Background

Dermatitis artefacta, also known as factitious dermatitis or self-inflicted dermatosis, is a psychological condition in which individuals intentionally create or exaggerate skin lesions or symptoms to gain attention, sympathy, or medical treatment. It falls under the broader category of factitious disorders, which involve the deliberate production of physical or psychological symptoms without any underlying medical cause. 

This condition is often considered a form of self-harm and is driven by underlying psychological factors such as a desire for attention, a need to be cared for, or a way to communicate distress when words alone might not suffice. Individuals with dermatitis artefacta may use various methods to induce skin damage, including scratching, cutting, burning, or otherwise injuring their skin. These actions can lead to real skin damage and may even result in infections, scarring, or other complications. 

Treatment of dermatitis artefacta is complex and requires a multidisciplinary approach. It involves addressing both the underlying psychological issues and the physical skin damage. Psychotherapy, particularly cognitive-behavioral therapy (CBT), can be effective in helping individuals understand and manage the psychological factors driving their behavior. 

Epidemiology

• Prevalence: The prevalence of dermatitis artefacta in the general population is estimated to be low. It is often encountered in clinical settings that specialize in dermatology or psychiatry. 
• Gender: Dermatitis artefacta appears to be more common in females. This gender disparity might be related to differences in seeking medical attention and expression of emotional distress. 
• Age: While dermatitis artefacta can occur at any age, it is most observed in adolescents and young adults. The exact age range can vary, but the condition is often first identified during the teenage years or early adulthood. 
• Psychiatric Comorbidity: Individuals with dermatitis artefacta often have underlying psychiatric conditions, such as depression, anxiety, personality disorders, or other mental health issues. Addressing these comorbidities is important in the overall management of the condition. 
• Healthcare Utilization: Individuals with dermatitis artefacta frequently seek medical care for their skin lesions. They may undergo numerous unnecessary procedures and treatments, leading to significant healthcare utilization and costs. 
• Chronicity: Dermatitis artefacta can be a chronic condition if left untreated. The behavior may wax and wane over time, with periods of remission and exacerbation. 
• Diagnostic Challenges: Diagnosis can be difficult due to the intentional deception and concealment associated with the disorder. Medical professionals need to carefully assess the medical history, clinical presentation, and psychological aspects to arrive at an accurate diagnosis. 

Anatomy

Pathophysiology

• Psychological Factors: Dermatitis artefacta is considered a somatic symptom disorder within the realm of factitious disorders. It often arises from psychological issues such as the need for attention, a desire to be cared for, a way to communicate emotional pain, or a need to take control over a situation. Individuals may lack healthy coping mechanisms and turn to self-inflicted skin damage to cope with their emotional struggles. 
• Distorted Body Image and Perception: Some individuals with dermatitis artefacta may have a distorted perception of their body and appearance. They might focus intensely on perceived flaws or imperfections, leading them to intentionally create or exacerbate skin lesions to “fix” or draw attention to these issues. 
• Seeking Medical Attention: Individuals with dermatitis artefacta often seek medical care for their skin lesions. This can result in a cycle of reinforcement, where the attention and care they receive from medical professionals serve as a reward for their behavior, further motivating them to continue the self-inflicted actions. 

• Neurobiological Factors: Research suggests that alterations in brain function and neurobiological processes may contribute to the development of factitious disorders, including dermatitis artefacta. Dysregulation in brain areas associated with emotional processing, impulse control, and reward mechanisms might play a role. 
• Dermatological Changes: The physical manifestations of dermatitis artefacta result from deliberate actions taken by individuals to damage their skin. These actions can range from scratching, cutting, and burning to using various substances to induce skin irritation. The skin damage caused by these actions can lead to physiological changes, including inflammation, scarring, and in some cases, secondary infections. 

Etiology

• Psychological Factors: The primary underlying factor in dermatitis artefacta is psychological distress. Individuals who engage in self-inflicted skin damage often have underlying emotional issues, such as depression, anxiety, trauma, or personality disorders. The behavior may serve to cope with emotional pain or communicate distress that is difficult to express through words alone. 
• Attention-Seeking: Individuals with dermatitis artefacta may have a strong need for attention, care, and validation from others. The physical manifestations of the condition draw attention to them and can lead to interactions with healthcare professionals, family members, and friends. 
• Underlying Mental Health Conditions: People with pre-existing mental health conditions, such as borderline personality disorder, somatic symptom disorder, or factitious disorder imposed on self (formerly known as Munchausen syndrome), may be more prone to developing dermatitis artefacta. 
• Past Trauma: Traumatic experiences, whether physical or emotional, can contribute to the development of dermatitis artefacta. The behavior might be a way to cope with or recreate past traumatic events. 
• Unconscious Psychological Conflicts: Some individuals may engage in self-inflicted skin damage unconsciously as a manifestation of unresolved psychological conflicts. These conflicts might be related to identity, self-worth, or feelings of powerlessness. 

Genetics

Prognostic Factors

• Early Intervention: Timely recognition and intervention can lead to better outcomes. If the condition is identified and treated early, individuals may have a greater chance of learning healthier coping mechanisms and addressing underlying psychological issues. 
• Severity of Underlying Psychological Issues: The severity of the individual’s underlying emotional and psychological distress plays a significant role. Those with more severe emotional struggles may face a more challenging recovery process. 
• Motivation for Change: An individual’s willingness and motivation to engage in treatment and make positive changes can impact the prognosis. A strong commitment to addressing the underlying issues is associated with better outcomes. 
• Social Support: Having a supportive network of family, friends, or caregivers can positively influence the individual’s ability to manage the condition and engage in treatment. 
• Treatment Adherence: Consistent participation in therapy, medication management (if applicable), and other recommended treatments can contribute to better outcomes. 
• Ability to Develop Coping Skills: Learning healthy coping mechanisms to manage emotional distress is a key factor. Individuals who can develop alternative ways of dealing with stress and emotional pain have a better chance of recovery. 

Clinical History

Age: Dermatitis artefacta can occur at any age, but it is commonly observed in adolescents & young adults. It may also be seen in older adults, though less frequently. The age of onset can provide insight into potential underlying psychological factors and triggers. 

Physical Examination

Skin Lesions: 

• Careful observation of the self-inflicted skin lesions, including their size, shape, color, and appearance. 
• Assessment of the depth of the lesions, which can range from superficial scratches to deeper wounds. 
• Determining whether the lesions are consistent with patterns or shapes that suggest self-infliction. 

Distribution and Location: 

• Examining the distribution of the lesions on the body. Self-inflicted lesions might appear in areas easily accessible to the individual, such as the forearms, thighs, or face. 
• Noting any clustering or specific patterns that might indicate deliberate self-harm. 

Abrasions and Scars: 

• Differentiating between acute abrasions (recent injuries) and scars (healed wounds) resulting from previous self-inflicted behaviours. 

Surrounding Skin: 

• Checking the condition of the skin around the lesions for signs of irritation, inflammation, or infection. 
• Identifying signs of secondary infections that might have resulted from the self-inflicted wounds. 

Nail and Hair Examination: 

• Examining the nails for any signs of self-induced trauma, such as nail biting or picking. 

• Observing the hair for any signs of self-induced hair pulling (trichotillomania) if relevant. 

Age group

Associated comorbidity

Individuals with dermatitis artefacta often have underlying psychological comorbidities, such as depression, anxiety disorders, personality disorders, or somatic symptom disorder. These conditions can contribute to the development and maintenance of the self-inflicted behavior. 

Associated activity

Acuity of presentation

The acuity of presentation can vary. Some individuals may present with acute and severe skin damage, while others might have a more chronic pattern with multiple episodes of self-inflicted lesions over time. 

Differential Diagnoses

Other Dermatological Conditions: 

• Delusional Infestation (Delusional Parasitosis): Individuals believe they are infested with parasites, even if no evidence of infestation exists. 
• Excoriation (Skin-Picking) Disorder: Repetitive picking of the skin, resulting in skin lesions, often due to psychological distress. 
• Dermatitis Disorders: Other forms of dermatitis, such as atopic dermatitis, contact dermatitis, or psoriasis, can cause skin lesions that may resemble self-inflicted damage. 

Physical Illness with Skin Symptoms: 

• Systemic Lupus Erythematosus (SLE): Autoimmune disorder with a range of skin manifestations, including rashes. 
• Vasculitis: Inflammation of blood vessels can lead to skin lesions and other symptoms. 
• Infections: Certain infections, such as fungal or bacterial infections, can cause skin lesions. 
• Eczema Herpeticum: Herpes simplex virus infection that worsens eczema symptoms. 

Psychological Conditions: 

• Somatic Symptom Disorder: Persistent physical symptoms that may or may not have an underlying medical cause, often related to psychological distress. 
• Conversion Disorder: Physical symptoms that cannot be explained by a medical condition but have a psychological origin. 
• Body Dysmorphic Disorder: Obsessive focus on perceived flaws in appearance, leading to distress and often repetitive behaviors. 

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

Assessment and Diagnosis: 

• Thoroughly evaluate the patient’s medical and psychiatric history to understand the context of the behavior. 
• Conduct a comprehensive physical examination to assess the extent of skin damage and rule out other medical conditions. 
• Collaborate with mental health professionals to assess underlying psychological factors and develop an appropriate treatment plan. 

Establish Therapeutic Alliance: 

• Develop a strong and trusting relationship with the patient to create a safe space for them to discuss their emotions and behaviors. 
• Establish open communication and empathy to encourage the patient’s engagement in treatment. 

Psychotherapy: 

• Cognitive-Behavioral Therapy (CBT): Identify and challenge maladaptive thought patterns, develop coping skills, and address the underlying emotional issues. 
• Dialectical Behavior Therapy (DBT): Focus on emotional regulation, distress tolerance, interpersonal effectiveness, and mindfulness. 
• Individual or group therapy sessions provide opportunities for the patient to explore their feelings and learn effective coping strategies. 

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

non-pharmacological-treatment-of-dermatitis-artefacta

Lifestyle modifications: 

Psychological Support: 

• Engage in regular psychotherapy or counselling with a mental health professional experienced in treating self-inflicted skin disorders. 
• Cognitive-behavioural therapy (CBT) and other therapeutic approaches can help address the underlying emotional issues driving the behavior. 

Stress Management: 

• Learn and practice stress-reduction techniques, such as deep breathing, mindfulness, meditation, and yoga. 

Healthy Coping Strategies: 

• Develop healthier ways to cope with emotions, stress, and emotional pain. 
• Identify alternative activities or outlets for expressing feelings and managing distress. 

Social Support: 

• Build a strong support network of friends, family, and loved ones who can provide understanding, encouragement, and emotional assistance. 

Hobbies and Activities: 

• Engage in enjoyable and fulfilling hobbies or activities that can distract from the urge to self-inflict skin lesions. 

Addressing Underlying Issues: 

• Work on addressing any underlying psychological issues, trauma, or unresolved emotions that may contribute to the behavior. 

Avoidance of Triggers: 

• Identify triggers that lead to self-inflicted behavior and develop strategies to avoid or manage them. 

Use of Topical Antimicrobials in the treatment of Dermatitis Artefacta

Topical antimicrobial agents, such as Neomycin/polymyxin B/bacitracin (Neo-Polycin, Neosporin) and fusidic acid, are not typically used as primary treatments for dermatitis artefacta, which is a psychological condition involving self-inflicted skin lesions.

The focus of treatment for dermatitis artefacta is addressing the underlying psychological factors that drive the behavior. 

Neomycin/Polymyxin B/Bacitracin (Neo-Polycin, Neosporin): Used to prevent or treat infections in minor cuts, scrapes, and burns. 

• Mechanism of Action: Neomycin and polymyxin B are antibiotics that can help prevent bacterial growth, while bacitracin works to stop bacterial growth. 
• Application: Applied topically to clean, dry skin. 

• Use in Dermatitis Artefacta: Topical antimicrobials might be considered in cases where self-inflicted skin lesions become infected 

Fusidic Acid: Used to treat bacterial skin infections, particularly those caused by Staphylococcus aureus. 

• Mechanism of Action: Fusidic acid interferes with bacterial protein synthesis, inhibiting bacterial growth. 
• Application: Applied topically to the affected area. 
• Use in Dermatitis Artefacta: Like other topical antimicrobials, fusidic acid might be considered if an infection arises due to self-inflicted skin lesions. 

Use of antibiotics in the treatment of Dermatitis Artefacta

Cephalexin (Keflex):  

Cephalexin is a broad-spectrum antibiotic used to treat bacterial infections. 

• Mechanism of Action: Cephalexin inhibits bacterial cell wall synthesis, preventing bacterial growth. 
• Use in Dermatitis Artefacta: If self-inflicted skin lesions become infected, cephalexin might be prescribed to treat the bacterial infection. 

Erythromycin (E.E.C. 400, PCE, Ery-Tab): 

• Erythromycin is an antibiotic used to treat various bacterial infections. 
• Mechanism of Action: Erythromycin inhibits bacterial protein synthesis, preventing bacterial growth. 
• Use in Dermatitis Artefacta: Erythromycin might be considered in cases of bacterial skin infections resulting from self-inflicted lesions. 

Use of Antidepressants, SSRIs in the treatment of Dermatitis Artefacta

SSRIs are used to treat various mental health conditions, primarily depression and anxiety disorders. While SSRIs are not a direct treatment for dermatitis artefacta (self-inflicted skin lesions), they might be considered as part of a comprehensive treatment plan if the self-inflicted behavior is associated with underlying depression, anxiety, or other mental health issues. 

Fluoxetine (Prozac): 

• It is an SSRI used to treat depression, anxiety disorders, and certain other mental health conditions. 
• It may help regulate mood and reduce symptoms of depression or anxiety that might contribute to self-inflicted behavior. 

Sertraline (Zoloft): 

• Sertraline is another SSRI commonly used to treat depression, anxiety, and other mental health conditions. 
• It might be considered if there is an underlying mood or anxiety disorder associated with self-inflicted behavior. 

Paroxetine (Paxil, Pexeva): 

• Paroxetine is used to treat conditions like depression, anxiety disorders, and obsessive-compulsive disorder (OCD). 
• It might be considered if the self-inflicted behavior is related to anxiety, OCD, or other relevant mental health concerns. 

Fluvoxamine (Luvox CR): 

• It is approved for the treatment of obsessive-compulsive disorder (OCD) and may be considered if OCD symptoms contribute to self-inflicted behavior. 

Citalopram (Celexa) and Escitalopram (Lexapro): 

• Both citalopram and escitalopram are SSRIs used to treat depression and anxiety disorders. 
• They might be considered for individuals with underlying mood or anxiety disorders. 

Use of Antidepressants, TCAs in the treatment of Dermatitis Artefacta

TCAs are not a direct treatment for dermatitis artefacta (self-inflicted skin lesions), they might be considered as part of a comprehensive treatment plan if the self-inflicted behavior is associated with underlying depression, anxiety, or other mental health issues. 

Doxepin: 

• Doxepin is a TCA that is sometimes prescribed to treat depression, anxiety, and sleep disorders. 
• It might be considered if there is an underlying mood disorder or sleep disturbances associated with the self-inflicted behavior. 

Amitriptyline: 

• Amitriptyline is used to treat depression, certain anxiety disorders, and neuropathic pain. 
• It might be considered if the self-inflicted behavior is related to mood or pain issues. 

Clomipramine (Anafranil): 

• Clomipramine is a TCA approved for the treatment of obsessive-compulsive disorder (OCD). 
• It might be considered if OCD symptoms contribute to self-inflicted behavior. 

Nortriptyline (Pamelor): 

• Nortriptyline is used to treat depression, certain anxiety disorders, and neuropathic pain. 
• Like amitriptyline, it might be considered if mood or pain issues are present. 

Desipramine (Norpramin): 

• Desipramine is used to treat depression and certain anxiety disorders. 
• It might be considered if there is an underlying mood disorder or anxiety associated with self-inflicted behavior. 

Use of 1st Generation Antipsychotics of Dermatitis Artefacta

Antipsychotic medications, including first-generation antipsychotics like pimozide (Orap), are not typically considered as primary treatments for dermatitis artefacta (self-inflicted skin lesions).

Antipsychotics might be considered if there are concurrent mental health conditions, like psychosis or severe mood disorders, that contribute to the self-inflicted behavior. 

Pimozide (Orap): 

• Pimozide is an antipsychotic medication primarily used to treat Tourette syndrome and certain types of delusional disorders. 
• Mechanism of Action: Pimozide blocks dopamine receptors in the brain, which can help alleviate symptoms of psychosis and certain behavioral disorders. 
• Use in Dermatitis Artefacta:Pimozide might be considered in cases where there is a co-occurring severe mental health condition contributing to self-inflicted behavior. 

Use of 2nd Generation Antipsychotics in the treatment of Dermatitis Artefacta

Second-generation antipsychotics, also known as atypical antipsychotics, are a class of medications commonly used to treat schizophrenia, bipolar disorder, and certain mood disorders.

While these medications are not typically used as primary treatments for dermatitis artefacta (self-inflicted skin lesions), they might be considered in cases where there are concurrent severe mental health issues contributing to the self-inflicted behavior. 

Risperidone (Risperdal): 

• It is used in the treatment of bipolar disorder, schizophrenia, and certain behavioral issues associated with autism. 
• It might be considered in cases where severe underlying mental health conditions contribute to self-inflicted behavior. 

Iloperidone (Fanapt): 

• Iloperidone is used to treat schizophrenia. 
• Like other second-generation antipsychotics, it might be considered if there are severe mental health conditions associated with self-inflicted behavior. 

Paliperidone (Invega): 

• It is used to treat schizophrenia and schizoaffective disorder. 
• It might be considered in cases where the individual has severe mental health conditions contributing to the self-inflicted behavior. 

Olanzapine (Zyprexa): 

• Olanzapine is used to treat schizophrenia, bipolar disorder, and certain mood disorders. 
• It might be considered if severe mood or mental health issues are present alongside the self-inflicted behavior. 

Quetiapine (Seroquel): 

• Quetiapine is used to treat schizophrenia, bipolar disorder, and major depressive disorder. 
• It might be considered if there are concurrent severe mood disorders or mental health issues contributing to self-inflicted behavior. 

various-procedures-involved-in-dermatitis-artefacta

Wound Care and Dressings: 

• For individuals with self-inflicted wounds or skin lesions, proper wound care and dressings can help promote healing, prevent infection, and manage discomfort. 

Skin Lesion Management: 

• In cases of severe self-inflicted skin damage, medical professionals might perform procedures to clean, treat, and manage the affected areas to prevent complications. 

Scar Management: 

• Procedures like scar revision or laser therapy might improve the appearance of scars resulting from self-inflicted wounds. 

Infection Management: 

• If self-inflicted lesions become infected, procedures may be needed to drain abscesses or treat infections. 

Surgical Consultation: 

• In extreme cases where self-inflicted lesions have caused significant tissue damage, consultation with a plastic surgeon or dermatologic surgeon might be considered to evaluate the need for surgical intervention. 

management-of-dermatitis-artefacta

1. Acute Phase:

Assessment and Diagnosis: 

• Identification of self-inflicted skin lesions and thorough assessment of the individual’s psychological state. 

Psychological Intervention: 

• Immediate focus on addressing the psychological factors contributing to the self-inflicted behavior. 
• Psychotherapy and counseling to explore the underlying emotions, triggers, and motivations. 

Wound Care and Treatment: 

• Addressing any wounds or skin lesions caused by self-inflicted behavior. 
• Proper wound care to prevent infection, promote healing, and manage pain. 

Safety and Risk Assessment: 

• Ensuring the individual’s safety and addressing any immediate risk factors related to self-inflicted behavior. 

Supportive Care: 

• Providing emotional support, education, and guidance to the individual and their support system. 

2. Chronic Phase:

Psychological Treatment: 

• Continued psychotherapy and counseling to address deeper psychological issues that contribute to the behavior. 
• Developing coping strategies and healthier ways to manage emotions and stress. 

Relapse Prevention: 

• Identifying triggers and developing strategies to prevent relapses of self-inflicted behavior. 

• Learning skills to manage urges and redirect negative emotions. 

Emotional Regulation: 

• Focus on improving emotional regulation and resilience to prevent recurrence. 

Supportive Care: 

• Ongoing support from mental health professionals, family, and support groups. 

Medication

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References

www.Dermatitis Artefacta.ncbi.nlm.nih.gov 

www.Dermatitis Artefacta: A Review of Five Cases.nlm.nih.gov