








key: cord-297400-l8fhy1hu
authors: Adebanjo, Ganiyat Adenike Ralitsa; Francesca Romana, Parisella; Cittadini, Andrea; Luzi, Fabiola; Tammaro, Antonella
title: A case of dermatitis artefacta during a pandemic
date: 2020-08-26
journal: Dermatol Ther
DOI: 10.1111/dth.14235
sha: 
doc_id: 297400
cord_uid: l8fhy1hu

nan

Dear Editor,

The beginning of the pandemic of COVID-19 was associated to extreme measures taken by different countries to prevent and contain its spread: Italy was among the first states that decided to set up travels bans and policies in order to limit the burden of the disease.

The implications of this crisis have been associated to adverse psychological outcomes in the general population: as a matter of fact, individuals who were already at risk had to endure additional psychological trauma because of the loss of their loved ones, unemployment and the need to be isolated or quarantined 1 .

A 68-year-old woman, who had been affected by mood and anxiety disorders for many years, presented during the COVID-19 lockdown period with self-inflicted skin lesions on several part of the body.

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On physical examination, she had numerous pruritic circular erythematous lesions on the extensor surfaces of her forearms ( Figure 1, Figure 2 ). A biopsy of the lesioned skin was performed and it showed an excoriated epidermis with pseudoepitheliomatous hyperplasia (pruritic eczema-like findings). Furthermore, the superficial dermis was characterized by small proliferating capillary vessels indicating a chronic process. Laboratory routine investigations were normal.

All in all, given the clinical picture of the patient, a diagnosis of dermatitis artefacta was made and the patient was sent to the Psychiatry department of our hospital for a consultation.

The diagnosis was confirmed by the psychiatrist as well: in fact, he reported that the patient injured her skin in a compulsive way and could not avoid it although aware of the risks underlying this behavior. In previous distressing conditions of her life (a conflicting relationship with her adopted child, breast cancer and chemotherapy at 58 years old, and pituitary gland surgery), the patient had never injured her skin producing dermatitis. Nevertheless, she experienced depression and anxiety. During the recent period, the fear of a possible COVID-19 infection, reinforced by media information, the lockdown condition and staying at home all day for several weeks produced an increased anxiety state with severe emotional distress.

The patient was prescribed oral tablet sertraline (100 mg/day) and oral tablet alprazolam (1 mg/day); plus, she was given additional appointments to follow up her psychological status.

Emollient creams were applied on the lesions, improving the pruritus and the appearance of the erythematous areas.

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week follow-up ( Figure 3 ).

Dermatitis artefacta, which is also referred to as factitious dermatitis, is a frequently unrecognized clinical entity associated with self-injury behavior, in which conscious or unconscious manipulation causes skin lesions 2,3 . The auto-inflicted damage is likely to be found in areas of the body that are easily reachable and it stems from an attempt to shift the focus from psychological and/or social conflicts to a tangible entity like the skin 4 . Factitious dermatitis is a psychocutaneous disorder which is more prevalent among women and it is frequently associated to a variable degree of psychological distress and a history of psychiatric disorders 4 .

There is a plethora of skin lesions which may be associated to dermatitis artefacta and they are often endowed with non-specific pathophysiological findings 5 as in the case of our patient. The diagnosis can be challenging because of the dearth of unequivocal diagnostic tools 3, 4 , hence it is made by exclusion of other skin diseases. The conditions that should be included in the differential diagnosis are vascular disorders, allergic contact dermatitis and prurigo nodularis 6, 7 . Typically, the latter presents with dome shaped lesions on the extensor surfaces of the limbs on the background of a preexisting chronic pruritic condition 8 . On the other hand, dermatitis artefacta is usually associated to lesions which are heterogeneous in appearance and that are produced to fulfill a subconscious need to be seen as vulnerable 9 : in this case the pruritus is a consequence of the disease and not a preceding factor. This article is protected by copyright. All rights reserved.

We decided to report this case because in this patient dermatitis artefacta seems to be related to and appeared in coincidence with the COVID-19 emergency and lockdown. Moreover, we believe that there will be an increase of dermatitis artefacta incidence in the near future resulting from the ubiquitous effects of the COVID-19 emergency.

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