Dermatitis artefacta in a patient with recurrent larynx cancer: a rare self-inflicted dermatosis.

To the editor: Dermatitis artefacta is one of the self-induced dermatological disorders, which is also referred to as a variant of the obsessive-compulsive disorder. (1) Although it is a rare disorder, the lesions may be reminiscent of various dermatoses. (2)

A 51-year-old male was diagnosed with locally advanced supraglottic larynx cancer, and total laryngectomy and left radical neck lymph node dissection was performed 4 years prior. Radiotherapy was also applied postoperatively. The patient was in remission until recurrent lesions appeared on the neck region, and were confirmed by fine needle biopsy as squamous cell carcinoma. Chemotherapy was started. During his hospital stay, excoriative erosive cutaneous lesions on the chin, the interscapular area, and on the dorsal side of his legs were observed in routine physical examination (Fig. 1). On delicate follow-up, it was realized that the lesions were made by the patient himself. Later, the patient and his wife did also confess that the lesions were self-inflicted. Thus eventually the diagnosis of dermatitis artefacta was established. Accordingly, he was treated with anxiolytics and antidepressants, whereupon the lesions disappeared.

Dermatitis artefacta is a rarely encountered factitious disease with wide-ranging morphologic features. It is a psychogenic, self-inflicted syndrome, the lesions of which resemble trichotillomania, neurotic excoriations, and Munchausen syndrome. Although our patient is male, dermatitis artefacta is a female-predominant psychocutaneous syndrome. (1) It can be seen at any age, although adolescents and young adults are by far the most frequently affected. (3) The lesions in dermatitis artefacta are various, and include vesicles, erosions, ulcers, abrasions, purpura, erythema, and nodules. (4) It thus entails the following differential diagnoses: contact dermatitis, Koebner reaction, lichen striatus, lymphangitis, pemphigus, pemphigoid, porphyria cutanea tarda, staphylococcal impetigo, basal cell carcinoma, vasculitis, sensory nerve lesions, excoriations due to scabies, pediculosis, and eczema. The causes of the lesions are also various. Excoriation and chemical or thermal burns are some of the methods used by the patient. (5)

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Diagnosis is made by way of vigilant evaluation of the patient's affect, personality, and medical history, (4) and by exclusion of the other likely pathologies. Self-inflicted injury can also be detected by using systems with cameras and mirrors. (2) Innocent smile, obsessive care for the lesion, and also enjoying the prediction of the appearance of a new lesion are the other noteworthy clues.

There are both medical and nonmedical therapeutic approaches to dermatitis artefacta. The nonmedical approach starts with supportive and empathic contact with the patient, rather than direct confrontation. (2) Protective dressing may be another option. Antianxiety and antidepressant drugs are sometimes used. (4) When the patient starts to rely on the physician and a stable patient-doctor relationship is established, a treatment such as psychotherapy can be commenced. It is commonly accepted that a positive change in the psychosocial life conditions of the patient is generally more successful than a medical treatment.

This rare case of ours suggests that such a complication may be seen in cancer patients in addition to the debilitating impact of their malignancy.

References

1. Murray AT, Goble R, Sutton GA. Dermatitis artefacta presenting as a basal cell carcinoma--an important clinical sign missed. Br J Ophthalmol 1998;82:97-100.

2. Gieler U. Factitious diseases in the field of dermatology. Psychoter Psychosom 1994;62:48-55.

3. Koblenzer CS. Psychological aspects of skin disease, in Dermatology in Fitzpatrick TB, Eisen AZ, Wolff K, et al (eds): General Medicine. New York, Mc Graw-Hill, 1993, ed 4, pp 14-26.

4. Gubta MA, Gubta AK, Haberman HF. The self-inflicted dermatoses: a critical review. Gen Hosp Psych 1987;9:45-52.

5. Savin JA, Cotterill JA. Psychocutaneous disorders, in Champion RH, Burton JL, Ebling FJG (eds): Textbook of Dermatology. Oxford, Blackwell, 1992, ed 5, pp 2479-2496.

Metin Isik, MD

Oguz Dikbas, MD

Levent Ozcakar, MD

Bunyamin Isik, MD

Kadri Altundag, MD

Departments of Internal Medicine, Medical Oncology, and Physical Medicine and Rehabilitation, Hacettepe University Faculty of Medicine, and Department of Family Medicine, Fatih University Faculty of Medicine, Ankara, Turkey