Inked with Melancholy Blues: A Case of Dermatitis Simulata Set in the Realm of Factitious Disorders

Dear Editor, Factitious disorders (Latin; factitious: self-induced) encompass a broad spectrum of feigned physical and/or psychological symptoms and signs to assume a sick role.[1] Such patients dramatically report their history, although the symptoms are quite inconsistent and vague, making them difficult to diagnose. They can simulate any systemic or cutaneous disorder. A 35-year-old unmarried female presented to the dermatology outpatient department with recurrent, painful blue lesions on her right forearm, right calf, and right side of the forehead for 5 months. On enquiry, she denied any history of trauma or history suggestive of Raynaud’s phenomenon, a term that she was aware of. She presented us with extensive documentation from various specialists, including orthopedic surgeons, neurologists, physicians, and rheumatologists. She had undergone multiple investigations, including several blood works (inclusive of anti-nuclear antibodies panel) and various radiological tests that were all within normal limits. On examination, there was presence of linear “macules” with a bluish hue on the right forearm, right calf, and right side of the forehead [Figure 1]. On asking the patient to raise her arm above her head to rule out any vascular occlusion syndrome, she complained of pain in the arm. The patient was then counselled for a skin biopsy for which she willingly agreed. In the guise of taking a sample for biopsy, the area was cleaned with an alcohol swab and the bluish discoloration could be wiped off easily [Figure 2]. We informed her that the biopsy could not be performed. She insisted and seemed distraught when we refused the same. The patient was asked to wait while we spoke to her mother who denied any history of her daughter feigning illnesses. She informed us that it was the passing of her father that set off a series of health issues in the daughter. Over the last 2 years, she has had diabetes mellitus, sinusitis, tinnitus, pulmonary tuberculosis, dysmenorrhea, and COVID-19 for all of which she had sought treatment. On further inquiry, other chronic stressors were her unmarried status and a dependent brother with intellectual disability. She was referred for psychiatric evaluation. However, neither did she get evaluated in the psychiatry department nor did she follow up with dermatology.Figure 1: Linear bluish macule on the volar aspect of left forearmFigure 2: On rubbing the lesion with an alcohol swab, the color was wiped off completely. The inset showing blue pigment on the alcohol swabThe term “Munchausen syndrome” (MS) was first described in 1951 by Richard Asher,[2] who termed the disorder after Baron von Münchhausen (1720–1797), whose name had become famous as the narrator of false and ridiculously exaggerated stories.[3] Formerly, Folks and Freeman described three characteristic features of MS [Table 1].[4,5] Other terminologies like hospital addiction syndrome, polysurgical addiction, professional patient syndrome, or hospital vagabonds have been proposed for MS.[6] Although the term itself is gradually becoming obsolete, it is reserved to describe the most superlative forms of factitious disorders.[7] It is now included in the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders as a “factitious disorder imposed on self” [Table 2].[8]Table 1: Folks and Freeman’s depiction of MS[ 4 , 5 ]Table 2: Diagnostic criteria for factitious disorder imposed on self[ 8 ]Patients with factitious disorder imposed on self can present to the hospital with a wide variety of symptoms ranging from undefined neurological symptoms (paralysis, seizures) to chronic pain (chest pain, abdominal pain, osteoarticular pain).[9] Dermatological involvement is reported to be infrequent. Dermatitis artefacta or factitial dermatitis is one such presentation where the patient self-inflicts cutaneous injury or illness.[10] Clinical history is often ambiguous and misleading with lesions produced to satisfy a psychological need that is not consciously understood. Typical presentation includes bizarre cutaneous lesions (abrasions, erosions, ulcers, alopecia, crusted lesions) in a rather accessible location (face, arm, forearm, hands, scalp). It can be mistaken for a plethora of other dermatologic disorders. Therefore it is a diagnosis of exclusion. Dermatitis simulata is a subtype of factitial dermatitis where the patient inflicts lesions that do not significantly damage their skin [Figure 3].[11] Patients apply cosmetic or colored products to feign organic skin pathology, which can be easily removed by spirit swabs, or crystallized sugar to simulate keratin crusts that can be dissolved in water.[12]Figure 3: A Venn diagram simplifying factitious disorders and malingeringIn our case, the patient had a history of several hospital visits with repeated investigations performed for various symptoms. Although her medical file was extensive and she seemed to be riddled with multiple disorders, each disorder was hollow with no corroborating objective proof of the same. Various etiological factors, such as psychosocial conflicts, disturbed interpersonal relations, associated neurosis, personality disorders, or depression, have been implicated in MS. Here, the father’s demise was the triggering event that might have led to a domino effect. The mother’s non-confrontational attitude towards the patient’s psychological distress made the case challenging to diagnose and treat. Such cases should be approached in a way that allows patients to express their difficulties liberally, without any fear of judgment. Management of factitious disorders is particularly difficult as a loss to follow up in such cases is inordinately high. Establishing a psycho-dermatology clinic or accompanying the patient to the psychiatrist could be the first step towards sensitising them. Until these steps are implemented, management will remain curbed, and attempting to diagnose such conditions will yield no sense of fulfilment. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.