Dermatology Oasis

Editor: Nameer Al-Sudany, MD (IRAQ)

Dermatitis artefacta



Dermatitis artefacta (DA) is a condition in which skin lesions are solely produced or inflicted by the patient’s own actions due to underlying psychological problem.
Synonym: (Factitial dermatitis)

What is the difference between DA and malingering?
DA is self-inflicted skin lesions with the intent to elicit sympathy, whereas malingering is self-produced lesions either to escape responsibility, or collect disability insurance (attempt to secure an insurance claim) i.e. the objective behind malingering is material gain while in DA there is an unconscious goal of gaining attention and assuming the sick patient role.

* DA is more common among females than males with a ratio of 3:1.
* It commonly occurs in teen’s age group or early adulthood.
* DA often is encountered among:
(a) Persons who are emotionally immature.
(b) Those having psychosocial or interpersonal difficulty.
(c) Persons with an attention seeking behavior.

How to expect a rash to be DA?
1. Lesions do not conform to those of known dermatoses. However, occasionally it may closely simulates a known dermatosis that it becomes very difficult to differentiate !
2. Lesions having bizarre shapes with irregular outlines in a linear or geometric pattern.
3. Lesions are usually clearly demarcated from surrounding normal skin.
4. The lesions usually present all of a sudden and do not evolve gradually without any prior signs or symptoms.
5. The lesions usually found on sites that are readily accessible to the patient’s hands e.g. face, hands, arms or legs. The lesions are rarely seen on the right hand, right wrist, or right arm, unless the patient is left-handed.
6. The patients will usually deny that the rash is self induced.
7. Often there is a “hollow” history and the patient isusually unable to detail how the lesions appeared or evolved.

Mechanism of induction: Lesions may be produced by a variety of mechanical or chemical means, including fingernails, sharp or blunt objects, lit cigarettes and application or injection of chemical irritants and caustics.

Clinically: The appearance of lesions varies depending on methods used to injure the skin. The lesions range from red patches, swelling, blisters, denuded areas, crusts, cuts, burns, gangrene and scars. At times the only sign may be the indefinitely delayed healing of an operative wound, which is purposely kept open by the patient.

1. Avoid direct confrontation with the patient. Instead the doctor should create an empathetic and non-judgemental environment.
2. It is best not to reveal any suspicion of the cause to the patient and to establish the diagnosis definitively without the patient’s knowledge.
3. Consultation with an experienced psychiatrist is prudent, although this is often refused.
Prognosis: Resolution of the current underlying psychological problem will bring about a cure for the time being but dermatitis artefacta tends to wax and wane with the circumstances of the patient’s life.