Bustindy_subbed.qxp 19/5/09 12:47 pm Page 32
Self-inflicted Dermatoses
From Theory to Practice – Dermatitis Artefacta in Daily Practice
Marta García-Bustínduy
1
and Cristina Rodríguez García
2
1. Dermatology Professor, La Laguna University School of Medicine;
2. Dermatology Resident, Hospital Universitario de Canarias, La Laguna
Abstract
Dermatitis artefacta is a skin condition where the patient creates the lesions but denies doing so. Moreover, patients usually provide poor
anamnestic information and are characteristically able to predict when the pathology is going to appear or get worse. There are always
mental disorders underlying the illness, but patients usually oppose psychiatric referral. Clinical appearance and distribution vary widely,
but the lesions share characteristics that may lead us to suspect the cause. Sharp and well-limited margins and angulated and geometrical
borders with crusted or necrotic surface are common. Erosions and ulcers are the most common clinical forms of the disease. General
practitioners, surgeons and dermatologists often have to deal with this illness and suspect a self-inflicted condition, but have to try not to
confront the patient. We have to let them ‘know that we know’ and stay by their side, treating their skin and their mind because the
prognosis for cure is poor. In this article, we describe the long-term case of an unemployed single woman who has damaged not only her
skin but other parts of her body for more than 20 years.
Keywords
Dermatitis artefacta, pathomimia, self-inflicted skin disease, factitious disorder, topical treatment, psychiatric treatment
Disclosure: The authors have no conflicts of interest to declare.
Received: 26 February 2009 Accepted: 14 April 2009
Correspondence: Marta García-Bustínduy, La Laguna University School of Medicine, Hospital Universitario de Canarias, Tenerife, Canary Islands, Spain.
mgbustinduy@gmail.com
This article addresses the case of one of our patients who suffers from slowly improved the problem; however, since then the patient has
dermatitis artefacta. In dermatitis artefacta, the patient creates skin presented to us with more problems. Eventually, psychiatrists
lesions to satisfy an internal psychological need – usually the desire to properly evaluated and confronted the patient and now both she
be taken care of
1
(for some people, hospitals are comfortable places). and we know her correct diagnosis, but diseases are still appearing.
According to Ian and John Sneddon, “skin disease is never easy to In the course of her treatment, we have discovered that we do not
treat even when the patient wishes to recover. It becomes far more talk to our colleagues in other departments of the hospital as much
difficult when the patient deliberately manufactures lesions.”
2
as we should, and we do not read other doctors’ contributions to
Dermatitis artefacta may not be an isolated problem, but rather part the medical history of our patients – both of which are necessary
of a condition that involves other organs of the body. Therefore, a for optimal treatment.
patient is able to produce a variety of lesions and visit several
departments at the same hospital. Clinical Case
In 1987, a 37-year-old single woman presented with severe arterial
Dermatitis artefacta is not a common illness
3
and is rarely seen in hypertension. She underwent a surgical adrenalectomy because
clinical practice; therefore, as this patient has been with us for 14 nephrologists saw an adrenal cyst on axial computed tomography
years, we hope that an overview of her case and the mistakes we (CT). The surgical procedure did not improve the problem. In 1994, she
have made in her treatment will help others to understand how to began to visit the Dermatological Department because of a trauma on
deal with this condition. her right leg that she told us was caused by a nail and that did not
heal (see Figure 1). It seemed to be an abscess. We performed many
When the patient first presented to our practice, we were unable to different cultures and treated her with systemic and topical
believe that she had inflicted the lesions herself; this delayed the antibiotics. The trauma grew so much and became so solid to the
correct diagnosis. One of our colleagues suggested covering touch that we thought it was a squamous cell carcinoma; therefore, it
the lesion with a bandage and placing a piece of paper inside; after was surgically excised (see Figure 2). The cutaneous biopsy revealed
removing the bandage some days later, we observed that it had multiple foreign bodies inside (see Figure 3), so we should have
several small holes – as might be produced by a needle – going suspected dermatitis artefacta. However, the lesion grew again while
through it, confirming that the symptoms were indeed self-inflicted. she was still at the hospital; once again, it was excised and covered
Proper occlusive dressings, including putting her leg in plaster, with another graft. It then became an ulcer (see Figure 4), and was
32 © TOUCH BRIEFINGS 2009
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84 |
Page 85 |
Page 86 |
Page 87 |
Page 88 |
Page 89 |
Page 90 |
Page 91 |
Page 92 |
Page 93 |
Page 94 |
Page 95 |
Page 96 |
Page 97 |
Page 98 |
Page 99