Dermatological pathomimicry: a form of patient maladjustment

A Rare Case of Focused Pulling Type of Trichotillomania Presenting as Dermatological Pathomimicry

Nonhealing ulcers are defined as spontaneous or traumatic lesions, unresponsive to initial therapy, or which persist despite appropriate care. Trichotillomania (TTM) is an impulse control disorder, where severe form may cause ulcer and scarring. After extensive research, we could not find any case showing the association of TTM with large-sized factitious ulcer. Hence, we report a rare case of 30 year old female presenting with TTM and large sized factitious ulcer.

[Self-inflicted lesions in the context of hidradenitis suppurativa: Pathomimicry]

BACKGROUND

Factitious disorders constitute a complex pathology for the dermatologist. Although a diagnosis is often indicated, it is difficult to confirm and treatment is complicated. Dermatitis artefacta is the somatic expression of an often serious psychiatric disorder consciously created by patients on their own cutaneous-mucosal surfaces but the motivation is unconscious and no secondary benefits are sought (in contrast to simulation). Pathomimicry represent a specific entity: the provocation of outbreaks of a known disease, triggered by voluntary exposure to a causative agent. Herein we report on a case of pathomimicry in a context of hidradenitis suppurativa.

PATIENTS AND METHODS

A teenage girl whose main previous medical history consisted of grade-2 obesity and an episode of pubic abscess was seen at our clinic for axillary lesions. She presented in a state of negligence, was suspicious and aggressive, and refused to undress. After gaining her trust, clinical examination revealed prominent ulcerations (each with a granulated base) at a distance from the folds in the axillary areas, as well as typical hidradenitis lesions of Hurley Grade 2 with purulent openings and rope-like scars from the inguinal folds. Hospitalization was recommended and a positive outcome was achieved under antibiotic therapy with doxycycline, topical alginate and hydrocellular dressings. A psychiatric evaluation concluded that the patient was presenting dysmorphophobic narcissistic weakness, probably in reaction to recurrent harassment at school since childhood. Once she developed trust with us, which was difficult to establish, the patient admitted to having caused the lesions herself. Given the history and clinical data, as well as the negative laboratory tests, a diagnosis of pathomimicry was made.

DISCUSSION

Several cases of dermatological pathomimicry (sustainment by the patient of an ulcer with a known cause, contact with an allergen found in eczema, or renewed use of a medication implicated in toxiderma) or systemic disease (insulin injection in a diabetic patient) have been reported. To the best of our knowledge, this is the first description of pathomimicry associated with hidradenitis suppurativa. Regarding therapy, aftercare should be multidisciplinary. Confessions should not be forced and confrontations, which risk serious psychiatric collapse, should be avoided. A reassuring attitude enables psychiatry to be applied once trust has been sustainably established, hence the crucial role of the dermatologist.

Primary psychiatric conditions: dermatitis artefacta, trichotillomania and neurotic excoriations

Primary psychiatric conditions encountered in dermatology include dermatitis artefacta, trichotillomania (TTM) and neurotic excoriations. For these disorders, the primary pathologic condition involves the psyche; therefore, any cutaneous findings are self-induced. Herein, we review common primary psychiatric conditions in dermatology – dermatitis artefacta, neurotic excoriations and TTM – and examine their epidemiology, clinical presentation, differential diagnosis and treatment strategies. For all primary psychiatric disorders, the most effective underlying strategy is to first establish a strong therapeutic rapport with the patient. Various pharmacologic and non-pharmacologic therapies can then be attempted afterwards to successfully manage these patients.

Dermatitis artefacta in pediatric patients: experience at the national institute of pediatrics

Dermatitis artefacta is a factitious disorder in which there is deliberate conscious production of skin lesions. There are only a few reports that evaluate instances of dermatitis artefacta in the pediatric population. The aim of this retrospective study was to assess the characteristics of patients with this disorder who were seen at the National Institute of Pediatrics in Mexico City. The records of all patients diagnosed with dermatitis artefacta from January 1980 to December 1999 were analyzed. There were 29 patients (25 females, 4 males). The upper limbs and the face were the most commonly involved areas. Superficial erosions were the most frequent initial event, and residual lesions consisted of scars and crusts. Time taken to diagnosis was on average 10 months. Half of the patients were lost to follow-up. No correlation was found between the length of time from the disease onset to diagnosis, the type of lesions, and the clinical outcome. Twelve patients had an associated systemic disorder. The possible association with chronic disease has not been sufficiently stressed and demonstrates the importance of providing psychological support for these patients. Psychiatric diagnoses were anxiety, depression, and personality disorder. No correlation was found between the psychiatric diagnosis and the outcome of dermatitis artefacta. A young age at presentation, which has been considered important as a favorable prognostic sign, could not be demonstrated in our patients.

Self-inflicted wounding. 2: Identification, assessment and management

The spectrum of conditions associated with self-inflicted wounding and their presenting features were outlined in the first part of this article (Moffatt, 1999). In part two, the assessment and management of self-wounding patients is discussed. Manipulative behaviour can be a barrier to treatment, as well as a disruptive force within the healthcare team. Awareness of its effects are essential to the successful development of a therapeutic relationship. However, the current possibilities for effective treatment of self-wounding are limited, and there is an urgent need for more research into both its causes and the various management options available.

Dermatitis artefacta. Clinical features and approaches to treatment

In dermatitis artefacta, the patient creates skin lesions to satisfy an internal psychological need, usually a need to be taken care of. The clinical presentation is characteristic, and differs from that of neurotic excoriations, delusional disorders, malingering, and Munchausen's syndrome. Munchausen's syndrome by proxy is a form of dermatitis artefacta. Except where disease is mimicked, lesions that do not conform to those of known dermatoses are shrouded in mystery, appearing fully formed on accessible skin, within the context of a characteristic psychological constellation. The patient is friendly but bewildered, and the relatives, angry and frustrated. Because of lack of diagnostic stringency, quoted female-to-male ratios range from 3:1 to 20:1, with the highest incidence of onset in late adolescence to early adult life. Most patients have a personality disorder; borderline features are common. The patient's denial of psychic distress, and negative feelings aroused in healthcare personnel, make management difficult. Limit-setting for the protection of both the physician and patient; creation of an accepting, empathic, and nonjudgmental environment; and close supervision of symptomatic dermatologic care will permit development of a therapeutic relationship in which psychological issues may gradually be introduced, that may occasionally permit psychiatric referral. Issues of etiology should be sidestepped because confrontation is counter productive. When psychiatric referral is refused by the patient, the use of psychotropic drugs by dermatologists is helpful and appropriate. The upper dose range of selective serotonin reuptake inhibitors (SSRIs), or low dose atypical antipsychotic agents, may be effective. Except in mild transient cases triggered by an immediate stress, the prognosis for cure is poor. The condition tends to wax and wane with the circumstances of the patient's life. Lesions can be kept to a minimum, the patient can be protected from unnecessary and intrusive studies, and society can be protected from escalating and unnecessary expenditure of medical resources if, rather than discharging the patient, the dermatologist continues to see the patient on an ongoing basis for supervision and support, whether or not lesions are present. Research studies are necessary to document more accurately the expectable cause, treatment outcome, and prognosis for this group of patients.

Allergic contact dermatitis to adhesive tape and contrived disease

A case of allergic contact dermatitis, caused by colophony in an orthopaedic tape, is presented. This failed to heal, despite removal of the allergen. Only after a period of observation in hospital and, finally, gentle confrontation with the patient, did it become clear that the perpetuation of the dermatitis was an example of contrived disease.

Neurotic excoriations and dermatitis artefacta

Patients with different psychiatric disorders produce artefacts on the skin, each requiring a different therapeutic approach. These different disorders are outlined briefly. The clinical picture, pathology, psychopathology, differential diagnosis, treatment, course, and prognosis of dermatitis artefacta and neurotic excoriations are reviewed in greater detail.

Malignant change in dermatitis artefacta

Dermatitis artefacta is a chronic skin lesion produced by self-trauma. Avoidance of further trauma, topical steroids and psychological therapy all play a part in the treatment of such lesions. Unresolved lesions may become large and disfiguring and subject to infection. We report a case of one such lesion in an elderly woman who persistently excoriated a cholecystectomy scar over 40 years. Malignant transformation occurred in a manner analogous to the neoplastic change observed in other types of chronic ulcer (Marjolin's ulcer). The squamous cell carcinoma presented with widespread metastases from which the patient eventually died. Recent literature concerning Marjolin's ulcers is reviewed and it is noted that this is the first reported case of death caused by malignant change in dermatitis artefacta.

Factitious disorders in a general hospital setting: clinical features and a review of the literature

Factitious disorder is an uncommon, but probably underdiagnosed, condition associated with considerable morbidity, mortality, and health care expenditure. This diagnosis was made in 10 (0.8%) of 1,288 patients consecutively referred to the psychiatric consultation-liaison service of a tertiary-care general hospital. Seven of 10 identified cases were female. Associated psychiatric disturbances included substance use, psychogenic pain disorder, malingering, dysthymic disorder, and borderline personality disorder. Only two cases accepted ongoing psychotherapy. One death due to factitious behavior occurred during the brief period of follow-up. Greater awareness of this condition among primary caregivers is necessary in order to improve case identification and to reduce associated morbidity.

Psychological and behavioral factors in dermatitis

Dermatitis and eczema are described in terms of physiological, psychological, and behavioral characteristics in the sparse psychological literature on this phenomenon. Knowledge is quite limited. Lacking are prospective studies that might demonstrate whether the psychological and behavioral characteristics ate etiological and not merely descriptive. Given the number of persons estimated to experience symptoms of dermatitis (7 to 24 per 1000), further research is warranted on the relationship among dermatitis, scratching, and the psychological factors of stress, aggression, hostility, or other moods. Methodological suggestions and an experimental design are proposed.

Self-inflicted tongue ulcer: an unusual form of factitious disorder

Factitious disorders in the buccal cavity are infrequent. A 9-year-old boy with a 5-year history of an artefact ulcer of the tongue is described. Psychiatric evaluation revealed an altered personality structure with a background of psychotic traits. Complete remission was observed with psychiatric management.

Successful treatment of a chronic and disabling dermatosis by psychotherapy. A case report and discussion

It behooves us all to help contain rising medical costs. Accurate diagnosis and institution of appropriate treatment contribute to cost containment. A patient is described who entered psychotherapy after 14 years of competent dermatologic care for incapacitating and painful skin lesions with arthralgias. Drug and alcohol abuse, deteriorating peer and family relationships, and poor job performance had supervened. The successful outcome of her treatment is discussed.