxing and waning course of disease that fluctuates with life circumstances. Even when DA is under control, physicians should continue to follow patients at regular intervals to prevent a relapse in self-destructive behavior. Regular visits , whether or not the lesions are present, will help patients feel cared for and diminish the conscious or unconscious desire to self-harm.
Specific Investigations
Dermatitis artefacta
Lavery MJ, Stull C, McCaw I, et al. Clin Dermatol 2018; 719–22.
An up-to-date review of DA.
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