Dermatitis Artefacta

Synonyms: factitious dermatitis, factitial dermatitis

An artefact is a man-made object and the term 'artefacts' is often applied to items such as pottery or tools found in excavations of historic or prehistoric sites. Dermatitis artefacta invokes a fully conscious and self-inflicted skin lesion. There may be an unconscious compulsion based on psychological or emotional need and some view it as an extreme form of non-verbal communication.¹ The patient will normally deny the aetiology and so the definition does not really include self-mutilation such as multiple superficial cuts to the skin. It does not cover lesions made by others such as cigarette burns that may be a feature of child abuse. Lesions may be produced by a variety of mechanical or chemical means, including fingernails, sharp or blunt objects, burning cigarettes and caustic chemicals.

There are some circumstances in which the application of the diagnosis may be debated. In neurotic excoriation what seemed at first to be normal skin is scratched. It is inappropriate to refer to imaginary itch as itch, like pain, is a subjective sensation. The excoriation sets up a reaction in the skin that makes it itch more and a vicious circle is produced. Itching may be produced in a healthy skin by neurological disease. Formication means a sensation like ants running on the skin. It can occur with alcohol abuse and some forms of psychosis. Delusional parasitosis may also occur. Dermatitis artefacta may be a feature of Munchausen syndrome by-proxy.

The condition is fairly rare, diagnosis is frequently uncertain and many times not even entertained. Dermatitis artefacta is thought to account for between 1 in 200 to 1 in 2000 dermatological consultations.²
Authors concur that there is a female preponderance but estimates vary from just over 50% to 90% and more. Presentation typically appears to be in 20-30s,³ although there is wide variation with some describing a late adolescence to early adulthood peak.⁴ It is also reported in children.⁵

Risk factors

It is reasonable to assume that this condition represents a psychological abnormality although the patient may not be known to have a psychiatric illness. About a third will have a co-existing psychiatric disorder (anxiety, depression, personality disorders, psychotic illness, dissociative disorders). Intelligence is variable. Stress and PTSD may be involved.⁶ There is often abnormal self perception as in body dysmorphic syndromes such as anorexia nervosa.⁷ Onset or relapse of dermatitis artefacta is often precipitated by definable pyschosocial stressors, varying according to age and life situations.

• Lesions can be enormously variable in character, depending upon how they are produced but often what is presented is quite florid. The doctor may be quite shocked whilst the patient is remarkably unperturbed with 'la belle indifference' that is typical of hysterical illness.
• The range of lesions includes red patches, swelling, blisters, denuded areas, crusts, cuts, burns, and scars and there may be more than one type of lesion.
• They are often in bizarre shapes with irregular outlines in a linear or geometric pattern.
• There is usually clear demarcation with normal skin around the lesions.
• Sometimes it is hard to distinguish dermatitis artefacta from natural diseases, particularly if lesions inflicted mimic those with an organic cause.
• Lesions do not usually evolve gradually but appear almost overnight without any prior signs or symptoms.
• They are usually found on sites that are readily accessible to the patient's hands, such as face, hands, arms or legs but not in inaccessible areas such as between the scapulae.
• The patient will usually deny that the rash is self induced.

There is no investigation that is specific for the disease. Swabs may be taken if secondary infection is suspected. If applicable, tests may be used to exclude other diseases such as skin biopsy. There is almost certainly some psychiatric pathology that will merit investigation at some stage.

They may resemble many other lesions but the classical features of dermatitis artefacta include:

• Clearly circumscribed lesions with normal intervening skin
• A geometrical or other pattern that is rarely seen in organic disease
• Lesions are confined to areas of easy access by the patient

Linear lesions may follow trauma due to Koebner's phenomenon that usually affects psoriasis, lichen planus and occasionally erythema multiforme. Dermatitis artefacta can mimic a multitude of different skin disorders including basal cell carcinoma,⁸ pyoderma gangrenosum,⁹ and cutaneous T cell lymphoma.¹⁰
Trichotillomania may be seen as a form of dermatitis artefacta but often it is just a neurotic trend and people who are concentrating on something wrap their hair around a finger and pull it tight.
An important differential diagnosis is malingering in which the patient is consciously aware of producing factitious lesions, the purpose being to avoid work or claim compensation.¹¹

• Avoid direct confrontation when the disease is suspected although a gentle probe such as, "Do you have any idea what might have caused this?" would be appropriate. Instead the doctor should create an accepting, empathetic and non-judgemental environment. The management is rather akin to Munchausen syndrome. Close supervision and symptomatic care of skin lesions will hopefully lead to a doctor-patient relationship in which psychological issues may gradually be introduced. If appropriate, psychiatric referral may be recommended, although this is often refused. Regularly review suicide and self-harm risk.
• Palliative dermatological measures such as occlusive bandages, ointments or placebo drugs, as well as admission to hospital that includes bathing and massaging by nurses, can have a therapeutic impact on the psychiatric problem by symbolizing the medical attention and care for which the dermatitis artefacta patient is craving.
• Antidepressants may be of value. The SSRIs are often preferred although the tricyclic antidepressants may have some antipruritic effect and sedation can be beneficial.¹³ If the patient is motivated cognitive and behavioural therapy may be helpful as part of a package of care, although the literature on the subject is sadly lacking. The atypical antipsychotic, olanzapine, appears to have much potential.¹⁴ Inevitably, patients with different psychiatric illnesses require different approaches.

• Disfiguring scars on highly visible parts of the body, often the face.
• Psychiatric comorbidity, increasing risk of suicide.
• Iatrogenic side-effects from investigation and treatment.

Resolution of the current underlying psychological problem or stressors facilitates a cure for the time at least but dermatitis artefacta tends to be a chronic condition that waxes and wanes with events in the patient's life. To minimise damage, a patient should continue to see the doctor intermittently for supervision or support, whether or not lesions are present.¹²

The Stigmata are regarded as a historical fact and part of doctrine by the Roman Catholic Church. The stigmata are the physical signs of the Passion of Christ that have been borne by many ecstatics over the centuries. One academic has counted 321 stigmatics "in whom there is every reason to believe in a Divine action". Of this 321 there were 280 women and 41 men. An alternative medical or psychiatric interpretation is as dermatitis artefacta. The 5 features represent:

• Flagellation of the back
• The crown of thorns
• Signs of nails from crucifixion on the hands and feet (hands and feet represent 2 separate signs)
• The mark of the soldier's spear in the side

The stigmata were not recorded before the 13th century and the first recorded person to bear them was St Francis of Assisi who is better known for his association with animals. He lived from 1186 to 1226. With many stigmatics these apparitions were cyclical. For example, St. Catherine de' Ricci, whose ecstasies of the Passion began when she was 20 years old in 1542, had recurrences at regular intervals for 12 years. They lasted exactly 28 hours, from Thursday noon until Friday afternoon at 4pm, the only interruption being for her to receive Holy Communion. Catherine conversed aloud, as if enacting a drama. This drama was divided into about 17 scenes. On coming out of the ecstasy her limbs were covered with wounds produced by whips, cords etc. A number of stigmatics felt that the physical signs of their piety were an unworthy source of pride and prayed to be relieved of them. Their prayers were granted.