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.[6]
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.
Epidemiology
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.[7] 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.[8]
- 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.
Shah KN, Fried RG. Factitial dermatoses in children. Curr Opin Pediatr. Aug 2006;18(4):403-9. [Medline].
Gupta MA, Gupta AK, Ellis CN, Koblenzer CS. Psychiatric evaluation of the dermatology patient. Dermatol Clin. Oct 2005;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. May-Jun 2004;21(3):205-11. [Medline].
Ozmen M, Erdogan A, Aydemir EH, Oguz O. Dissociative identity disorder presenting as dermatitis artefacta. Int J Dermatol. Jun 2006;45(6):770-1. [Medline].
Urpe M, Pallanti S, Lotti T. Psychosomatic factors in dermatology. Dermatol Clin. Oct 2005;23(4):601-8. [Medline].
Sambhi R, Lepping P. Psychiatric treatments in dermatology: an update. Clin Exp Dermatol. Mar 2010;35(2):120-5. [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. Mar 2011;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. Mar 11 2009;[Medline].
Ilter N, Adisen E, Gurer MA, Kevlekci C, Tekin O, Sayin A. Dermatitis artefacta masquerading as pyoderma gangrenosum. Int J Dermatol. Sep 2008;47(9):975-7. [Medline].
Harries MJ, McMullen E, Griffiths CE. Pyoderma gangrenosum masquerading as dermatitis artefacta. Arch Dermatol. Nov 2006;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. May-Jun 2007;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. Dec 22 2008;[Medline].
Cohen AD, Vardy DA. Dermatitis artefacta in soldiers. Mil Med. Jun 2006;171(6):497-9. [Medline].
Koblenzer CS. The current management of delusional parasitosis and dermatitis artefacta. Skin Therapy Lett. Oct 2010;15(9):1-3. [Medline].
Shenefelt PD. Complementary psychocutaneous therapies in dermatology. Dermatol Clin. Oct 2005;23(4):723-34. [Medline].
Gupta MA, Guptat AK. The use of antidepressant drugs in dermatology. J Eur Acad Dermatol Venereol. Nov 2001;15(6):512-8. [Medline].
Lee CS, Koo J. Psychopharmacologic therapies in dermatology: an update. Dermatol Clin. Oct 2005;23(4):735-44. [Medline].
Koblenzer CS. Dermatitis artefacta. Clinical features and approaches to treatment. Am J Clin Dermatol. Jan-Feb 2000;1(1):47-55. [Medline].
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