A 57-year-old man has a 5-year history of a persistent facial eruption. He insists that the lesions are not pruritic and that
he does not scratch or rub his face.
Irregular, eroded, and ulcerated papules on the central part of the face.
|
On examination, there are several irregularly shaped, eroded or ulcerated papules with minimal or no surrounding erythema
(Figure).
Differential diagnoses
Diseases that should be considered in this case are those that produce multiple erosions or shallow ulcerations. BULLOUS PEMPHIGOID, an immune-mediated blistering disease, produces vesicles that rupture and create crusted papules. There may or may not be
erythema at the base of the lesions, as in this case. The irregular shapes of the papules and the limited distribution to
the face are both very unusual findings in bullous pemphigoid.
IMPETIGO causes erosions that may occur on the face, often clustered, as seen in this case. However, the long duration of disease activity,
the absence of serous (honey-colored) crusting, and the lack of perilesional erythema make this diagnosis less likely.
HERPES SIMPLEX VIRUS INFECTION can cause vesicles that almost always result in crusted lesions. However, the lesions are typically more closely clustered,
and there is always perilesional redness.
PEMPHIGUS VULGARIS often presents on the face and can produce somewhat irregularly shaped erosions after the superficial vesicles have ruptured.
In almost all cases of this disease, there is oral mucous membrane involvement, and it is often accompanied by lesions on
the scalp.
FACTITIAL DERMATITIS is the correct diagnosis. The lesions are the direct result of self-manipulation such as rubbing or scratching and are most
commonly seen in patients with malingering or mental illness.
The patient refused to accept the diagnosis even after a skin biopsy ruled out all other diagnostic possibilities. He also
refused therapy for this condition. Had he been interested in therapy, either doxepin or a selective serotonin reuptake inhibitor
would have been considered.
Diagnostic pearl
Consider factitial dermatitis if the lesions are irregularly shaped and there is little or no perilesional inflammation.
Suggested reading
Eastwood S, Bisson JI. Management of factitious disorders: a systematic review. Psychother Psychosom. 2008;77(4):209-218.
Harth W, Mayer K, Linse R. The borderline syndrome in psychosomatic dermatology. Overview and case report. J Eur Acad Dermatol Venereol. 2004;18(4):503-507.
Louis DS, Doro C, Hayden RJ. Factitious disorders. Clin Occup Environ Med. 2006;5(2):435-443.
Dr Levine is in the private practice of dermatology in Tucson, Arizona.
Practice Tools
