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
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.
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).