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CASE REPORT
Year : 2022 | Volume
: 23
| Issue : 2 | Page : 172-174
Dermoscopic aid in the diagnosis of dermatitis artefacta
KM Sudhakar Rao, SV Smitha
Department of Dermatology, Venereology and Leprosy, S. Nijalingappa Medical Collage, Bagalkot, Karnataka, India
Correspondence Address:
Dr. S V Smitha
Department of Dermatology, Venereology and Leprosy, S. Nijalingappa Medical Collage, Navanagar, Bagalkot, Karnataka
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijpd.ijpd_94_21
Dermatitis artefacta (DA) is a condition where the patient produces cutaneous lesions to fulfil an unconscious psychological need. It is most commonly seen in prepubertal and adolescent age group with female predominance. Among children, causes include delayed developmental milestones, disturbed parent–child relationship, bullying in school, conflict with siblings, academic pressure, gender bias, and loss of close relative in the recent past. We present a case of DA in an 8-year-old girl with dermoscopic evaluation. In pediatric age group, special attention is required to identify such cases. Early diagnosis and intervention for the DA is required for the prevention chronic physical and psychological disabilities.
Keywords: Dermatitis, dermoscopy, pediatric psychology, self-injurious behavior
Primary psychiatric disorders may present with various dermatological manifestations. Approximately 30%–40% of patients seeking treatment for skin disorders will have psychiatric disorders as causative or aggravating factor.[1] In children and adolescents, thumb sucking, onychotillomania, onychophagia, mutilation of skin (dermatitis artefacta [DA]), trichotillomania, and acne excoriee are common examples for self-mutilating conditions.[2] DA is a condition where the patient produces cutaneous lesions to fulfill an unconscious psychological need.[3] The diagnosis is often challenging when patient belongs to pediatric age group. It is important to identify such children to prevent chronic physical and psychological disability. Here, we report a case of DA in a pediatric patient with its dermoscopic findings.
Case ReportAn 8-year-old girl was brought by her mother to the dermatology outpatient department for complaints of multiple recurrent lesions on the face and limbs for six months. Lesions were sudden in onset and recurrent. Every alternate day, she used to present with new lesions on her face which used to disappear spontaneously without treatment with postinflammatory hyperpigmentation within eight days. There was no pain or itching over the lesions. She was evaluated by many dermatologists for skin lesions as insect bite reaction, fixed drug eruptions, polymorphic light eruptions, and treated with mild topical steroids for the same. The patient had normal uneventful birth history and was adequately vaccinated. There was no history of similar lesions in the past or any family members and there was no history of photosensitivity. The mother informed that the child had a few friends with whom she did not talk much or play with them and her school performance was average. When asked the child about the skin lesions, we noticed her having speech defect and she gave a hollow history about the skin lesions. The patient's built and weight was appropriate for her age. On examination, there were multiple, oval, well-defined excoriations, erosions with crusting, and scab formation of varying sizes over the face, forearms, dorsa of the hands, lateral aspect of lower thighs, and shins [Figure 1] and [Figure 2]. Only the accessible parts of the body were involved and inaccessible parts were spared. Routine hematological and biochemical investigations were within normal limits. ANA profile was negative. Skin biopsy was not done as the child's parents refused to give consent and the patient was apprehensive. Differential diagnoses of contact dermatitis, DA, impetigo, and blister beetle dermatitis were made.
Figure 1: Oval, resolving, hyperpigmented dermatitis artefacta lesions with well-defined excoriation marks on forehead and cheeks
Figure 2: Well-defined excoriations and postinflammatory hyperpigmented macules on bilateral forearmsDermoscopy was done using a FotoFinder videodermoscope (Medicam 1000s, FotoFinder Systems GmbH, Bad Birnbach, Germany) in polarized mode at ×20 magnification, which demonstrated lesions with three zones as central crusting and scabbing surrounded by peripheral erythematous to whitish halo with outer hyperpigmented area [Figure 3]. Few red blotches were seen with the central scab. The surrounding skin appeared normal. On careful history and multiple sessions of counseling of the child and parents with the help of a psychiatrist, the child confessed self-inducing the lesions with her bare hands when she was alone. The child was primarily affected with speech defect, for which she was bullied and ignored by her family members. The diagnosis of DA was confirmed and the child was referred to the psychiatry department. Detailed psychological evaluation, speech therapy was done and the child was advised counseling without any medications, following which she improved, which was confirmed by telephonic conversation with the parents.
Figure 3: Dermoscopy showing three zones which consists of central crusting (yellow star), middle zone of hypopigmented area (red star) surrounded by outer zone of hyperpigmented area (green star). Red blotches can be seen within the central crusting (blue circles). (FotoFinder videodermoscope, polarized mode, ×20) Discussion DA, also known as factitious dermatitis, is a condition in which skin lesions are solely produced or inflicted by the patient's own actions without any rational motive for this behavior.[4] Precipitating events range from simple anxiety to interpersonal conflicts and severe personality disorders, including compulsive behavior, depression, and psychotic disturbances.[5]
Skin lesions are always self-injurious and the morphology varies widely depending on the mode of injury: cutting, abrasion, burning, applying chemicals, and injecting various products. Bizarre lesions with sharp geometric borders surrounded by normal skin are characteristic of DA.[6],[7],[8] Lesions may be produced by a variety of mechanical or chemical means, including fingernails, sharp or blunt objects, burning cigarettes, and caustic chemicals.[9]
DA presenting as asymptomatic monomorphic geometric lesions on the anterolateral surfaces of the arms was reported in a 12-year-old girl with attention deficit hyperactivity disorder.[10]
Multinucleated epithelial cells and epidermal necrosis were the common histology findings in DA.[11] Blistering with a mild inflammatory infiltrate, rupture of collagen fibers, and elongated and vertically arranged keratinocyte nuclei along with multinucleated keratinocytes on histology suggest factitious dermatoses.[12]
Recently, social media challenges have become fads among children and adolescents. Children following social media phenomena such as eraser challenge, salt-ice challenge, deodorant challenge, and fire challenge present as nonaccidental traumatic skin lesions, which are intentional and performed for secondary gains like gaining acceptance among peers.[13]
A high degree of suspicion is required for diagnosing DA, especially in pediatric cases with a hollow history. The diagnosis of DA in children can be distressing to parents, who often vacillate between accepting and challenging the diagnosis.[14] In dermoscopic evaluation of lesions, the central red blotches can be due to capillary oozing and yellowish crust can due to serum exudation secondary to excoriation hints toward the act of scratching by the patient. Surrounding zones of hypo- and hyperpigmentation denote healing phase of traumatic lesions. Dermoscopy helped us to come to accurate diagnosis by showing traumatic nature of the lesions and ruling out other possible skin conditions in that age group. However, diagnosis of DA is mainly based on clinical history and typical morphology and distribution of the lesions. Psychocutaneous disorders like DA are usually referred to psychiatrists for the definite treatment.
Declaration of consent
The authors certify that they have obtained all appropriate consent forms, duly signed by the parent(s) of the patient. In the form the parent(s) has/have given his/her/their consent for the images and other clinical information of their child to be reported in the journal. The parents understand that the names and initials of their child will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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