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CONCISE COMMUNICATION
Year : 2021  |  Volume : 12  |  Issue : 4  |  Page : 597-599  

Factitious ulcer: A diagnostic challenge


1 Department of Dermatology and Venereology, AIIMS, Bhubaneswar, Odisha, India
2 Department of Psychiatry, AIIMS, Bhubaneswar, Odisha, India
3 Department of Pathology, AIIMS, Bhubaneswar, Odisha, India

Date of Submission04-Feb-2021
Date of Acceptance19-Mar-2021
Date of Web Publication14-Jul-2021

Correspondence Address:
Aparna Palit
Department of Dermatology and Venereology, AIIMS, Bhubaneswar - 751 019, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/idoj.IDOJ_745_20

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How to cite this article:
Behera B, Palit A, Pattnaik JI, Mishra P. Factitious ulcer: A diagnostic challenge. Indian Dermatol Online J 2021;12:597-9

How to cite this URL:
Behera B, Palit A, Pattnaik JI, Mishra P. Factitious ulcer: A diagnostic challenge. Indian Dermatol Online J [serial online] 2021 [cited 2022 Jan 26];12:597-9. Available from: https://www.idoj.in/text.asp?2021/12/4/597/321551



An 18-year-old boy with a large ulcer on the nape of the neck for three months was brought for dermatological consultation by his father. He denied any preceding trauma. Despite the large size and significant depth, pain was not his foremost complaint, and constitutional or systemic symptoms were absent. Cutaneous examination revealed a solitary ulcer (12 cm × 10 cm) with punched-out irregular edges and surrounding erythema [Figure 1]a, located on the right side of the nape of the neck. The surface was covered with thick brown-black adherent crust. Multiple atrophic scars of size ranging from 1 cm2 to 15 cm2 were noticed over the anterior chest, abdomen, axilla, and neck, sparing the back [Figure 1]b and [Figure 1]c. Differential diagnoses of ecthyma, ulcerative lupus vulgaris, atypical mycobacterial infection, deep fungal infection, and pyoderma gangrenosum were considered. On investigation, the erythrocyte sedimentation rate was 36 mm at 1st hour. Other investigations were within normal limits. Histopathology from the ulcer base showed necrotic epidermis and upper and mid-dermal sparse perivascular lymphocytic infiltrate [Figure 2]a. The margin showed an acanthotic epidermis with mild perivascular lymphocytic infiltrate [Figure 2]b. Special stains and cultures for bacteria, mycobacteria, and fungi were negative. The ulcer started healing with daily dressing and antibiotics.
Figure 1: (a) Solitary punched out ulcer with irregular margin and thick adherent crust. Healed atrophic scars over the neck (b) and anterior chest and abdomen (c)

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Figure 2: (a) Histopathology from the ulcer base shows epidermal necrosis and mild perivascular lymphocytic infiltration (H & E, ×100). (b) Histopathology from the margin shows acanthotic epidermis and mild perivascular lymphocytic infiltration (H & E, ×100)

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On the fourth week of admission, the patient complained of bleeding from the ulcer and sudden pain, which developed overnight. Cutaneous examination showed irregular ecchymotic areas at the margin and away from the existing ulcer and a bleeding surface [Figure 3]a. At this point, the possibility of a self-inflicted ulcer was considered. On questioning, the patient denied manipulation of the ulcer area. A search of the patient's belongings revealed scissors, a metal divider, and some unknown plant products [Figure 3]b. A provisional dermatological diagnosis of factitious ulcer (FU) was made.
Figure 3: (a) Irregular-shaped ecchymosis around the margin and away from the ulcer (arrows). (b) Inset shows sharp instruments and the unknown plant products found from the patient's belongings. (c) Completely healed ulcer with atrophic scarring

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During the psychotherapeutic sessions, difficulties encountered were repeated insistence on underlying medical illness, denial of any psychiatric illness, and difficulty in engaging in the exploratory psychotherapy process. The therapeutic alliance was established after multiple interviews, and a non-confrontational approach was used. Multiple stressors were elicited: Emotional deprivation in early childhood, disturbed self-image, and poor identity formation. Repeated hospitalizations served as an escape from the traumatic home situation, and the desired parent-child bond was recreated with multiple caretakers in the hospital. Following admission to the hospital, he received emotional warmth from his family, financial support from his distant elder brother, attention and care from hospital staff, doctors, nurses, and “sympathy calls” from his girlfriend, which provided some psychological comfort.

Along with psychotherapy, he was started on duloxetine 20 mg per day, hiked up to 40 mg and clonazepam 0.5 mg at night for sedation. Supportive psychotherapy, coping skill enhancement, relaxation training, family intervention, and occupational rehabilitation were attempted. With this treatment and daily dressing, there was complete healing of the ulcer with atrophic scarring [Figure 3]c. However, he continued to inflict new ulcers [Figure 4]a and [Figure 4]b after stopping duloxetine.
Figure 4: (a) Second episode of ulcer over the occipital area. Inset shows the knife used to inflict the ulcer. (b) The fourth episode of the ulcer over the right side of the face

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Factitious dermatoses are self-inflicted cutaneous lesions that satisfy the unmet psychological or emotional needs of a patient. Clinically, it can have varied morphology; blisters, ulcers, eschars, lichenoid plaques, and nodules.[1],[2],[3] It is imperative to explore the underlying psychopathology of each patient and treat it accordingly. An association with underlying stress, social issues, and psychiatric disorder ranging from anxiety, depression, obsessive-compulsive disorder, somatization disorder, or borderline personality disorder can be found.[4],[5]

Diagnosing FU may be challenging for a dermatologist, especially if the patient is in denial.[2] The probable clues indicative of self-infliction in the index case are the following: no definitive diagnosis despite visiting multiple hospitals, inability to explain the ulcer's evolution, non-progression of the ulcer after admission, ulcer over the accessible sites, sudden development of ecchymosis due to manipulation around the ulcer, reveal of the sharp instruments from the patients' belonging and complete healing with daily dressing.

The diagnostic challenges are intensified when the patient and/or family members deny to accept the underlying psychiatric illness and refuse to consult a psychiatrist. This is a factual situation in India where psychiatric illnesses are stigmatizing, resulting in social isolation of the affected person and the family. Hence, primary intervention by a dermatologist is vital, as many patients admit to and accept underlying psychiatric illness only after some improvement of their dermatological condition.[1]

An interdisciplinary approach addressing the patients' dermatological and psychological needs is the best way to manage. Along with pharmacotherapy, daily care of the ulcer and occlusion of the area promote ulcer healing.[6] Cognitive-behavioural therapy, relaxation therapy, and psychotherapy may address the underlying psychiatric disorder. An approach, including acceptance, non-confrontation, sympathy, and moral support, may be helpful.[2],[5]

In conclusion, we report the case to highlight the challenges a dermatologist has to face to diagnose and manage FU in a patient with complete denial about self-infliction. It is more so in a tropical country like India, where infectious aetiologies are the leading cause of isolated ulcers. A step-wise dermatological approach includes suspecting a case, gathering sufficient evidence for self-infliction, and excluding other possible causes.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Nico MM, Nagano CP, Fernandes JD, Lourenço SV. A destructive ulcer on the lower lip. Clin Exp Dermatol 2010;35:e180-1.  Back to cited text no. 1
    
2.
Soo JK, Marsden RA. A hand in the diagnosis of persistent facial ulceration. Clin Exp Dermatol 2005;30:729-30.  Back to cited text no. 2
    
3.
Gonçalves PS, Mendez DA, Santos PS, Damante JH, Rios D, Cruvinel T. The diagnosis and treatment of multiple factitious oral ulcers in a 6-year-old boy. Case Rep Dent 2017;2017:1986834.  Back to cited text no. 3
    
4.
Barańska-Rybak W, Cubała WJ, Kozicka D, Sokołowska-Wojdyło M, Nowicki R, Roszkiewicz J. Dermatitis artefacta-a long way from the first clinical symptoms to diagnosis. Psychiatr Danub 2011;23:73-5.  Back to cited text no. 4
    
5.
Lavery MJ, Stull C, McCaw I, Anolik RB. Dermatitis artefacta. Clin Dermatol 2018;36:719-22.  Back to cited text no. 5
    
6.
Zalewska A, Kondras K, Narbutt J, Sysa-Jedrzejowska A. Dermatitis artefacta in a patient with paranoid syndrome. Acta Dermatovenerol Alp Pannonica Adriat 2007;16:37-9.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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