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38 Hand Necrosis
249
38.5 Clinical Presentation
ofDigital Ischemia
The diagnosis of digital ischemia is easy at the
stage of gangrene.
The clinical process is divided into three steps:
1. The early phase: pallor, poikilothermia, live-
doid aspect, pulpar petechiae, periungual
infarction, and splinter subungual
hemorrhages.
2. The state phase: digital ulceration.
3. The late phase: distal gangrene.
The associated symptoms caused by the ischemia
are the pain and the paresthesia.
The distal gangrene is a risk of complication
including cutaneous and bone infection.
We can distinguish two classical types of digital necrosis presentations, the dry necrosis and
the wet necrosis.
The dry necrosis (Fig. 38.1) is more often
observed after arterial blood ow occlusion and
is characterized by red-black dry necrotic tissue
surrounded by painful red borders. The dry
necrosis tissue spreads slowly and is often free of
microbial infection resembling mummied esh.
The wet necrosis has a less mummied aspect
compared to dry necrosis due to microbiological
load.
The wet necrosis results from a microbial critical colonization (Clostridium perfringens,
Bacillus fusiformis, etc.), which causes the tissue
to swell and emit a fetid smell. Wet necrosis usually develops rapidly due to blockage of venous
and/or arterial blood ow. The affected part is
saturated with stagnant blood, which promotes
the rapid growth of bacteria and can lead to soft
tissue infection and sepsis.
38.6 Diagnosis
The diagnosis is based on the clinical presentation as described above in a specic context.
The most important point is to investigate the
etiological factors by doing a complete anamnesis and examination of the patient. Appropriate
tests will be recommended according to the clinical ndings.
Fig. 38.1 Typical severe dry necrosis
• The anamnesis will highlight some important
points:
– Circumstances of occurrence (acute or
chronic, trauma, etc.)
– Aggravating factors (cold, etc.)
– Medications
– Smoking habits
– A history of Raynaud’s phenomenon
– Exposure to chemicals or physical agents
– Personal and familial medical history
– History of surgical operation, interven-
tional procedure, or intravenous use
– The profession and occupational activities
– The presence of systemic symptoms (can-
cer, vasculitis, endocrinopathy, etc.)
• The clinical examination will look for:
– Ischemia signs (see above)
– The extra-digital signs correlated with the
underlying conditions: signs for arthritis,
vasculitis, and connectivitis (scleroderma,
lupus); signs of infection; signs of endocrinopathy; signs of cardiopathy, etc.
250
Y. Farid et al.
• The clinical testing:
– The venous relling time
– Arterial pulse
– Allen’s test
– The blood pressure (right and left arms)
– Cardiac auscultation
– Phalen and Tinel maneuver
• The complementary testing:
– Blood tests (hematology and coagulopathy,
renal function, inammatory syndrome,
thyroid tests, antinuclear factors, lipids,
serology, proteins and cryoproteins, etc.)
– Capillaroscopy if Raynaud’s phenomenon
or suspicion of connective tissue diseases
– Hand radiography if suspicion of CREST
syndrome, rheumatoid arthritis, or
calciphylaxis
– Chest X-ray if scleroderma or compressive
process is suspected
– Cardiogram if arrhythmia is suspected
– Echo Doppler of upper limbs
– If asymmetric necrosis, an arteriography is
recommended
– The presence of systemic symptoms and
clinical signs will help you to choose the
appropriate tests [2]
38.7 Management
Up to date, the literature dealing with the clinical
management of the necrotic nger is very poor.
Management of ischemic ngers should be
divided into two stages, the early ischemic stage
and the late necrotic stage.
In the early stage of ischemia of the ngers,
we need to:
1. Identify the etiological factors(see Table38.1)
2. Improve local perfusion by:
• Vasodilators
• Antiaggregants and anticoagulants
• Hyperbaric oxygen
• Surgical arteriolysis
3. Control the pain
4. Avoid nger infection and adapt local treat-
ment in each case
If despite early ischemia management, we get
to the late necrotic stage, we need to:
1. Dene the type of necrosis (dry or wet)
2. Dene its localization (proximal or distal)
3. Dene the perfusion status of the different tissues, and in case of digit necrosis of frostbite
origin, dene the extent of necrosis (deep or
supercial)
All of these factors will help in choosing between
a more conservative treatment that involves
mummication and auto-amputation or an early
surgical treatment.
The type of necrosis: We can classify two
types of digital necrosis presentations, the wet
and dry necrosis.
If dry necrosis: As surgical amputation means
often mandatory shortening, directed healing
under the mummifying part gives the best length
conservation. For this reason, dry dressings are
recommended in an effort to keep the mummied
part dry. The line of separation usually leads to a
complete separation, with eventual falling off of
the gangrenous tissue if it is not removed surgically; it is also called auto-amputation. Splinting
is only recommended if nger retraction is occurring. Active nger motion is started early in all
cases. Auto-amputation is a long process and is
often not accepted by the patient. Anyway, waiting for a clear delimitation of the mummifying
part often allows to limit the surgical shortening
if the patient asks for it.
If wet necrosis: The prognosis is poor compared to dry necrosis due to the risk of infection and sepsis. Application of antiseptic
dressing is recommended. The affected tissues
have to be surgically removed. It is sometimes
possible to convert the development of wet
necrosis to dry necrosis by application of dry
38 Hand Necrosis
251
dressings (betadine gauze, alcohol-based
dressing, etc.).
38.7.1 The Localization ofNecrosis
The localization of necrosis demarcation is an
important aspect of managing nger necrosis
treatment, and we differentiate two main cases of
nger necrosis linked to the anatomic blood supply of the ngers: necrosis of the ngertips and
necrosis beyond the second phalange.
If necrosis is localized at the distal phalanx/
ngertip, reperfusion can occur and conservative
treatment is favored because of the rich and dense
anastomosis network capable to compensate
interruption of one digital artery.
If necrosis is localized at a trans-diaphysis
location proximal to the distal phalange, then
reperfusion is less frequent to occur, and evaluating the nger perfusion should be considered
with the help of triple-phase bone scan. Triplephase bone scan helps in assessing the extent of
damaged tissue [7–10].
Three patterns are described to assess the
extent of damaged tissue. In case we have a normal blood and bone pool images, then we should
consider a conservative/auto-amputation treatment. In case we have an intermediate pattern
with absent blood ow and absent early bone
pool but with delayed bone blood ow, then
demarcation and supercial debridement should
be considered. When we have no or little blood
ow in blood and bone pool, then a more aggressive attitude should be considered by early amputation (see Fig.38.2).
38.7.2 The Perfusion Status
andtheExtent ofNecrosis
In case of nger necrosis due to frostbite injuries,
the mechanism of necrosis is different than when
vascular obstruction occurs.
Tissue freezes slowly from outside to the
inside in frostbite necrosis, whereas in necrosis
due to vascular obstruction, necrosis starts from
the inside and affects all layers of ngers at once.
In frostbite injuries, there may be a wide discrepancy between the extent of damage to the skin
versus that to the deeper structures, hence the
need to evaluate the extent of necrosis with the
help of triple-phase scan [7–10].
A triple-phase bone scan helps assess tissue
perfusion to the different layers and affected area
and should be used to better evaluate nger perfusion and hence helps in the decision-making
(see Fig.38.2).
Management of digital necrosis is summarized in Fig.38.2 [7–13].
252
c
Y. Farid et al.
Superficial(frostbite)
/distal (full thickness
necrosis)
Digital ischemia
Dry necrosis
Clinical
evaluation
(Early stage)
No Trauma
-Find etiology
-Improve perfusion
Digital necrosis
(Late stage)
Deep (frostbite)
/proximal full thickness
necrosis)
Triple phase scan
Trauma
Drying dressing
Failure to revascularize
Wet necrosis
No
Yes
Surgical
amputation
Sign of
infection
Yes
Antibiotic, antisepti
dressing
Resolution
Normal blood
and blood
pool images
Necrosis delimitation
+ observe
Little or no blood
pool, little but
visible bone pool
Necrosis
delimitation +
debridement
Fig. 38.2 Management of digital necrosis
images
Little or no flow in
both blood and
bone pool images
Early
debridement/amputation +
flap transfer
No
Surgical
amputation
38 Hand Necrosis
253
References
1. Hand anatomy. www.medscape.com.
2. Jones NF.Acute and chronic ischemia of the hand:
pathophysiology, treatment and prognosis. J Hand
Surg Am. 1991;16(6):1074–83.
3. Esculier B, Barrier J, Bletry O, Malinsky M, Cabane
J, Godeau P. Une cause rare d’artérite digitale avec
phénomène de Raynaud et nécroses pulpaires: le
virus b de l’hepatite-3 observations. Ann Med Interne.
1982;133:600–3.
4. Vayssairat M, Debure C, Cormier J, Bruneval P,
Laurian C, Juillet Y.Hypothenar hammer syndrome;
17 cases with long term follow up. Vasc Surg.
1987;5:838–43.
5. Dompmartin A, Lemaitre M, Letessier D, Leroy
D. Nécroses sous béta-bloquants? Ann Dermatol
Vénéréol. 1988;115:593–6.
6. Werquin S, Kacet S, Caron J, etal. Phénomène de
Raynaud et nécrose digitale après traitement d’un
séminome ovarien par bléomycine, vinblastine et
5-FU.Ann Cardiol Angeiol (Paris). 1978;36:409–12.
7. Cauchy E, Chetaille E, Marchand V, Marsigny
B. Retrospective study of 70 cases of severe frostbite lesions: a proposed new classication scheme.
Wilderness Environ Med. 2001;12(4):248–55.
8. Cauchy E, Chetaille E, Lefevre M, Kerelou E,
Marsigny B. The role of bone scanning in severe
frostbite of the extremities: a retrospective study of 88
cases. Eur J Nucl Med. 2000;27(5):497–502.
9. Hutchison RL. Frostbite of the hand. J Hand Surg.
2014;39(9):1863–8.
10. Greenwald D, Cooper B, Gottlieb L.An algorithm for
early aggressive treatment of frostbite with limb salvage directed by triple-phase scanning. Plast Reconstr
Surg. 1998;102(4):1069–74.
11. Kaba A, Shoofs M, Leps P, Verlet E, Gstach JG,
Mathevon H.Management of digital ischemia. 5 cases.
Ann Chir Main Memb Super. 1991;10(4):364–72.
12. Pinede L, Ninet J. Les nécroses digitales du
membre supérieur. Sang Thrombose Vaisseaux.
1995;7(5):323–32.
13. Batra M, Tandon P, Gupta N. Clinical approach to
a patient with isolated digital ischaemia. JIACM.
2002;3(1):23–8.
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obtain permission directly from the copyright holder.
Factitious Disorders (Pathomimia)
andNecrosis
FrancoisePoot
39
39.1 Introduction
When facing a cutaneous necrosis of unknown
origin, the clinician should always have in mind
factitious disorder.
In this chapter, we will make clearer where to
classify factitious disorders in the broader spectrum of self-inicted skin lesions (SISLs). A
clearer classication approach could result in
better healthcare for these often difcult and
“disarming” patients.
We will then describe the different clinical
entities in factitious disorders.
In diagnosis and treatment, we will describe the
comorbidities and the communication options
adapted to the emotional structure of these patients.
Finally, we will propose some specic therapeutic
options and see what the prognosis can be.
39.2 Classication
In our paper published in 2013 with the European
Society for Dermatology and Psychiatry [1], we
proposed the utilization of the diagnostic category of self-inicted skin lesion (SISL) as synonymous to “pathological SISL”, to restrict this
classication to dermatological lesions whose
cause implies pathological behaviour.
F. Poot (*)
HUB Erasme Hospital, Department of Dermatology,
Brussels, Belgium
There are three questions that are helpful for
the classication of abnormal behaviour that
potentially leads to somatic damage (Fig.39.1):
• Is the behaviour responsible for the somatic
damage denied or kept “secret” by the patient?
A “yes” answer points to a factitious
disorder1.
• If the answer to the rst question is “yes”, are
there any external incentives? A “yes” answer
indicates malingering, and a “no” answer
points to factitious disorder.
Obviously, clinicians should refrain from asking patients with suspicious skin lesions direct
and confronting questions: “Are you responsible
for the lesions on your skin?” Rather, open-ended
questions should be formulated: “How did these
lesions appear?” Answers such as “I don’t know!”
or “I have no idea!” or “It is certainly not me!”
point to a possible underlying pathological
behaviour, denied or kept secret by the patient.
On the other hand, answers like “When it itches,
I can’t stop picking my skin” or “When I am
tired, I pull my hair without realizing it” conrm
patients’ responsibility for their lesions, even
though they refer to mitigating circumstances.
If the answer to the rst question is “yes”, are
there any external incentives? A “yes” answer
indicates malingering, and a “no” answer points
to factitious disorders.
© The Author(s) 2024
L. Téot et al. (eds.), Skin Necrosis, https://doi.org/10.1007/978-3-031-60954-1_39
255
256
sN
Isolated, episodic
or repeated skin
manipulation
Skin lesion?
F. Po ot
Esthetic or cultural
Yes
Non pathalogical Body
Modifying Behaviour
(BMB)
Diagnostic procedure to
collaboration with mental
Yes
incentives?
Yes
be completed in
health specialists
Yes
No
Non pathalogical
grooming behaviour
No
Psychotic symptoms?
(Delusions,
hallucinations)
No
Skin lesion = indirect
consequence of pathological
behaviour?
No
SELF-INFLICTED SKIN
LESIONS
Q1: Behaviour denied /
maintained secret?
YesNo
Q2: External incentives?
Yes
Malingering in
Dermatology
Do the lesions imitate
a defined dermatological
disease?
YesYes
Pathomimicry
Hospital shopping?
Delegate self-harm?
Pseudologia phantastica?
No
Factitious
Disorders in
Dermatology
Skin lesions due to
Münchausen’s
syndrome
syndromes: trichotillomania,
Q3: Compulsive, repeated
behaviour?
Ye
Pathological Skin
Picking and related
acne excoriée, etc.
Yes
Diagnostic procedure to be
completed in collaboration
with mental health specialists
Suicide attempt?
Fig. 39.1 Flow chart for the management of self-inicted skin lesions Q1, Q2, and Q3
o
Impulsive, episodic
behaviour
No
Scarification,
cutting, burning,
hitting...
39 Factitious Disorders (Pathomimia) andNecrosis
257
39.3 Syndromes Associated
withaDenied or Hidden
Pathological Behaviour
1. Factitious disorders: This expression refers to
articial or faked, self-provoked or alleged
diseases, without clear external incentives, in
the elds of internal medicine, psychiatry, and
all somatic specialties [2–4]. It should be
noted that an “external” trigger can precipitate, through emotional stress, the creation of
the lesions, but the main contribution to the
genesis must be found in internal, mainly
unconscious, determinants. Child physical,
sexual, or psychological abuse or neglect is
2. Pathomimicry: This term has been used in a
range of factitious disorders, referring to the
resemblance with some genuine, natural diseases. In the dermatological context, this term
can be used to signify the induction of lesions
mimicking features of a recognized dermatological disorder [5], for example, atopic
dermatitis- like lesions produced by contact
with an irritating agent. Malingering may also
underlie pathomimicry.
(a) Munchausen syndrome: This syndrome,
belonging to the factitious disorder category, is dened as the triad of (1) factitious symptoms, (2) hospital or doctor
shopping and (3) pseudologia fantastica.
Patients with Munchausen syndrome
present, or claim, acute symptoms with
demonstrative dramatic descriptions of
complaints and false information on their
medical history. It is also common for
these patients to have a history of multiple hospitalizations and surgical procedures, sometimes with visible multiple
sequels [6]. Self-harm is delegated to the
care providers.
(b) In Munchausen’s syndrome by proxy, it is
mainly children who are harmed by their
caregivers in order to establish contact
with health professionals.
3. Malingering: This term indicates the produc-
tion or feigning of a symptom due to social
(e.g. nancial) incentives.
4. Simulation: This term is generally restricted
to those cases of malingering or factitious disorders that simulate or mimic a known disease: general or dermatological (see the
denition of pathomimicry above).
39.4 Diagnosis andTreatment
The diagnosis is not easy. However, usually these
lesions do not mimic any of the known dermatosis and are associated with inconclusive skin
biopsy. The history of the lesions, their chronic
evolution, and cutaneous damages displayed on
attainable areas of the body are characteristics
[7]. In a review of atypical wounds [8], the
authors found that factitious wounds were especially in young subjects. Differing markedly
from other groups of atypical wounds in the present study, psychiatric comorbidities affected over
20% of the patients (Figs.39.2, 39.3 and 39.4).
The basis for the management of all types of
SISL is the patient-doctor relationship [9, 10].
1. Factitious disorders: The subject may be
aware that he or she is driven to create the
lesions, or in some instances, the activity may
take place in a dissociative state outside the
patient’s awareness. The main motivation is
assumed to be a method for coping with a
severe psychological background and a pref-
Fig. 39.2 Factitious disorder in a young girl
258
Fig. 39.3 Factitious disorder in an adolescent
Fig. 39.4 Caustic wounds or burning as factitious
disorders
erence for the sick role with no immediate
tangible benets. Factitious disorders in dermatology are at least twice more frequent in
women than in men.
(a) Comorbidities
Cutaneous lesions can be accompanied by other factitious disorders; for
example, a chronic fever can be associated, due to the manipulation of thermometer. These associations may
F. Po ot
complicate and delay the diagnosis,
which is always difcult to establish.
Borderline personality disorder, substance abuse, somatoform pain disorder,
conversion disorders, sexual disorders,
dysthymia and suicide attempts are frequently associated with factitious disorders [11]. Substance abuse, eating
disorders and personality disorders are
more frequently associated with factitious disorders consisting of direct selfharm (scratching, stabbing, burning) than
in those consisting of indirect self-harm
(using medications, chemicals or infectious substances) where anxiety disorders, adaptation disorders and somatoform
disorders look more frequent.
(b) Communication between the patient and
the healthcare providers
On the patient side: The relationship
that the patient suffering from a factitious
disorder establishes with the doctor is
modelled on the relationship the patient
may have had with his/her parental gures or relatives. Any close relationship or
love bond, so vital and needed by patients
with factitious disorders and on which
these patients are dependent, is experienced as bearing a threat of betrayal,
abandonment and even aggression. This
may explain two things: rst, the ambivalent attitude of patients with factitious
disorders towards their physicians.
Although initially a fusional relationship
may develop between the physician and
the patient, sooner or later, patients with a
factitious disorder tend to show disappointment, snub and sometimes even
develop an accusatory attitude towards
their physicians. Secondly, the effects
produced by the factitious skin disorder
on the others will reproduce this ambivalence. The damaged skin represents a call
for help, an appeal for care and love, and
a means of distancing others, defying and
aggressively manipulating others, who
are perceived as unreliable and even dan-
39 Factitious Disorders (Pathomimia) andNecrosis
259
gerous. It is a way to “control” people
while keeping them at hand.
On the physician side: If the physician
manages to think in terms of psychological suffering, he might nd it easier to
diagnose a factitious disorder and to follow up the patient. This would enable the
diagnosis to be made initially, and not by
elimination at the end of a long process,
when the patient-physician relationship is
already seriously deteriorated and no longer allows the psychological problems of
the patient to be addressed serenely [12].
Attempts should be made to adhere to
appointment schedules and limit investigations to a minimum and to create a safe
and accepting environment during the
consultation [13]. It is preferable to avoid
any reference to the physical mechanisms
causing the lesions, and instead focus on
the “stress” as the probable mediator,
which may be easier for the patient to
accept and could be a rationale for the
introduction of psychotherapy or a psychiatric consultation.
(c) Communication between the physician
and healthcare teams
The whole healthcare team must function coherently, despite the patient’s
manipulation and ambivalence, to determine a common approach and to preserve
the links between the various healthcare
providers.
(d) Communication between the physician,
patient’s relatives and his/her general
practitioner
Precautions must be taken when
informing relatives, and even the patient’s
general practitioner, of the patient’s condition. The dermatologist should insist on
the seriousness of the psychological suffering expressed through the self-inicted
skin lesions [14]. It is important not to
disclose to the relatives the patient’s
responsibility in provoking his/her lesions
unless the relatives themselves proposed
such a hypothesis. General practitioners
should not transmit the suspicion to the
patient and therefore jeopardize the further therapeutic approach.
(e) Specic therapeutic options
Most authors consider that confrontation is counterproductive and even dangerous [15]. Aggravating the cutaneous
lesions, breaking off contact with the
team, becoming delirious or committing
suicide is reported when patients are confronted with the responsibility for the
lesions.
Strictly occlusive dressings may be
applied, and local treatments including
antiseptic may be prescribed. As regards
general treatment, antibiotics may be
administered to treat secondary
infections.
Surgical procedures should be avoided.
Reparative plastic surgery should only be
envisaged in collaboration with a
psychiatrist- psychotherapist after a reasonable time has elapsed following healing of the skin and on condition that a
marked improvement is observed in the
patient’s psychological frame of mind.
Regarding psychotropic drugs, antidepressants can be useful to treat an associated depressive syndrome and for making
the patient accept a psychological
approach without shocking or hurting
him/her. Tranquillizers and antipsychotics should be used carefully, given the
risk of abuse, for the rst, and that of
altering the trust towards the doctors, for
the latter.
2. Prognostic aspects
In adolescents, factitious disorders repre-
sent more often than in adults “a call for help”.
More generally, an early onset of factitious disorders is of better prognosis than a late onset,
as are the mild forms of factitious skin lesions,
a shorter duration of the disease and the lesions
produced in a dissociative state outside the
patient’s awareness. The quality of the psychotherapeutic relationship also contributes to a
more favourable evolution. The prognosis is
mostly worse, while the patients cannot be
motivated into a specic therapy [16].