A 42-year-old man, who worked at a diesel locomotive workshop as mechanic, presented with a 1-year history of recurrent blisters over his chest and abdomen. The blisters were painful and black and, although they were healing, scars remained. The patient had no history of any systemic illness and attributed the skin lesions to contact with engine lubricants at his workplace.
Examination revealed a few bullae filled with haemorrhagic fluid on the anterior aspect of the patient’s chest and abdomen. The lesions were typically found on the easily accessible areas of the chest and abdomen, atrophic scars from previously healed lesions were also noted (Figures 1 and 2) and there was normal skin over rest of the body areas (Figure 3). The findings from the systemic examination were normal.
The clinical diagnosis was dermatitis artefacta based on:
the presence of skin lesions on accessible body areas;
adjoining areas of the body were completely clear;
the recurrence of similar lesions over a period of 1 year;
absence of any associated systemic illness.
The patient was prescribed oral and topical antibiotics to heal the lesions, but after 2 months the patient returned with new blisters. He received counselling but confrontation with the patient was deliberately avoided as this can result in the patient being stigmatized with psychiatric illness and, therefore, a loss of follow-up.
The patient’s family members confided that the patient had a history of marking himself, causing localized irritant dermatitis with formation of blisters that healed but resulted in scarring. The patient was then referred to a psychiatrist and counselled. He was prescribed fluoxetine 20 mg daily. At a 3-month follow-up, no new skin lesions were seen.
This case report is presented owing to the rarity of this condition and the typical clinical manifestations, as discussed below.
Dermatitis artefacta is also known as factitious dermatitis. The key characteristics are:
It is more commonly found in women.
The motive is usually unconscious.
The self-inflicted cutaneous lesions are often induced by foreign objects.
Lesions are often found in areas that are easily accessible by patient’s own hands.
This is a psychocutaneous disorder in which patients self-inflict cutaneous lesions as a means of satisfying a psychological need, of which they are not always consciously aware. However, if asked, the patient will deny taking part in any aspect of the process. Although some patients create skin lesions as a maladaptive response to an acute psychosocial stress, the vast majority of patients suffer from a borderline personality disorder.1 Given the frequent lack of honest disclosure and cooperation from the patient, this disorder is often difficult to diagnose and treat.
The lesions can mimic any dermatosis and can be single or multiple, unilateral or bilateral and, although usually within easy reach of the hands, the lesions may also be created by an external auxiliary agent.1 Lesions can range from vesicles to purpura to subcutaneous emphysema and can be caused by carving the flesh with sharp instruments, applying chemicals to the skin, injecting foreign substances into the body, etc.2
The histological changes vary considerably, depending on the manner in which the lesions were produced. The findings are generally not diagnostic, but most of the damage is seen in the epidermis. Conditions such as hyperkeratosis, irregular acanthosis, blood vessel proliferation and fibroplasia are commonly associated with dermatitis artefacta and, occasionally, polarizing exogenous material with a variable foreign body response is seen.3
Dermatitis artefacta is extremely rare and is reported to have a female to male ratio of 8 : 1. Although its onset is most frequently seen in adolescence and young adulthood, it can occur at any age. Interestingly, many of these patients either work in, or have close family members who work in, the health care field.4
Other than primary skin disorders, dermatitis artefacta can often be confused with monosymptomatic hypochondriacal psychosis as well as malingering, in which a person will self-inflict skin lesions for conscious gain, and obsessive–compulsive behaviour, in which an individual will produce lesions by repetitive picking and scratching. Münchhausen syndrome by proxy also needs to be considered: an individual with this condition will inflict lesions on another person to satisfy a psychological need that is not consciously understood.1
Initially, the treatment for dermatitis artefacta is symptomatic with dressings and emollients to help with healing. The possibility of a primary dermatological disorder needs to be excluded and there is controversy regarding whether or not the patient should be confronted in the initial stages of diagnosis. Given the nature of the disorder, it may be more fruitful to provide a supportive environment early in the relationship and then work up to the psychological aspects of the disease at subsequent visits. Antidepressants, antianxiety or antipsychotic medications can be used if symptoms of an underlying psychiatric disorder are suspected.4 The most favourable prognosis exists for children or adults in whom the lesions represent a response to a transient stress. However, in most cases, the condition is chronic and the severity often waxes and wanes with the circumstances in the patient’s life.5