eMedicine Specialties > Dermatology > Psychocutaneous Diseases

Dermatitis Artefacta

Author: John YM Koo, MD, Vice Chair, Department of Dermatology, University of California San Francisco Medical Center; Professor, Clinical Dermatology, Department of Dermatology, University of California at San Francisco School of Medicine
Coauthor(s): Patricia T Ting, MSc, MD, Dermatology Resident, Division of Dermatology and Cutaneous Sciences, Department of Medicine, University of Alberta
Contributor Information and Disclosures

Updated: Jul 8, 2009

Introduction

Background

The skin and nervous system develop adjacent to each other as the ectoderm and neuroectoderm, respectively, in the embryo and remain interconnected throughout life. Dermatitis artefacta is defined as the deliberate and conscious production of self-inflicted skin lesions to satisfy an unconscious psychological or emotional need. These skin lesions serve as powerful, self-expressive, nonverbal messages. Patients often deny responsibility for their creation. Neurotic excoriation is differentiated from dermatitis artefacta by its conscious compulsive nature. Dermatitis artefacta falls under the general category of factitious disorders, which excludes neurotic excoriations, delusional disorders, malingering, and Münchhausen syndrome (except Münchhausen syndrome by proxy).¹

Psychiatric conditions, in particular depression,^2,3  anxiety,³  personality disorders,³ delusional disorders, and dissociative disorders,⁴ are often coexistent in 25-33% of all dermatological conditions.⁵ Dermatitis artefacta may occur in persons of any age and commonly manifests within the context of chronic medical and/or dermatological conditions. These self-induced skin lesions may be present continuously, or they may be episodic, occurring during periods of heightened psychosocial stress and/or uncontrolled psychoses. Patients with dermatitis artefacta require both dermatological assessment and psychosocial support.

Pathophysiology

The pathophysiology of dermatitis artefacta is poorly understood. Multifactorial causes include genetics, psychosocial factors, and personal or family history of psychiatric illness. Commonly, a family member is involved in the medical field, and patients tend to be well versed in medical terminology.

Acute episodes of dermatitis artefacta often represent a maladaptive response to a psychosocial stressor. Long-standing cases may be secondary to underlying anxiety or depression, emotional deprivation, an unstable body image, or a personality disorder with borderline features. Many dermatitis artefacta patients also have an associated chronic medical or dermatological condition.

Frequency

International

The prevalence of dermatitis artefacta in the pediatric population is 1 case in 23,000 persons. It is more common than is typically thought because it is poorly recognized and underreported.

Mortality/Morbidity

Dermatitis artefacta is poorly recognized and underreported. Additionally, many patients are lost to follow-up.

• Continuous or repeated episodes of self-mutilation may result in disfiguring scars on exposed areas of the body.
• Approximately 30% of all dermatological conditions are associated with a psychiatric disorder.
• Suicide is an important consideration in patients with a comorbid psychiatric illness.

Race

No racial or ethnic predisposition has been noted for dermatitis artefacta.

Sex

Most patients with dermatitis artefacta are females.⁶

• In persons younger than 16 years, the female-to-male ratio is 4.7-7:1.
• In the general population, the female-to-male ratio is 3-20:1.

Age

The highest incidence of dermatitis artefacta occurs between late adolescence (age 11-14 y) and early adulthood.

Clinical

History

• 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.

Physical

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^7,8
  • Acquired hemophilia⁹
  • T-cell lymphoma¹⁰
  • Hepatitis C virus–associated porphyria cutanea tarda.¹¹

Causes

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 structure¹²
• 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

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• Neurotic Excoriations (Dermatology)