Dermatitis Artefacta

Updated: Jan 06, 2016
  • Author: John YM Koo, MD; Chief Editor: Dirk M Elston, MD  more...
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Overview

Practice Essentials

Dermatitis artefacta is defined as the deliberate and conscious production of self-inflicted skin lesions to satisfy an unconscious psychological or emotional need. Patients with this condition require both dermatologic assessment and psychosocial support.

Signs and symptoms

Patients with dermatitis artefacta may report the following:

  • Otherwise good health
  • Personal history of chronic dermatoses
  • Personal or family history of psychiatric illness.
  • Personal history of chronic medical conditions, chronic pain syndromes, or both.

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

Typical locations for the lesions 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, ulceration (17%)
  • Irritant dermatoses (17%)
  • Papules (17%)
  • Crusts (8%)
  • Scars - Pinpoint, star-shaped, atypically shaped (8%)
  • Onychodystrophy
  • Other - Keratosis, tattoolike

See Presentation for more detail.

Diagnosis

General principles of workup are as follows:

  • No specific laboratory blood tests are required
  • No diagnostic imaging studies are indicated
  • No other general tests are required
  • Skin biopsy of a representative dermatitis artefacta lesion may be performed to rule out any underlying pathology and, in some cases, to establish a definite diagnosis

Dermatitis artefacta must be distinguished from the following conditions:

  • Dermatitis neglecta
  • Excoriation disorder
  • Trichotillomania
  • Painful bruise syndrome
  • Pyoderma gangrenosum
  • Acquired hemophilia
  • T-cell lymphoma
  • Hepatitis C virus–associated porphyria cutanea tarda

See Presentation and DDx for more detail.

Management

Treatment of dermatitis artefacta requires dermatologic and, often, psychiatric expertise. The following must be addressed as necessary:

  • Chronic dermatoses
  • Chronic medical conditions
  • Psychiatric illnesses
  • Psychosocial problems

No surgical care is required.

A psychiatric evaluation is warranted if severe self-mutilation is noted or if there is any evidence of psychiatric illness, psychosis, suicide risk, or need for hospitalization.

Complementary adjuvant therapies may include the following:

  • Acupuncture
  • Cognitive-behavioral therapy
  • Biofeedback and relaxation therapy
  • Hypnosis

Medications that may be given include the following:

  • Topical antimicrobials
  • Oral antibiotics (for impetiginized lesions)
  • Selective serotonin reuptake inhibitors (SSRIs; eg, paroxetine, sertraline, citalopram, and fluoxetine)
  • Tricyclic antidepressants (TCAs; eg, doxepin and amitriptyline)
  • Typical (eg, pimozide) and atypical antipsychotics (eg, risperidone, olanzapine, and quetiapine)

See Treatment and Medication for more detail.

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Background

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.

Excoriation disorder is differentiated from dermatitis artefacta by its compulsive nature. Dermatitis artefacta falls under the general category of factitious disorder, [1] which excludes excoriation disorder, delusional disorders, and malingering. [2] Psychiatric conditions, in particular depression, [3, 4] anxiety, [4] personality disorders, [4] delusional disorders, anddissociative disorders, [5] may be coexistent in as many as 25-33% of all dermatologic conditions. [6]

Dermatitis artefacta may occur in persons of any age and commonly manifests within the context of chronic medical or dermatologic conditions. These self-induced skin lesions may be present continuously, or they may be episodic, occurring during periods of heightened psychosocial stress or uncontrolled psychoses. Patients with dermatitis artefacta require both dermatologic assessment and psychosocial support. [7]

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Pathophysiology

The pathophysiology of dermatitis artefacta is poorly understood. Genetics, psychosocial factors, and personal or family history of psychiatric illness may all play a role. 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 dermatologic condition.

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Etiology

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

A genetic predisposition is likely. Many psychiatric disorders tend to be familial.

Psychiatric illnesses that may be associated with dermatitis artefacta include anxiety disorders, major depressive disorder, dysthymia, body dysmorphic disorder, factitious disorders, and somatoform disorders. The following must be taken into account:

  • Neuropsychological trauma - Child abuse or neglect, sexual abuse, and posttraumatic stress disorder
  • Personality disorders - Attention-seeking traits (eg, borderline or dependent), obsessions, and compulsions
  • Psychosocial factors - Poor coping mechanisms, family dysfunction, and inadequate social support structure [8]

Chronic illnesses commonly associated with dermatitis artefacta include the following:

  • Dermatologic disorders – Acne, alopecia (eg, alopecia areata or androgenic alopecia), atopic dermatitis, chronic idiopathic urticaria, psoriasis, rosacea, and vitiligo
  • Chronic pain syndromes
  • Any other long-standing medical illness
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Epidemiology

The prevalence of dermatitis artefacta in the pediatric population is 1 case in 23,000 persons. The condition is poorly recognized and underreported, [9] and many patients are lost to follow-up. Consequently, dermatitis artefacta probably is considerably more common than is typically thought.

The highest incidence of dermatitis artefacta occurs between late adolescence (11-14 years) and early adulthood. Most patients with dermatitis artefacta are female. [10] In persons younger than 16 years, the female-to-male ratio is 4.7-7:1, whereas in the general population, it is 3-20:1. No racial or ethnic predisposition has been noted for dermatitis artefacta.

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Prognosis

Mild cases of dermatitis artefacta secondary to identifiable psychosocial stressors usually have a good outcome; cure is possible. However, chronic cases of dermatitis artefacta that are associated with chronic dermatologic or medical issues usually have a poor outcome, and cure generally is not possible.

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

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Patient Education

The unique presentation and appearance of skin lesions may be a cause of significant concern both for patients and for parents or caregivers.

During initial patient visits, confrontational issues regarding the etiology of lesions should be avoided. During subsequent visits, one may gradually begin to address the role of psychosocial factors or psychiatric issues that may contribute to the self-inflicted skin lesions. [11] Regular assessment of the risk of self-harm (suicide) or harm towards others is essential.

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