Factitial ulcers (a manifestation of dermatitis artefacta) occur secondary to a patient digging, excoriating, or generally manipulating their own skin. They are part of a psychiatric condition in which patients self-induce skin lesions in order to satisfy an unconscious or conscious psychological need to assume the sick role. Patients will not admit to creating the lesions, which are usually more elaborate than simple excoriations. Factitial ulcers should be differentiated from malingering, in which lesions are created deliberately for secondary gain, such as collecting disability or obtaining prescriptions. Malingering is not a mental illness.
To diagnose a factitious disorder, the Diagnostic and Statistical Manual of Mental Disorders requires that the following 3 criteria be met:
Intentional production or feigning of physical or psychological signs or symptoms,
Motivation for the behavior is to assume the sick role, and
Absence of external incentives for the behavior (eg, economic gain, avoiding legal responsibility, and improving physical well-being).
The diagnosis of self-abuse tends to occur more frequently in women and in those working in health care. Such patients may inject foreign substances into their skin, leading to ulceration. The psychological profile of the patient with self-induced skin disease is the patient with a dependent and manipulative personality or borderline personality disorder.
The patient's typical lack of concern for how disfiguring the lesions appear is out of proportion to the reality of their presentation. The patient history never seems to add up to explain the unusual cutaneous findings. This so-called "hollow history" is a characteristic of the disease. There is also a lack of findings to support the diagnosis of an alternative ulcerative process.
The lesions are often produced by digging, picking, biting, cutting, injecting, and puncturing. More serious wounds can be complicated by gangrene, abscess formation, or other life-threatening infections. Treatment is often challenging and requires a multidisciplinary approach.
Codes
ICD10CM: L98.1 – Factitial dermatitis
SNOMEDCT: 15304008 – Factitial ulcer
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Differential Diagnosis & Pitfalls
There are a number of skin disorders that worsen because of trauma (pathergy). Consider diagnoses such as Behçet syndrome and pyoderma gangrenosum.
Repetitive skin trauma in a patient with a neuropathy
Factitious disorder imposed on another, or medical child abuse, is the intentional production or feigning of physical or psychological signs or symptoms by the patient's caregiver.
