CASE REPORT A Psycho-Cutaneous Disorder: Dermatitis Artefacta
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CASE REPORT A Psycho-Cutaneous Disorder: Dermatitis Artefacta
Turan Sönmez F et al. CASE REPORT Feruza Turan Sönmez1 Harun Güneş1 Ayhan Sarıtaş1 Hayati Kandiş1. 1. Duzce University, School of Medicine, Department of Emergency Medicine, Duzce, Turkey. A Psycho-Cutaneous Artefacta Disorder: Dermatitis SUMMARY Dermatitis artefacta is a psycho-cutaneous disorder that is commonly associated with mood and anxiety disorders. The morphology of lesions may call to mind violence exposure. Studies have shown preponderance of female, and frequency of the disease among main psycho-cutaneous disorders is about 6-7%. Emergency physicians frequently encountered with many lesions that need differential diagnosis. Dermatitis artefacta is one of them and often it is a challenge for clinicians, because it is relatively rare disease with vague history, bizarre and polymorphic morphology. We, hereby, report a case of acute onset cutaneous reactions that later was diagnosed as Dermatitis artefacta. Key words: Dermatitis Artefacta, Psycho-Cutaneous Disorders, Emergency Corresponding Author: Dr. Feruza Turan Sönmez Duzce University School of Medicine, Department of Emergency Medicine, Duzce, Turkey. Mail: feruzaturan@yahoo.com Geliş Tarihi: 04.04.2016 Kabul Tarihi: 15.04.2016 Prusias Medical Journal Prusias Tıp Dergisi e-ISSN 2459–0681 prusiasdergi@gmail.com www.prusiasacademic.com Psiko-kütanöz Bozukluk: Dermatitis Artefacta ÖZET Dertamitis artefakta, sıklıkla duygu durum ve anksiyete bozuklukları ile ilişkili olan bir hastalıktır. Lezyonların görünüşü akla şiddete maruziyeti akla getirebiliyor. Çalışmalar, bu hastalıkta bayan sayısının ağırlıkta olduğunu gösteriyor ve majör psikodermatozlar arasında % 6-7’lik orana sahiptir. Acil hekimleri sıklıkla ayırıcı tanı gerektiren deri lezyonlarıyla karşılaşırlar. Dermatitis artefakta bunlardan biridir ve göreceli olarak nadir görülmesi, hikayesinin müphem olması, değişken ve polimorfik morfolojiye sahip olması nedeni ile klinisyenler için bir sorundur. Bu yazımızda akut gelişen ve daha sonra dermatitis artefakta olarak tanı alan bir deri reaksiyonu sunduk. Anahtar Kelimeler: Dermatitis Artefakta, Psiko-Kütanöz Bozukluklar, Acil Prusias Medical Journal 2016;1(1):48-50 48 Turan Sönmez F et al. INTRODUCTION Dermatitis artefacta (DA) is a psychocutaneous disorder that is commonly associated with mood and anxiety disorders. The patient intentionally induces skin lesion to mimic an illness. Dermatitis artefacta lesions usually appear at an indistinguishable stage of development, can be single or multiple, are often geometric, unilateral or bilateral, and generally within reach of the hands (1). The patient forms lesions by rubbing or scratching, by the use of a sharp instrument or not or by applying chemical substance into the skin. Characteristically, patients describe the sudden appearance of complete lesions, with little or no prodrome ("hollow history"), and usually deny taking part in the process, exhibiting a "belle indifference" and lack of frustration despite the recurrent nature of their symptomatology (2,3). Studies have shown preponderance of female, and frequency of the disease among main psychocutaneous disorders is about 6-7% (4). We, hereby, report a case of acute onset cutaneous reactions that later was diagnosed as DA. CASE REPORT A 24-year-old female presented with swallowing of periorbital skin, multiple cone-form, hyperemic lesions no face and forehead and irregular, non-itchy ecchymotic areas on neck (Figure 1). She appeared anxious and had slight tremor. On physical examination heart rate was 110 beats/minute. The patient denied self-harm or violence, she could not explain the cause of the lesions. She declared that ever she has a trouble to bear any anxiety she suffers from such itchy lesions that appear immediately after. We investigated allergic reaction history, questioned for assault, checked laboratory findings and found no further abnormalities. We treated the patient with diazepam for anxiety and with prednisolone and feniramine for the lesions. Later we consulted the patient to dermatology. Skin biopsy was determined. Biopsy samples showed diffuse non-specific inflammatory pattern and the patient was diagnosed as dermatitis artefacta. Figure 1. A 24-year-old female presented with swallowing of periorbital skin, multiple cone-form, hyperemic lesions no face and forehead and irregular, non-itchy ecchymotic areas on neck DISCUSSION Dermatitis artefacta is a self-inflicted cutaneous lesion where the patient denies self-harm (5). Lesions may call to mind violence exposure and generally unwillingness to provide any explanation about the lesions maces the decision critical. Important dermatological differentials are necrotizing vasculitis, pyoderma gangrenosum, and cutaneous T-cell lymphoma. The Munchausen syndrome should be considered as an important psychiatric differential, characterized by flamboyant males who feign multiple symptoms and shifting complains not limited to only the skin, just to draw attention (6). Emergency physicians frequently encountered with many lesions that need differential diagnosis. DA is one of them and often it is a challenge for clinicians, because it is relatively rare disease with vague history, bizarre and polymorphic morphology (6). For, dermatitis artefacta is a psychocutaneous disorder, management of the patient should be supportive, non-confrontational, flexible, and should involve building mutual trusts and understanding between patient and treating clinician. Conflict of interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article. Prusias Medical Journal 2016;1(1):48-50 49 Turan Sönmez F et al. REFERENCES 1. KyungHwa Park K, Koo J. Skin picking (excoriation) disorder and related disorders 2016 [updated Nov 09, 2015]. Available from: http://www.uptodate.com/contents/skin-picking-excoriation-disorder-and-relateddisorders. 2. Paller AS, Mancini AJ, Hurwitz S. Hurwitz clinical pediatric dermatology: a textbook of skin disorders of childhood and adolescence. Philadelphia: Elsevier Saunders; 2006. 3. Millard L, Millard J. Psychocutaneous disorders. Rook's Textbook of Dermatology, Eighth Edition. Oxford: Wiley, 2010:1-55. 4. Ehsani AH, Toosi S, Mirshams Shahshahani M, Arbabi M, Noormohammadpour P. Psycho-cutaneous disorders: an epidemiologic study. Journal of the European Academy of Dermatology and Venereology. JEADV. 2009;23(8):945-7. 5. Sinha S, De A, Thomas KG, Vaughan-Williams E. Dermatitis artefacta of the breast: a diagnostic dilemma. The Breast Journal. 2008;14(5):500-1. 6. Saha A, Seth J, Gorai S, Bindal A. Dermatitis Artefacta: A Review of Five Cases: A Diagnostic and Therapeutic Challenge. Indian Journal Of Dermatology. 2015;60(6):613-5. Prusias Medical Journal 2016;1(1):48-50 50