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

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Answering The Key Diagnostic Questions

1. Do you currently have any increase in stress (school, work, family situation), depression or anxiety going on in your life?
2. Self-inflicted or factitial dermatitis (dermatitis artefacta).
3. Contact dermatitis, drug allergy, fungal infection, bacterial infection, malignant skin lesions, xerosis, atopic dermatitis and infestation with mites.
4. Self-inflicted excoriations are characterized as clean, linear erosions, scabs and scrapes of the skin. All lesions are typically similar in size and shape but may be bizarre in appearance. Typically, the patient digs at the skin with the fingernails and these excoriations appear in various stages with dug-out ulcers, lesions covered with crusts and surrounded by erythema, and areas showing receding depressed scars and healing areas. The number of lesions may vary from a few to several hundred and many of them may exhibit delayed healing due to recurrent scratching.
5. Initially, for localized areas (such as in this case), the first treatment is to cover the area with a medicated wrap such as an Unna’s boot dressing (a moist, gauze bandage made up of zinc oxide, calamine lotion and glycerine). The patient changes the bandage in one week and, in most cases, clinicians will see considerable healing to the involved skin.

Treating A Patient With Multiple, Pruritic Open Lesions On Both Feet
Treating A Patient With Multiple, Pruritic Open Lesions On Both Feet
By G. “Dock” Dockery, DPM, FACFAS

   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.

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