A bizarre presentation of dermatitis artefacta

Dermatitis artefacta (DA), also known as factitious dermatitis, is a psychocutaneous disorder in which the patient self-inflicts the lesions in the skin to fulfill an unconscious psychological need [1, 2]. It is a diagnostic and therapeutic challenge owing to the extremely variable clinical presentation as well as the patient’s denial. We report an interesting case of a patient with DA who presented with torn undergarments, relating those tears to some mysterious discharge from underlying skin lesions.
A 65-year-old man presented with a bag containing several torn undergarments (Figure 1). The patient attributed these tears to the results of a discharge from the skin. Examination showed multiple, linear, erythematous to purpuric, well-defined macules with cauterized appearance and erosions over the anterolateral aspect of the right thigh (Figure 2) corresponding to the tears in the undergarments. The general physical and systemic examination was unremarkable. Further interrogation revealed a history of two similar episodes during the last 1.5 months. The lesions used to heal spontaneously over a period of 4–5 days with mild hyperpigmentation (Figure 2). There was no history of skin disease in the past. A tentative diagnosis of dermatitis artefacta was made. The patient was treated with a corticosteroid-antibiotic cream and advised to report back as soon the lesion recurred. The patient returned after 10 days with another torn undergarment but without any new skin lesion. On interrogation, his wife and son disclosed that the patient was overstressed due to his business matters and had a financial dispute with his younger brother. The episodes of skin lesions and torn garments occurred during periods of stress and insomnia. Samples of torn garments when sent for chemical analysis showed the pH between 3 and 4. Psychiatric evaluation revealed the patient to have an attention seeking behavior and obsessive compulsive disorder with depression. The patient was started on antidepressants and sedatives, after which he did not report back to us.
In DA, the patient injures his skin and produces bizarre lesions to satisfy his psychological needs. The condition waxes and wanes according to the fluctuating situations in life [3]. On psychiatric evaluation, patients are found to be emotionally immature or have psychosocial or interpersonal difficulty [4]. The skin lesions enable the patient to express one’s agony in a silent, non-verbal manner; therefore...


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