Factitial dermatitis

Factitious dermatitis, also known as dermatitis artefacta, is a psychodermatologic disorder in which individuals deliberately produce skin lesions to fulfill an internal psychological need rather than for external incentives. It is classified as a type of factitious disorder, similar to Munchausen syndrome, but localized to the skin.

Pathophysiology

Factitious dermatitis is considered a self-inflicted skin disorder, usually resulting from repetitive trauma, friction, scratching, or application of caustic substances. The exact cause is psychological, with underlying factors including:

• Emotional distress or psychiatric disorders – Such as depression, anxiety disorders, or borderline personality disorder.
• Desire for medical attention – Some individuals may crave care, validation, or sympathy.
• History of trauma or abuse – Psychological trauma can manifest as self-destructive skin behaviors.
• Unconscious or compulsive behavior – Unlike malingering, where actions are intentional for external gain, factitious dermatitis is linked to internal psychological distress.

Clinical Features

The skin lesions in factitious dermatitis often have unique characteristics:

• Bizarre or geometric shapes – Unlike naturally occurring skin diseases.
• Sharp demarcation – Lesions often appear linear, rectangular, or artificial-looking.
• Inconsistent distribution – Typically located on easily accessible areas such as:
• Forearms
• Face
• Legs
• Upper chest
• Absence of primary lesions – Unlike true dermatologic diseases, factitious dermatitis lacks primary inflammatory signs.
• Variable stages of healing – Suggesting recurrent self-inflicted trauma.

Patients often deny self-infliction, making diagnosis challenging.

Diagnosis

The diagnosis of factitious dermatitis is clinical and relies on:

• Detailed medical history – Identifying inconsistent explanations or frequent visits to multiple healthcare providers.
• Skin examination – Looking for atypical lesions with sharp margins.
• Histopathology (biopsy) – Non-specific findings with inflammatory infiltrates and disrupted epidermis.
• Psychiatric assessment – Screening for co-existing mental health conditions.
• Provocation tests – Observing whether new lesions appear during hospitalization (Dermatitis Artefacta Test).

Differential Diagnosis

Factitious dermatitis must be distinguished from organic dermatologic conditions, including:

• Atopic dermatitis – Chronic inflammatory skin disease with eczematous lesions.
• Psoriasis – Autoimmune disorder with well-defined plaques and silvery scaling.
• Contact dermatitis – Caused by allergens or irritants.
• Skin picking disorder (excoriation disorder) – A type of obsessive-compulsive disorder leading to repetitive skin damage.

Treatment and Management

Managing factitious dermatitis requires a multidisciplinary approach addressing both dermatologic and psychiatric aspects.

Dermatologic Management

• Wound care – Treating skin infections and ulcers.
• Topical treatments – Mild steroids and moisturizers to promote healing.
• Avoidance of unnecessary procedures – Preventing iatrogenic harm.

Psychological and Behavioral Therapy

• Cognitive-behavioral therapy (CBT) – Helps address underlying emotional triggers.
• Psychiatric counseling – Identifying co-occurring mental health conditions.
• Selective serotonin reuptake inhibitors (SSRIs) – May be helpful for underlying depression, anxiety, or OCD.

A non-confrontational approach is essential, as accusing patients outright may lead to denial or healthcare avoidance.

Prognosis

The prognosis of factitious dermatitis depends on early recognition and psychological intervention. Chronic cases may lead to permanent skin scarring and functional impairment. Untreated psychological distress may result in recurrent relapses or progression to more severe factitious disorders.

Related pages

• Dermatitis artefacta
• Skin picking disorder
• Munchausen syndrome
• Psychodermatology
• Obsessive-compulsive disorder