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which is more didactic as it is based on the current concepts of psychiatric disease defined by the Diagnostic and Statistical Manual of Mental Disorders &#40;DSM-IV&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">The term <span class="elsevierStyleItalic">dermatitis artefacta</span> is only used to refer to the condition in which skin lesions appear in a secret and mysterious way while the patient denies all responsibility for their production&#46; In DA&#44; the patient produces skin lesions to satisfy a psychological need&#44; often a desire to receive medical treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Malingerers also deny responsibility for producing the signs and symptoms of their disease&#44; but they do so for easy-to-discover reasons&#44; such as financial gain or a lawsuit&#46; 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some authors consider that the nosological definition of DA should specifically exclude cases in which a rational motive exists for the self-infliction of lesions&#44; thereby excluding malingerers&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Another essential characteristic of DA is that the patients conceal their role in producing the signs of their condition&#59; this concealment is what differentiates DA from other self-inflicted dermatoses&#44; such as self-mutilations by psychotic patients&#44; neurotic excoriation&#44; and trichotillomania&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Epidemiology</span><p id="par0020" class="elsevierStylePara elsevierViewall">Since DA is rare in routine dermatological practice&#44; the literature contains few case series&#46; Most authors have described isolated clinical cases of particular interest to specialists either because of the diagnostic challenges involved or the severity of the clinical presentation&#46; However&#44; it is believed that up to 5&#37; of medical visits may relate to factitious disease&#44; and such cases are not only observed in dermatology but also encountered by internal medicine&#44; ophthalmology&#44; endocrinology&#44; and ear nose and throat specialists&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;14</span></a> Owing to the ease with which it can be damaged&#44; the integrumentary system is the organ that is most often the object of self-inflicted lesions&#46; This was shown by a study of 31 patients who presented with factitious conditions in a general hospital<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#59; in that study there were 13 cases of DA&#44; 12 cases of simulated fever&#44; 3 of self-inflicted bleeding&#44; 1 of polyuria-polydipsia syndrome&#44; 1 of hypoglycemia&#44; and 1 of hyperthyroidism&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Few series provide data that can be used to compare the relative incidence of DA and other psychodermatologic disorders&#46; In a 3-year study carried out in Iran&#44; 178 patients were diagnosed with various psychodermatologic disorders<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#58; 128 neurotic excoriations &#40;71&#46;9&#37;&#41;&#44; 22 trichotillomania &#40;12&#46;4&#37;&#41;&#44; 16 delusional parasitosis &#40;9&#37;&#41;&#44; and 12 DA &#40;6&#46;7&#37;&#41;&#46; Women outnumbered men in all of these diagnoses except delusional parasitosis&#44; which was more frequent among men&#46; DA was the least common diagnosis&#46; In a study of 35 patients with dermatological disorders of strictly psychological origin&#44; 8 patients had DA&#44; 8 had delusional parasitosis&#44; and 19 had various dysmorphic disorders&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">One of the first case series of DA was published by Az&#250;a in 1909&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> After studying the cases of 4 women who had been diagnosed with &#8220;hysterical gangrene&#8221;&#44; he confirmed the hysterical origin in 1 case but redefined the other 3 as self-inflicted lesions&#46; One review of 59 articles on DA included 130 patients &#40;116 women and 14 men&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> A retrospective study in Denmark covering 20 years included 57 patients with a diagnosis of DA&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> That group consisted largely of women &#40;74&#37;&#41;&#44; with a female-to-male ratio of 2&#46;8&#58;1&#59; the median age was 39 years &#40;range&#44; 12-86&#41;&#46; A review of the records of a French dermatology department over a 15-year period identified 31 patients with a diagnosis of DA<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#59; 23 of the patients were women &#40;mean age&#44; 32&#46;4 years&#41; and 8 were men &#40;mean age&#44; 23&#46;7 years&#41;&#46; Our series of patients diagnosed between 1976 and 2006 included 201 patients&#44; with a clear preponderance of women &#40;female-to-male ratio&#44; 3&#46;1&#58;1&#41; and mean age overall of 31&#46;2 years&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;21</span></a> Other interesting characteristics observed in our series were the low or nonexistent skill level&#44; low income&#44; and low cultural level of the patients and the higher proportion of single people&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In children&#44; DA is more common among girls than boys&#44; as shown by a Mexican series of pediatric patients covering a period of 20 years&#44; which included 25 girls and only 4 boys&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Similarly&#44; an Australian study covering a 15-year period included 24 girls and only 8 boys&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">DA can appear at any age&#44; but the incidence is highest around 20 years of age&#46; In many cases onset is preceded by a period of psychosocial stress&#44; which is generally easily identified&#44; such as the psychological disturbance that produced acne symptoms in an adolescent who injured his skin with a blister agent&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> It is not unusual to find a connection with the hospital setting in these patients&#44; who may be nursing aides&#44; nurses&#44; relatives of physicians&#44; or individuals who have had prolonged diseases in childhood<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> or who have been affected by the death of a family member&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In summary&#44; we can say that DA is more common among females and<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> in early adulthood and that a high proportion of those affected have a low social and cultural level&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Clinical Features</span><p id="par0050" class="elsevierStylePara elsevierViewall">DA presents in a great variety of clinical forms &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; depending on the patient&#39;s creativity and the method used to produce the lesion&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;25</span></a> The most common presentations are as follows&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Excoriations&#46; Excoriations are the most easily diagnosed factitious lesions&#46; They are usually linear &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; and are most often inflicted using the fingernails &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41; although a variety of sharp objects may also be used &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; Distinguishing between DA and neurotic excoriations can sometimes be difficult&#44; but patients who have the latter condition recognize that they have caused the lesions&#46; Excoriations are highly susceptible to infection and an indicative finding is the absence of itching before the onset of the lesion&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Excoriations are a common clinical form of DA because the lesions are easy to inflict&#59; in our case series they were observed in 52 &#40;25&#46;8&#37;&#41; of 201 patients and were more common in women &#40;28&#46;4&#37;&#41; than in men &#40;17&#46;7&#37;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Ulcers&#46; Ulcers are the most common lesions in most series&#46; They are found either in the early stages of development or after resolution&#44; when they take the form of an eschar &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; The morphology of these ulcers tends to be odd&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> either because they have perfectly regular borders or because they have an irregular shape that includes linear segments &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#44; acute and obtuse angles&#44; triangular forms&#44; star shapes etc&#46; Linear lesions that extend outwards from a primary lesion are also observed &#40;the drip sign&#41;&#46; Sometimes&#44; clearly ulcerated lesions appear together with other lesions that are either incompletely executed or caused by splashes of the caustic agent used to produce the ulcers&#46; Scars from past or old injuries may also be observed&#46; Old ulcerations that have been subjected to repeated irritation or modified by multiple treatments exhibit characteristics of torpidity &#40;sclerosis&#44; atrophy&#41;&#44; and underlying osteitis or necrosis caused by secondary infections is sometimes present&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Patients may also have scars with an irregular geometric shape&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Litmus paper can be used to test the alkalinity or acidity of unexplained ulcers as the results may indicate the use of a chemical product as a probable cause&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;27</span></a> Repeated failure of skin grafts&#44; usually due to vascular problems&#44; should raise the suspicion of interference by the patient&#44; especially when the only organism found in cultures is fecal flora &#40;a finding observed in 4 of our cases&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">In our series&#44; a clinical presentation described as an ulcer was observed in 52 patients &#40;25&#46;8&#37;&#41;&#44; making it&#44; together with the category of excoriations&#44; the leading manifestation&#46; Ulcers were more common among males &#40;31&#46;1&#37;&#41; than females &#40;23&#46;8&#37;&#41;&#46; In a study of patients with DA affecting the breast&#44; excoriations and ulcers were found to be equally common &#40;33&#46;33&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Blisters&#46; Self-inflicted lesions sometimes take the form of blisters&#46; The appearance of these lesions may be odd&#59; they may be elongated &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>&#41;&#44; angular&#44; polygonal&#44; or occasionally very large&#44; sometimes with several lobules&#46; In most cases&#44; blisters are found together with other lesions&#44; such as ulcerations&#44; scabs&#44; and erythema in more or less geometric shapes&#46;</p><elsevierMultimedia ident="fig0035"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">The lesions may be irregularly shaped and have an unusual distribution&#44; for example perfectly irregular&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;27</span></a> The course is always benign&#44; but the size&#44; number&#44; and gangrenous nature of the blisters can sometimes produce veritable mutilations&#46; Self-inflicted blisters are caused by burns or cauterization and are produced through the application of chemical or medical products&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Blisters can also be produced through friction on sites where the epidermis is thick and firmly attached to the underlying tissues&#46; The histologic findings in such cases are characteristic and can distinguish these lesions from the blisters found in bullous disorders&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">In one report a rubber nipple was used to produce suction blisters mimicking pemphigoid&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> In another case of DA&#44; an aerosol spray deodorant was used by a 12-year-old girl to induce blistering&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> The same method was used by 3 patients &#40;a 12-year-old boy and 2 women aged 21 and 36 years&#41;&#44; who induced bullous lesions on the extensor surfaces of the limbs by producing cold burns using a spray deodorant&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> This was probably also the method used in the case of a 13-year-old girl described in another case report&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In our series&#44; 21 &#40;10&#46;3&#37;&#41; of the 201 patients presented with a variety of bullous symptoms&#44; a presentation more common among men &#40;13&#46;3&#37;&#41; than women &#40;9&#46;2&#37;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Panniculitis&#46; Ackerman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> reported the case of an adolescent with fever&#44; nodular syndrome&#44; and nonsuppurating panniculitis&#8212;a presentation clinically and histologically consistent with Weber-Christian disease&#46; By chance it was discovered that the manifestations were caused by self-injections of milk that produced erythematous nodules around the injection site accompanied by chills&#44; fever&#44; sweating&#44; and general malaise&#46; Steinman and colleagues<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> described a similar case in a nurse whose symptoms were also produced by self-inoculation with milk on the dorsum of the left hand&#46; In a study of 5 women with factitious panniculitis&#44;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> the signs of disease were found to be produced by repeated trauma&#46; The diagnosis was only confirmed after histologic examination revealed inflammatory features and bruising and after the lesions had been cured by means of occlusive dressings&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">It is important to note that some patients develop indurated lesions on the breast&#44; which sometimes ulcerate&#44; and when they are referred for surgical treatment they may undergo a mastectomy without any prior biopsy having been performed&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> A recent Spanish study summarized the etiologic&#44; pathogenic&#44; clinical&#44; and histologic features and treatment of panniculitis produced by trauma or the injection of drugs or chemicals&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">In our series&#44; 7 patients &#40;3&#46;4&#37;&#41; were diagnosed with factitious panniculitis &#40;<a class="elsevierStyleCrossRefs" href="#fig0040">Figs&#46; 8 and 9</a>&#41;&#46; In 1 case&#44; the symptoms were caused by subcutaneous injection of urine&#46;</p><elsevierMultimedia ident="fig0040"></elsevierMultimedia><elsevierMultimedia ident="fig0045"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5&#46;</span><p id="par0120" class="elsevierStylePara elsevierViewall">Localized crusting&#46; Carteaud<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> described a case of factitious cheilitis&#44; which he called <span class="elsevierStyleItalic">le tic des levres</span>&#46; Some years later&#44; Savage<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> reported a similar condition&#44; which he called localized crusting&#59; he described cases of keratotic or bleeding scabs on the lips that had no apparent cause in which he suspected deliberate or unconscious manipulation by the patient&#46; Several terms have been used to describe this clinical picture&#44; including <span class="elsevierStyleItalic">factitious lip crusting</span>&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a><span class="elsevierStyleItalic">factitious cheilitis</span>&#44;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">38&#8211;40</span></a> and <span class="elsevierStyleItalic">exfoliative cheilitis artefacta</span>&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">41&#8211;43</span></a> It has been speculated that the mechanism of production might be repeated manipulation of the lips with the teeth&#44; tongue&#44; or even instruments&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> In some cases&#44; the nasal pyramid is affected&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Our series included 6 patients &#40;5 women and 1 man&#41; with localized crusting&#59; in one of the women&#44; the crust was located on a finger&#46; One of the woman &#40;<a class="elsevierStyleCrossRef" href="#fig0050">Fig&#46; 10</a>&#41; had concomitant anorexia nervosa&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">45&#44;46</span></a></p><elsevierMultimedia ident="fig0050"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6&#46;</span><p id="par0130" class="elsevierStylePara elsevierViewall">Eczematous lesions&#46; Some patients produce eczematous lesions by applying irritants to the skin<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> or exposing themselves repeatedly to an allergen in the case of patients with allergic contact dermatitis&#46; It is sometimes difficult to prove the cause of such lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7&#46;</span><p id="par0135" class="elsevierStylePara elsevierViewall">Edemas&#46; In 1911&#44; Secretan<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> described swollen limbs as a possible presentation of self-inflicted disease&#46; Angelini et al&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> later called this form of self-harm Secretan syndrome&#46; Smith<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> defined a set of criteria that should raise a suspicion that the lymphedema is factitious&#58; recurrent unilateral lymphedema without any apparent lymphatic or venous obstruction and any lymphedema that is clearly delimited by a ring of a different coloration&#46; Several types of edema caused by ligatures are reported in the literature&#44; including edema of the nipple&#44;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> the tongue&#44;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a> the neck&#44;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a> and even of the scrotum leading to self-castration&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a></p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8&#46;</span><p id="par0140" class="elsevierStylePara elsevierViewall">Purpuras and bruises&#46; Gardner and Diamond<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a> first described the autoerythrocyte sensitization syndrome&#44; which is characterized by painful ecchymoses in sites within reach of the hands&#44; typically in women with psychological disorders &#40;<a class="elsevierStyleCrossRef" href="#fig0055">Fig&#46; 11</a>&#41;&#46; The patients&#8217; hypersensitivity to injections of their own blood has been used as a diagnostic criterion&#46; Some authors have tried to differentiate between purpura factitia and autoerythrocyte hypersensitivity syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a> In their view&#44; the latter condition is characterized by the presence of prior pain and possibly bleeding in internal organs&#44; while the appearance of lesions in purpura factitia is not preceded by pain and the results of challenge tests with the patient&#39;s own blood are negative if the site is protected with a bandage&#46; However&#44; the criteria for differentiating between purpura factitia and autoerythrocyte hypersensitivity syndrome are unclear&#46; Despite these nosological difficulties&#44; the authors of a recent review of the literature including 162 cases propose treatment with psychotropic drugs and psychotherapy&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">58</span></a> While differentiating these 2 disorders is difficult&#44;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a> the case of a patient with DA and painful bruising syndrome may be of some help&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">60</span></a></p><elsevierMultimedia ident="fig0055"></elsevierMultimedia></li></ul></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0145" class="elsevierStylePara elsevierViewall">In our series&#44; 3 women &#40;aged 26&#44; 27&#44; and 36 years&#41; had this condition&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">The spectrum of clinical presentations of DA could be even broader than that described here as the manifestations depend on the patient&#39;s imagination&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Diagnosis</span><p id="par0155" class="elsevierStylePara elsevierViewall">A diagnosis of DA is difficult to establish because of the great variety of possible dermatologic conditions&#46; The situation is further complicated by the diversity of methods used by patients to self-harm and the ingenuity they employ in doing so &#40;<a class="elsevierStyleCrossRef" href="#fig0060">Fig&#46; 12</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a></p><elsevierMultimedia ident="fig0060"></elsevierMultimedia><p id="par0160" class="elsevierStylePara elsevierViewall">Three aspects can be used to establish a diagnosis of self-inflicted skin lesions&#58; <span class="elsevierStyleItalic">a&#41;</span> the morphology of the lesion&#59; <span class="elsevierStyleItalic">b&#41;</span> the patient&#39;s personality&#59; and <span class="elsevierStyleItalic">c&#41;</span> the medical history&#46; However&#44; it is not advisable to establish a diagnosis based on just one of these criteria&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a> DA is the somatic expression of extremely serious and deeply buried mental suffering&#44; of which the patient is unaware&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> In DA&#44; the normal roles of patient&#44; physician&#44; and disease are subverted&#46; This subversion takes the form of a twofold challenge&#44; psychological on the one hand and a challenge to the standards underpinning medical practice on the other&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">The diagnosis should not be reached merely by a process of elimination&#44; but should rather be established from among the possible alternatives&#46; The diagnosis of DA is made on the basis of a combination of positive dermatological and psychological findings and requires the collaboration of the medical team and their acceptance that DA is the expression of significant mental suffering&#44; of which the patient is unaware&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Although very old&#44; the Stokes and Gardner classification is still a useful tool for establishing a diagnosis of self-inflicted lesions&#46; In the following sections we will outline the different aspects that form the basis of that classification&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">62</span></a></p><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Shape and Configuration of Lesions</span><p id="par0175" class="elsevierStylePara elsevierViewall">The diagnosis should be determined by the shape of the lesions and by ruling out other skin disorders with clearly defined characteristics&#46; Although the lesions may be caused by chemical or thermal burns&#44; they can also be the result of trauma&#46; Cutaneous artifacts caused by an instrument tend to be regular and geometric in shape &#40;<a class="elsevierStyleCrossRef" href="#fig0065">Fig&#46; 13</a>&#41;&#44; an uncommon morphology in the case of spontaneous eruptions&#46; Chemical burns are regular in shape&#44; although at times their borders may be interrupted by fingerlike projections caused by the linear spread of drips of the caustic liquid used to produce the lesion&#46;</p><elsevierMultimedia ident="fig0065"></elsevierMultimedia><p id="par0180" class="elsevierStylePara elsevierViewall">Lesions sometimes have a bizarre or fantastic appearance<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">63</span></a> &#40;<a class="elsevierStyleCrossRefs" href="#fig0070">Figs&#46; 14 and 15</a>&#41;&#44; appearing suddenly at irregular intervals&#44; generally singly or in pairs&#46; The course may be unusually rapid&#46; When the caustic substance is applied using a needle or tweezers&#44; a method frequently used in gangrenous areas&#44; the edges of the lesion have a saw-tooth or serrated appearance&#44; caused by the repeated pricks made along the leading edge&#46; When escharotic lesions are observed&#44; they tend to be superficial and the scabbed area is separated from the normal skin by an intensely erythematous border&#46;</p><elsevierMultimedia ident="fig0070"></elsevierMultimedia><elsevierMultimedia ident="fig0075"></elsevierMultimedia><p id="par0185" class="elsevierStylePara elsevierViewall">It is sometimes possible to determine that the nails&#44; fingers or a sharp object in the patient&#39;s possession are impregnated with the causal agent&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">In summary&#44; to the eyes of an expert&#44; these lesions will appear odd from the very beginning and are easily recognized as unexpected and dubious&#46; The initial impression of self-harm is strong &#40;<a class="elsevierStyleCrossRef" href="#fig0080">Fig&#46; 16</a>&#41; and this is of great importance for the diagnosis&#59; however&#44; a diagnosis of self-harm should not be reached without careful critical analysis&#46; Closer examination of the manifestations may provide the physician with evidence that will confirm the diagnosis of a self-inflicted lesion&#46; DA is always destructive &#40;ulcers&#44; enucleations&#44; gangrene&#41;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> although such a clinical picture alone is not enough to establish a diagnosis of DA&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p><elsevierMultimedia ident="fig0080"></elsevierMultimedia><p id="par0195" class="elsevierStylePara elsevierViewall">Our series yielded a number of findings not yet reported in the literature&#58; we were able to establish that the creation of lesions in multiple sites was more common among women&#44; while solitary lesions were mainly observed in men&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Distribution of the Lesions</span><p id="par0200" class="elsevierStylePara elsevierViewall">The lesions are generally located in areas accessible to the hands and tend to be more numerous in sites accessible to the right hand in right-handed patients and vice versa&#46; When choosing sites for lesions patients typically avoid the palms&#44; soles&#44; nose&#44; mouth&#44; scalp&#44; genitals&#44; and the outer ear&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">63</span></a> The presence of lesions in an area inaccessible to the hands does not necessarily rule out a diagnosis of DA&#44; since such sites can be reached by other means&#46; Lesions are sometimes distributed regularly around a central point&#44; such as a nipple or the navel&#44; and they are often located close to a previous lesion&#44; in an attempt to extend the original damage&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">The sites found in our series were as follows&#58; the face &#40;34&#46;5&#37;&#41;&#44; the lower limbs &#40;25&#37;&#41;&#44; the upper limbs &#40;16&#46;6&#37;&#41;&#44; and the hands &#40;15&#46;5&#37;&#41;&#46; The most common site in men was the legs &#40;51&#37;&#41; and in women the face &#40;40&#37;&#41;&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">If&#44; as Fabisch<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">64</span></a> has suggested&#44; the anatomical site of the lesion has a psychological significance that should be taken into account by the psychotherapist&#44; it is interesting to highlight the large number of women in our case series with lesions affecting the breasts &#40;<a class="elsevierStyleCrossRef" href="#fig0085">Fig&#46; 17</a>&#41;&#44; in some cases involving very destructive clinical forms&#46;</p><elsevierMultimedia ident="fig0085"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">The Patient&#39;s Demeanor</span><p id="par0215" class="elsevierStylePara elsevierViewall">Great importance is placed on the appearance and demeanor of the patient with DA&#46; Typical descriptions include anxiousness&#44; fine tremor of the facial muscles&#44; tearful eyes&#44; or on the contrary&#44; a poker face or Mona Lisa expression&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> Some patients exhibit the calm of a tense person or a gaze with erotic connotations &#40;bedroom eyes&#41;&#46; Another remarkable characteristic seen in some patients is an attitude of great mental calm and complacency about their condition &#40;what the French call <span class="elsevierStyleItalic">la belle indifference</span>&#41;&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Young patients are sometimes accompanied by domineering parents or solicitous parents will accompany a difficult and precocious child&#46; The patient&#39;s interest in their lesions&#44; a tendency to display them and to express anger are all signs that should raise a suspicion of self-harm&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">The patient&#39;s expression can range from guilty&#44; furtive&#44; or unfriendly to one of obvious pretense&#46; Some patients may be reserved and uncommunicative or display signs of low intelligence&#44; although in Lyell&#39;s<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> view a high level of intelligence is also compatible with a diagnosis of DA&#44; while a mature personality is not&#46; Obviously none of these criteria is absolute&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Timing</span><p id="par0230" class="elsevierStylePara elsevierViewall">Recurrence following periods of stress&#44; sleepwalking episodes&#44; the patient&#39;s failure to return after several visits&#44; the appearance of lesions on certain dates&#44; and lesions that appear overnight are all signs of self-harm&#46; Another circumstance that may suggest DA is when the recurrence of lesions coincides with a new job&#44; moving house&#44; a new school&#44; the death of a family member&#44; or any other event likely to cause mental stress&#44; depending on the age and circumstances of the patient&#46; In such cases&#44; the lesion can be interpreted as an attempt at nonverbal communication&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">64</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">The patients&#8217; inability to talk about the origin of their lesions or their lack of interest in the subject prevents the dermatologist from gaining a clear idea of the situation&#46; The patient&#39;s account of the lesions is sometimes so lacking in substance that Gandy<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> coined the term <span class="elsevierStyleItalic">hollow history</span>&#46; This perplexity about what is happening is expressed by the patient in bitter and hostile terms&#44; and new lesions will continue to appear as long as the conditions are favorable&#44; that is&#44; as long as the patient enjoys privacy and a supply of the necessary materials&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">Another term used in DA is <span class="elsevierStyleItalic">melodramatic prophecy</span>&#44; referring to predictions by patients concerning when and where new lesions will appear&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Many patients with DA play games with their physicians informing them 12 or 24<span class="elsevierStyleHsp" style=""></span>hours before the lesions appear what sites will be affected&#44; explaining that the lesion will be preceded by heat&#44; burning&#44; or some other abnormal sensation&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">63</span></a> In other cases lesions appear in a place where the dermatologist has suggested they might occur&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Assessment of Neurological Signs and Symptoms</span><p id="par0245" class="elsevierStylePara elsevierViewall">Subjective sensations&#44; such as pain and burning&#44; may be exaggerated by patients with DA&#46; The patient&#39;s psychiatric history should be investigated to establish whether he or she has had any previous psychiatric diagnosis or has a family history of mental illness&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study of Motives</span><p id="par0250" class="elsevierStylePara elsevierViewall">In the case of patients with a hysterical personality&#44; the motive for self-harm is to deceive&#44; but the underlying cause is solely the desire to be a sick person in order to escape personal obligations and inner conflicts<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">65&#44;66</span></a> even though there may be no apparent justification for the patient&#39;s conduct&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">67</span></a> The possible motives for DA will be as varied as are human personalities and the situations of life itself&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> The motive can sometimes be a simple desire to arouse the sympathy of relatives or friends or an attempt to rationalize feelings of frustration or failure in life&#59; in other cases the behavior may be a result of conflict in the patient&#39;s social environment&#44; financial problems&#44; a lack of self-esteem&#44; atonement for guilt&#44; revenge&#44; or a way to escape responsibilities&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">68</span></a> Patients who create skin artifacts are also trying&#44; often unconsciously&#44; to attract the attention of those around them to an inner conflict for which they have no solution&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">Malingerers and fraudsters do not easily fool doctors<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;69</span></a> because the patient who merely contrives disease is an impostor&#59; in such cases the external incentive for the behavior must be found to confirm the diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> Such individuals typically use lesions to achieve a secondary goal&#58; to excuse failure&#44; attract sympathy&#44; escape responsibilities&#44; or simply to delay making a payment that is due&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">70</span></a> They may have criminal motives&#44; such as fraud or avoidance of a legal obligation&#44;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">67</span></a> or even use the situation to obtain privileges&#44; money&#44; or narcotics&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Histology</span><p id="par0260" class="elsevierStylePara elsevierViewall">A fairly common characteristic in the histology of DA is that superficial involvement predominates over deeper involvement&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a> Typically&#44; abnormal findings are restricted to the epidermis and no accumulation of lymphocytes or signs of vasculitis are found&#46; However&#44; the findings are not diagnostic and in most cases will depend on the method used to create the lesion&#46; A wide range of histologic findings have been reported&#44; including<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">71</span></a> erosion&#44; acanthotic epidermis&#44; chronic perivascular infiltrate&#44; and foreign-body reaction with birefringent material&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">33&#44;34</span></a></p><p id="par0265" class="elsevierStylePara elsevierViewall">Whenever possible a biopsy should be obtained because histologic findings have in many cases been fundamental to the diagnosis&#44; particularly when other skin conditions have been confused with DA&#46; Perhaps the dermatological diagnosis most often confused with DA is pyoderma gangrenosum&#46; DA has also been confused with pyoderma and vice versa&#46;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">72&#8211;74</span></a> Conditions misdiagnosed as DA on the basis of clinical findings have been shown by histologic findings to be genuine panniculitis-like T-cell lymphoma&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">75</span></a> By contrast&#44; a case of DA on a girl&#39;s face mimicked a lymphoma&#44;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">76</span></a> while in other cases erosive lichen planus&#44;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">77</span></a> cryoglobulinemia&#44;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">78</span></a> and acquired hemophilia<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">79</span></a> were misdiagnosed as DA&#46; In other cases DA presented clinically as vasculitis<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">80</span></a> and trigeminal trophic syndrome was misdiagnosed as DA due to the absence of abnormal histologic findings&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">81</span></a></p><p id="par0270" class="elsevierStylePara elsevierViewall">It is sometimes essential to use more complex histologic techniques&#44; such as X-ray analysis and spectrophotometry&#46; In one case&#44; spectrophotometry demonstrated that the cause of recurrent abscesses was cellulose&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">82</span></a> In an earlier case&#44; electron probe microanalysis was used to determine the presence and nature of factitious granulomas&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">83</span></a> Friction blisters at the level of the distal stratum granulosum have been reported&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">84</span></a> The presence of birefringent material and pseudocystic spaces replacing fat are important indications that will help to establish the diagnosis of factitious panniculitis&#46;</p><p id="par0275" class="elsevierStylePara elsevierViewall">There is no doubt that DA lesions can mimic other skin processes&#46; McCormac<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">67</span></a> makes the point that&#44; while it is clear that a patient cannot produce lesions that simulate psoriasis or lichen planus&#44; they can create lesions with a very obvious inflammatory substrate&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Differential Diagnosis</span><p id="par0280" class="elsevierStylePara elsevierViewall">The dermatological condition most likely to cause problems in the differential diagnosis of DA is neurotic excoriation&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">85</span></a> While the lesions in this condition are also self-inflicted&#44; the patients do not try to deceive the physician&#59; they are victims of an irresistible urge to pick&#44; scratch&#44; or otherwise manipulate the skin&#44; nails&#44; or hair&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Another important difference between neurotic excoriation and DA is that patients with the former only use their nails while patients with DA may use a range of methods to damage the skin&#46;</p><p id="par0285" class="elsevierStylePara elsevierViewall">DA must be differentiated from the skin lesions produced by psychotic patients&#44; who may use their fingernails to excoriate the skin and cause ulcers that may become infected&#46; In such cases&#44; there is no doubt about the origin of the lesions because the patient causes them in view of other people&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Psychopathology</span><p id="par0290" class="elsevierStylePara elsevierViewall">Experts concur that DA is a cutaneous manifestation of a psychiatric disorder and the condition is classified in the DSM-IV &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0295" class="elsevierStylePara elsevierViewall">One of the chief concerns of physicians who study DA is to identify a motive that would justify the behavior of patients who self-harm&#44; although some clinicians and dermatologists have minimized the role of the mind in the development and perpetuation of certain types of skin disease by applying the frivolous designation &#8220;nervous&#8221; and have failed to ensure that the patient receive appropriate psychiatric treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">86</span></a> Fortunately&#44; the work of English&#44;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">87</span></a> Cormia&#44;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">88</span></a> and Zaidens<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">89</span></a> has led to a better understanding of psychosomatic conditions and improved treatment&#46;</p><p id="par0300" class="elsevierStylePara elsevierViewall">There is no consensus about the personality type involved in DA&#46; Some authors consider that there are 2 types of patients&#44; some hysterical and others who are simply malingerers&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;25&#44;67&#44;70&#44;90</span></a> Others classify patients with DA as hysterical or psychotic&#46;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">68&#44;86</span></a> Michelson<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">66</span></a> and Susskind<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">90</span></a> believe that all DA patients are hysterical&#44; while Koblenzer<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">91</span></a> considers them all to be borderline psychotic&#46; Factitious disease appears to be a kind of emotional safety valve in emotionally immature patients who typically present hysterical and masochistic characteristics&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Lesions may be produced when patients are in an altered psychogenic&#44; borderline&#44;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">92</span></a> or dissociative state&#44; so that they are not conscious of their actions&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The psychological importance of DA is that while the patients consciously produce the lesions&#44; they are unaware of the reasons for their self-destructive behavior&#46; Patients may exaggerate pain&#44; adopting the role of martyr&#44; and this posture is confirmed by their great capacity to take pleasure in tolerating pain&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">86</span></a></p><p id="par0305" class="elsevierStylePara elsevierViewall">Although they cannot be considered to have psychotic personalities&#44; many patients with DA do have a borderline personality structure and are unable to develop mature relationships&#46; They use their lesions to maintain contact with others and to get the attention they desperately need to fill their emotional vacuum&#46; Another motive for self-harm may be a desire to do penance for unconscious sins or their behavior may be a displaced expression of infantile rage&#46;<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">91</span></a></p><p id="par0310" class="elsevierStylePara elsevierViewall">Musaph<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">93</span></a> considers that patients with DA produce their symptoms unconsciously&#44; and psychiatric-psychological studies have revealed that the condition is in part due to aggressive sexual feelings directed against key figures in the patient&#39;s childhood&#46;</p><p id="par0315" class="elsevierStylePara elsevierViewall">Zaidens<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">92</span></a> is the author who has perhaps contributed the most psychological and psychiatric studies on DA&#46; She believes that self-inflicted dermatitis represents frustration&#44; resentment&#44; a demand for attention&#44; anxiety&#44; hostility&#44; and helplessness&#46; The self-destruction is proportional to the severity of the underlying emotional disturbance&#46;</p><p id="par0320" class="elsevierStylePara elsevierViewall">Auto-destructive mechanisms develop in dependent and timid individuals who are unable to express themselves&#46; These patients have been conceived and reared in an environment fettered by emotional barriers&#44; and their growth has not been very important to their parents&#44; particularly their mothers&#46; Most patients with DA are adults in middle-age who have not achieved their life goals or have not achieved the levels of success typical of their class models&#44; in either social or economic terms&#46;<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">94</span></a> In psychological terms&#44; they use DA to get sympathy&#44; attention&#44; pity&#44; or compensation&#46; Moreover&#44; since patients with DA are unable to deal with their problems&#44; or to even admit that they have a problem&#44; the lesions provide them with an excuse they can use to rationalize their frustrations&#46;</p><p id="par0325" class="elsevierStylePara elsevierViewall">DA sometimes appears in the context of a <span class="elsevierStyleItalic">folie &#224; deux</span> or shared dementia&#46; Shared dementia is a psychotic disorder characterized by the development of a hallucinatory pattern shared by 2 people&#46; Since those affected have a long-lasting intimate relationship&#44; the disorder is not uncommon in older adults&#46;<a class="elsevierStyleCrossRefs" href="#bib0475"><span class="elsevierStyleSup">95&#44;96</span></a> It sometimes involves a mother and her children<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">97</span></a> and forms part of a syndrome of childhood abuse&#46;</p><p id="par0330" class="elsevierStylePara elsevierViewall">Self-inflicted dermatoses are also observed in patients with anorexia nervosa&#46;</p><p id="par0335" class="elsevierStylePara elsevierViewall">Factitious disease involves many paradoxes&#44; the most important of which is that the patient causes the physical symptoms and seeks a remedy for them&#46; The psychodynamic etiology of factitious disorders may be related to a history of abuse or neglect in childhood&#44; early emotional deprivation&#44; or lack of care&#46; All of these factors are found frequently in the history of these patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">47&#44;98</span></a> Some authors have interpreted DA to be a disorder caused by borderline personality&#46; In their opinion&#44; the patient is both victim and punisher&#44; a person intent on capturing the attention of doctors while at the same time challenging them and devaluing their usefulness&#46; The additional benefit of playing the role of a sick person &#40;thereby obtaining attention&#44; support&#44; and sympathy while escaping responsibilities&#41; may also be important to these patients&#46; By simulating a disease patients can evade responsibilities and satisfy their dependence needs&#44; even though in DA this goal is achieved in a bizarre and self-destructive manner&#46;</p><p id="par0340" class="elsevierStylePara elsevierViewall">DA is not indicative of a particular personality organization&#44; but the patient&#39;s personality type is a prognostic factor&#44; as is the age of onset&#46; In adolescents the disorder is usually a cry for help&#46; The most common personality type in men with DA is paranoid while in women it is hysterical&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0345" class="elsevierStylePara elsevierViewall">It is currently thought that DA occurs in patients with a borderline personality disorder&#44; although an association has also been described with impulse control disorder<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">99</span></a> and obsessive compulsive disorder&#46;<a class="elsevierStyleCrossRefs" href="#bib0500"><span class="elsevierStyleSup">100&#44;101</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Prognosis</span><p id="par0350" class="elsevierStylePara elsevierViewall">Several follow-up studies have been carried out to assess the prognosis in patients with DA&#46; The first of these was undertaken by McCormack&#44;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">67</span></a> who sent a questionnaire to 10 patients&#46; Only 5 answered&#44; and the findings of that study indicated that the condition is more uncommon in patients over 25 years of age&#46; Subsequently&#44; Sneddon et al&#44;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">101</span></a> who studied 43 patients &#40;38 women and 5 men&#41;&#44; reported that DA was only one incident in a long history of mental illness&#46; However&#44; 30&#37; of the patients in that study &#40;12 women and one man&#41; continued to self-inflict lesions or had other mental illnesses 12 years after the onset of DA&#46; Years later&#44; Haenel et al&#46;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">98</span></a> invited 59 patients &#40;52 women and 7 men&#41; who had been diagnosed with DA to be reassessed&#46; Of the 36 women and 2 men who responded&#44; DA had resolved in 9&#44; but the others still had recurrent lesions&#46; Eight of the 36 women reported one or more suicide attempts&#46; In a follow-up study carried out in our own department&#44;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;102</span></a> 61 patients who had been diagnosed with DA were invited to attend the clinic for reassessment&#46; Nine &#40;8 women and 1 man&#41; of the 34 patients who responded &#40;24 women and 10 men&#41; were still affected by DA&#44; an indication that this is a chronic and insidious disorder&#46;</p><p id="par0355" class="elsevierStylePara elsevierViewall">Malignant transformation of a lesion was reported in a woman with DA who persistently excoriated a cholecystectomy scar over 40 years&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">103</span></a> Another similar case involved the development of a malignant tumor in an ulcer on the face of a 49-year-old man&#44; which the patient scratched compulsively&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">104</span></a> In both these cases&#44; the malignancy was a Marjolin ulcer&#44; a squamous cell carcinoma that arises in a chronic ulcer&#46; The most common complications of DA are related to infections&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Treatment</span><p id="par0360" class="elsevierStylePara elsevierViewall">DA probably represents one of the greatest therapeutic challenges in dermatology&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Consoli<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> suggested that the 3 pillars of treatment should be <span class="elsevierStyleItalic">a&#41;</span> restructuring the patient&#39;s personality&#44; <span class="elsevierStyleItalic">b&#41;</span> drug treatment for the psychiatric condition&#44; and <span class="elsevierStyleItalic">c&#41;</span> medical treatment of the skin lesions&#46; A prolonged period during which a friendly relationship can be established with the patient may help to prevent abrupt termination of treatment when the patient is finally confronted with the real situation&#46; If this initial confrontation does not provoke a negative reaction or cause the patient to abandon treatment&#44; a mental health treatment plan can be implemented&#44; if possible including inpatient treatment&#46; A supportive approach avoiding condemnation is always preferable&#46; The dermatologist should be prepared for a prolonged course of treatment with repeated relapses and should never express disappointment or hostility over these failures&#46; The cost of treating DA in 1 patient over 5 years of consultations has been estimated at &#8364;64&#160;500&#46;<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">105</span></a></p><p id="par0365" class="elsevierStylePara elsevierViewall">The treatment of factitious disease is often unsatisfactory&#44; whether it is managed by a dermatologist&#44; a psychiatrist&#44; or both&#46; Maybe the underlying reason is that these patients are in hiding and although they have to consult a physician because their symptoms are so obvious they do not wish to be cured&#46;</p><p id="par0370" class="elsevierStylePara elsevierViewall">The ideal approach is to refer the patient to a psychiatrist&#44; but patients find such a referral incomprehensible because they believe they have a dermatological condition and do not understand why the dermatologist does not want to cure the lesions&#46; As Sneddon<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> has said&#44; the treatment of patients with DA is difficult because&#44; although they need the help of a psychiatrist&#44; they reject this advice and any suggestion that their disease is not organic leads to a traumatic and conflictive visit after which they change doctors&#46; When it is impossible to convince the patient to consult a psychiatrist&#44; therapy with psychotropic drugs can be very helpful&#46; The following drugs have been shown to be useful&#58; selective serotonin reuptake inhibitors&#44;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">58</span></a> pimozide &#40;0&#46;5-1<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#41;&#44; aripiprazole &#40;2-5<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#41;&#44; or risperidone &#40;0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0530"><span class="elsevierStyleSup">106&#44;107</span></a> Other measures and treatments that have been proposed include relaxation therapy&#44; anxiolytics&#44; antidepressants&#44; and low doses of second-generation antipsychotics&#46;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">108</span></a>The skin lesions can be cured with the aid of occlusive dressings &#40;adhesive zinc or sometimes plaster wrap&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">106</span></a> Rapid healing of a bandaged ulcer that has previously proved refractory to all treatment is a sign of great diagnostic value&#44; as is the appearance of new lesions on unbandaged and&#44; in most cases&#44; previously unaffected areas&#46; As occlusive bandages can be pierced by sharp instruments and patients can inject substances through the dressing&#44; a sheet of aluminum foil may be included in the dressing to record the evidence of any such manipulations on the part of the patient&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Ethical Disclosures</span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Protection of human and animal subjects</span><p id="par0375" class="elsevierStylePara elsevierViewall">The authors state that no experiments were performed on humans or animals for this investigation&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Confidentiality of data</span><p id="par0380" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their workplace concerning the publication of patient data&#44; and that all the patients included in this study have been appropriately informed and gave their written informed consent to participate in this study&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Right to privacy and informed consent</span><p id="par0385" class="elsevierStylePara elsevierViewall">The authors declare that no private patient data are disclosed in this article</p></span></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflicts of Interests</span><p id="par0390" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Keywords"
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          "titulo" => "Introduction"
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          "titulo" => "Definition"
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          "titulo" => "Clinical Features"
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          "titulo" => "Diagnosis"
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            0 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Shape and Configuration of Lesions"
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              "titulo" => "Distribution of the Lesions"
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            2 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "The Patient&#39;s Demeanor"
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              "identificador" => "sec0045"
              "titulo" => "Timing"
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              "titulo" => "Assessment of Neurological Signs and Symptoms"
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              "identificador" => "sec0055"
              "titulo" => "Study of Motives"
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          "titulo" => "Histology"
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          "titulo" => "Differential Diagnosis"
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          "identificador" => "sec0070"
          "titulo" => "Psychopathology"
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          "titulo" => "Prognosis"
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          "titulo" => "Treatment"
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          "titulo" => "Ethical Disclosures"
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            0 => array:2 [
              "identificador" => "sec0090"
              "titulo" => "Protection of human and animal subjects"
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              "identificador" => "sec0095"
              "titulo" => "Confidentiality of data"
            ]
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              "titulo" => "Right to privacy and informed consent"
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          ]
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          "identificador" => "sec0105"
          "titulo" => "Conflicts of Interests"
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          "titulo" => "References"
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    "fechaRecibido" => "2011-11-23"
    "fechaAceptado" => "2012-10-14"
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          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec279229"
          "palabras" => array:3 [
            0 => "Dermatitis artefacta"
            1 => "Self-inflicted lesions"
            2 => "Factitious dermatitis"
          ]
        ]
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
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            0 => "Dermatitis artefacta"
            1 => "Lesiones autoprovocadas"
            2 => "Dermatitis facticia"
          ]
        ]
      ]
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      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Dermatitis artefacta is a rarely diagnosed disorder that is often a source of perplexity and anxiety for dermatologists because they know less about the cause of this self-inflicted condition than the patients themselves&#46; It differs from other skin disorders in that diagnosis is made by exclusion rather than on the basis of histologic and biochemical findings and therefore involves a considerable investment of time and resources&#46; Based on the findings of a study of 201 patients diagnosed with dermatitis artefacta between 1976 and 2006&#44; we review the different clinical presentations of this skin disorder and discuss its diagnosis and treatment&#46; The series analyzed comprised 152 women and 49 men &#40;female to male ratio of 3&#46;1&#58;1&#41; with a mean age of 31&#46;2 years&#46; The patients were mostly single and had a low educational level and few or no job qualifications or skills&#46;</p>"
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        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La dermatitis artefacta &#40;DA&#41; es un diagn&#243;stico excepcional&#44; que genera perplejidad y ansiedad al dermat&#243;logo al encontrase ante una patolog&#237;a autoprovocada y de la que el paciente sabe m&#225;s que el m&#233;dico en cuanto a su etiolog&#237;a&#46; Al contrario que otras dermatosis en la que existen pruebas histol&#243;gicas o bioqu&#237;micas&#44; en la DA el diagn&#243;stico es de exclusi&#243;n lo que exige un gran consumo de recursos y de tiempo&#46; En el presente trabajo repasamos las diversas formas cl&#237;nicas&#44; criterios diagn&#243;sticos y manejo de estos pacientes y para ello nos basamos en la experiencia del estudio que realizamos de 201 casos de DA diagnosticados entre 1976 y 2006&#44; de los cuales 152 eran mujeres y 49 varones&#44; con una proporci&#243;n de mujeres&#47;varones de 3&#46;1&#47;1&#46; La edad media fue de 31&#46;2 a&#241;os y estaba mayoritariamente constituida por personas con escasa o nula cualificaci&#243;n laboral&#44; bajo nivel cultural y mayoritariamente solteros&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Rodr&#237;guez Pichardo A&#44; Garc&#237;a Bravo B&#46; Dermatitis artefacta&#58; revisi&#243;n&#46; Actas Dermosifiliogr&#46; 2013&#59;104&#58;854&#8211;866&#46;</p>"
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          "leyenda" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Source&#58; Gupta et al&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46; Primary psychiatric symptom that manifests as a dermatological condition&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>a&#41; Delirium&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>b&#41; Hallucinations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>c&#41; Body dysmorphic disorder&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46; Disorders associated with self-inflicted dermatoses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>a&#41; Dermatitis artefacta&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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Review
Dermatitis Artefacta: A Review
Dermatitis artefacta: revisión
A. Rodríguez Pichardo
Corresponding author
arodriguezpi@aedv.es

Corresponding author.
, B. García Bravo
Departamento de Dermatología, Hospital Universitario Virgen Macarena, Sevilla, Spain
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            "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Skin metastases can manifest as primary or secondary skin lesions&#46; A&#44; Metastasis from a gastric adenocarcinoma&#46; Papule of 7<span class="elsevierStyleHsp" style=""></span>mm diameter on the abdomen&#46; B&#44; Metastasis from an adenocarcinoma of the ovary presenting as a plaque&#46; C&#44; Metastasis from a urothelial carcinoma of the bladder presenting as a nodule&#46; D&#44; Metastasis from an adenocarcinoma of the breast&#46; The lesion started as a macule over the mastectomy scar&#46; E&#44; Ulcerated infiltrated plaque corresponding to a metastasis from an adenocarcinoma of the lung&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Distribution by sex of various clinical forms of dermatitis artefacta&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The nosological position of dermatitis artefacta &#40;DA&#41; is clear in the numerous classification schemes of skin conditions linked to mental disorders&#44;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;6</span></a> in which it is invariably classified as a manifestation of a primary psychiatric disorder&#46; While the Vienna Diagnoses Schedule for Psychodermatological Disorders is probably the most complete and comprehensive classification published to date&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> it is of little practical use for dermatologists who do not work in the field of psychodermatology&#46; It may therefore be preferable to use Gupta&#39;s<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> classification of psychodermatoses &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#44; which is more didactic as it is based on the current concepts of psychiatric disease defined by the Diagnostic and Statistical Manual of Mental Disorders &#40;DSM-IV&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">The term <span class="elsevierStyleItalic">dermatitis artefacta</span> is only used to refer to the condition in which skin lesions appear in a secret and mysterious way while the patient denies all responsibility for their production&#46; In DA&#44; the patient produces skin lesions to satisfy a psychological need&#44; often a desire to receive medical treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Malingerers also deny responsibility for producing the signs and symptoms of their disease&#44; but they do so for easy-to-discover reasons&#44; such as financial gain or a lawsuit&#46; Munchausen syndrome sometimes includes skin involvement&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> generally DA&#44; but in that setting the skin involvement is just 1 element in a broad spectrum of conditions affecting other organs<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> and will be associated with repeated hospital admissions&#44; which the patient tries to conceal while demanding medication and exploratory tests&#46; Unlike DA&#44; Munchausen syndrome is more common in men than in women&#46; It is not unusual for DA to occur following treatment for another condition that brought the patient into contact with the hospital environment&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Definition</span><p id="par0015" class="elsevierStylePara elsevierViewall">DA is defined as any condition involving self-inflicted skin lesions for which the patient denies all responsibility&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a> However&#44; some authors consider that the nosological definition of DA should specifically exclude cases in which a rational motive exists for the self-infliction of lesions&#44; thereby excluding malingerers&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Another essential characteristic of DA is that the patients conceal their role in producing the signs of their condition&#59; this concealment is what differentiates DA from other self-inflicted dermatoses&#44; such as self-mutilations by psychotic patients&#44; neurotic excoriation&#44; and trichotillomania&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Epidemiology</span><p id="par0020" class="elsevierStylePara elsevierViewall">Since DA is rare in routine dermatological practice&#44; the literature contains few case series&#46; Most authors have described isolated clinical cases of particular interest to specialists either because of the diagnostic challenges involved or the severity of the clinical presentation&#46; However&#44; it is believed that up to 5&#37; of medical visits may relate to factitious disease&#44; and such cases are not only observed in dermatology but also encountered by internal medicine&#44; ophthalmology&#44; endocrinology&#44; and ear nose and throat specialists&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;14</span></a> Owing to the ease with which it can be damaged&#44; the integrumentary system is the organ that is most often the object of self-inflicted lesions&#46; This was shown by a study of 31 patients who presented with factitious conditions in a general hospital<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#59; in that study there were 13 cases of DA&#44; 12 cases of simulated fever&#44; 3 of self-inflicted bleeding&#44; 1 of polyuria-polydipsia syndrome&#44; 1 of hypoglycemia&#44; and 1 of hyperthyroidism&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Few series provide data that can be used to compare the relative incidence of DA and other psychodermatologic disorders&#46; In a 3-year study carried out in Iran&#44; 178 patients were diagnosed with various psychodermatologic disorders<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#58; 128 neurotic excoriations &#40;71&#46;9&#37;&#41;&#44; 22 trichotillomania &#40;12&#46;4&#37;&#41;&#44; 16 delusional parasitosis &#40;9&#37;&#41;&#44; and 12 DA &#40;6&#46;7&#37;&#41;&#46; Women outnumbered men in all of these diagnoses except delusional parasitosis&#44; which was more frequent among men&#46; DA was the least common diagnosis&#46; In a study of 35 patients with dermatological disorders of strictly psychological origin&#44; 8 patients had DA&#44; 8 had delusional parasitosis&#44; and 19 had various dysmorphic disorders&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">One of the first case series of DA was published by Az&#250;a in 1909&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> After studying the cases of 4 women who had been diagnosed with &#8220;hysterical gangrene&#8221;&#44; he confirmed the hysterical origin in 1 case but redefined the other 3 as self-inflicted lesions&#46; One review of 59 articles on DA included 130 patients &#40;116 women and 14 men&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> A retrospective study in Denmark covering 20 years included 57 patients with a diagnosis of DA&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> That group consisted largely of women &#40;74&#37;&#41;&#44; with a female-to-male ratio of 2&#46;8&#58;1&#59; the median age was 39 years &#40;range&#44; 12-86&#41;&#46; A review of the records of a French dermatology department over a 15-year period identified 31 patients with a diagnosis of DA<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#59; 23 of the patients were women &#40;mean age&#44; 32&#46;4 years&#41; and 8 were men &#40;mean age&#44; 23&#46;7 years&#41;&#46; Our series of patients diagnosed between 1976 and 2006 included 201 patients&#44; with a clear preponderance of women &#40;female-to-male ratio&#44; 3&#46;1&#58;1&#41; and mean age overall of 31&#46;2 years&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;21</span></a> Other interesting characteristics observed in our series were the low or nonexistent skill level&#44; low income&#44; and low cultural level of the patients and the higher proportion of single people&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In children&#44; DA is more common among girls than boys&#44; as shown by a Mexican series of pediatric patients covering a period of 20 years&#44; which included 25 girls and only 4 boys&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Similarly&#44; an Australian study covering a 15-year period included 24 girls and only 8 boys&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">DA can appear at any age&#44; but the incidence is highest around 20 years of age&#46; In many cases onset is preceded by a period of psychosocial stress&#44; which is generally easily identified&#44; such as the psychological disturbance that produced acne symptoms in an adolescent who injured his skin with a blister agent&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> It is not unusual to find a connection with the hospital setting in these patients&#44; who may be nursing aides&#44; nurses&#44; relatives of physicians&#44; or individuals who have had prolonged diseases in childhood<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> or who have been affected by the death of a family member&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In summary&#44; we can say that DA is more common among females and<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> in early adulthood and that a high proportion of those affected have a low social and cultural level&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Clinical Features</span><p id="par0050" class="elsevierStylePara elsevierViewall">DA presents in a great variety of clinical forms &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; depending on the patient&#39;s creativity and the method used to produce the lesion&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;25</span></a> The most common presentations are as follows&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Excoriations&#46; Excoriations are the most easily diagnosed factitious lesions&#46; They are usually linear &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; and are most often inflicted using the fingernails &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41; although a variety of sharp objects may also be used &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; Distinguishing between DA and neurotic excoriations can sometimes be difficult&#44; but patients who have the latter condition recognize that they have caused the lesions&#46; Excoriations are highly susceptible to infection and an indicative finding is the absence of itching before the onset of the lesion&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Excoriations are a common clinical form of DA because the lesions are easy to inflict&#59; in our case series they were observed in 52 &#40;25&#46;8&#37;&#41; of 201 patients and were more common in women &#40;28&#46;4&#37;&#41; than in men &#40;17&#46;7&#37;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Ulcers&#46; Ulcers are the most common lesions in most series&#46; They are found either in the early stages of development or after resolution&#44; when they take the form of an eschar &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; The morphology of these ulcers tends to be odd&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> either because they have perfectly regular borders or because they have an irregular shape that includes linear segments &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#44; acute and obtuse angles&#44; triangular forms&#44; star shapes etc&#46; Linear lesions that extend outwards from a primary lesion are also observed &#40;the drip sign&#41;&#46; Sometimes&#44; clearly ulcerated lesions appear together with other lesions that are either incompletely executed or caused by splashes of the caustic agent used to produce the ulcers&#46; Scars from past or old injuries may also be observed&#46; Old ulcerations that have been subjected to repeated irritation or modified by multiple treatments exhibit characteristics of torpidity &#40;sclerosis&#44; atrophy&#41;&#44; and underlying osteitis or necrosis caused by secondary infections is sometimes present&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Patients may also have scars with an irregular geometric shape&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Litmus paper can be used to test the alkalinity or acidity of unexplained ulcers as the results may indicate the use of a chemical product as a probable cause&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;27</span></a> Repeated failure of skin grafts&#44; usually due to vascular problems&#44; should raise the suspicion of interference by the patient&#44; especially when the only organism found in cultures is fecal flora &#40;a finding observed in 4 of our cases&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">In our series&#44; a clinical presentation described as an ulcer was observed in 52 patients &#40;25&#46;8&#37;&#41;&#44; making it&#44; together with the category of excoriations&#44; the leading manifestation&#46; Ulcers were more common among males &#40;31&#46;1&#37;&#41; than females &#40;23&#46;8&#37;&#41;&#46; In a study of patients with DA affecting the breast&#44; excoriations and ulcers were found to be equally common &#40;33&#46;33&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Blisters&#46; Self-inflicted lesions sometimes take the form of blisters&#46; The appearance of these lesions may be odd&#59; they may be elongated &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>&#41;&#44; angular&#44; polygonal&#44; or occasionally very large&#44; sometimes with several lobules&#46; In most cases&#44; blisters are found together with other lesions&#44; such as ulcerations&#44; scabs&#44; and erythema in more or less geometric shapes&#46;</p><elsevierMultimedia ident="fig0035"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">The lesions may be irregularly shaped and have an unusual distribution&#44; for example perfectly irregular&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;27</span></a> The course is always benign&#44; but the size&#44; number&#44; and gangrenous nature of the blisters can sometimes produce veritable mutilations&#46; Self-inflicted blisters are caused by burns or cauterization and are produced through the application of chemical or medical products&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Blisters can also be produced through friction on sites where the epidermis is thick and firmly attached to the underlying tissues&#46; The histologic findings in such cases are characteristic and can distinguish these lesions from the blisters found in bullous disorders&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">In one report a rubber nipple was used to produce suction blisters mimicking pemphigoid&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> In another case of DA&#44; an aerosol spray deodorant was used by a 12-year-old girl to induce blistering&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> The same method was used by 3 patients &#40;a 12-year-old boy and 2 women aged 21 and 36 years&#41;&#44; who induced bullous lesions on the extensor surfaces of the limbs by producing cold burns using a spray deodorant&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> This was probably also the method used in the case of a 13-year-old girl described in another case report&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In our series&#44; 21 &#40;10&#46;3&#37;&#41; of the 201 patients presented with a variety of bullous symptoms&#44; a presentation more common among men &#40;13&#46;3&#37;&#41; than women &#40;9&#46;2&#37;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Panniculitis&#46; Ackerman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> reported the case of an adolescent with fever&#44; nodular syndrome&#44; and nonsuppurating panniculitis&#8212;a presentation clinically and histologically consistent with Weber-Christian disease&#46; By chance it was discovered that the manifestations were caused by self-injections of milk that produced erythematous nodules around the injection site accompanied by chills&#44; fever&#44; sweating&#44; and general malaise&#46; Steinman and colleagues<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> described a similar case in a nurse whose symptoms were also produced by self-inoculation with milk on the dorsum of the left hand&#46; In a study of 5 women with factitious panniculitis&#44;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> the signs of disease were found to be produced by repeated trauma&#46; The diagnosis was only confirmed after histologic examination revealed inflammatory features and bruising and after the lesions had been cured by means of occlusive dressings&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">It is important to note that some patients develop indurated lesions on the breast&#44; which sometimes ulcerate&#44; and when they are referred for surgical treatment they may undergo a mastectomy without any prior biopsy having been performed&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> A recent Spanish study summarized the etiologic&#44; pathogenic&#44; clinical&#44; and histologic features and treatment of panniculitis produced by trauma or the injection of drugs or chemicals&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">In our series&#44; 7 patients &#40;3&#46;4&#37;&#41; were diagnosed with factitious panniculitis &#40;<a class="elsevierStyleCrossRefs" href="#fig0040">Figs&#46; 8 and 9</a>&#41;&#46; In 1 case&#44; the symptoms were caused by subcutaneous injection of urine&#46;</p><elsevierMultimedia ident="fig0040"></elsevierMultimedia><elsevierMultimedia ident="fig0045"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5&#46;</span><p id="par0120" class="elsevierStylePara elsevierViewall">Localized crusting&#46; Carteaud<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> described a case of factitious cheilitis&#44; which he called <span class="elsevierStyleItalic">le tic des levres</span>&#46; Some years later&#44; Savage<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> reported a similar condition&#44; which he called localized crusting&#59; he described cases of keratotic or bleeding scabs on the lips that had no apparent cause in which he suspected deliberate or unconscious manipulation by the patient&#46; Several terms have been used to describe this clinical picture&#44; including <span class="elsevierStyleItalic">factitious lip crusting</span>&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a><span class="elsevierStyleItalic">factitious cheilitis</span>&#44;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">38&#8211;40</span></a> and <span class="elsevierStyleItalic">exfoliative cheilitis artefacta</span>&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">41&#8211;43</span></a> It has been speculated that the mechanism of production might be repeated manipulation of the lips with the teeth&#44; tongue&#44; or even instruments&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> In some cases&#44; the nasal pyramid is affected&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Our series included 6 patients &#40;5 women and 1 man&#41; with localized crusting&#59; in one of the women&#44; the crust was located on a finger&#46; One of the woman &#40;<a class="elsevierStyleCrossRef" href="#fig0050">Fig&#46; 10</a>&#41; had concomitant anorexia nervosa&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">45&#44;46</span></a></p><elsevierMultimedia ident="fig0050"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6&#46;</span><p id="par0130" class="elsevierStylePara elsevierViewall">Eczematous lesions&#46; Some patients produce eczematous lesions by applying irritants to the skin<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> or exposing themselves repeatedly to an allergen in the case of patients with allergic contact dermatitis&#46; It is sometimes difficult to prove the cause of such lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7&#46;</span><p id="par0135" class="elsevierStylePara elsevierViewall">Edemas&#46; In 1911&#44; Secretan<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> described swollen limbs as a possible presentation of self-inflicted disease&#46; Angelini et al&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> later called this form of self-harm Secretan syndrome&#46; Smith<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> defined a set of criteria that should raise a suspicion that the lymphedema is factitious&#58; recurrent unilateral lymphedema without any apparent lymphatic or venous obstruction and any lymphedema that is clearly delimited by a ring of a different coloration&#46; Several types of edema caused by ligatures are reported in the literature&#44; including edema of the nipple&#44;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> the tongue&#44;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a> the neck&#44;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a> and even of the scrotum leading to self-castration&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a></p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8&#46;</span><p id="par0140" class="elsevierStylePara elsevierViewall">Purpuras and bruises&#46; Gardner and Diamond<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a> first described the autoerythrocyte sensitization syndrome&#44; which is characterized by painful ecchymoses in sites within reach of the hands&#44; typically in women with psychological disorders &#40;<a class="elsevierStyleCrossRef" href="#fig0055">Fig&#46; 11</a>&#41;&#46; The patients&#8217; hypersensitivity to injections of their own blood has been used as a diagnostic criterion&#46; Some authors have tried to differentiate between purpura factitia and autoerythrocyte hypersensitivity syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a> In their view&#44; the latter condition is characterized by the presence of prior pain and possibly bleeding in internal organs&#44; while the appearance of lesions in purpura factitia is not preceded by pain and the results of challenge tests with the patient&#39;s own blood are negative if the site is protected with a bandage&#46; However&#44; the criteria for differentiating between purpura factitia and autoerythrocyte hypersensitivity syndrome are unclear&#46; Despite these nosological difficulties&#44; the authors of a recent review of the literature including 162 cases propose treatment with psychotropic drugs and psychotherapy&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">58</span></a> While differentiating these 2 disorders is difficult&#44;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a> the case of a patient with DA and painful bruising syndrome may be of some help&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">60</span></a></p><elsevierMultimedia ident="fig0055"></elsevierMultimedia></li></ul></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0145" class="elsevierStylePara elsevierViewall">In our series&#44; 3 women &#40;aged 26&#44; 27&#44; and 36 years&#41; had this condition&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">The spectrum of clinical presentations of DA could be even broader than that described here as the manifestations depend on the patient&#39;s imagination&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Diagnosis</span><p id="par0155" class="elsevierStylePara elsevierViewall">A diagnosis of DA is difficult to establish because of the great variety of possible dermatologic conditions&#46; The situation is further complicated by the diversity of methods used by patients to self-harm and the ingenuity they employ in doing so &#40;<a class="elsevierStyleCrossRef" href="#fig0060">Fig&#46; 12</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a></p><elsevierMultimedia ident="fig0060"></elsevierMultimedia><p id="par0160" class="elsevierStylePara elsevierViewall">Three aspects can be used to establish a diagnosis of self-inflicted skin lesions&#58; <span class="elsevierStyleItalic">a&#41;</span> the morphology of the lesion&#59; <span class="elsevierStyleItalic">b&#41;</span> the patient&#39;s personality&#59; and <span class="elsevierStyleItalic">c&#41;</span> the medical history&#46; However&#44; it is not advisable to establish a diagnosis based on just one of these criteria&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a> DA is the somatic expression of extremely serious and deeply buried mental suffering&#44; of which the patient is unaware&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> In DA&#44; the normal roles of patient&#44; physician&#44; and disease are subverted&#46; This subversion takes the form of a twofold challenge&#44; psychological on the one hand and a challenge to the standards underpinning medical practice on the other&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">The diagnosis should not be reached merely by a process of elimination&#44; but should rather be established from among the possible alternatives&#46; The diagnosis of DA is made on the basis of a combination of positive dermatological and psychological findings and requires the collaboration of the medical team and their acceptance that DA is the expression of significant mental suffering&#44; of which the patient is unaware&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Although very old&#44; the Stokes and Gardner classification is still a useful tool for establishing a diagnosis of self-inflicted lesions&#46; In the following sections we will outline the different aspects that form the basis of that classification&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">62</span></a></p><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Shape and Configuration of Lesions</span><p id="par0175" class="elsevierStylePara elsevierViewall">The diagnosis should be determined by the shape of the lesions and by ruling out other skin disorders with clearly defined characteristics&#46; Although the lesions may be caused by chemical or thermal burns&#44; they can also be the result of trauma&#46; Cutaneous artifacts caused by an instrument tend to be regular and geometric in shape &#40;<a class="elsevierStyleCrossRef" href="#fig0065">Fig&#46; 13</a>&#41;&#44; an uncommon morphology in the case of spontaneous eruptions&#46; Chemical burns are regular in shape&#44; although at times their borders may be interrupted by fingerlike projections caused by the linear spread of drips of the caustic liquid used to produce the lesion&#46;</p><elsevierMultimedia ident="fig0065"></elsevierMultimedia><p id="par0180" class="elsevierStylePara elsevierViewall">Lesions sometimes have a bizarre or fantastic appearance<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">63</span></a> &#40;<a class="elsevierStyleCrossRefs" href="#fig0070">Figs&#46; 14 and 15</a>&#41;&#44; appearing suddenly at irregular intervals&#44; generally singly or in pairs&#46; The course may be unusually rapid&#46; When the caustic substance is applied using a needle or tweezers&#44; a method frequently used in gangrenous areas&#44; the edges of the lesion have a saw-tooth or serrated appearance&#44; caused by the repeated pricks made along the leading edge&#46; When escharotic lesions are observed&#44; they tend to be superficial and the scabbed area is separated from the normal skin by an intensely erythematous border&#46;</p><elsevierMultimedia ident="fig0070"></elsevierMultimedia><elsevierMultimedia ident="fig0075"></elsevierMultimedia><p id="par0185" class="elsevierStylePara elsevierViewall">It is sometimes possible to determine that the nails&#44; fingers or a sharp object in the patient&#39;s possession are impregnated with the causal agent&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">In summary&#44; to the eyes of an expert&#44; these lesions will appear odd from the very beginning and are easily recognized as unexpected and dubious&#46; The initial impression of self-harm is strong &#40;<a class="elsevierStyleCrossRef" href="#fig0080">Fig&#46; 16</a>&#41; and this is of great importance for the diagnosis&#59; however&#44; a diagnosis of self-harm should not be reached without careful critical analysis&#46; Closer examination of the manifestations may provide the physician with evidence that will confirm the diagnosis of a self-inflicted lesion&#46; DA is always destructive &#40;ulcers&#44; enucleations&#44; gangrene&#41;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> although such a clinical picture alone is not enough to establish a diagnosis of DA&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p><elsevierMultimedia ident="fig0080"></elsevierMultimedia><p id="par0195" class="elsevierStylePara elsevierViewall">Our series yielded a number of findings not yet reported in the literature&#58; we were able to establish that the creation of lesions in multiple sites was more common among women&#44; while solitary lesions were mainly observed in men&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Distribution of the Lesions</span><p id="par0200" class="elsevierStylePara elsevierViewall">The lesions are generally located in areas accessible to the hands and tend to be more numerous in sites accessible to the right hand in right-handed patients and vice versa&#46; When choosing sites for lesions patients typically avoid the palms&#44; soles&#44; nose&#44; mouth&#44; scalp&#44; genitals&#44; and the outer ear&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">63</span></a> The presence of lesions in an area inaccessible to the hands does not necessarily rule out a diagnosis of DA&#44; since such sites can be reached by other means&#46; Lesions are sometimes distributed regularly around a central point&#44; such as a nipple or the navel&#44; and they are often located close to a previous lesion&#44; in an attempt to extend the original damage&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">The sites found in our series were as follows&#58; the face &#40;34&#46;5&#37;&#41;&#44; the lower limbs &#40;25&#37;&#41;&#44; the upper limbs &#40;16&#46;6&#37;&#41;&#44; and the hands &#40;15&#46;5&#37;&#41;&#46; The most common site in men was the legs &#40;51&#37;&#41; and in women the face &#40;40&#37;&#41;&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">If&#44; as Fabisch<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">64</span></a> has suggested&#44; the anatomical site of the lesion has a psychological significance that should be taken into account by the psychotherapist&#44; it is interesting to highlight the large number of women in our case series with lesions affecting the breasts &#40;<a class="elsevierStyleCrossRef" href="#fig0085">Fig&#46; 17</a>&#41;&#44; in some cases involving very destructive clinical forms&#46;</p><elsevierMultimedia ident="fig0085"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">The Patient&#39;s Demeanor</span><p id="par0215" class="elsevierStylePara elsevierViewall">Great importance is placed on the appearance and demeanor of the patient with DA&#46; Typical descriptions include anxiousness&#44; fine tremor of the facial muscles&#44; tearful eyes&#44; or on the contrary&#44; a poker face or Mona Lisa expression&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> Some patients exhibit the calm of a tense person or a gaze with erotic connotations &#40;bedroom eyes&#41;&#46; Another remarkable characteristic seen in some patients is an attitude of great mental calm and complacency about their condition &#40;what the French call <span class="elsevierStyleItalic">la belle indifference</span>&#41;&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Young patients are sometimes accompanied by domineering parents or solicitous parents will accompany a difficult and precocious child&#46; The patient&#39;s interest in their lesions&#44; a tendency to display them and to express anger are all signs that should raise a suspicion of self-harm&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">The patient&#39;s expression can range from guilty&#44; furtive&#44; or unfriendly to one of obvious pretense&#46; Some patients may be reserved and uncommunicative or display signs of low intelligence&#44; although in Lyell&#39;s<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> view a high level of intelligence is also compatible with a diagnosis of DA&#44; while a mature personality is not&#46; Obviously none of these criteria is absolute&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Timing</span><p id="par0230" class="elsevierStylePara elsevierViewall">Recurrence following periods of stress&#44; sleepwalking episodes&#44; the patient&#39;s failure to return after several visits&#44; the appearance of lesions on certain dates&#44; and lesions that appear overnight are all signs of self-harm&#46; Another circumstance that may suggest DA is when the recurrence of lesions coincides with a new job&#44; moving house&#44; a new school&#44; the death of a family member&#44; or any other event likely to cause mental stress&#44; depending on the age and circumstances of the patient&#46; In such cases&#44; the lesion can be interpreted as an attempt at nonverbal communication&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">64</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">The patients&#8217; inability to talk about the origin of their lesions or their lack of interest in the subject prevents the dermatologist from gaining a clear idea of the situation&#46; The patient&#39;s account of the lesions is sometimes so lacking in substance that Gandy<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> coined the term <span class="elsevierStyleItalic">hollow history</span>&#46; This perplexity about what is happening is expressed by the patient in bitter and hostile terms&#44; and new lesions will continue to appear as long as the conditions are favorable&#44; that is&#44; as long as the patient enjoys privacy and a supply of the necessary materials&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">Another term used in DA is <span class="elsevierStyleItalic">melodramatic prophecy</span>&#44; referring to predictions by patients concerning when and where new lesions will appear&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Many patients with DA play games with their physicians informing them 12 or 24<span class="elsevierStyleHsp" style=""></span>hours before the lesions appear what sites will be affected&#44; explaining that the lesion will be preceded by heat&#44; burning&#44; or some other abnormal sensation&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">63</span></a> In other cases lesions appear in a place where the dermatologist has suggested they might occur&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Assessment of Neurological Signs and Symptoms</span><p id="par0245" class="elsevierStylePara elsevierViewall">Subjective sensations&#44; such as pain and burning&#44; may be exaggerated by patients with DA&#46; The patient&#39;s psychiatric history should be investigated to establish whether he or she has had any previous psychiatric diagnosis or has a family history of mental illness&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study of Motives</span><p id="par0250" class="elsevierStylePara elsevierViewall">In the case of patients with a hysterical personality&#44; the motive for self-harm is to deceive&#44; but the underlying cause is solely the desire to be a sick person in order to escape personal obligations and inner conflicts<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">65&#44;66</span></a> even though there may be no apparent justification for the patient&#39;s conduct&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">67</span></a> The possible motives for DA will be as varied as are human personalities and the situations of life itself&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> The motive can sometimes be a simple desire to arouse the sympathy of relatives or friends or an attempt to rationalize feelings of frustration or failure in life&#59; in other cases the behavior may be a result of conflict in the patient&#39;s social environment&#44; financial problems&#44; a lack of self-esteem&#44; atonement for guilt&#44; revenge&#44; or a way to escape responsibilities&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">68</span></a> Patients who create skin artifacts are also trying&#44; often unconsciously&#44; to attract the attention of those around them to an inner conflict for which they have no solution&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">Malingerers and fraudsters do not easily fool doctors<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;69</span></a> because the patient who merely contrives disease is an impostor&#59; in such cases the external incentive for the behavior must be found to confirm the diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> Such individuals typically use lesions to achieve a secondary goal&#58; to excuse failure&#44; attract sympathy&#44; escape responsibilities&#44; or simply to delay making a payment that is due&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">70</span></a> They may have criminal motives&#44; such as fraud or avoidance of a legal obligation&#44;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">67</span></a> or even use the situation to obtain privileges&#44; money&#44; or narcotics&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Histology</span><p id="par0260" class="elsevierStylePara elsevierViewall">A fairly common characteristic in the histology of DA is that superficial involvement predominates over deeper involvement&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a> Typically&#44; abnormal findings are restricted to the epidermis and no accumulation of lymphocytes or signs of vasculitis are found&#46; However&#44; the findings are not diagnostic and in most cases will depend on the method used to create the lesion&#46; A wide range of histologic findings have been reported&#44; including<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">71</span></a> erosion&#44; acanthotic epidermis&#44; chronic perivascular infiltrate&#44; and foreign-body reaction with birefringent material&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">33&#44;34</span></a></p><p id="par0265" class="elsevierStylePara elsevierViewall">Whenever possible a biopsy should be obtained because histologic findings have in many cases been fundamental to the diagnosis&#44; particularly when other skin conditions have been confused with DA&#46; Perhaps the dermatological diagnosis most often confused with DA is pyoderma gangrenosum&#46; DA has also been confused with pyoderma and vice versa&#46;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">72&#8211;74</span></a> Conditions misdiagnosed as DA on the basis of clinical findings have been shown by histologic findings to be genuine panniculitis-like T-cell lymphoma&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">75</span></a> By contrast&#44; a case of DA on a girl&#39;s face mimicked a lymphoma&#44;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">76</span></a> while in other cases erosive lichen planus&#44;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">77</span></a> cryoglobulinemia&#44;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">78</span></a> and acquired hemophilia<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">79</span></a> were misdiagnosed as DA&#46; In other cases DA presented clinically as vasculitis<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">80</span></a> and trigeminal trophic syndrome was misdiagnosed as DA due to the absence of abnormal histologic findings&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">81</span></a></p><p id="par0270" class="elsevierStylePara elsevierViewall">It is sometimes essential to use more complex histologic techniques&#44; such as X-ray analysis and spectrophotometry&#46; In one case&#44; spectrophotometry demonstrated that the cause of recurrent abscesses was cellulose&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">82</span></a> In an earlier case&#44; electron probe microanalysis was used to determine the presence and nature of factitious granulomas&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">83</span></a> Friction blisters at the level of the distal stratum granulosum have been reported&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">84</span></a> The presence of birefringent material and pseudocystic spaces replacing fat are important indications that will help to establish the diagnosis of factitious panniculitis&#46;</p><p id="par0275" class="elsevierStylePara elsevierViewall">There is no doubt that DA lesions can mimic other skin processes&#46; McCormac<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">67</span></a> makes the point that&#44; while it is clear that a patient cannot produce lesions that simulate psoriasis or lichen planus&#44; they can create lesions with a very obvious inflammatory substrate&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Differential Diagnosis</span><p id="par0280" class="elsevierStylePara elsevierViewall">The dermatological condition most likely to cause problems in the differential diagnosis of DA is neurotic excoriation&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">85</span></a> While the lesions in this condition are also self-inflicted&#44; the patients do not try to deceive the physician&#59; they are victims of an irresistible urge to pick&#44; scratch&#44; or otherwise manipulate the skin&#44; nails&#44; or hair&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Another important difference between neurotic excoriation and DA is that patients with the former only use their nails while patients with DA may use a range of methods to damage the skin&#46;</p><p id="par0285" class="elsevierStylePara elsevierViewall">DA must be differentiated from the skin lesions produced by psychotic patients&#44; who may use their fingernails to excoriate the skin and cause ulcers that may become infected&#46; In such cases&#44; there is no doubt about the origin of the lesions because the patient causes them in view of other people&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Psychopathology</span><p id="par0290" class="elsevierStylePara elsevierViewall">Experts concur that DA is a cutaneous manifestation of a psychiatric disorder and the condition is classified in the DSM-IV &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0295" class="elsevierStylePara elsevierViewall">One of the chief concerns of physicians who study DA is to identify a motive that would justify the behavior of patients who self-harm&#44; although some clinicians and dermatologists have minimized the role of the mind in the development and perpetuation of certain types of skin disease by applying the frivolous designation &#8220;nervous&#8221; and have failed to ensure that the patient receive appropriate psychiatric treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">86</span></a> Fortunately&#44; the work of English&#44;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">87</span></a> Cormia&#44;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">88</span></a> and Zaidens<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">89</span></a> has led to a better understanding of psychosomatic conditions and improved treatment&#46;</p><p id="par0300" class="elsevierStylePara elsevierViewall">There is no consensus about the personality type involved in DA&#46; Some authors consider that there are 2 types of patients&#44; some hysterical and others who are simply malingerers&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;25&#44;67&#44;70&#44;90</span></a> Others classify patients with DA as hysterical or psychotic&#46;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">68&#44;86</span></a> Michelson<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">66</span></a> and Susskind<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">90</span></a> believe that all DA patients are hysterical&#44; while Koblenzer<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">91</span></a> considers them all to be borderline psychotic&#46; Factitious disease appears to be a kind of emotional safety valve in emotionally immature patients who typically present hysterical and masochistic characteristics&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Lesions may be produced when patients are in an altered psychogenic&#44; borderline&#44;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">92</span></a> or dissociative state&#44; so that they are not conscious of their actions&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The psychological importance of DA is that while the patients consciously produce the lesions&#44; they are unaware of the reasons for their self-destructive behavior&#46; Patients may exaggerate pain&#44; adopting the role of martyr&#44; and this posture is confirmed by their great capacity to take pleasure in tolerating pain&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">86</span></a></p><p id="par0305" class="elsevierStylePara elsevierViewall">Although they cannot be considered to have psychotic personalities&#44; many patients with DA do have a borderline personality structure and are unable to develop mature relationships&#46; They use their lesions to maintain contact with others and to get the attention they desperately need to fill their emotional vacuum&#46; Another motive for self-harm may be a desire to do penance for unconscious sins or their behavior may be a displaced expression of infantile rage&#46;<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">91</span></a></p><p id="par0310" class="elsevierStylePara elsevierViewall">Musaph<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">93</span></a> considers that patients with DA produce their symptoms unconsciously&#44; and psychiatric-psychological studies have revealed that the condition is in part due to aggressive sexual feelings directed against key figures in the patient&#39;s childhood&#46;</p><p id="par0315" class="elsevierStylePara elsevierViewall">Zaidens<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">92</span></a> is the author who has perhaps contributed the most psychological and psychiatric studies on DA&#46; She believes that self-inflicted dermatitis represents frustration&#44; resentment&#44; a demand for attention&#44; anxiety&#44; hostility&#44; and helplessness&#46; The self-destruction is proportional to the severity of the underlying emotional disturbance&#46;</p><p id="par0320" class="elsevierStylePara elsevierViewall">Auto-destructive mechanisms develop in dependent and timid individuals who are unable to express themselves&#46; These patients have been conceived and reared in an environment fettered by emotional barriers&#44; and their growth has not been very important to their parents&#44; particularly their mothers&#46; Most patients with DA are adults in middle-age who have not achieved their life goals or have not achieved the levels of success typical of their class models&#44; in either social or economic terms&#46;<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">94</span></a> In psychological terms&#44; they use DA to get sympathy&#44; attention&#44; pity&#44; or compensation&#46; Moreover&#44; since patients with DA are unable to deal with their problems&#44; or to even admit that they have a problem&#44; the lesions provide them with an excuse they can use to rationalize their frustrations&#46;</p><p id="par0325" class="elsevierStylePara elsevierViewall">DA sometimes appears in the context of a <span class="elsevierStyleItalic">folie &#224; deux</span> or shared dementia&#46; Shared dementia is a psychotic disorder characterized by the development of a hallucinatory pattern shared by 2 people&#46; Since those affected have a long-lasting intimate relationship&#44; the disorder is not uncommon in older adults&#46;<a class="elsevierStyleCrossRefs" href="#bib0475"><span class="elsevierStyleSup">95&#44;96</span></a> It sometimes involves a mother and her children<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">97</span></a> and forms part of a syndrome of childhood abuse&#46;</p><p id="par0330" class="elsevierStylePara elsevierViewall">Self-inflicted dermatoses are also observed in patients with anorexia nervosa&#46;</p><p id="par0335" class="elsevierStylePara elsevierViewall">Factitious disease involves many paradoxes&#44; the most important of which is that the patient causes the physical symptoms and seeks a remedy for them&#46; The psychodynamic etiology of factitious disorders may be related to a history of abuse or neglect in childhood&#44; early emotional deprivation&#44; or lack of care&#46; All of these factors are found frequently in the history of these patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">47&#44;98</span></a> Some authors have interpreted DA to be a disorder caused by borderline personality&#46; In their opinion&#44; the patient is both victim and punisher&#44; a person intent on capturing the attention of doctors while at the same time challenging them and devaluing their usefulness&#46; The additional benefit of playing the role of a sick person &#40;thereby obtaining attention&#44; support&#44; and sympathy while escaping responsibilities&#41; may also be important to these patients&#46; By simulating a disease patients can evade responsibilities and satisfy their dependence needs&#44; even though in DA this goal is achieved in a bizarre and self-destructive manner&#46;</p><p id="par0340" class="elsevierStylePara elsevierViewall">DA is not indicative of a particular personality organization&#44; but the patient&#39;s personality type is a prognostic factor&#44; as is the age of onset&#46; In adolescents the disorder is usually a cry for help&#46; The most common personality type in men with DA is paranoid while in women it is hysterical&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0345" class="elsevierStylePara elsevierViewall">It is currently thought that DA occurs in patients with a borderline personality disorder&#44; although an association has also been described with impulse control disorder<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">99</span></a> and obsessive compulsive disorder&#46;<a class="elsevierStyleCrossRefs" href="#bib0500"><span class="elsevierStyleSup">100&#44;101</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Prognosis</span><p id="par0350" class="elsevierStylePara elsevierViewall">Several follow-up studies have been carried out to assess the prognosis in patients with DA&#46; The first of these was undertaken by McCormack&#44;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">67</span></a> who sent a questionnaire to 10 patients&#46; Only 5 answered&#44; and the findings of that study indicated that the condition is more uncommon in patients over 25 years of age&#46; Subsequently&#44; Sneddon et al&#44;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">101</span></a> who studied 43 patients &#40;38 women and 5 men&#41;&#44; reported that DA was only one incident in a long history of mental illness&#46; However&#44; 30&#37; of the patients in that study &#40;12 women and one man&#41; continued to self-inflict lesions or had other mental illnesses 12 years after the onset of DA&#46; Years later&#44; Haenel et al&#46;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">98</span></a> invited 59 patients &#40;52 women and 7 men&#41; who had been diagnosed with DA to be reassessed&#46; Of the 36 women and 2 men who responded&#44; DA had resolved in 9&#44; but the others still had recurrent lesions&#46; Eight of the 36 women reported one or more suicide attempts&#46; In a follow-up study carried out in our own department&#44;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;102</span></a> 61 patients who had been diagnosed with DA were invited to attend the clinic for reassessment&#46; Nine &#40;8 women and 1 man&#41; of the 34 patients who responded &#40;24 women and 10 men&#41; were still affected by DA&#44; an indication that this is a chronic and insidious disorder&#46;</p><p id="par0355" class="elsevierStylePara elsevierViewall">Malignant transformation of a lesion was reported in a woman with DA who persistently excoriated a cholecystectomy scar over 40 years&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">103</span></a> Another similar case involved the development of a malignant tumor in an ulcer on the face of a 49-year-old man&#44; which the patient scratched compulsively&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">104</span></a> In both these cases&#44; the malignancy was a Marjolin ulcer&#44; a squamous cell carcinoma that arises in a chronic ulcer&#46; The most common complications of DA are related to infections&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Treatment</span><p id="par0360" class="elsevierStylePara elsevierViewall">DA probably represents one of the greatest therapeutic challenges in dermatology&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Consoli<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> suggested that the 3 pillars of treatment should be <span class="elsevierStyleItalic">a&#41;</span> restructuring the patient&#39;s personality&#44; <span class="elsevierStyleItalic">b&#41;</span> drug treatment for the psychiatric condition&#44; and <span class="elsevierStyleItalic">c&#41;</span> medical treatment of the skin lesions&#46; A prolonged period during which a friendly relationship can be established with the patient may help to prevent abrupt termination of treatment when the patient is finally confronted with the real situation&#46; If this initial confrontation does not provoke a negative reaction or cause the patient to abandon treatment&#44; a mental health treatment plan can be implemented&#44; if possible including inpatient treatment&#46; A supportive approach avoiding condemnation is always preferable&#46; The dermatologist should be prepared for a prolonged course of treatment with repeated relapses and should never express disappointment or hostility over these failures&#46; The cost of treating DA in 1 patient over 5 years of consultations has been estimated at &#8364;64&#160;500&#46;<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">105</span></a></p><p id="par0365" class="elsevierStylePara elsevierViewall">The treatment of factitious disease is often unsatisfactory&#44; whether it is managed by a dermatologist&#44; a psychiatrist&#44; or both&#46; Maybe the underlying reason is that these patients are in hiding and although they have to consult a physician because their symptoms are so obvious they do not wish to be cured&#46;</p><p id="par0370" class="elsevierStylePara elsevierViewall">The ideal approach is to refer the patient to a psychiatrist&#44; but patients find such a referral incomprehensible because they believe they have a dermatological condition and do not understand why the dermatologist does not want to cure the lesions&#46; As Sneddon<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> has said&#44; the treatment of patients with DA is difficult because&#44; although they need the help of a psychiatrist&#44; they reject this advice and any suggestion that their disease is not organic leads to a traumatic and conflictive visit after which they change doctors&#46; When it is impossible to convince the patient to consult a psychiatrist&#44; therapy with psychotropic drugs can be very helpful&#46; The following drugs have been shown to be useful&#58; selective serotonin reuptake inhibitors&#44;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">58</span></a> pimozide &#40;0&#46;5-1<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#41;&#44; aripiprazole &#40;2-5<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#41;&#44; or risperidone &#40;0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0530"><span class="elsevierStyleSup">106&#44;107</span></a> Other measures and treatments that have been proposed include relaxation therapy&#44; anxiolytics&#44; antidepressants&#44; and low doses of second-generation antipsychotics&#46;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">108</span></a>The skin lesions can be cured with the aid of occlusive dressings &#40;adhesive zinc or sometimes plaster wrap&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">106</span></a> Rapid healing of a bandaged ulcer that has previously proved refractory to all treatment is a sign of great diagnostic value&#44; as is the appearance of new lesions on unbandaged and&#44; in most cases&#44; previously unaffected areas&#46; As occlusive bandages can be pierced by sharp instruments and patients can inject substances through the dressing&#44; a sheet of aluminum foil may be included in the dressing to record the evidence of any such manipulations on the part of the patient&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Ethical Disclosures</span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Protection of human and animal subjects</span><p id="par0375" class="elsevierStylePara elsevierViewall">The authors state that no experiments were performed on humans or animals for this investigation&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Confidentiality of data</span><p id="par0380" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their workplace concerning the publication of patient data&#44; and that all the patients included in this study have been appropriately informed and gave their written informed consent to participate in this study&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Right to privacy and informed consent</span><p id="par0385" class="elsevierStylePara elsevierViewall">The authors declare that no private patient data are disclosed in this article</p></span></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflicts of Interests</span><p id="par0390" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Keywords"
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          "titulo" => "Introduction"
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          "titulo" => "Definition"
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          "titulo" => "Clinical Features"
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          "titulo" => "Diagnosis"
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            0 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Shape and Configuration of Lesions"
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              "titulo" => "Distribution of the Lesions"
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            2 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "The Patient&#39;s Demeanor"
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              "titulo" => "Timing"
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              "titulo" => "Assessment of Neurological Signs and Symptoms"
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              "identificador" => "sec0055"
              "titulo" => "Study of Motives"
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          "titulo" => "Histology"
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        10 => array:2 [
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          "titulo" => "Differential Diagnosis"
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        11 => array:2 [
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          "titulo" => "Psychopathology"
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        12 => array:2 [
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          "titulo" => "Ethical Disclosures"
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              "titulo" => "Protection of human and animal subjects"
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            1 => array:2 [
              "identificador" => "sec0095"
              "titulo" => "Confidentiality of data"
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            2 => array:2 [
              "identificador" => "sec0100"
              "titulo" => "Right to privacy and informed consent"
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          "titulo" => "Conflicts of Interests"
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          "titulo" => "References"
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    "fechaRecibido" => "2011-11-23"
    "fechaAceptado" => "2012-10-14"
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          "palabras" => array:3 [
            0 => "Dermatitis artefacta"
            1 => "Self-inflicted lesions"
            2 => "Factitious dermatitis"
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            0 => "Dermatitis artefacta"
            1 => "Lesiones autoprovocadas"
            2 => "Dermatitis facticia"
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        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Dermatitis artefacta is a rarely diagnosed disorder that is often a source of perplexity and anxiety for dermatologists because they know less about the cause of this self-inflicted condition than the patients themselves&#46; It differs from other skin disorders in that diagnosis is made by exclusion rather than on the basis of histologic and biochemical findings and therefore involves a considerable investment of time and resources&#46; Based on the findings of a study of 201 patients diagnosed with dermatitis artefacta between 1976 and 2006&#44; we review the different clinical presentations of this skin disorder and discuss its diagnosis and treatment&#46; The series analyzed comprised 152 women and 49 men &#40;female to male ratio of 3&#46;1&#58;1&#41; with a mean age of 31&#46;2 years&#46; The patients were mostly single and had a low educational level and few or no job qualifications or skills&#46;</p>"
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        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La dermatitis artefacta &#40;DA&#41; es un diagn&#243;stico excepcional&#44; que genera perplejidad y ansiedad al dermat&#243;logo al encontrase ante una patolog&#237;a autoprovocada y de la que el paciente sabe m&#225;s que el m&#233;dico en cuanto a su etiolog&#237;a&#46; Al contrario que otras dermatosis en la que existen pruebas histol&#243;gicas o bioqu&#237;micas&#44; en la DA el diagn&#243;stico es de exclusi&#243;n lo que exige un gran consumo de recursos y de tiempo&#46; En el presente trabajo repasamos las diversas formas cl&#237;nicas&#44; criterios diagn&#243;sticos y manejo de estos pacientes y para ello nos basamos en la experiencia del estudio que realizamos de 201 casos de DA diagnosticados entre 1976 y 2006&#44; de los cuales 152 eran mujeres y 49 varones&#44; con una proporci&#243;n de mujeres&#47;varones de 3&#46;1&#47;1&#46; La edad media fue de 31&#46;2 a&#241;os y estaba mayoritariamente constituida por personas con escasa o nula cualificaci&#243;n laboral&#44; bajo nivel cultural y mayoritariamente solteros&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Rodr&#237;guez Pichardo A&#44; Garc&#237;a Bravo B&#46; Dermatitis artefacta&#58; revisi&#243;n&#46; Actas Dermosifiliogr&#46; 2013&#59;104&#58;854&#8211;866&#46;</p>"
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                      "titulo" => "Dermatitis artefacta&#46; Clinical study of 201 patients &#40;1976-2006&#41;"
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