Dermatitis Artefacta and Artefactual Skin Disease

The Need for a Psychodermatology Multidisciplinary Team to Treat a Difficult Condition

P. Mohandas; A. Bewley; R. Taylor

Disclosures

The British Journal of Dermatology. 2013;169(3):600-606. 

In This Article

Abstract and Introduction

Abstract

Background Dermatitis artefacta (DA) is a factitious skin disorder caused by the deliberate production of skin lesions by patients with a history of underlying psychological problems. The patient may not be fully aware of this, and the true extent of this disorder, especially in children, is currently unknown. Management of these patients is challenging as many fail to engage effectively with their dermatologist.

Objectives To explore the various clinical presentations and strategies employed to treat DA in our local population, and note outcomes in order to evaluate effectiveness of our management.

Methods A retrospective case note review was conducted of 28 patients attending the regional psychodermatology clinic at the Royal London Hospital from January 2003 to December 2011.

Results Out of 28 patients identified with DA, the majority of patients were female, and the most frequent sites for skin lesions were the face and upper body. Anxiety, depression and personality disorders were common underlying psychiatric diagnoses. Ninety-three per cent of patients were successfully managed (i.e. the DA resolved or was in remission at the time of writing) in our combined psychodermatology clinic by a multidisciplinary psychocutaneous medicine team. Thirty-two per cent of our cases were children (aged < 16 years) and one of these was referred to local child protection services; 46% of patients had a concomitant mental health disease at the time of presentation with DA.

Conclusions A multidisciplinary psychocutaneous team is important in this condition particularly as the patient is likely to require psychological intervention (to facilitate the resolution of the precipitant), in addition to dermatological (to make the diagnosis and, importantly, to exclude organic disease) and psychiatric (to manage concomitant psychiatric disease) input. Our findings indicate that our model of a psychodermatology multidisciplinary team will achieve greater successful treatment of patients with DA and we are the first to describe this important service in the U.K.

Introduction

The skin is a readily accessible and highly visible organ, and is therefore an ideal location for the expression of underlying psychological need, as is seen in dermatitis artefacta (DA). The skin lesions in this condition may be produced consciously by the patient, followed by an attempt to conceal and deny any involvement in their production. The subject may be aware that he or she is driven to create the lesions, or in some instances the activity may take place in a dissociated state outside the patient's awareness.[1]

Artefactual skin lesions often have a bizarre appearance. They can be linear or have a geometric outline and are often somewhat demarcated from normal skin. They are usually seen in areas that are available to the handedness of the patient. The lesions have a pattern of appearing suddenly on previously normal skin, and can occur overnight. Patients are usually vague about their disorder and recount a rather 'hollow' history.[2] They are unable to describe in detail when the lesions appear or disclose much about their development. DA and artefactual skin disease (ASD) are terms used to specify the dermatological expression of an artificially produced disorder, and are given a formal Diagnostic and Statistical Manual of Mental Disorders-IV mental health diagnosis of a factitious disorder 300.19.[3] DA is not well understood, and is probably underdiagnosed due to diagnostic uncertainties. Also, the aetiology of DA is multifactorial with a strong psychological component, and its management can be challenging for clinicians. Our aim was to review the clinical presentation, management and outcomes of patients with DA in our local population.

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