Dermatitis Artefacta Clinical Presentation

• Dermatitis artefacta patients are usually otherwise healthy and usually do not provide a substantial indicative history, perhaps revealing vague accounts of antecedent events.
• Dermatitis artefacta patients may report a personal history of chronic dermatoses, including acne, alopecia (ie, alopecia areata, androgenic alopecia), atopic dermatitis, chronic idiopathic urticaria, psoriasis, rosacea, or vitiligo.
• They may have a personal or family history of psychiatric illness, including anxiety, depression, personality disorder (ie borderline, dependent, obsessive-compulsive), dissociative disorder, body dysmorphic disorder, or posttraumatic stress disorder. Patients typically are also reluctant to seek a consultation with a psychiatrist.
• They may have a personal history of chronic medical conditions, chronic pain syndromes, or both.
• Dermatitis artefacta patients may report a history of childhood neglect or abuse, sexual abuse, or psychological trauma.
• Münchhausen syndrome by proxy (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 patient's quality of life with regard to health-related issues, his or her perception of the skin condition, the role of a psychosocial stressor, the presence of a lengthy medical file with numerous consultations, an extensive list of previously used medications, and a history of substance abuse. Also inquire 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. It is suggested based on findings that include an absence of other dermatoses to explain the lesions and histological findings that are inconsistent with the clinical presentation.

• The morphology of the dermatitis artefacta skin lesions is variable and bizarre and is typically dependent on the mechanism of injury. Features may include sharp margins adjacent to normal skin, geometric shapes, and linear tracks (ie, secondary to exposure to corrosive liquids).
• Most often, the dermatitis artefacta lesions are found at sites accessible to the patient. Typical locations include the face (45%), upper extremity (ie, hand and forearm; 24%), lower extremities (31%), trunk (24%), upper arm (7%), and scalp (7%). Lesions are usually within reach of the dominant hand.
• The appearance of the dermatitis artefacta lesions, in decreasing order of frequency, is as follows:

  • Superficial erosion (50%)
  • Hyperpigmented macule or purpura (30-42%)
  • Excoriation (17%)
  • Deep necrosis, ulceration (17%)
  • Irritant dermatoses (17%)
  • Papules (17%)
  • Crusts (8%)
  • Scars - Pinpoint, star-shaped, atypically shaped (8%)
  • Onychodystrophy
  • Other - Keratosis, tattoolike
• Usually, 72% of patients have one type of lesion morphology, 41% have 2 types of lesion morphology, and 31% have 3 types of lesion morphology.
• In 66% of patients, involvement is limited to one body segment. In 34%, involvement is with 2 body segments.
• Dermatitis artefacta must be distinguished from dermatitis neglecta, neurotic excoriations, trichotillomania, and painful bruise syndrome.
• Reported mimics and associations are as follows:

  • Pyoderma gangrenosum^{[9, 10]}
  • Acquired hemophilia^[11]
  • T-cell lymphoma^[12]
  • Hepatitis C virus–associated porphyria cutanea tarda.^[13]

The cause of dermatitis artefacta is multifactorial. One should be sure to rule out hypochondriasis, substance abuse disorder, and psychotic disorders.

• Genetic predisposition: Many psychiatric disorders tend to be familial.
• Psychiatric illness: Associations include anxiety disorders, major depressive disorder, dysthymia, body dysmorphic disorder, factitious disorders, and somatoform disorders.

  • Neuropsychological trauma - Child abuse/neglect, sexual abuse, posttraumatic stress disorder
  • Personality disorders - Attention-seeking traits (eg, borderline, dependent), obsessions, compulsions
  • Psychosocial factors - Poor coping mechanisms, family dysfunction, inadequate social support structure^[14]
• Chronic illnesses: These are commonly associated with dermatitis artefacta.

  • Dermatological disorders - Specifically, acne, alopecia (ie, alopecia areata, androgenic alopecia), atopic dermatitis, chronic idiopathic urticaria, psoriasis, rosacea, and vitiligo
  • Any long-standing medical illness
  • Chronic pain syndromes