engleski

Jumping to conclusions - dermatitis artefacta

NTRODUCTION & OBJECTIVES: Dermatitis artefacta describes self-inflicted skin lesions with various clinical expressions depending on manner of injuries infliction. Typically, lesions are localized on self reachable parts of skin. Personality disorders and, rarely, psychotic disorders are foundation of such behavior. Other risk factors are genetic predisposition and chronic diseases. Dermatitis artefacta can mimic variety of dermatoses with broad spectrum of differential diagnoses. MATERIAL & METHODS: Case: A 55-years old female presented in our Clinic with symmetric cicatricial lesions on cheeks and superficial erosion with indurated erythematous border all covered with serous crust located on nose and left cheek. For the last three years she has had the same symptoms, diagnostic procedure in another institution excluded tumors, sarcoidosis and tuberculosis cutis. Three biopsies revealed cicatricial changes and nonspecific inflammatory process and consequently has been treated under the diagnosis Dermatitis artefacta. Our working diagnosis was discoid lupus erythematosus (DLE) and new biopsy showed some elements which correspond to DLE, on the other hand, direct immunofluorescence of biopsied skin lesion, sun protected and unprotected uninvolved skin did not identify deposits of immunoglobuline or complement components. Basic laboratory findings were in normal ranges, chest x-ray was normal ; ANA were negative as well as dsDNA antibody. Clinical psychologist found no basis for diagnosis of Dermatitis artefacta and immunologist excluded systemic lupus erythematosus. Chloroquine was introduced in dosage of 2x250 mg daily for 10 days and afterwards 1x250 mg daily. Topical high-potency corticosteroids and topical antibiotics were applied locally. Since there was no appropriate respond to therapy, systemic metylprednisolone was included in initial dosage of 24 mg daily tapered to maintenance doses of 8 mg daily. Applied therapy resulted with regression of lesions without relapses. Metylprednisolone was excluded due to gastrointestinal side-effects which led to exacerbation of skin disease. Immunologist advised extension of chloroquine therapy. CONCLUSIONS: Non characteristic clinical presentation, negative DIF of involved skin, weak therapeutic effect to chloroquine and frequent relapses of erosions, diagnosis of dermatitis artefacta was never completely excluded, regardless to no psychological substrate.

dermatitis artefacta; DLE

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