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What is dermatitis artefacta and its treatment?

Q: My friends son is 12 years old. From the last two years, he is suffering from cracking of the skin. The cracks are 1 mm to 8 mm deep and bleeding continues for 2 to 3 hours then the cracks get healed in a week leaving marks on the skin. The cracks are very sharp and it looks that they are made by a sharp knife or blade. After consulting many doctors ultimately he took his son to AIIMS Delhi but doctor there declared that it is not a disease and child may be mentally sick and he cuts himself with a hidden blade or something like that. They also said these are not symptoms of any known disease in the world. The child was taken back home and kept under strict observation. Things happened again in front of at least 15 persons including family members and friends and there was no doubt that it was the disease cracking the skin. The child was not cutting himself. Photographs were also taken. Again the child was taken to Varanasi where it was told that deficiency of phosphorous may be the cause and minerals were advised. The problem is still persisting and it has an increasing trend. The cuts are now deeper and more bleeding takes place. It is often painless or little pain. It repeats in a week or two. Please help and save the life of the child.

A:Your friend's son seems to be suffering from Dermatitis artefacta (also known as factitial dermatitis). Though like any other clinician I would love to see him before passing the final judgement. It is a condition in which skin lesions are solely produced or inflicted by the patients own actions. This could be a manifestation of a psychological problem or of an emotional release in situations of distress or part of an attention seeking behaviour. Features of dermatitis artefacta include: 1. Lesions are often in bizarre shapes with irregular outlines occurring in a linear or geometric pattern. 2. Lesions are usually clearly demarcated from surrounding normal skin. 3. The appearance of lesions varies depending on methods used to injure the skin. 4. Lesions range from red patches, swelling, blisters, crusts, cuts, burns, and scars. 5. Lesions may be produced by a variety of mechanical or chemical means, including fingernails, sharp or blunt objects, lit cigarettes and caustic chemicals. 6. Lesions do not evolve gradually but emerge almost overnight without any prior signs or symptoms. 7. They are usually found on sites that are readily accessible to the patients hands, e.g. face, hands, arms or legs. 8. The patient will usually deny that the rash is self induced. Please pay special attention to the last point as the patient rarely will agree to his actions. When dermatitis artefacta is suspected: 1. Direct confrontation of the problem should be avoided & the doctor should create an accepting, empathetic and non-judgemental environment. 2. Close supervision and symptomatic care of skin lesions will hopefully lead to a doctor-patient relationship in which psychological issues may gradually be introduced. 3. Psychiatric referral may be recommended, although this is often refused by the patient and his family. 4. Resolution of the current underlying psychological problem will bring about a cure for the time being but dermatitis artefacta tends to wax and wane with the circumstances of the patients life. To minimise occurrences of dermatitis artefacta, a patient should continue to see their doctor on an ongoing basis for supervision or support, whether or not lesions are present.

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