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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5254_Библиотеки_им_академика_М_И_Перельмана.pdf
5 Factitious Skin Disorders withExternal Incentives
Fig. 5.4 A 22-year-old man with gured pigmented lesions as outcome of dermatitis induced by
propane gas from a cigarette lighter. (Reproduced from Angelini and Bonamonte [55]. All rights
reserved)
99
Fig. 5.5 A 22-year-old man with ecchymotic and erosive lesions induced by hot vinegar compresses and physical trauma. (Reproduced with permission by Bonamonte etal. [10])
Occupational dermatitis artefacta of the second type can be provoked directly on
healthy skin or can be subsequent to the aggravation of a pre-existing contact dermatitis. The diagnosis can be fairly simple when the simulator attempts to reproduce eczema on healthy skin: in fact, it is difcult to provoke erythematous vesicular
spongiotic lesions in different phases of evolution, and so self-inicted lesions tend
to manifest as groups of gross blisters. These criteria do not apply if the subject
aggravates a pre-existing spontaneous eczematous dermatitis. The simulator may, in
fact, be well aware of what substance provokes the dermatitis and so make use of it.
100
Fig. 5.6 A 23-year-old man with bullous and erosive lesions induced by salted sardines in occlusion. (Reproduced with permission by Bonamonte etal. [10])
D. Bonamonte et al.
In this event, hospitalization and continual supervision of the subject can sometimes
enable a precise diagnosis [10, 48, 53–60].
Over the years, we have observed 46 cases of occupational dermatitis artefacta.
The suspicion of a true simulation, suggested by the combination of “work problems”, the particular morphology of the lesions, and repeated negative ndings of
all relative tests and clinical dermatological and psychiatric consultations, was then
conrmed by confessions obtained from all the patients after repeated condential
and informal discussions [61–63]. The causal agents used included metal objects,
incandescent needles, lighted cigarettes, and chrome mixtures (Figs. 5.13, 5.14,
5.15, 5.16, 5.17, 5.18, 5.19, 5.20, 5.21, 5.22, 5.23, 5.24, 5.25, 5.26 and 5.27). Most
of the subjects were masons. In 38 cases, the reason for the simulation was to obtain
legal recognition of an occupational disease, in 2 to gain a higher class of disability
pension, and in 6 to prolong the disease.
Table 5.2 reports some indicative clinical criteria that could be useful for the differential diagnosis between occupational dermatitis artefacta and dermatitis artefacta (aside, of course, from psychiatric problems underlying the latter).
Malingering has to be differentiated from deliberate non-compliance to medical
prescriptions, a condition that can lead to the persistence or aggravation of a disease
and hence to hospitalization. Many cases of poor compliance need ostensibly to be
ignored by physicians that will explore the failed compliance in an empathic way,
without making the patient feel guilty [13]. Nevertheless, cases of a hidden
5 Factitious Skin Disorders withExternal Incentives
Fig. 5.7 A 22-year-old man with ulcerative lesions induced by salted sardines in occlusion.
(Reproduced with permission by Bonamonte etal. [10])
101
Fig. 5.8 A 23-year-old man with papular dermatitis induced by rubbing a cut leaf of Agave ameri-
cana on abdomen. (Reproduced with permission by Bonamonte etal. [49])
non-compliance can also be supported by a social incentive and so come under the
heading of malingering.
Malingering must also be differentiated from dermatological pathomimicry, a
condition described in 1984 by Millard in 13 patients who had caused recurrences
102
Fig. 5.9 Agave americana. (Reproduced with permission by Bonamonte etal. [49])
D. Bonamonte et al.
Fig. 5.10 A 22-year-old-man with erythemato-vesicular dermatitis due to wet compresses of
leaves of Urtica dioica. (Reproduced with permission by Bonamonte etal. [49])
or exacerbations of their existing skin disease [64]. These patients had aggravated
their condition by deliberate exposure to the noxae they knew had triggered the
complaint. Most of these patients described by Millard were young women, who
were trying to gain greater sympathy from their families. The author considers
5 Factitious Skin Disorders withExternal Incentives
Fig. 5.11 Urtica dioica. (Reproduced with permission by Bonamonte etal. [49])
103
Fig. 5.12 A 21-year-old patient with ulcerative lesions of the scrotum self-induced by incandescent metal object
104
Fig. 5.13 A self-artefact induced by metal object on pre-existing spontaneous contact dermatitis.
(Reproduced with permission by Bonamonte etal. [62])
D. Bonamonte et al.
Fig. 5.14 Self-artefact induced by incandescent metal object. (Reproduced with permission by
Bonamonte etal. [62])
pathomimicry to differ from dermatitis artefacta, characterized rather by lesions
differing from those of true organic skin disease. All the same, it should be remembered that the same behaviour can be observed in conscious simulators with a nancial objective, as stated above.
5 Factitious Skin Disorders withExternal Incentives
Fig. 5.15 Self-artefact induced by lighted cigarette. (Reproduced with permission by Bonamonte
etal. [62])
105
Fig. 5.16 Self-artefact induced by incandescent needles. (Reproduced with permission by
Bonamonte etal. [62])
5.3 Dermatitis Artefacta withPatch Test Artefacts
In addition to the above two classical types of occupational dermatitis artefacta,
provoked on healthy skin or damaged skin, there is another aspect to the problem.
106
Fig. 5.17 Floor layer
(stigmata on the knees)
with self-inicted lesions
by metal object.
(Reproduced with
permission by Bonamonte
etal. [62])
D. Bonamonte et al.
This consists of attempts to produce positive results to skin tests which would otherwise give negative results.
As these methods of diagnostic investigation have grown more common, simulators’ attention has shifted from the clinical disease picture towards the results of
such tests, knowing that recognition of this condition as a professional complaint
largely depends on the latter.
The phenomenon had already been reported in 1962 by Meneghini and Rantuccio
in two of eight cases of occupational dermatitis artefacta [65] and has since been
observed by ourselves [56, 63, 66] (Fig.5.28). Meigel and Koops reported a case in
which the patient attempted to simulate a positive patch test reaction to neomycin
by scratching the site [67]. Lyell mentions the case of a patient who was able to
produce a chemical burn by applying a caustic liquid on one of her patch test sites
[68]. Three cases of dermatitis artefacta with manipulation of patch tests are
described by Maurice and Coll. [69]: the subjects were intelligent, single females
who produced chemically severe patch tests reactions but denied self-induction.
Clearly, in suspicious cases, the patch tests must be applied without allowing the
patient to identify the site of the individual substances and the results must be interpreted with caution. In most such cases, the self-induced reactions are clearly
5 Factitious Skin Disorders withExternal Incentives
Fig. 5.18 Linear ulcerative lesions self-induced by metal object. (Reproduced with permission by
Bonamonte etal. [10])
107
Fig. 5.19 Self-induced lesions by lighted cigarette. (Reproduced with permission by Bonamonte
etal. [62])
irritant in nature, but the ingenuity of these patients can be such that even a genuine
allergic reaction might be mimicked [69].
5.4 Witchcraft Syndrome
Dermatitis artefacta can even be voluntarily provoked on the skin of unaware subjects by proxy [70, 71]. Various clients of a hairdresser developed urticarial lesions
after having been served by the hairdresser’s daughter. To revenge herself on her
father, she had applied benzyl-ether of nicotinic acid on the clients’ skin, inducing
local hyperaemia, with some oedema, after about 10min. The absorption of this
108
Fig. 5.20 Ulcerative self-induced lesions by chromic mixture. (Reproduced with permission by
Bonamonte etal. [62])
D. Bonamonte et al.
Fig. 5.21 Ulcerative dermatitis artefacta induced by chromic mixture. (Reproduced with permission by Bonamonte etal. [62])
substance on the palms of the hands is very low and so the simulator found it easy
to apply it to the customer’s skin without harming herself [70].
A 28-year-old man presented a history of several episodes of blisters and intense
redness over the cheeks and external ears, associated with a burning sensation. The
episodes had a sudden onset and were always associated with a drinking spree the
previous night. The peculiar history and the morphology of the lesions, that escaped
any classic diagnosis classication, gave rise to the suspicion of simulation. After
much persuasion and an assurance of secrecy, the wife of the patient admitted that
her husband was an alcoholic and was neglecting his family. When her efforts to
prevent his drinking failed, she poured acid, that she used for domestic cleaning, on
his cheeks, hoping that the sequelae would frighten him off drinking. The psychiatric evaluation revealed that the patient was an alcoholic with a cyclothymic