To the Editor: Dermatitis artifacta is defined as “Deliberate and conscious production of self-inflicted skin lesions to satisfy an unconscious psychological or emotional need.” These skin lesions serve as powerful, self-expressive, nonverbal messages.¹ Patients often deny responsibility for the creation of the lesions. Most patients with dermatitis artifacta are girls and women, and the highest incidence occurs between adolescence (age 11–14 years) and early adulthood.² It is a more common condition than is believed, because it is poorly recognized and underreported¹. Here, we report an unusual, early-onset case of Dermatitis artifacta in a 9-year-old girl from Wardha, whose lesions were present on her face.

A 9-year-old girl from Wardha (India) was brought to the Skin outpatient department (OPD) by her mother with multiple linear erosions over face of 1 month duration. According to the mother, initial lesions appeared over her chest, which healed by themselves in a span of a few days. Later, similar lesions started appearing on her face. The patient would get 2–3 erosions in 3–4 days, mostly in the same skin area as that of the previous lesions. The lesions were sudden in onset, and were not associated with injury, insect bite, or intake of drugs.

Cutaneous examination revealed multiple fresh erosions on her face involving the bridge of the nose, both malar eminences, chin, and forehead. Skin between erosions was absolutely normal. Most of the lesions were linear, with slight atrophy in the center and hyperpigmentation along the margins. A few lesions were slightly tapering towards the periphery (Figure 1). Lesions would heal with scarring and depigmentation (Figure 2, Figure 3). The lesions were asymptomatic, except for a few fresh lesions that were tender to the touch. The patient was treated earlier with diagnoses such as impetigo contagiosa and photodermatitis by different private practitioner, before reaching the OPD without any significant relief.

The diagnosis of dermatitis artifacta was provisionally suspected, based on the presentation (nonconclusive linear tapering erosions, hollow history). The patient was admitted to the skin ward for observation and exclusion of possible dermatological conditions. Her preliminary routine investigations were within normal limits. ANA titer was within normal range (reading: 0.16). The punch biopsy of the lesion revealed ulcerated epidermis and dense inflammation of dermis. The patient was treated conservatively with topical and systemic antibiotics. Lesions healed within 4–5 days, leaving slight hypopigmentation, and no fresh lesions appeared. She was discharged after 5 days at parents’ request, with the same treatment advice. After 2 days of discharge, the girl was brought in by her mother with fresh erosions over her chin and bridge of nose. This time, she was kept in the Skin ward for the next 2 weeks for observation. During this period, not a single lesion appeared. The patient denied the role of anyone else or herself in producing the lesions. She was referred to Department of Psychiatry for psychodiagnostic evaluation.

The psychiatrist held elaborate sessions of interview and mental status examination of the patient along with her mother. The patient was the first of the three siblings, with disturbed family dynamics. Reportedly, the father, who was a day-wage laborer, consumed alcohol in dependent fashion. Parents frequently indulged in physical fights and at times the father hit the children, including the patient. Her mental status examination revealed significant anxiety and depressive cognition. After multiple sessions of interview, the interviewer was able to establish rapport. The patient confessed having significant stress due to the prevailing family situation and reported rubbing insecticide over her face, which was kept in the store-room of her house. She was not able to give any satisfactory reason for her behavior. She was further given the TAT (Thematic Apperception Test) to gain insight into her conflicts and personality dynamics. It revealed adjustment difficulties. Based on the above findings and assessments, the psychiatrist was of the opinion that a psychological basis for the somatic manifestation of the symptoms could not be ruled out, and the skin lesions could well be her outlet of getting rid of her internal conflicts. The secondary gains in form of the care and affection she received from the family members after the onset of the symptoms was evident.

The patient was given emotional ventilation and later was subjected to supportive followed by insight-oriented psychotherapy. She was prescribed escitalopram, an SSRI (selective serotonin reuptake inhibiter). It was prescribed with the view to tackle significant anxiety apart from depressive features she had. The doses were gradually increased from 5 mg to 10 mg per day. She was also prescribed clonazepam 0.25 mg twice per day for the first 2 weeks, which was tapered off in the third week.

Psycho-education was offered to the family members, and the father was offered de-addiction services. The patient was reviewed at four follow-ups, spaced initially at 2 weeks, and later at monthly intervals after discharge. The patient responded well to treatment, and her skin lesions, along with the depression and anxiety improved. The patient, who was followed for next 6 months, showed no lesions after psychiatric intervention.

Dermatitis artifacta is an artifactual skin disease produced entirely by the actions of the fully-aware patient. There is no rational motive for this behavior.³ The pathophysiology of dermatitis artifacta is poorly understood. Multifactorial causes include genetic, psychosocial factors, and personal or family history of psychiatric illness.¹ Dermatitis artifacta has been associated with severe personality disorders, dissociative disorders, sexual abuse, child abuse, obsessive-compulsive disorders, depression, psychosis, and mental retardation.⁴ However, in the vast majority of patients, obvious evidence of secondary gain is not present. In the patient under discussion, significant association of anxiety and depression were evident on mental status examination. The child was apparently distressed by the punitive attitude of the alcoholic father.

Characteristic clinical features are “hollow history,” that is, sudden appearance of complete lesions without prodrome, lack of history of progression of lesions, and strenuous denial by the patient of inflicting the lesions; sometimes the patient can forecast the site and timing of lesions.^3,4 Lesions are bizarre, with sharp, angulated, geometric borders and surface necrosis, do not correspond to any known dermatosis, and are confined to areas accessible to dormant hand.⁴ Typical locations include the face (45%), upper extremity (24%), lower extremity (31%), trunk (24%), upper arm (7%), and the scalp (7%), but, to the best of our knowledge, very few cases of dermatitis artifacta have been reported in Indian literature with lesions confined to the face. Apart from the early onset, the facial lesions make the case interesting and worth being discussed in scientific community.

Differential diagnosis varies greatly because of various methods used for inflicting lesions. As the differentials of the current case, irritant dermatitis; photodermatosis, especially SLE, and porphyria were considered, which were excluded with apt clinical judgment and investigations.

General dermatological care measures include baths, debridement, emollients, and topical and oral antimicrobials. The skin lesions of the patient discussed healed completely with emollients and antimicrobials. In cases where patient is relatively healthy psychologically, supportive and symptomatic therapy is adequate,⁴ but a psychiatric evaluation is warranted for severe self-mutilation and for management of any evidence of psychiatric illness. Hospitalization should be considered for cases where either the diagnosis is in doubt or initial evaluation does not reveal any clue about the psychogenic etiology. The patient needed hospitalization for detailed psychiatric evaluation and management. She responded well to escitalopram, which is an SSRI and has proven efficacy for symptoms of both anxiety⁵ and depression . Escitalopram, the S-enantiomer of RS-citalopram, is a highly selective inhibitor for the serotonin transporter, and ameliorates depressive⁶ symptoms in patients with major depressive disorder. It has a rapid onset of symptom improvement and has a predictable tolerability profile of generally mild adverse events. It has low propensity for drug interactions and a potential benefit in the management of patients with comorbidities. This makes escitalopram, like other SSRIs, a first-line therapy in patients with major depressive disorder and anxiety additionally. The case discussed emphasizes the need for multidisciplinary approach of treatment in cases of dermatitis artifacta if it shows signs of resistance to routine treatment.

Dermatitis artifacta is a challenging condition that requires collaboration of dermatologic and psychiatric expertise.¹ Presentation can be early, and, when significant stressor and comorbid psychopathology are present, the lesions can be disfiguring.