Treating A Patient With Multiple, Pruritic Open Lesions On Both Feet

A 32-year-old female presents to the clinic with a chief complaint of multiple pruritic lesions on the tops of both feet. The lesions have been present for several months and appear to be increasing in number and size. The patient has not seen any other physician for this problem and she has not been putting any medications on the condition.    The patient reports the lesions start as very small red bumps and itch a great deal. After scratching the bumps, she says the lesions get bigger and new itchy bumps occur around the area in a few days or so. The condition is so bad at this time that she cannot wear closed shoes, go to work or take care of her family. After further questioning, the patient stated that prior to the current skin condition, she had no known exposure to any chemicals, paints, toxins, irritants or other potential allergens. She also notes she is not taking any medication, vitamins or supplements. The patient also has no known allergies to any medications or environmental agents. No one else in her household or within her family has any similar skin conditions.

What Does The Physical Examination Reveal?

The physical examination revealed a large number of scratches, excoriations and open areas with surrounding erythema on the dorsum of both feet. Some of the lesions appeared new and some looked much older. There were no primary lesions anywhere else on the feet or lower legs. There were no other rashes, skin changes or edema. At the time of the visit, the lesions were symptomatic and the patient was reporting pruritus as the main complaint.    A careful examination found no other similar appearing lesions on the upper extremities, torso, head and neck region. There were no other obvious dermatological findings other than the ones noted on the initial examination. There were no other positive findings during the rest of the physical examination.

What You Should Know About Factitial Dermatitis

Factitial dermatitis (dermatitis artefacta) means self-inflicted lesions of the skin. The lesions are in sites that are readily accessible to the patient’s hands. In many cases, patient may cause deep excoriations with the fingernails but they may also be caused by sharp instruments such as knives, the application of caustic chemicals and burning, sometimes with cigarettes or matches. The most common locations are the extensor surfaces of the extremities, the tops of the feet, the face, the upper shoulders and back. The patients may or may not be aware that they caused the skin damage themselves, and they usually deny having intentionally inflicted the injury.    There are several reasons for patients to self-inflict wounds on their own bodies. Most patients with dermatitis artefacta have some underlying psychological issue that may be caused by stress, anxiety, depression or drugs. If the dermatitis is a single episode that was triggered by a particularly difficult situation (such as divorce, loss of job, death in the family), about 70 percent of all patients will stop the self-injury once the situation is resolved. However, about 30 percent of the cases of dermatitis artefacta are ongoing and recurrent, and represent a long history of psychological problems. Other issues, such as the use of street drugs, especially methamphetamine, may cause some patients to see or feel bugs on their skin (crank bug bites). They attempt to remove them by picking at them until they create open wounds or sores.    Patients with factitial dermatitis, in which the skin lesions are directly produced or inflicted by their own actions, usually present with this condition as a result or manifestation of a psychological problem. It could be a form of emotional release in situations of distress, anxiety or depression or part of an attention-seeking behavior (usually seen among younger women). In a few cases, the cause may be an underlying attempt to secure a work-related insurance claim or disability payment.    However, in all cases of dermatitis artefacta, the presenting lesions are difficult to recognize and do not conform to those of known dermatoses. In other words, there are no primary skin lesions (those that are a direct expression of a skin disease such as macules, papules, plaques, nodules, vesicles, pustules or cysts). There are only secondary skin lesions (those lesions that follow a skin condition such as ulcers, erosions, excoriations, crusts, scabs, scars or atrophy). This typically will give the doctor a clue as to the origin of the condition.    There is a 4:1 female to male ratio for factitial dermatitis. Some associated traits include low self-confidence, generalized apprehension, meticulousness, depressive mood disorder and hypersensitivity to perceived negativism toward themselves. Concurrent symptoms of severe headache or menstrual disorders are common in many of these patients.    The lesions in very young children are characteristically not self-inflicted but are caused by abusive adults. There is also a condition called Munchausen’s syndrome by proxy, whereby a parent or guardian will inflict skin injuries on a child in an attempt to convince doctors that their child has a serious dermatitis or needs ongoing medical care.    One would diagnose factitial dermatitis via classical clinical findings. A patient’s history may suggest some obvious reasons for the pruritus. These reasons may include preexisting atopic dermatitis, contact dermatitis, insect bites or food allergies. In order to exclude any medical causes of generalized pruritus, physicians may perform the following simple tests: complete blood count with differential; chemistry profile; thyroid-stimulating hormone levels; and fasting plasma glucose level. Patch testing for allergens and fungal cultures may be necessary when the condition appears to be non-responsive to the initial treatment of covering the lesions. Perform the appropriate workup for malignancy if this is indicated by the patient’s history. In persistent cases, a simple biopsy will be beneficial.    Xerosis, or generalized dry skin, is the most common cause of pruritus among older patients. These patients usually lack certain fatty acids in the skin that augment hydration and barrier function, leading to the development of dry itchy skin. This may then generate the “itch-scratch” cycle that, in some patients, develops into chronic dermatitis. The generalized pruritus that results can also lead to emotional conditions such as anxiety or depression and, subsequently, progression to self-inflicted skin conditions.    Unlike xerosis in older patients, atopic dermatitis predominantly affects infants, children and young adults. Approximately 60 percent of the cases of atopic dermatitis are diagnosed with the first year of life and 90 percent of all cases are diagnosed by the age of 5. Only 10 percent of atopic dermatitis cases are diagnosed over the age of 5 and it is rare for the condition not to be identified before a patient reaches his or her teens.    The condition follows a relapsing course and most adults who suffer from atopic dermatitis have had it nearly all of their lives. In both of these conditions, xerosis and atopic dermatitis, simply rehydrating the skin, applying moisturizing creams or applying products like MimyX™ cream (Stiefel Laboratories) will replace the fatty acids and repair the skin barrier function, and thereby decrease most of the patient’s symptoms.

A Guide To Prevention And Treatment

Prevention of factitial dermatitis includes getting patients to understand that their actions are making the condition worse and if they stop rubbing, scratching and excoriating the skin, the problem will quickly resolve. This is not as easy as it might seem. Most authorities agree that when one suspects dermatitis artefacta, one should avoid direct confrontation. One should evaluate the patient’s emotional situation or stresses, and refer the patient for psychiatric counseling. In some cases, referral to a university-based dermatologist with experience treating psychocutaneous disorders is the best approach.    Treatment options for self-inflicted lower extremity dermatitis are relatively limited. As stated earlier, the initial approach when one suspects this diagnosis is to cover the affected area with a medicated paste Unna’s boot dressing. Other dermatologic approaches include the use of antibiotics, topical steroids and lubricants, as well as adjunctive therapy such as MimyX cream. If there is significant crusting and/or secondary bacterial infection of the erosions and excoriations, antibiotic therapy (topical mupirocin 2% ointment) is indicated.    Applying steroid topicals twice a day can be very effective in reducing the erythema and inflammation of the area. Try low-potency (group IV–V) topical steroids first and gradually progress to high-potency steroids (group I–II) if there is slow response. Long-term use of topical steroids is not recommended due to the increasing side effects with chronic usage. I have found that one can reduce much of the compulsive scratching and rubbing by having the patient apply a corticosteroid-impregnated occlusive tape cover (Cordran Tape) to problem areas. This provides both a physical barrier to skin trauma as well as an effective form of short-term relief.    As with other dermatology conditions, it is best to recommend that the patient learn to use only mild soaps and decrease the frequency of bathing. Reducing the temperature of the bath water or showers also helps to reduce drying of the skin. They should try to increase the moisture in their home environment by adding humidifiers whenever possible. Additionally, patients can also try substituting regular application of skin lubricants and lotions that are without fragrance or alcohol in place of rubbing and scratching. The most difficult time for many patients is at night and, in these cases, the patient may sleep with a pair of thin cotton gloves in an attempt to reduce the amount of scratching that occurs subconsciously.    Counseling should be supportive and empathic but should also be open to other approaches as new issues emerge. Cognitive-behavioral approaches may focus on helping the patient understand his or her illness through education and finding alternative responses to the pruritic sensations. The podiatric physician should maintain a close working relationship with the patient’s family physician and therapist, and offer education and explanations to the patient’s family. Treatment aimed at a primary psychiatric diagnosis is usually fundamental for effective results in these patients.

In Summary

Factitial dermatitis, also known as dermatitis artefacta, is a psychocutaneous disorder in which patients damage their skin but usually deny their self-involvement. This disorder encompasses a wide range of potential lesions including blisters, cuts, excoriations, ulcers and burns. Patients often are unable to describe how the lesions evolved. Upon examining the lesions, practitioners may see bizarre patterns that are not characteristic of any known skin disease.    Factitial dermatitis more commonly affects young adults and adolescents, and it is four times more common among women than men. Psychological disorders involved with factitial dermatitis include personality disorders, anxiety, depression and posttraumatic stress disorder. Dr. Dockery is a Fellow of the American College of Foot and Ankle Surgeons, and the American Society of Podiatric Dermatology. He is board certified in foot and ankle surgery. Dr. Dockery is the Chairman of the Board and Director of Scientific Affairs for the Northwest Podiatric Foundation for Education & Research, USA. Dr. Dockery is the author of Cutaneous Disorders of the Lower Extremity (Saunders, 1997) and Lower Extremity Soft Tissue & Cutaneous Plastic Surgery (Elsevier Sciences, 2006).
 

References:

Suggested Reading 1.    Antony SJ, Mannion SM: Dermatitis artefacta revisited. Cutis. 1995;55(6):362-364. 2.    Cyr PR, Dreher GK: Neurotic excoriations. Am Fam Physician 2001;64:1981-1984. 3.    Dockery GL: Psychocutaneous disorders: Some lower extremity presentations. J Am Podiatr Assoc. 1982;72;388-395. 4.    Dockery GL: Psychocutaneous Disorders, ch 17, Cutaneous Disorders of the Lower Extremity, WB Saunders, Phila. Pp 288-298, 1997. 5.    Dockery GL: How to Detect and Treat Pruritus. Podiatry Today. 19(8); 52-64, 2006. 6.    Joe EK, Li VW, Magro CM, et al: Diagnostic clues to dermatitis artefacta. Cutis; 1999; 63(4):209-214. 7.    Koblenzer CS: Neurotic excoriations and dermatitis artefacta. Dermatol Clin. 1996;14(3):447-455. 8.    Koo J, Lebwohl A: Psychodermatology: the mind and skin connection. Am Fam Physician. 2001;64:1873-1878. 9.    Nielsen K, Jeppesen M, Simmelsgaard L, et al: Self-inflicted skin diseases. A retrospective analysis of 57 patients with dermatitis artefacta seen in a dermatology department. Acta Derm Venereol. 2005;85(6):512-515.