Dermatitis Artefacta: Self - Inflicted Upper Back Ulcer

Abstract

Introduction and Objectives. Dermatitis artefacta (DA), also known as factitious dermatitis, is a rare psychosomatic syndrome characterized by self-induced skin lesions in a variety of forms and localisations. Females more often than males and those who have an underlying psychiatric diagnosis or external stress are more likely to DA. The diagnosis of DA is frequently difficult to confirm and the treatment is challenging and requires a multidisciplinary concept of medical specialists. [Lavery MJ, et al. Clin Dermatol. 2018]. Materials and methods. A 74-year-old woman presented with a 1-year history of painful skin lesions on arms, lower legs and upper back, and 6 months history of hair loss on a scalp. She denied any history of self-harm or having any psychiatric diseases. The skin examination revealed red, infiltrated plaques covered with scabs on the neck and shoulders, excoriations on the chest, liner scars on both lower legs, irregular, about 10 x 15 cm in diameter and 1-2 mm deep ulcer on the upper back with seropurulent discharge and minimal granulation tissue on the wound bed. Short and broken hairs were observed on the frontal scalp area. The hair pull test was negative. Trichoscopy showed scarred areas of the scalp and abundant regrowth of broken hair. Results. The diagnosis of DA was not recognised for about 10 months. The patient was symptomatically treated bydermatologists with topical steroids. Primary skin biopsy from the lesions could not exclude autoimmune subepidermal dermatitis. A new skin biopsy and the direct immunofluorescence (DIF) from the skin lesions were performed. Histopathological evaluation showed findings similar to lichen planus. DIF test turned out negative. The histopathological evaluation from the ulcer showed scratched epithelium, dermal edema, perivascular infiltration with lymphocytes and plasma cells, vascular and fibroblast proliferation. During the hospitalisation the new psychiatric complaints were documented, that ‘rod-shaped parasites are living and moving under the skin, in eyes and in urine. A psychiatrist diagnosed organic hallucinosis, and the dermatological diagnosis was changed to DA. The oral tiapride 50 mg 3 times a day was commenced. The upper back ulcer was treated with silicone dressings and healed in 2 weeks. Conclusions. Dermatitis artefacta is a factitious disorder that involves falsification of psychological or physical signs or symptoms caused entirely by the patients themselves, in a clear state of consciousness, in order to play the role of a sick person. The correlation of anamnestic data and clinical exams is very important for the diagnosis of dermatitis artefacta.