Approach Considerations
Dermatitis artefacta is a challenging condition whose management requires dermatologic and, often, psychiatric expertise. [8, 18, 19] A detailed assessment of the patient history for chronic dermatoses, chronic medical conditions, psychiatric illnesses, and psychosocial problems is necessary. General dermatologic care measures include baths, debridement, emollients, and topical antimicrobials. Any underlying psychiatric disorder that may be present should be addressed.
No surgical care is required for dermatitis artefacta. Hospitalization may be required for some patients, depending on the severity of the skin lesions and the risk of suicide. Consultation with a psychiatrist is recommended.
Psychiatric and Other Nonpharmacologic Therapies
An effective therapeutic relationship in dermatitis artefacta patients requires a nonjudgmental, empathetic, and supportive environment. Every effort should be made to avoid discussing the etiology of the condition or confronting the patient regarding the behavior. Developing a good rapport with the patient and encouraging the patient to return for follow-up appointments are important.
A psychiatric evaluation is warranted in dermatitis artefacta patients 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 in dermatitis artefacta patients may include acupuncture, cognitive-behavioral therapy (eg, aversion therapy, systemic desensitization, or operant conditioning), biofeedback and relaxation therapy (eg, for anxiety-related dermatitis artefacta), and hypnosis. [20]
Pharmacologic Therapy
Topical antimicrobials are the medications most commonly prescribed for dermatitis artefacta; however, these agents are of limited efficacy when used alone. Oral antibiotics may be given for impetiginized lesions.
In many instances, treating the underlying psychiatric disorder with antidepressants, antianxiety drugs, and antipsychotic agents is necessary. [21, 22] Analgesics should be avoided because of the high probability for dependence and addiction.
Selective serotonin reuptake inhibitors (SSRIs; eg, paroxetine, sertraline, citalopram, and fluoxetine) are first-line therapy for depression. A tricyclic antidepressant (TCA) with antihistamine, antipruritic, and antidepressant properties (eg, doxepin) is recommended for depression with or without agitation and with pruritus as the primary symptom. A TCA with analgesic properties (eg, amitriptyline) is appropriate for depression with pain sensations (eg, burning, chafing, or stinging) as the primary symptom.
Typical (eg, pimozide) and atypical antipsychotics (eg, risperidone, olanzapine, [23] quetiapine) may be considered for short-term use, particularly if skin lesions are associated with psychotic or delusional symptoms.
Long-Term Monitoring
Frequent follow-up visits with a dermatologist, a psychiatrist, or both are recommended for dermatitis artefacta patients. It should be kept in mind that such patients are often lost to follow-up.
In cases of Münchausen syndrome by proxy, removal of the child to a safe environment is mandatory.
