Dermatitis Factitia

Belonging to the group of self-inflicted dermatoses, dermatitis factitia (more commonly termed dermatitis artefacta) is rarely described in the medical literature, although various reports suggest it is not uncommon in clinical practice [1]. Dermatitis factitia is primarily a psychiatric disorder characterized by the presence of intentional, self-inflicted injuries for which the patient claims he/she had nothing to do with them [1] [2] [3] [4]. This condition is most commonly diagnosed around 20 years of age, with a significant predilection toward female gender [1] [2] [5]. The clinical presentation is quite broad, and various types of skin lesions have been identified. The predominant type of lesion, however, are ulcers that might be of various sizes and shapes (depending on the underlying mechanism of injury, eg. cigarette or chemical burns) [1] [6]. Excoriations are also common, usually arising from fingernail-induced injury or by using sharp objects [1]. Additional types of skin lesions that may be encountered in dermatitis factitia are blisters, scarring, bruises, and eczema [1] [2] [5] [6]. The majority of injuries are localized within the reach of the patient's dominant hand [1]. In most cases, the exact shape and size, as well as the appearance of the lesion, can provide sufficient information about the mechanism of trauma [1] [2] [6]. One of the distinguishing features of dermatitis factitia is that individuals cause self-harm in areas covered by clothing (concealment of wounds), which is used to discern from malingering and other types of self-inflicted dermatoses [1].

A carefully obtained patient history and thorough physical examination are the essential steps during the diagnostic workup [1] [2] [5]. The presence of irregular, oddly shaped, or bizarre lesions seen in various forms (erosions, ulcerations, bruising, etc.) must raise suspicion toward intentional injuries [1]. Based on the behavior and mental status of the patients, history taking might be the vital component for narrowing the differential diagnosis. During the interview, patients may be either completely relaxed and almost "'too calm", or show obvious signs of anxiety [1]. The physician must not be too confronting when discussing the nature of the lesions with the patient, as they will strongly deny any involvement in the formation of skin lesions [1] [2] [3] [6]. Instead, a calm and careful approach is warranted, particularly if the patient's parents or relatives are present [1] [3]. If the patient or the accompanying persons are not cooperative (commonly occurring when suggesting self-infliction as the underlying cause), a detailed neurological and psychological assessment is necessary before pursuing treatment strategies [1] [6]. Laboratory studies and histopathological examination of the skin could be performed in order to exclude other etiologies [6].

1. Rodríguez Pichardo A, García Bravo B. Dermatitis artefacta: a review. Actas Dermosifiliogr. 2013;104(10):854-866.
2. Chiriac A, Foia L, Birsan C, Goriuc A, Solovan C. Cutaneous factitia in elderly patients: alarm signal for psychiatric disorders. Clin Interv Aging. 2014;9:421-424.
3. Sarin A, Ummar SA, Ambooken B, Gawai SR. Dermatitis Artefacta Presenting with Localized Alopecia of Right Eyebrow and Scalp. Int J Trichology. 2016;8(1):26-28.
4. Barańska-Rybak W, Cubała WJ, Kozicka D, Sokołowska-Wojdyło M, Nowicki R, Roszkiewicz J. Dermatitis artefacta--a long way from the first clinical symptoms to diagnosis. Psychiatr Danub. 2011;23(1):73-75.
5. Chatterjee SS, Mitra S. Dermatitis Artefacta Mimicking Borderline Personality Disorder: Sometimes, Skin Could Be Misleading. Clin Psychopharmacol Neurosci. 2016;14(3):311-313.
6. Saha A, Seth J, Gorai S, Bindal A. Dermatitis Artefacta: A Review of Five Cases: A Diagnostic and Therapeutic Challenge. Indian J Dermatol. 2015;60(6):613-615.