Dermatitis Artefacta Clinical Presentation
- Author: John YM Koo, MD; Chief Editor: Dirk M Elston, MD more...
In most cases, patients with dermatitis artefacta are otherwise healthy and do not provide a substantial indicative history; on occasion, they may relate vague accounts of antecedent events. These patients report a personal history of chronic dermatoses, including acne, alopecia (ie, alopecia areata, androgenic alopecia), atopic dermatitis, chronic idiopathic urticaria, psoriasis, rosacea, or vitiligo.
Dermatitis artefacta patients may also have a personal or family history of psychiatric illness, including anxiety, depression, personality disorder (borderline, dependent, or obsessive-compulsive), dissociative disorder, body dysmorphic disorder, or posttraumatic stress disorder. Typically, they are reluctant to seek a consultation with a psychiatrist.
Patients may have a personal history of chronic medical conditions, chronic pain syndromes, or both. They may report a history of childhood neglect or abuse, sexual abuse, or psychological trauma.
Münchausen syndrome by proxy (a form of dermatitis artefacta) manifests as skin lesions caused by a parent or caregiver (often the mother). It usually occurs with children younger than 5 years.
Pertinent information from the history includes the following:
- Patient’s quality of life with regard to health-related issues
- Patient’s perception of the skin condition
- Role of a psychosocial stressor
- Presence of a lengthy medical file with numerous consultations
- Extensive list of previously used medications
- History of substance abuse
Inquiries should also be made about family members or significant others and their reaction to the skin lesions. Anger, frustration, and impatience are commonly reported reactions.
Dermatitis artefacta is a challenging clinical diagnosis. Factors suggesting this diagnosis include the following:
- Absence of other dermatoses to explain the lesions
- Histologic findings that are inconsistent with the clinical presentation
The morphology of the dermatitis artefacta skin lesions is variable and bizarre and typically depends on the mechanism of injury. Features may include sharp margins adjacent to normal skin, geometric shapes, and linear tracks (such as occur secondary to exposure to corrosive liquids). Most often, the dermatitis artefacta lesions are found at sites accessible to the patient, usually within reach of the dominant hand. Typical locations are as follows:
- Face (45%)
- Distal upper extremity (ie, hand and forearm; 24%)
- Lower extremities (31%)
- Trunk (24%)
- Upper arm (7%)
- Scalp (7%)
The appearance of the dermatitis artefacta lesions may vary as follows:
- Superficial erosion (50%)
- Hyperpigmented macule or purpura (30-42%)
- Excoriation (17%)
- Deep necrosis or ulceration (17%)
- Irritant dermatoses (17%)
- Papules (17%)
- Crusts (8%)
- Scars - Pinpoint, star-shaped, or atypically shaped (8%)
- Other – Keratosis or tattoolike appearance
Overall, 72% of patients have 1 type of lesion morphology, 41% have 2 types, and 31% have 3 types. In 66% of patients, involvement is limited to 1 body segment; in 34%, 2 body segments are involved.
Dermatitis artefacta must be distinguished from dermatitis neglecta, excoriation disorder, trichotillomania, and painful bruise syndrome. Other conditions that may be associated with or may mimic dermatitis artefacta include the following:
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. 5th ed. Arlington, VA: American Psychiatric Association; 2013. 324-6.
Shah KN, Fried RG. Factitial dermatoses in children. Curr Opin Pediatr. 2006 Aug. 18(4):403-9. [Medline].
Gupta MA, Gupta AK, Ellis CN, Koblenzer CS. Psychiatric evaluation of the dermatology patient. Dermatol Clin. 2005 Oct. 23(4):591-9. [Medline].
Saez-de-Ocariz M, Orozco-Covarrubias L, Mora-Magana I, et al. Dermatitis artefacta in pediatric patients: experience at the national institute of pediatrics. Pediatr Dermatol. 2004 May-Jun. 21(3):205-11. [Medline].
Ozmen M, Erdogan A, Aydemir EH, Oguz O. Dissociative identity disorder presenting as dermatitis artefacta. Int J Dermatol. 2006 Jun. 45(6):770-1. [Medline].
Urpe M, Pallanti S, Lotti T. Psychosomatic factors in dermatology. Dermatol Clin. 2005 Oct. 23(4):601-8. [Medline].
Sambhi R, Lepping P. Psychiatric treatments in dermatology: an update. Clin Exp Dermatol. 2010 Mar. 35(2):120-5. [Medline].
Cohen AD, Vardy DA. Dermatitis artefacta in soldiers. Mil Med. 2006 Jun. 171(6):497-9. [Medline].
Baranska-Rybak W, Cubala WJ, Kozicka D, Sokolowska-Wojdylo M, Nowicki R, Roszkiewicz J. Dermatitis artefacta--a long way from the first clinical symptoms to diagnosis. Psychiatr Danub. 2011 Mar. 23(1):73-5. [Medline].
Ehsani AH, Toosi S, Shahshahani MM, Arbabi M, Noormohammadpour P. Psycho-cutaneous disorders: an epidemiologic study. J Eur Acad Dermatol Venereol. 2009 Mar 11. [Medline].
Koblenzer CS. Dermatitis artefacta. Clinical features and approaches to treatment. Am J Clin Dermatol. 2000 Jan-Feb. 1(1):47-55. [Medline].
Ilter N, Adisen E, Gurer MA, Kevlekci C, Tekin O, Sayin A. Dermatitis artefacta masquerading as pyoderma gangrenosum. Int J Dermatol. 2008 Sep. 47(9):975-7. [Medline].
Harries MJ, McMullen E, Griffiths CE. Pyoderma gangrenosum masquerading as dermatitis artefacta. Arch Dermatol. 2006 Nov. 142(11):1509-10. [Medline].
Brod CS, Garbe C, Schleicher J, Rocken M, Schilling M. Acquired haemophilia mimicking dermatitis artefacta. Acta Derm Venereol. 2009. 89(2):194-5. [Medline].
Angus J, Affleck AG, Croft JC, Leach IH, Slater DN, Millard LG. Dermatitis artefacta in a 12-year-old girl mimicking cutaneous T-cell lymphoma. Pediatr Dermatol. 2007 May-Jun. 24(3):327-9. [Medline].
Giunta A, Demin F, Campione E, Chimenti S, Bianchi L. Dermatitis artefacta in sporadic sclerodermoid hepatitis C virus-associated porphyria cutanea tarda. J Eur Acad Dermatol Venereol. 2008 Dec 22. [Medline].
Koblenzer CS. The current management of delusional parasitosis and dermatitis artefacta. Skin Therapy Lett. 2010 Oct. 15(9):1-3. [Medline].
Mohandas P, Bewley A, Taylor R. Dermatitis artefacta and artefactual skin disease: the need for a psychodermatology multidisciplinary team to treat a difficult condition. Br J Dermatol. 2013 Sep. 169(3):600-6. [Medline].
Shenefelt PD. Complementary psychocutaneous therapies in dermatology. Dermatol Clin. 2005 Oct. 23(4):723-34. [Medline].
Gupta MA, Guptat AK. The use of antidepressant drugs in dermatology. J Eur Acad Dermatol Venereol. 2001 Nov. 15(6):512-8. [Medline].
Lee CS, Koo J. Psychopharmacologic therapies in dermatology: an update. Dermatol Clin. 2005 Oct. 23(4):735-44. [Medline].
Lowry CL, Bewley A, Taylor R. Facial ulcer treated with olanzapine. Clin Exp Dermatol. 2013 Jul. 38(5):504-6. [Medline].
Wong JW, Nguyen TV, Koo JY. Primary psychiatric conditions: dermatitis artefacta, trichotillomania and neurotic excoriations. Indian J Dermatol. 2013 Jan. 58 (1):44-8. [Medline].