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From Theory to Practice – Dermatitis Artefacta in Daily Practice
even treated with cyclosporine A on suspicion of being a pyoderma Figure 1: Cutaneous Abscess with Superficial Erosion –
gangrenosum (we thought the lesion was re-appearing due to
How the Lesion Started
pathergy). We began treatment with cyclosporine A as an inpatient
therapy and observed the patient very closely, mainly because of her
uncontrollable arterial hypertension; the hypertension disappeared as
soon as nurses began staying with the patient while she took her daily
pills, as we had asked them to do. The lesion got better, so we thought
cyclosporine A was the correct treatment, but the healing lasted for
only one month; as soon as the patient returned home, severe
hypertension appeared and the lesion, of course, got worse.
We understood that what had really healed her various problems
was the close observation in the hospital; as a result, we started to
use occlusive dressings on her lesion. As mentioned above, at first
we just used a bandage with a piece of paper underneath it, which
is how we came to understand (and believe) that she was inflicting
Figure 2: Rapidly Growing Painless, Hard
the lesion herself. We therefore put her leg in plaster once or twice
Skin Tumour on the Left Leg
a week, and over a period of months the lesion healed. She has
now been wearing a gauze dressing for six years, which we told her
is “to keep her delicate skin free from the contact of air, clothes and
so on”, avoiding confronting her with the real problem.
At this stage her visits became more infrequent and we received
fewer telephone calls from the patient. We saw her every two to
three months, and she called only when her pain was terrible to ask
for analgesia. This corresponds to her starting to take care of one
of her nephews; all of her time was taken up with looking after the
baby. Three years later, when the child started school, we had to
treat some small recurrences. In 2007, she started having
abscesses on her breasts. She told us that she thought it might be
cancer; as, unfortunately, breast cancer is not uncommon, we had
to treat this as a serious possibility. The problem was so chronic
and difficult to treat that the patient underwent bilateral
Figure 3: Haematoxilin Eosin Image with Foreign
mastectomy on the advice of gynaecologists; however, no cancer
Body Granulomas from the Biopsy of the Surgically
Excised Tumour
cells could be found in the biopsy. We only found out about this
when a gynaecology resident came to our service with another
problem, but could not avoid mentioning this surprising case. After
hearing the conversation, I knew this was the same patient.
Psychiatrists, dermatologists and gynaecologists have all discussed
this patient and even confronted her. In her psychiatrist’s opinion,
the patient is now very well controlled: she is taking a selective
serotonin re-uptake inhibitor and a benzodiazepine at night.
However, in the Dermatology Department we are once again
following her more closely because of new ulcers on her right leg.
After harming her breasts, she has returned to harming her skin. Figure 4: Cutaneous Ulcer Covered by Dense Yellow
Crust Before Treatment with Cyclosporine A and
Occlusive Dressings
The patient is now living alone. She has no relationship with her
parents and no friends. She cannot work; all she does is come to
our hospital. We are sure she will be able to inflict such lesions on
herself again. Unfortunately, sometimes we do not have enough
time for all of our patients: our hospitals are asking us to treat more
and more patients, but the conditions we are working under are far
from ideal, and we often do not have enough peace and time to
properly engage with our patients.
Discussion
This patient must have had problems during infancy. Van Moffaert
would perhaps suspect that the patient had been subject to
physical abuse according to the location of the lesion (the leg)
4
and,
EUROPEAN DERMATOLOGY 33
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