Patterned Erosions over Breasts in an Adolescent Girl

A 17-year-old girl presented with recurrent skin lesions involving bilateral breasts for 10 months. The patient has a history of sudden eruption of mustard seed-sized solid elevated lesions in crops that develop crusting and resolve with atrophic scars. Enquiring regarding the progression of lesions, the patient denied any change in color and size. The patient also failed to explain the progression of these lesions and repetitively stressed on overnight development of the lesions. The patient completely denied any form of prior trauma or self-harm. On examination, multiple crusted erosions with atrophic scars present in a symmetrical pattern almost equidistant from one another involving bilateral breasts sparing the intermammary and surrounding regions [Figure 1]. Because of the hollow history and presence of similar crusted erosions equidistant from one another specifically involving the bilateral breast in a symmetrical pattern directed towards the diagnosis of dermatitis artefacta. The patient was given topical antibacterial cream, and the parents were counseled and were referred to the psychiatry department for further evaluation.Figure 1: Multiple discrete crusted erosions and atrophic scars with perilesional hyperpigmentation distributed symmetrically involving bilateral breastDermatitis artefacta is a factitious disorder where the patient consciously inflicts self-harm to satisfy a psychological need to attract attention or evade responsibility.[1] A female preponderance with the highest incidence reported among late adolescent to early adults.[2] Psychosocial conflicts, emotional immaturity, unconscious motivations, and disturbed interpersonal relationships are some of the underlying factors.[3] Symmetrical, bizarre-shaped, and monomorphic lesions at variable stages of healing are the common clinical presentations.[3] Any chronic dermatosis not responding to treatment with a hollow history should raise suspicion.[1] Due to the vague history, bizarre-shaped lesions (induced by chemical irritants, injectables, etc.), and monomorphic morphology (when used a particular object/instrument like pins, needles, etc.), this entity poses a diagnostic challenge. Our patient was also previously misdiagnosed as a chronic recurrent folliculitis case and was treated with multiple courses of antibiotics by a private practitioner. We were able to diagnose this case by looking at the symmetrical patterned erosions only involving the breasts with the patient unable to explain the evolution of lesions. Furthermore, the recurrence, uniform morphology, and chronicity of lesions every time at the same site with a hollow history were the clinical pointers in diagnosis. Declaration of consent The authors certify that they have obtained all appropriate consent forms, duly signed by the parent(s)/guardian(s) of the patient. In the form, the parent(s)/guardian(s) has/have given his/her/their consent for the images and other clinical information of their child to be reported in the journal. The parents understand that the names and initials of their child/children 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.