eMedicine Specialties > Dermatology > Psychocutaneous Diseases

Dermatitis Artefacta: Treatment & Medication

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

Treatment

Medical Care

Dermatitis artefacta is a challenging condition that requires dermatologic and, often, psychiatric expertise.

• General dermatological care measures include baths, debridement, emollients, and topical antimicrobials.
• A detailed assessment of the patient history for chronic dermatoses, chronic medical conditions, psychiatric illnesses, and psychosocial problems is necessary in the care of dermatitis artefacta.
• An effective therapeutic relationship in dermatitis artefacta patients requires a nonjudgmental, empathetic, and supportive environment. Avoid etiology issues and confrontation. Developing a good rapport with the patient and encouraging the patient to return for follow-up appointments are important.
• A psychiatric evaluation is warranted for severe self-mutilation and any evidence of psychiatric illness, psychosis, risk of suicide, and/or need for hospitalization in dermatitis artefacta patients.
• Complementary adjuvant therapies in dermatitis artefacta patients may include acupuncture, cognitive behavioral therapy (ie, aversion therapy, systemic desensitization, operant conditioning), biofeedback and relaxation therapy (ie, anxiety-related dermatitis artefacta), and hypnosis.¹³

Surgical Care

No surgical care is required for dermatitis artefacta.

Consultations

Consultation with a psychiatrist is recommended.

Medication

Topical antimicrobials are the most commonly prescribed medication; however, topical agents alone have shown limited efficacy. In many instances, treating the underlying psychiatric disorder with antidepressants, antianxiety drugs, and antipsychotic agents is necessary.^14,15 Analgesics should be avoided because of the high probability for dependence and addiction.

Topical antimicrobials

Self-inflicted lesions are often accompanied by a localized skin infection.

Bacitracin, Neomycin and Polymyxin B (AK-Spore Ointment, Neocin, Neosporin)

Bacitracin prevents transfer of mucopeptides into growing cell wall, inhibiting bacterial growth.
Neomycin is used for treatment of minor infections; inhibits bacterial protein synthesis and growth. Polymyxin B disrupts bacterial cytoplasmic membrane, permitting leakage of intracellular constituents and causing inhibition of bacterial growth.

Fusidic acid (Fucidin, Fusidin, Fusidin Leo)

Topical antibacterial that inhibits bacterial protein synthesis, causing bacterial death.

Oral antibiotics

For impetiginized skin lesions.

Cephalexin (Keflex, Keftab, Biocef)

First-generation cephalosporin that inhibits bacterial replication by inhibiting bacterial cell wall synthesis. Bactericidal and effective against rapidly growing organisms forming cell walls. Resistance occurs by alteration of penicillin-binding proteins. Effective for treatment of infections caused by streptococci or staphylococci, including penicillinase-producing staphylococci. May use to initiate therapy when streptococcal or staphylococcal infection is suspected. Used orally when outpatient management is indicated. Recommended for impetigo caused by Staphylococcus aureus resistant to erythromycin. Primary activity against skin florae. Used for skin infections or prophylaxis in minor procedures.

Erythromycin (E-Mycin, Eryc, Ery-Tab)

Use with hypersensitivity or contraindication to penicillin or cephalexin. May result in GI upset, prompting prescription of an alternative macrolide or a change to tid dosing. Covers most potential etiologic agents, including Mycoplasma species.
Less active against Haemophilus influenzae. Although 10 d seems to be a standard course of treatment, treating until patient has been afebrile for 3-5 d seems more rational. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. For treatment of staphylococcal and streptococcal infections.
In children, age, weight, and severity of infection determine proper dosage. When bid dosing is desired, half the total daily dose may be taken q12h. For more severe infections, double the dose. Has added advantage of being a good anti-inflammatory agent by inhibiting migration of polymorphonuclear leukocytes.

Selective serotonin reuptake inhibitors

First-line therapy for depression. Other medications in this category include paroxetine, citalopram, and sertraline. For dermatitis artefacta associated with obsessive-compulsive disorder, the use of an SSRI for at least 6 months to 1 year accompanied by psychotherapy is recommended.

Fluoxetine (Prozac)

Selectively inhibits presynaptic serotonin reuptake with minimal or no effect in reuptake of norepinephrine or dopamine.
May cause more adverse GI effects than other SSRIs currently available, which is the reason it is not recommended as a first choice. May be given as a liquid and a cap.
May give as single dose or in divided doses. Presence of food does not appreciably alter medication levels. May take up to 4-6 wk to achieve steady-state levels because of long half-life (72 h).
Long half-life is both an advantage and a drawback. If it works well, an occasional missed dose is not a problem; if problems occur, eliminating all active metabolites takes a long time. Choice depends on adverse effects and drug interactions. Adverse effects of SSRIs seem to be quite idiosyncratic; thus, if dosing is started at a conservative level and advanced as tolerated, relatively few reasons exist to recommend one over another.

Tricyclic antidepressants

Doxepin (Sinequan, Zonalon)

Has antihistamine, antipruritic, and antidepressant properties. May be effective for depression (with agitation) and a primary symptom of pruritus.
Increases concentration of serotonin and norepinephrine in CNS by inhibiting their reuptake by presynaptic neuronal membrane, which is associated with a decrease in symptoms of depression.

Amitriptyline (Elavil, Endep)

May be effective for depression with primary symptoms of pain sensations (eg, burning, chafing, stinging). Analgesia usually requires doses <50 mg qhs.
Inhibits reuptake of serotonin and/or norepinephrine at presynaptic neuronal membrane, which increases concentration in CNS. May increase or prolong neuronal activity because reuptake of these biogenic amines is important physiologically in terminating transmitting activity.

Typical antipsychotics

Pimozide (Orap)

Previously shown to be effective for delusions of parasitosis. Centrally acting dopamine-receptor antagonist. Available in 2-mg scored tab in United States; 2-, 4-, and 10-mg tab available in Canada. Clinical response usually occurs within 10-14 d.

Atypical antipsychotics

Lower risk of extrapyramidal adverse effects than with typical antipsychotics.

Risperidone (Risperdal)

Previously shown to be effective for delusions of parasitosis. Binds to dopamine D2 receptor with 20-times lower affinity than for 5-HT2 receptor. Improves negative symptoms of psychoses and reduces prevalence of extrapyramidal adverse effects. Indicated for treatment of psychotic disorders, including schizophrenia and bipolar disorder. Clinical response usually occurs within 10-14 d.

Olanzapine (Zyprexa)

May inhibit serotonin, muscarinic, and dopamine effects. Efficacy similar to risperidone; has fewer dose-dependent adverse effects but is associated with more concern about weight gain.

Quetiapine (Seroquel)

May act by antagonizing dopamine and serotonin effects. Efficacy similar to risperidone and olanzapine. Fewer dose-dependent adverse effects and less concern for weight gain.

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