AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

The skin and nervous system develop adjacent to each other as the ectoderm and neuroectoderm, respectively, in the embryo and remain interconnected throughout life. Dermatitis artefacta is defined as the deliberate and conscious production of self-inflicted skin lesions to satisfy an unconscious psychological or emotional need. These skin lesions serve as powerful, self-expressive, nonverbal messages. Patients often deny responsibility for their creation. Neurotic excoriation is differentiated from dermatitis artefacta by its conscious compulsive nature. Dermatitis artefacta falls under the general category of factitious disorders, which excludes neurotic excoriations, delusional disorders, malingering, and Münchhausen syndrome (except Münchhausen syndrome by proxy).

Psychiatric conditions, in particular depression, anxiety, personality disorders, delusional disorders, and dissociative disorders, are often coexistent in 25-33% of all dermatological conditions. Dermatitis artefacta may occur in persons of any age and commonly manifests within the context of chronic medical and/or dermatological conditions. These self-induced skin lesions may be present continuously, or they may be episodic, occurring during periods of heightened psychosocial stress and/or uncontrolled psychoses. Patients with dermatitis artefacta require both dermatological assessment and psychosocial support.

Pathophysiology

The pathophysiology of dermatitis artefacta is poorly understood. Multifactorial causes include genetics, psychosocial factors, and personal or family history of psychiatric illness. Commonly, a family member is involved in the medical field, and patients tend to be well versed in medical terminology.

Acute episodes often represent a maladaptive response to a psychosocial stressor. Long-standing cases may be secondary to underlying anxiety or depression, emotional deprivation, an unstable body image, or a personality disorder with borderline features. Many patients also have an associated chronic medical or dermatological condition.

Frequency

International

The prevalence in the pediatric population is 1 case in 23,000 persons. It is more common than is typically thought because it is poorly recognized and underreported.

Mortality/Morbidity

Dermatitis artefacta is poorly recognized and underreported. Additionally, many patients are lost to follow-up.

• Continuous or repeated episodes of self-mutilation may result in disfiguring scars on exposed areas of the body.
• Approximately 30% of all dermatological conditions are associated with a psychiatric disorder.
• Suicide is an important consideration in patients with a comorbid psychiatric illness.

Race

No racial or ethnic predisposition has been noted.

Sex

Most patients with dermatitis artefacta are females.

• In persons younger than 16 years, the female-to-male ratio is 4.7-7:1.
• In the general population, the female-to-male ratio is 3-20:1.

Age

The highest incidence occurs between late adolescence (age 11-14 y) and early adulthood.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• Patients are usually otherwise healthy and usually do not provide a substantial indicative history, perhaps revealing vague accounts of antecedent events.
• Patients may report a personal history of chronic dermatoses, including acne, alopecia (ie, alopecia areata, androgenic alopecia), atopic dermatitis, chronic idiopathic urticaria, psoriasis, rosacea, or vitiligo.
• They may have a personal or family history of psychiatric illness, including anxiety, depression, personality disorder (ie borderline, dependent, obsessive-compulsive), dissociative disorder, body dysmorphic disorder, or posttraumatic stress disorder. Patients typically are also reluctant to seek a consultation with a psychiatrist.
• They may have a personal history of chronic medical conditions, chronic pain syndromes, or both.
• Patients may report a history of childhood neglect or abuse, sexual abuse, or psychological trauma.
• Münchhausen syndrome by proxy (form of dermatitis artefacta) manifests as skin lesions caused by a parent or caregiver (often the mother). It usually occurs with children younger than 5 years.
• Pertinent information from the history includes the patient's quality of life with regard to health-related issues, his or her perception of the skin condition, the role of a psychosocial stressor, the presence of a lengthy medical file with numerous consultations, an extensive list of previously used medications, and a history of substance abuse. Also inquire about family members or significant others and their reaction to the skin lesions. Anger, frustration, and impatience are commonly reported reactions.

Physical

Dermatitis artefacta is a challenging clinical diagnosis. It is suggested based on findings that include an absence of other dermatoses to explain the lesions and histological findings that are inconsistent with the clinical presentation.

• The morphology of the skin lesions is variable and bizarre and is typically dependent on the mechanism of injury. Features may include sharp margins adjacent to normal skin, geometric shapes, and linear tracks (ie, secondary to exposure to corrosive liquids).
• Most often, the lesions are found at sites accessible to the patient. Typical locations include the face (45%), upper extremity (ie, hand and forearm; 24%), lower extremities (31%), trunk (24%), upper arm (7%), and scalp (7%). Lesions are usually within reach of the dominant hand.
• The appearance of the lesions, in decreasing order of frequency, is as follows:
• • Superficial erosion (50%)
  • Hyperpigmented macule or purpura (30-42%)
  • Excoriation (17%)
  • Deep necrosis, ulceration (17%)
  • Irritant dermatoses (17%)
  • Papules (17%)
  • Crusts (8%)
  • Scars - Pinpoint, star-shaped, atypically shaped (8%)
  • Onychodystrophy
  • Other - Keratosis, tattoolike
• Usually, 72% of patients have one type of lesion morphology, 41% have 2 types of lesion morphology, and 31% have 3 types of lesion morphology.
• In 66% of patients, involvement is limited to one body segment. In 34%, involvement is with 2 body segments.
• Dermatitis artefacta must be distinguished from dermatitis neglecta, neurotic excoriations, trichotillomania, and painful bruise syndrome.

Causes

The cause is multifactorial. One should be sure to rule out hypochondriasis, substance abuse disorder, and psychotic disorders.

• Genetic predisposition: Many psychiatric disorders tend to be familial.
• Psychiatric illness: Associations include anxiety disorders, major depressive disorder, dysthymia, body dysmorphic disorder, factitious disorders, and somatoform disorders.
• • Neuropsychological trauma - Child abuse/neglect, sexual abuse, posttraumatic stress disorder
  • Personality disorders - Attention-seeking traits (eg, borderline, dependent), obsessions, compulsions
  • Psychosocial factors - Poor coping mechanisms, family dysfunction, inadequate social support structure
• Chronic illnesses: These are commonly associated with dermatitis artefacta.
• • Dermatological disorders - Specifically, acne, alopecia (ie, alopecia areata, androgenic alopecia), atopic dermatitis, chronic idiopathic urticaria, psoriasis, rosacea, and vitiligo
  • Any long-standing medical illness
  • Chronic pain syndromes

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Body dysmorphic disorder
Factitious disorder
Delusional disorder
Malingering
Münchhausen syndrome (by proxy)
Personality disorder - Borderline, dependent, obsessive-compulsive
Somatoform disorder

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• No specific laboratory blood tests are required.

Imaging Studies

• No imaging studies are required.

Other Tests

• No other general tests are required.

Procedures

• Skin biopsy is necessary.

Histologic Findings

A skin biopsy of a representative lesion may be performed to rule out any underlying pathology and, in some cases, to establish a definite diagnosis. The histologic findings in dermatitis artefacta are usually nonspecific and are often dependent on the mechanism of injury (eg, foreign body reaction with giant cells and noninfectious material for self-injection).

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

Dermatitis artefacta is a challenging condition that requires dermatologic and, often, psychiatric expertise.

• General dermatological care measures include baths, debridement, emollients, and topical antimicrobials.
• A detailed assessment of the patient history for chronic dermatoses, chronic medical conditions, psychiatric illnesses, and psychosocial problems is necessary.
• An effective therapeutic relationship requires a nonjudgmental, empathetic, and supportive environment. Avoid etiology issues and confrontation. Developing a good rapport with the patient and encouraging the patient to return for follow-up appointments are important.
• A psychiatric evaluation is warranted for severe self-mutilation and any evidence of psychiatric illness, psychosis, risk of suicide, and/or need for hospitalization.
• Complementary adjuvant therapies may include acupuncture, cognitive behavioral therapy (ie, aversion therapy, systemic desensitization, operant conditioning), biofeedback and relaxation therapy (ie, anxiety-related dermatitis artefacta), and hypnosis.

Surgical Care

No surgical care is required.

Consultations

Consultation with a psychiatrist is recommended.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Topical antimicrobials are the most commonly prescribed medication; however, topical agents alone have shown limited efficacy. In many instances, treating the underlying psychiatric disorder with antidepressants, antianxiety drugs, and antipsychotic agents is necessary. Analgesics should be avoided because of the high probability for dependence and addiction.

Drug Category: Topical antimicrobials

Self-inflicted lesions are often accompanied by a localized skin infection.

Drug Category: Oral antibiotics

For impetiginized skin lesions.

Drug Category: Selective serotonin reuptake inhibitors

First-line therapy for depression. Other medications in this category include paroxetine, citalopram, and sertraline. For dermatitis artefacta associated with obsessive-compulsive disorder, the use of an SSRI for at least 6 months to 1 year accompanied by psychotherapy is recommended.

Drug Category: Tricyclic antidepressants

Drug Category: Typical antipsychotics

Drug Category: Atypical antipsychotics

Lower risk of extrapyramidal adverse effects than with typical antipsychotics.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Hospitalization may be required depending on the severity of the skin lesions and the risk of suicide.

Further Outpatient Care

• Frequent follow-up visits with a dermatologist and/or psychiatrist are recommended.
• Note that many dermatitis artefacta patients are often lost to follow-up.
• With Münchhausen syndrome by proxy, removal of the child to a safe environment is mandatory.

In/Out Patient Meds

• Selective serotonin reuptake inhibitors (eg, paroxetine, sertraline, citalopram, fluoxetine) are first-line therapy for depression.
• A tricyclic antidepressant with antihistamine, antipruritic, and antidepressant properties (eg, doxepin) is recommended for depression with or without agitation and the primary symptom of pruritus.
• A tricyclic antidepressant with analgesic properties (eg, amitriptyline) is appropriate for depression with a primary symptom of pain sensations (eg, burning, chafing, stinging).
• Typical (eg, pimozide) and atypical antipsychotics (eg, risperidone, olanzapine, quetiapine) are for short-term use, particularly if skin lesions are associated with psychotic or delusional symptoms.

Prognosis

• Mild cases secondary to identifiable psychosocial stressors usually have a good outcome; cure is possible.
• Chronic cases with associated chronic dermatological or medical issues usually have a poor outcome, and cure is usually not possible.

Patient Education

• The unique presentation and appearance of skin lesions may be a cause of significant concern to the patient and the parents or caregivers.
• Avoid confrontational issues regarding the etiology of lesions during initial patient visits.
• Gradually introduce the role of psychosocial factors and/or psychiatric issues that may contribute to the self-inflicted skin lesions.
• Regularly assess the risk of self-harm (suicide) or harm towards others.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Identify any risk factors for suicide and a need for hospitalization, as well as the potential for harm to others.
• In cases of Münchhausen syndrome by proxy, the victim (usually a child younger than 5 y) must be removed from the offender (usually a female caregiver or the mother) and placed in a safe, protected environment.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Angus J, Affleck AG, Croft JC, Leach IH, Slater DN, Millard LG. Dermatitis artefacta in a 12-year-old girl mimicking cutaneous T-cell lymphoma. Pediatr Dermatol. May-Jun 2007;24(3):327-9. [Medline].
• Cohen AD, Vardy DA. Dermatitis artefacta in soldiers. Mil Med. Jun 2006;171(6):497-9. [Medline].
• Fabisch W. What is dermatitis artefacta?. Int J Dermatol. Jul-Aug 1981;20(6):427-8. [Medline].
• Gupta MA, Gupta AK, Ellis CNl, Koblenzer CS. Psychiatric evaluation of the dermatology patient. Dermatol Clin. Oct 2005;23(4):591-9. [Medline].
• Gupta MA, Guptat AK. The use of antidepressant drugs in dermatology. J Eur Acad Dermatol Venereol. Nov 2001;15(6):512-8. [Medline].
• Harries MJ, McMullen E, Griffiths CE. Pyoderma gangrenosum masquerading as dermatitis artefacta. Arch Dermatol. Nov 2006;142(11):1509-10. [Medline].
• Joe EK, Li VW, Magro CM, Arndt KA, Bowers KE. Diagnostic clues to dermatitis artefacta. Cutis. Apr 1999;63(4):209-14. [Medline].
• Koblenzer CS. Dermatitis artefacta. Clinical features and approaches to treatment. Am J Clin Dermatol. Jan-Feb 2000;1(1):47-55. [Medline].
• Lee CS, Koo J. Psychopharmacologic therapies in dermatology: an update. Dermatol Clin. Oct 2005;23(4):735-44. [Medline].
• Ozmen M, Erdogan A, Aydemir EH, Oguz O. Dissociative identity disorder presenting as dermatitis artefacta. Int J Dermatol. Jun 2006;45(6):770-1. [Medline].
• Saez-de-Ocariz M, Orozco-Covarrubias L, Mora-Magana I, et al. Dermatitis artefacta in pediatric patients: experience at the national instituteof pediatrics. Pediatr Dermatol. May-Jun 2004;21(3):205-11. [Medline].
• Shah KN, Fried RG. Factitial dermatoses in children. Curr Opin Pediatr. Aug 2006;18(4):403-9. [Medline].
• Shenefelt PD. Complementary psychocutaneous therapies in dermatology. Dermatol Clin. Oct 2005;23(4):723-34. [Medline].
• Urpe M, Pallanti S, Lotti T. Psychosomatic factors in dermatology. Dermatol Clin. Oct 2005;23(4):601-8. [Medline].

Article Last Updated: Aug 24, 2007