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Self-inflicted Dermatoses
moreover, pathomimicry and damage to other organs. The breasts, hyperpigmented macules or purpura, indurations, crusts, irritant
the other main location of dermatitis artefacta observed in this dermatoses, papules, oedema, scars (pinpoint, star-shaped or
patient, are associated with separation and grief as anamnesis atypically shaped) and keratosis-like, tattoo-like and nail lesions are
markers, as well as with masked depression.
4
Other authors, such other options. Tumours are not common.
3,13
In one study of 124
as Aenel and Sheppard,
5,6
have stated that the most characteristic patients, the affected site was the lower extremities in 49, the head
psychological feature among breast self-inflictors is an immature in 46, the hands in 26 and the upper trunk – including the breasts
personality. Episodes of lesions are usually precipitated by (especially among women) – in 21.
10
It is also interesting to note that
emotional stress that is associated with, for instance, unhappy the left side of the body is more frequently affected; most of the
social circumstances,
7
as was the case with our patient. population is right-handed. Other authors
12
have found that the face
is the most commonly affected location, followed by the upper
Repetitive dermatitis artefacta, especially with the purpose of extremities (hands and forearm), the lower extremities, the trunk
becoming a ‘false patient’, is most frequent in borderline and, finally, the upper arm. The mechanisms of production of the
individuals, who exhibit typical personality disorders with emotional various lesions are difficult to guess, as, again, they are limited only
and relational instability, impulsiveness, mood dysregulation and by human imagination.
inadequate aggression.
8
According to our patient, she started living
alone as “she could not stand her parents”. Diagnosis should be made by collecting the clinical history. It is
common to find a ‘hollow story’, with vague data, few antecedent
events and the absence of typical skin conditions that could explain
the lesions. It may be that the patient is able to predict when
Treatment is never easy and must
lesions are going to appear, and the various clinical shapes
take into account both aspects of the
described above may be of great help; in any case, they should lead
to suspicion. Cutaneous biopsy is useful to rule out any underlying
disease: the brain and the skin.
pathology, if the clinician is not positive of the diagnosis.
This is why a combined psychiatric and
Histological data are consistent with the mechanism of production;
therefore, in the case presented in this article, foreign body
dermatological approach is required.
granulomas, apoptotic cells, crusts and so on could be found.
However, the disease has no specific findings.
There are not many large series about dermatitis artefacta,
3,9,10
and Treatment is never easy and must take into account both aspects of
few of them include follow-up of patients.
2
The cases that have been the disease: the brain and the skin. This is why a combined
published only show impressive lesions without presenting enough psychiatric and dermatological approach is required. Both
evidence or experience about how the problem can be solved. There professionals should understand that patients with dermatitis
are only limited data about the epidemiology of the disease. A artefacta do not want to get well. It is therefore important that
Danish series
3
collected 57 patients over a 20-year period and clinicians set firm limits in order to protect their own boundaries
calculated a prevalence of 1.5 patients per million per year, although and avoid exploitation, which will lead to anger and loss of
they also suggested there may be more cases. In almost all series objectivity.
1
Clinicians must adhere firmly to the appointment
women are more frequently affected than men.
2,3,9
Young to middle- schedule, limit phone calls and avoid undertaking tests or
aged people seem to be more commonly afflicted,
3,9
as are single procedures or prescribing drugs that are not necessary.
1
It is also
people. Among 124 patients, Pichardo found 70 single people and very important to allow the patient to save face.
1
In general, we
four widows;
10
Ian and Joan Sneddon
2
found 26 singles in a total advise avoiding direct confrontation as it does not seem to help;
of 44 patients; and in the Danish series
3
only 41% of the women and however, many authors agree that it is necessary for clinicians to
42% of the men were married. Our patient is an unmarried woman; indicate to patients – indirectly and carefully – that they know the
however, the problem may not be whether a patient is married or true cause of the skin lesions.
part of a couple, but rather whether he or she feels loved and cared
for, or alone. Dermatological therapy can include occlusive dressings when
possible (there are locations where they are not suitable). Some
A close connection of either the patient or a family member with authors have suggested healing measures that allow tactile
some aspect of healthcare has also been commonly found. In other gratification but at the same time substitute mutilating activities. In
cases, prolonged illness has occurred, usually during childhood.
2
our experience, antibacterial ointments (mupirocine ointment or
These cases are difficult to manage because the patients ‘know more’ fusidic acid cream) and hydrating creams are very useful. If lesions
about healthcare. We have not found such a history in our patient. are infected, cultures should be performed and systemic
antibacterial or antifungal therapy applied. Analgesia is important
The clinical appearance and distribution of dermatitis artefacta are when the patient has pain, but it is important to be careful to avoid
extremely broad, and are limited only by human imagination. exacerbating the addictive tendencies such patients usually have.
However, they share some characteristics that may lead to
suspicion. Sharp, well-limited margins and angulated and The psychiatric approach includes selective serotonin re-uptake
geometrical borders with crusted or necrotic, abraded or atrophic inhibitors such as as fluoxetine, sertraline, paroxetine or
surfaces are common. Lesions may also mimic previous fluvoxamine as a first-line therapy. In addition to helping with
dermatoses. Erosions and ulcers are the most common clinical depression, these medications have anti-obsessive–compulsive
forms of the disease.
3,9,11,12
Blisters, excoriations, deep necrosis, properties that may be useful in controlling dermatitis artefacta,
34 EUROPEAN DERMATOLOGY
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