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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5254_Библиотеки_им_академика_М_И_Перельмана.pdf
4 Factitious Skin Disorders Without External Incentives
Fig. 4.12 The same patient as in Fig.4.11
Fig. 4.13 A 35-year-old
woman with rounded
erosive, ulcerative, and
hyperchromic lesions
induced by incandescent
metal object. (Reproduced
with permission by
Angelini and
Bonamonte [5])
69
70
Fig. 4.14 The same patient as in Fig.4.13. (Reproduced with permission by Bonamonte etal. [33])
D. Bonamonte et al.
Fig. 4.15 A 28-year-old man with linear cutting scars on abdomen and forearms. (Reproduced
with permission by Bonamonte etal. [33])
must the child be insistently questioned about “how” and “why”, nor accused of
deliberately producing the lesions. Such reactions are unproductive and can cause
the child to feel alienated, thus delaying the possibility of forming a trusting alliance
[85, 90, 96–101].
4 Factitious Skin Disorders Without External Incentives
Fig. 4.16 The same patient as in Fig.4.15 with rounded lesions on the back of hands and forearms
induced by lighted cigarette. (Reproduced with permission by Bonamonte etal. [33])
71
Table 4.3 Common
differential diagnosis of
dermatitis artefacta
Irritant/allergic contact dermatitis
Vasculitis
Pyoderma gangrenosum
Chronic lupus erythematosus
Panniculitis
Granulomas
Arthropod bites
Bullous disorders
Drug eruptions
Purpura
Sexual/physical abuse (especially
in children)
Bacterial infections
Viral infections
Nékam’s disease
72
Fig. 4.17 Excoriations in a 7-year-old boy
D. Bonamonte et al.
Fig. 4.18 Excoriations in an 8-year-old boy
4 Factitious Skin Disorders Without External Incentives
Fig. 4.19 Excoriations in a 4-year-old girl
73
Fig. 4.20 Pseudo-knuckle pads on the palmar region of the ngers. (Reproduced with permission
by Bonamonte etal. [73])
74
Fig. 4.21 Pseudo-knuckle pads on the dorsal nger joints. (Reproduced with permission by
Bonamonte etal. [73])
D. Bonamonte et al.
Fig. 4.22 Cheilitis and perioral dermatitis induced by saliva. (Reproduced with permission by
Bonamonte etal. [87])
4 Factitious Skin Disorders Without External Incentives
Fig. 4.23 Cheilitis and perioral dermatitis induced by saliva. (Reproduced with permission by
Bonamonte etal. [87])
75
Fig. 4.24 “Lick eczema”. (Reproduced with permission by Bonamonte etal. [87])
76
Fig. 4.25 “Lick eczema”. (Reproduced with permission by Bonamonte etal. [87])
D. Bonamonte et al.
Fig. 4.26 The same patient as in Fig.4.25. (Reproduced with permission by Bonamonte etal. [73])
4 Factitious Skin Disorders Without External Incentives
Fig. 4.27 “Lick eczema”
77
4.4 Dermatitis Simulata
In particularly ingenuous individuals, the use of makeup or topical printing dyes to
produce a rash or a birthmark can be observed. This so-called dermatitis simulata is
most common in children [102]. In this case, the skin is not badly damaged: in fact,
the signs can often be removed simply by an aqueous or alcoholic swab and analysed if necessary [103].
For this purpose, glue and crystallized sugar can be used to produce a desquamating rash, and various dyes to simulate discolorations [104, 105]. Differential
diagnosis is made in particular with apocrine and eccrine chromhidrosis or pseudochromhidrosis after accidental cutaneous absorption of dyes [16].
4.5 Dermatitis Passivata
This dermatitis, also called dermatitis neglecta, can be observed in adolescents and
adults, as a result of a deliberate failure to wash specic areas of the body, such as
the face, scalp, or arms [16, 98, 106, 107]. In the extreme form, it is also known as
“Diogenes syndrome” [108, 109]. In these cases, a build-up of sebum, dirt, and
keratin accumulates on the skin. The appearance is similar to that seen in vagrants,
or in geriatric or demented patients, in whom the lesions are usually found on the
upper central back chest and/or in the groin.
The material can easily be removed with an alcohol-soaked swab. Such subjects
are affected by various personality disorders.
78
D. Bonamonte et al.
4.6 Dermatological Pathomimicry
Pathomimicry is a particular form of factitious disorder, featuring the provocation
of outbreaks of a known disease, triggered by voluntary exposure to the specic
agent responsible. The patients mimic their original spontaneous disease that they
know a lot about and so are well able to reproduce the physiopathological mechanisms or interfere with the treatment.
The term “pathomimicry” was rst used by Millard in 1984in a study of 13
patients who had self-inicted exacerbations or recurrences of their own spontaneous skin diseases, achieved through exposure by contact or ingestion to the same
agent that had provoked the disease. Among them, six patients had provoked the
recurrence of contact dermatitis by using substances they knew they were allergic
to; four had provoked toxidermia by taking the incriminated drugs again, and three
had aggravated their leg ulcers by not using the local treatments [68]. Most of these
patients were young women with familial problems. Direct confrontation proved
helpful, unlike in the situation of dermatitis artefacta.
The distinction between dermatitis artefacta and pathomimicry is that in the rst
case the lesions are atypical, and do not evoke any known dermatitis, while in the
second they are those of a known complaint. Moreover, pathomimicry is achieved
in a conscious state, then completely dissimulated, but with no hidden motivation or
expected benet [49, 110]. This form of self-harm must also be differentiated from
self-inicted delayed healing of surgical or traumatic wounds, which is achieved by
external damage [16].
The clinical suspicion of pathomimicry must arise in the presence of unexplained
exacerbations of a known disease or when patients are unexpectedly unresponsive
to the adequate supervised treatment. According to the literature, the easiest diseases to reproduce are atopic dermatitis (by introducing animal danders, for example, or the topical use of notoriously irritant substances), irritant and allergical
contact dermatitis (by using known irritants and allergens on the skin), and systemic
drug sensitivities (due to ingestion of the implicated drug). In the latter case, it
should be remembered that the presence of the drug can be revealed in the blood or
urine. In cases of leg ulcers, known irritants or contaminated materials can be used
[76, 111–113]. It must also be borne in mind, however, that dermatological pathomimicry can be induced for illicit purposes, too [13].
4.7 Gardner-Diamond Syndrome
Gardner-Diamond syndrome (GDS) (also known as psychogenic purpura, autoerythrocyte sensitization syndrome, or painful bruising syndrome), is a rare clinical
condition characterized by recurrent atraumatic spontaneous, tender skin lesions
that develop into ecchymosis, closely correlated with episodes of severe, psychiatric
disorders [13, 16, 33, 114–124].