1. What essential question does one still need to ask in order to help make the diagnosis?
2. What is the tentative diagnosis?
3. Can you list at least three differential diagnoses?
4. What features of this condition differentiate it from other conditions in your differential diagnosis?
5. What is the suitable treatment for this condition?
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.