History
In most cases, patients with dermatitis artefacta are otherwise healthy and do not provide a substantial indicative history; on occasion, they may relate vague accounts of antecedent events. These patients report a personal history of chronic dermatoses, including acne, alopecia (ie, alopecia areata, androgenic alopecia), atopic dermatitis, chronic idiopathic urticaria, psoriasis, rosacea, or vitiligo.
Dermatitis artefacta patients may also have a personal or family history of psychiatric illness, including anxiety, depression, personality disorder (borderline, dependent, or obsessive-compulsive), dissociative disorder, body dysmorphic disorder, or posttraumatic stress disorder. Typically, they are reluctant to seek a consultation with a psychiatrist.
Patients may have a personal history of chronic medical conditions, chronic pain syndromes, or both. They may report a history of childhood neglect or abuse, sexual abuse, or psychological trauma.
Münchausen syndrome by proxy (a 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 following:
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Patient’s quality of life with regard to health-related issues
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Patient’s perception of the skin condition
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Role of a psychosocial stressor
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Presence of a lengthy medical file with numerous consultations
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Extensive list of previously used medications
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History of substance abuse
Inquiries should also be made about family members or significant others and their reaction to the skin lesions. Anger, frustration, and impatience are commonly reported reactions.
Physical Examination
Dermatitis artefacta is a challenging clinical diagnosis. Factors suggesting this diagnosis include the following:
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Absence of other dermatoses to explain the lesions
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Histologic findings that are inconsistent with the clinical presentation
The morphology of the dermatitis artefacta skin lesions is variable and bizarre and typically depends on the mechanism of injury. Features may include sharp margins adjacent to normal skin, geometric shapes, and linear tracks (such as occur secondary to exposure to corrosive liquids). Most often, the dermatitis artefacta lesions are found at sites accessible to the patient, usually within reach of the dominant hand. Typical locations are as follows:
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Face (45%)
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Distal upper extremity (ie, hand and forearm; 24%)
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Lower extremities (31%)
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Trunk (24%)
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Upper arm (7%)
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Scalp (7%)
The appearance of the dermatitis artefacta lesions may vary as follows:
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Superficial erosion (50%)
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Hyperpigmented macule or purpura (30-42%)
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Excoriation (17%)
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Deep necrosis or ulceration (17%)
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Irritant dermatoses (17%)
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Papules (17%)
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Crusts (8%)
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Scars - Pinpoint, star-shaped, or atypically shaped (8%)
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Onychodystrophy
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Other – Keratosis or tattoolike appearance
Overall, 72% of patients have 1 type of lesion morphology, 41% have 2 types, and 31% have 3 types. In 66% of patients, involvement is limited to 1 body segment; in 34%, 2 body segments are involved.
Dermatitis artefacta must be distinguished from dermatitis neglecta, excoriation disorder, trichotillomania, and painful bruise syndrome. Other conditions that may be associated with or may mimic dermatitis artefacta include the following:
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Hepatitis C virus–associated porphyria cutanea tarda [17]
