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On-line version ISSN 1806-4841
An. Bras. Dermatol. vol.85 no.1 Rio de Janeiro Jan./Feb. 2010
Náiade Maria Rêgo e SilvaI; Giannina Wanderley PetrucciII; Esther Bastos PalitotIII; Mohamed Arbaqui AzzouzIV; Samir de Figueiredo AzzouzV
IMedical student, Federal University of Paraíba (UFPB), João Pessoa, PB, Brazil
IIMedical student, Federal University of Paraíba (UFPB), João Pessoa, PB, Brazil
IIIMaster's Degree in Dermatology, Professor of Dermatology, Federal University of Paraíba (UFPB) João Pessoa, PB, Brazil
IVMaster's Degree in Dermatology, Professor of Dermatology, Federal University of Paraíba (UFPB), João Pessoa, PB, Brazil
VMedical student, Souza Marques School of Medicine, Rio de Janeiro, RJ, Brazil
Factitial dermatitis is a condition in which skin lesions are self-inflicted as the result of a psychiatric disorder. The lesions may be presented in various forms and produced by a wide variety of means. This report refers to the case of a patient with factitial dermatitis triggered by Munchausen syndrome, which refers to individuals who intentionally provoke physical symptoms in themselves in order to satisfy a need to receive frequent medical attention.
Keywords: Dermatitis; Psychopathology; Munchausen syndrome
Factitial dermatitis refers to a condition in which skin lesions are self-inflicted as the result or symptom of a psychiatric disorder. The lesions may be presented in various forms or patterns and are generally located in areas of the body easily reached by the patient's hands. They are produced by a wide variety of means such as nails, sharp objects, chemical substances and others. 1 A diagnosis of factitial dermatitis is considered after excluding all hypotheses of organic diseases. In rare cases, this dermatitis may be associated with Munchausen syndrome, which refers to individuals who deliberately provoke or present physical symptoms in order to receive frequent hospital care.2 Described for the first time in 1951, the diagnostic criteria defining Munchausen syndrome consist of the deliberate production or simulation of predominantly physical signs and symptoms, the patient's need to feel ill and the absence of external incentives for his/her behavior (economic gain, escape from legal responsibility or an improvement in physical well-being). Due to the inherent characteristics of the condition, few patients are seen by a psychiatrist. Most pass through numerous hospitals and are seen in different clinical and surgical emergency departments, diagnosis being hampered by the healthcare professionals' lack of knowledge on the syndrome.3,4 This report describes and discusses a rare case of a patient with factitial dermatitis triggered by Munchausen syndrome.
A female patient, 36 years old, single, a domestic servant, sought medical treatment in an emergency department, complaining of skin lesions of around 6 months' duration and attributing the cause of the lesions to her employer. On examination, she presented with regular, ulcerated, blistered lesions over her arms, thighs and trunk (Figure 1). She reported that she had received care in other hospitals, one of which had given her a clinical diagnosis of pemphigus vulgaris. Later, the lesion was biopsied and the histopathological findings were compatible with irritative contact dermatitis caused by an unspecified agent (Figure 2). As the patient was extremely agitated and confused, she was submitted to psychiatric evaluation, where it was found that the lesions resulted from application of a caustic substance to the skin, provoked by the patient herself. It was concluded that she was suffering from factitial dermatitis triggered by Munchausen syndrome. The patient received symptomatic topical treatment of the lesions and was referred for psychiatric follow-up.
The patient described in this case report feigned a skin condition by applying sodium hydroxide (caustic soda) to her skin. She strongly denied having done anything to cause the lesions, even accusing her employer of physical aggression, blaming him for provoking the lesions. The patient had received care at several different hospitals, always with the same complaint, and various other diagnostic hypotheses had been made. In view of the situation and the patient's current state of agitation during the final consultation, a psychiatric evaluation was requested. After several consultations with the psychiatrist, a diagnosis was given of factitial dermatitis triggered by Munchausen syndrome. The patient's behavior is characteristic of the syndrome in that she was motivated by an intrinsic need to receive attention, principally medically-related attention. The association of the two aforementioned conditions, in addition to being rare, often remains undiagnosed due to the lack of knowledge of healthcare professionals on the subject. The clinical management of these patients is hampered by their poor compliance with treatment and they need to be carefully monitored to ensure that no new lesions are provoked during medical follow-up. 5,6 Psychiatric management is fundamental and is the most important component of the patient's cure, avoiding the relapses that are so common in these cases. 6,7
1. Sun DK, Siegel DM. A nonhealing ulcer on the face. Arch Fam Med. 2000;9:787-9. [ Links ]
2. Zalewska A, Kondras K, Narbutt J, Sysa-Jedrzejowska A. Dermatitis artefacta in a patient with paranoid syndrome. Acta Derm Venereol. 2007;16:37-9. [ Links ]
3. Menezes APT, Holanda EM, Silveira VAL, Oliveira KCS, Oliveira FGM. Síndrome de Münchausen: relato de caso e revisão da liter atura. Rev Bras Psiquiatr. 2002;24:83-5. [ Links ]
4. Gattaz WF, Dressing H, Hewer W, Nunes P. Síndrome de Münchausen: diagnóstico e manejo clínico. Rev Assoc Med Bras. 2003;49:220-4. [ Links ]
5. Rosen T, Chen M. Factitious disease of the breast of a male due to injection of liquid plastic. Int J Dermatol. 2001;40:743-6. [ Links ]
6. Aleem A, Ajarim DS. Münchausen syndrome - presenting as immunodeficiency: a case report and review of literature. Ann Saudi Med. 1995;15:404-6. [ Links ]
7. Obasi OE, Naguib M. Dermatitis artefacta: a review of 14 cases. Ann Saudi Med. 1999;19:223-7. [ Links ]
Mailing Address: Recebido
em 14.08.2008. *
Study conducted at the Federal University of Paraíba (UFPB), João
Pessoa, PB, Brazil.
Mohamed Azzouz / Esther Palitot
Rua Augusto dos Anjos, 35 - Centro
58030090 João Pessoa, PB
Tel.:/Fax: 83 3241 8303, 9157 0502 e 9106 7840
E-mail: firstname.lastname@example.org / email@example.com
Aprovado pelo Conselho Editorial e aceito para publicação em 30.10.2008.
Conflict of interest: None
Financial support: None
* Study conducted at the Federal University of Paraíba (UFPB), João Pessoa, PB, Brazil.