A Case of Periocular Factitious Dermatitis in an Adult

A 70-year-old diabetic female presented to our academic center as a transfer from a rural hospital with a diagnosis of a progressive left preseptal cellulitis (Panel A demonstrates 1–2 weeks after onset) for 4 months, which had been treated with multiple rounds of oral antibiotics and now concern for superimposed infection. Comprehensive ophthalmic exam revealed a large patch of eschar and ulceration involving the left glabella, nasal sidewall, brow, and upper eyelid with madarosis (Panel B). Otherwise, ocular vitals were normal, and the anterior and posterior exams were unremarkable. CT orbits showed no fluid collections or signs of infection. Further history revealed that she had an outside biopsy consistent with factitious dermatitis per the family’s report; however, we were unable to obtain the report or the specimen to confirm the diagnosis. Broad-spectrum intravenous antibiotics were administered for 48 hours given concern for superimposed infection; however, there was only minimal improvement. Viral cultures for herpes simplex virus and varicella zoster virus were negative, and a repeat incisional biopsy showed ulceration with granulation tissue, fibrinous exudate, and naked hair shafts but no signs of malignancy. Repeat incisional biopsy took place within 24 hours of admission, and after no change on IV antibiotics to reach a definitive diagnosis. Our dermatology colleagues agreed that the lesion was most consistent with trauma-induced eroded plaque with concern for impetiginized changes. Additionally, we recommended to the primary team to consider pursuing a consultation with behavioral health. The exposed area was covered with 2% mupirocin and covered with a patch to prevent the patient from picking the wound. Just 12 hours after initiation of mupirocin and patching patient showed marked improvement and was discharged with outpatient follow-up (Panel C). On follow-up, 3 weeks after treatment, the lesion has markedly re-epithelialized (Panel D). This case report highlights a patient with self-induced dermatitis, which is a helpful etiology to highlight in the differential of nonhealing periocular dermatitis or cellulitis.