The daughter of an 80-year-old female patient recently noticed ulcerated lesions on her mothers face. The eyebrow area, maxilla and area immediately beneath the right nostril were affected. Patches of dermatitis surrounded the sharply demarcated ulcerations. No cellulitis was present. The daughter noted that she had seen her mother pick at these skin locations incessantly and surmised that she was causing them.

Also, the staff at the nursing home where the patient lived revealed that the patient started picking at her facial skin shortly after undergoing a tarsorrhaphy several months earlier to relieve severe dryness of her eye. Despite repeated admonitions by the nursing home staff, the patient continued the practice and was seemingly unaware of what she was doing.

In this case of self-inflicted trauma, the eyebrow area, maxilla and area immediately beneath the right nostril were affected. Patches of dermatitis surrounded the sharply demarcated ulcerations.

Have you seen similar patients in your practice? Self-inflicted traumatic lesions around the face and eyelids are often overlooked pathologic behaviors. The classification of factitious (artificially induced) disease includes such behaviors, each with its unique characteristics and varying treatment approaches. Here, well look at some of these factitious diseases.

Difficult Diagnosis
By its very nature, factitious disease is very difficult to diagnose because it is a disorder of exclusion. Many clinicians have never seen such a case. Those who have seen it may not have had the opportunity to investigate it completely because patients who have this disorder often do not return to the same practitioner. Instead, they move from doctor to doctor, starting the diagnostic process all over again. This leads to further frustration for the patient and no true recognition of the disorder by either the patient or clinician.

Cutaneous factitious disease is characterized by a self-induced excoriation of the skin and often involves the face and the periocular regions.^1,2 Three general categories of individuals may present with such a clinical complication:³

Patients who may actually have a local insult to their skin, such as a minor dermatosis, infection or injury. Through some irresistible urge, these patients may unconsciously yet compulsively continue to traumatize the area repeatedly. Some individuals stop this action if someone points it out to them, while others indignantly deny any responsibility and continue to repeat the trauma.

Patients who have an underlying primary psychiatric disorder. These include individuals who demonstrate neurotic activities, such as trichotillomania (self-hair pulling). These patients engage in this aberrant behavior unconsciously and do not attempt to deceive potential helpers.

Patients who intentionally try to deceive the clinician. These include various types of malingerers, especially those who are trying to obtain either a secondary financial or psychological gain. For example, patients who have dermatitis artefacta usually have an underlying psychopathology in which they must fulfill a need to be cared for.^4,5

These patients often have such characteristics as the presence of a doting caregiver that help give them away, especially when the differential diagnosis is not readily evident and the patient is not forthcoming.

Case: Elderly Male Presents with Lid Insult An 80-year-old white male with moderate dementia was evaluated for cataract surgery. His wife noted that, for the past three to four weeks, her husband had been rubbing and picking his right lower eyelid. A focal area of insult was evident in the medial aspect of the right lower eyelid. It extended down into the maxillary region. Although no excoriations were present, the area was edematous and hyperemic. No other focal lesions were present. This 80-year-old male presented with a focal area of insult in the medial aspect of the right lower eyelid. We instructed the patient to stop rubbing his eyelid. He appeared cooperative, but it was obvious that he did not completely comprehend the situation. His wife promised to watch his aberrant behavior more closely. No other treatment was initiated. He was scheduled for cataract surgery. The patient underwent successful cataract surgery. Shortly after the surgery, he stopped rubbing his eyelid and started scratching and picking at the skin about his right sideburn area. He returned with new, deeper excoriations in this location several weeks later. We treated these lesions with topical antibiotic ointment. The topical antibiotic ointment was applied, and his wife apparently watched him more closely. At his next visit, the lesions cleared up, and there were no signs that he was digging anywhere else.

The skin lesions often have a weeping, crusted or scarred appearance with post-inflammatory hypopigmentation or hyperpigmentation.² One study found that multiple lesions are present, that they are sharply demarcated from normal tissue with varying stages of healing, and that they are most commonly located on areas of easy accessibility.²

Histopathology of the epidermis shows amorphous, eosinophilic scale-like crusts that contain nuclear debris; in some instances, clumps of bacteria overly the dermis, with focal loss of epidermis demarcating sharply from areas of normal-appearing tissue.³ The dermis shows inflammatory infiltrates composed primarily of lymphocytes, histiocytes and neutrophils with numerous extravasated erythrocytes.³

Patients who have neurotic excoriations usually admit to the self-inflicted nature of their lesions and are agreeable to treatment to control their urges.² Because these individuals often have an underlying psychiatric disorder, consider recommending supportive psychotherapy. The most frequently associated psychiatric disorders are a personality with perfectionistic and compulsive traits, obsessive-compulsive disorder or depression.^5-7

Patients who have early dementia are often depressed and may exhibit such behavior due to their underlying depression and an inability to understand what they are doing. This appears to be an under-reported group of patients.

Delusional Parasitosis
Delusional parasitosis, also known as delusions of parasitosis, is the mistaken belief that one is infested by ectoparasites (mites, lice, fleas, spiders) or internal parasites (worms, bacteria).^8,9 This factitious disease occurs mostly in middle-aged or elderly women, although it can occur at any age. Younger patients tend to be white males who abuse drugs, especially those who use cocaine or methamphetamine.¹⁰ Skin lesions in these individuals include excoriations and ulcers that are caused by the users compulsive picking at meth bugs.¹¹

Younger women who have delusional parasitosis are likely to be divorced with children, have low or no income, have low self-esteem and feelings of social rejection, lead alternative life styles, and experience loneliness and stress.⁹

Patients describe the infestation as being on or just under the skin, in or around body openings, or internal (particularly in the stomach or intestines).^8,9 They believe that the parasites are widespread in the environment, especially in their homes. These individuals often state that they have had this infestation for a long time and that despite seeing numerous physicians and other professionals (e.g., parasitologists, hygienists, entomologists and exterminators), they have never received a definitive diagnosis.

Besides the skin excoriations, these patients share a common clinical presentation: the matchbox sign, in which the patient carries a small container of samples he or she has collected.⁹ These sample containers often contain dust, lint, skin scrapings, toilet paper, dried blood or scabs, hair or other pieces of human tissue.

These patients may have tried a long list of remedies, including potentially dangerous levels of pesticides.⁹ Psychotherapy, along with antipsychotic medications, can be beneficial.¹²

Trichotillomania
Trichotillomania is an impulse disorder in which an individual has an irresistible urge to pull his or her own hair and feels a sense of relief after doing so.¹³

Variations of this disorder include trichophagia, in which the patient eats the hair after it has been pulled out.^13-15 Patients who swallow hair can develop gastrointestinal hair balls, known as trichobezoars.¹³ Another variation is trichokryptomania, in which patients rub or break off their hair rather than pull and pluck it.^2,5

The most common site of involvement is the central region of the scalp, followed by the eyebrows and eyelashes. Some 15% of patients pull hair from more than one location.¹³

Many patients engage in repeated methods and rituals for both the hair removal and disposal (such as trichophagia). Some patients pull one individual hair or eyelash at a time and examine it, while others pull multiple hairs or eyelashes at one time.^14,15

Females are more likely than males to pull eyebrow and eyelash hair.¹⁶ Males represent only 25% to 33% of reported compulsive hair pullers.¹⁴ The mean age of onset is age 8 for males and age 12 for females.¹⁴

Trichotillomania can result from an unconscious pulling, while some patients complain of an irritating sensation in the area from which they pull their hair.^3,13 Hair pulling can be associated with depression, lack of impulse control or a habit disorder and may be precipitated by a stressful event, such as parental divorce, death of a relative or studying for an examination.¹⁴

Trichotillomania also has been associated with eating disorders. These patients are more likely to experience bulimia rather than anorexia.¹⁷ One theory is that hair pulling is an expression of various facets of psychosexual development, but in some studies, no specific personality disorders or traits were identified.¹⁸

Compulsive trichotillomaniacs frequently hide or deny their hair pulling.¹⁵ They may use make-up or wigs to conceal areas of hair loss.¹³

Clinical evaluation will show multiple broken hairs or eyelashes, usually with no accompanying skin irregularity. A skin biopsy may be beneficial in suspicious cases. The biopsy usually shows no epidermal involvement. The dermis histopathology may reveal corkscrew hair showing a wrinkled, smudged appearance (trichomalacia) and clumps of melanin.³

Empty hair or eyelash follicles may be present among otherwise normal follicles, and you may observe clefting between follicular epithelium and connective tissue sheaths, extravasated red blood cells, and in severe cases, replacement of hair and eyelash follicles with fibrotic tracts.³ In severe cases, in which scarring of the follicle occurs, the hair or eyelash no longer grows.

Treatment involves a combination of behavior therapy modification under the supervision of a psychiatrist or psychologist and pharmacologic intervention.¹⁹ Pharmacotherapy with selective serotonin reuptake inhibitors may help some patients.20,21

Case: Female Presents with Missing Lashes A 74-year-old white female was missing a section of lashes in the medial aspect of the right upper eyelid. The eyelid margin at this location was disrupted, and the skin was irregular with loose skin flaps. No evidence of infection was noted. This patient, who was diagnosed with trichotillomania, was missing a section of eyelashes in the medial aspect of the right upper lid. Upon further questioning, the patient admitted to digging at her eyelid. This problem began shortly after the death of her husband two months earlier and worsened as the sale of her home approached. After an extensive discussion, the patient admitted to just having too much stress in her life to bear at this time. We referred her for psychiatric counseling. The patient went to the psychiatrist, who agreed with the diagnosis, and she agreed to begin therapy. The patient was lost to follow-up.

Patients who have dermatitis artefacta usually have an underlying psychopathology. Psychiatric co-morbidities that have been identified in patients who have this condition include depression, psychotic disorders, Mnchausen syndrome, malingering, borderline personality disorder or severe personality disorder with immature coping mechanisms.^5,22,24,25 Dermatitis artefacta occasionally may result from a transient maladaptive response to acute psychosocial stress.²⁶

Because these patients deny causing their own mutilation, a correct diagnosis and eventual treatment is difficult to obtain.² It is helpful to provide an understanding and accepting environment and to sidestep the issue of cause.²⁶

Treatment for these patients includes psychotherapy and psychotropic medication.^22,26,27

Treatment
The damaged skin that is often present in patients with factitious disease should be medically treated. This may include antibiotic ointments, occlusive bandages, placebos, and hospitalization in severe cases in which cellulitis may have occurred secondary to more extensive self-mutilation. These therapeutic approaches not only quell the traumatized dermis; they have a therapeutic effect on the psychiatric problem by providing some secondary attention and care that the patient may need and seek.²⁸

In some instances, it may be best to avoid confrontation with a suspected self-abuser. Instead, gently refer the patient back to his or her general practitioner with the suggestion of psychiatric evaluation. Some patients, such as those who have neurotic excoriations, may be more cooperative to obtain therapy than others, such as patients who have dermatitis artefacta.^26,29

Generally, patients who have self-inflicted dermatologic lesions in the facial or genital area often are more willing to accept psychological help, and they respond well to a combination of psychotropic drugs and psychotherapy. By contrast, those patients who have lesions on their limbs or over their entire bodies usually are strongly resistant to psychological treatment.¹²

Although factitious disease of the face and eyelids is well documented in the dermatologic and psychiatric literature, it is under-reported in the ophthalmic literature. When patients present with skin excoriations, be sure to include factitious entities in your differential diagnosis, especially in elderly patients who exhibit mild to moderate signs of dementia. 

Dr. Skorin is the staff osteopathic ophthalmologist at Albert Lea Eye ClinicMayo Health System, Albert Lea, Minn.

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