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From Theory to Practice – Dermatitis Artefacta in Daily Practice
which is usually associated with such conditions. Our patient has anxiety, irritability, fatigue, headache, tremor, nausea or confusion
been treated with fluoxetine and sertraline. These drugs commonly could appear.
1
have gastrointestinal adverse effects that improve in seven to 10
days and should be treated symptomatically. They may also cause Dermatologists are often uncomfortable about prescribing
insomnia and restlessness, and may even affect sexual functioning, psychotropic drugs; however, in many cases patients refuse to
which can be chronic and troublesome for the patient.
1
Tricyclic consult psychiatric professionals at the initial presentation, so
antidepressants are thought to have more side effects and so are dermatologists need to know what to use and how to provide their
less useful, but doxepin is a drug that dermatologists know very patients with the optimal care.
well. It has antihistamine and antipruritic effects, which enables the
treatment of difficult itching conditions, such as pruritus sine In the case of our patient, she has absolutely nothing to do with her
materia, as well as all kind of ‘dinias’ – especially those located on time. She got better at a time when we were following her closely
the genital and oral areas. Doxepin also increases the concentration and she was taking care of her nephew; however, once the child
of serotonin and noeripinephrine in the central nervous system by started school, the problem reappeared. When we thought the
inhibiting their re-uptake by pre-synaptic neuronal membranes; this problem with her skin had been resolved, she started damaging her
is associated with a decrease in symptoms of depression. However, breasts. As soon as she feels lonely, it all starts again – and how can
it must be taken into account that doxepin decreases the we, as doctors, solve loneliness?
antihypertensive effects of clonidine but increases the effects of
sympathomimetics and benzodiazepines. It should not be used in Conclusion
the acute recovery phase of a myocardial infarction, glaucoma or Dermatitis artefacta is a well-known condition for dermatologists;
urinary retention, and care is needed in cases of hyperthyroidism however, it is not common in daily practice. We have to be suspicious
and thyroid replacement therapy.
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in order to make the correct diagnosis. It is important to include a
psychiatric approach, and psychotropic drugs are useful, but patients
Buspirone is a non-sedating anxiolytic with no potential for will continue to visit their dermatologist. The prognosis for cure is poor;
addiction (in contrast to benzodiazepines) that may help in patients in fact, there are not many longitudinal studies in the literature. We
with prominent anxiety.
1
The effect is delayed for two to three have the duty to follow these patients and keep our eyes open: even if
weeks. It may cause nausea, headache and dizziness, but these we follow to the letter the instructions and guidance for dealing with
improve with time; patience is required with this drug. such patients, they may well continue to produce lesions. ■
As dopaminergic dysfunction may play a role in self-injurious
Marta García-Bustínduy is a Professor of Dermatology
behaviour,
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antipsychotic drugs have been used either alone or in
and Vice Dean of La Laguna Medical School, where
conjunction with a selective serotonin re-uptake inhibitor. Pimozide, she has been teaching since 1989. Previously, she
olanzapine and risperidone are all useful in a lower dose range than
was a Resident in the Dermatology Department at
Hospital Universitario de Canarias in Santa Cruz.
in other psychiatric conditions.
1
The typical antipsychotic pimozide
Her special fields of interest are mainly clinical
has been very useful in delusions of parasitosis. It is contraindicated investigation, psoriasis, quality of life and
if the patient has a history of cardiac arrhythmias or long QT
psychodermatosis. Professor García-Bustíndy is a
member of the European Academy of Dermatology
syndrome, but in the dermatological dose range such problems are
and Venereology (EADV), the Iberian and Latin American College of Dermatology
uncommon. It should not be used in conjunction with macrolide and the Spanish Academy of Dermatology and Venereology, and works in the
antibiotics. Olanzapine and risperidone are atypical antipsychotics
psoriasis and psychodermatology groups of the latter. She also attends meetings of
the European Society of Dermatology and Psychiatry (ESDaP).
and thus have fewer extrapyramidal adverse effects. Olanzapine
may lead to weight gain and oedema, which can be controlled by
Cristina Rodríguez García is an Intern in the
diuretics if necessary. If sleep disturbances occur, giving the drug at
Dermatology Department at Hospital Universitario de
night will be of great help.
1
Canarias in La Laguna. Her main fields of interest are
psychodermatology, dermatopathology and paediatric
dermatology. She has presented several posters at
Benzodiazepines can also be used in the treatment of anxiety
the national meeting of the Spanish Academy and
among patients with dermatitis artefacta. It is very important to collaborated with works presented at the American
remember that these drugs have a very rapid onset of action, but
Academy of Dermatology (AAD) and the European
Academy of Dermatology and Venereology (EADV).
also great potential for addiction and tachyphylaxis. They should
therefore be used as short-term treatments with slow tapering, as
1. Koblenzer CS, Dermatitis artefacta. Clinical features and Psych Neurol Sci, 1984;234:38–41. 10. Rodríguez Pichardo A, Dermatitis Artefacta. In: Grimalt F,
approaches to treatment, A J Clin Dermatol, 2000;1:47–55. 6. Sheppard NP, O’Loughlin S, Malone JP, Psychogenic skin Cotterill JA (eds), Dermatología y Psiquiatría. Historias Clínicas
2. Sneddon I, Sneddon J, Self-inflicted Injury: A follow-up disease: a review of 35 cases, Br J Psych, 1986;149:636–43. comentadas, Aula Médica Ediciones, 2002;143–63.
study of 43 patients, Br Med J, 1975;3:527–30. 7. Farrier JN, Mansel RE, Dermatitis artefacta of the breast: a 11. Hollender MH, Abram HS, Dermatitis Factitia, South Med J,
3. Nielsen K, Jeppesen M, Simnelsgaard L, et al., Self series of case reports, Eur J Surg Oncol, 2002;28:189–92 1973;66:1279–85.
Inflicted skin diseases. A retrospective analysis of 57 8. Nadelson T, False patients, real patients: a spectrum of 12. Koo JYM, Dermatitis Artefacta, 2007. Available at:
patients with dermatitis artefacta seen in a Dermatology disease presentation, Psychoter Psychosom, 1985;44: www.emedicine.com/derm/TOPIC940.htm
Department, Acta Derm Venereol, 2005;85:512–15. 175–84. 13. García Bustínduy M, Guimerá F, Sánchez González R, et
4. Van Moffaert M, Localization of self-inflicted 9. Rodriguez Pichardo A, García Bravo B, Camacho F, al., Factitious Disorder: A patient with recurrent tumor,
dermatological lesions: What do they tell the Dermatitis artefacta. Clinical study of 201 patients Dermatol Psychosom, 2004;5;85–7.
dermatologist, Acta Derm Venereol (Stockl), 1991;156:23–7. (1996–2006), Poster, 21st World Congress on 14. Abend SM, Porder MF, Willick MF, Borderline patients:
5. Aenel T, Rauchfleisch H, Shippli R, Battegay R, The Dermatology, Buenos Aires, Argentina, 30 September – psychoanalytic perspective, New York: Int Univers Press,
psychiatric significance of dermatitis artefacta, Eur Arch 5 October, 2007. 1983:222–46.
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