DERMATITIS FACTITIA

Synonym.—Feigned eruptions; Dermatitis artefacta.

By this term is meant an eruption of artificial origin, usually limited
in extent, and purposely produced with the object of gaining sympathy
or for malingering, and of which many cases are now on record (Startin,

¹ Wolbach, “Pathologic Histology of Chronic x-Ray Dermatitis and Early x-Ray
Carcinoma,” Jour. Med. Research, Oct., 1909.

DERMATITIS FACTITIA                                 449

Fagge, Lavgier, Mattei, Mackintosh, Van Harlingen, Colcott Fox, and
others).¹

Symptoms.—The lesions may be of an erythematous, vesicular,
bullous, or ulcerative nature. They are rarely numerous, as a rule,
one or several patches being present. The individual spots are usually
small, but exceptionally may cover considerable area. The most com­
mon lesion met with is probably the small erythematous area, with slight
crusting, usually somewhat longer than wide, and at times distinctly
linear, resulting from persistent friction, as in a case of my own,² or from
the application of some mild irritant. Blebs are also not an uncommon
manifestation. Occasionally the lesions are shallow ulcers. In fact,

Fig. 112.—Dermatitis factitia—note the unusually uniform and regular character and
arrangement of the lesions.

almost all varieties of dermatic lesions may be produced by the ordi­
nary means at hand, such as acids, strong alkalies, and other chem­
icals, heat, friction, or other traumatic agencies. Carbolic acid is fre­
quently employed, and is, as with other caustics, apt to give rise to
patches with somewhat irregular edges, due to careless or unskilful ap­
plication. The lesions, for obvious reasons, make their appearance sud-

¹ Van Harlingen and Stout, Morrow‘s System, vol. iii (Dermatology), p. 364, give a
brief but good résumé with some references; consult also Lavgier, “Maladies simu-
lées,” Dict, de Med. et de Chir. Pratiques; Rasch, Dermat. Centralblatt, Aug., 1899, p.
322, relates a case of vesicobullous and gangrenous character and refers to several others;
F. J. Shepherd (4 cases), Jour. Cutan. Dis., 1897, p. 544; ibid., 1906, p. 164. For other
literature bearing upon the subject, see under “Multiple Gangrene of the Skin in
Adults.”

² Stelwagon, Arch. Derm., 1882, p. 236.

29

450                                      INFLAMMATIONS

denly, and apparently during the night or at other time when the patient
is unlikely to be seen or disturbed. They are, moreover, usually seated
on parts readily reached by the hands—not infrequently are on the one
side of the body.¹ The most common sites are the anterior or lateral
aspects of the legs and arms; occasionally the face and the trunk.

The lesions are scarcely gone before new ones make their appearance
suddenly near by or elsewhere upon the surface; or the original spot or
patches may be kept purposely in a constant state of irritation. Thus
the affair may continue almost indefinitely until the patient is weary of
the annoyance or the special object desired is attained or despaired
of. They have an artificial look, are usually sharply defined, and do
not correspond to either the appearance or distribution of ordinary
cutaneous diseases. Doubtless some of the cases of superficial gangrene
(erythema gangrænosum, dermatitis gangrænosa, neurotic excoriations)
have their origin in such manner. The subjects of these various mani­
festations are, for the most part, hysteric women, but they are also met
with, for the purpose of malingering, in criminals and mendicants, in
soldiers, sailors, and others desiring to be relieved of work or their duties.
Towle, Pernet, and a few others suggest the possibility that in some of
the cases in hysteric women the subjects may not be actually aware
of their own instrumentality in the production of the lesions, the act
having been done while in a pseudohypnotic or somnambulistic state.

The diagnosis is sometimes fraught with difficulty, but attention to
the features, behavior, and persistence and repetition of the eruption
will usually arouse suspicion, and the patient can be kept under secret
surveillance. An irregular outline and the presence of staining at the
borders from the chemical used are suggestive. A fixed dressing to the
parts involved will result in prompt cure, and if new lesions appear, they
will, of necessity, be on other situations. Too often, unfortunately, a
statement of the correct diagnosis to the family of the patient will be
received not only with incredulity, but often with dismissal.

Treatment of the lesions depends upon their characters and is essen­
tially that of the forms of dermatitis to which they may belong.

¹ Parts not accessible by the hands are, however, occasionally the seat of the
lesions also, the acid being conveyed by a stick with a cotton or rag swab on the end—
as in the case recorded by Menage (“An Interesting Neuro-dermatological Case”),
New Orleans Med. and Surg. Jour., Dec, i9io. The cunning and deception practised
by these patients are almost beyond belief, as shown in Parkes Weber‘s case (Brit.
Jour. Derm., 1912, p. 78; nineteen months’ duration: Woman aged thirty-seven,
had a chronic bullous eczema-like eruption with superficial ulceration on the front
of the abdomen; a starched bandage was applied, but this became loosened and
probably (by deflating the abdomen) the patient was able to introduce her hand under
the upper anterior portion; when bandage was removed bullæ were found over the cor­
responding portion; dark specks were also found in the raised epidermis over some of
the bullæ, which on microscopic examination proved to be powdered cantharides.
In connection with this case Weber referred to a case described by Hirsch (at a meeting
of Gynecologic Society of Munich), of a woman who within two years had had several
abdominal operations, and who later being treated by x-rays, developed ulcers which
gradually spread over her whole abdomen; it was subsequently discovered that these
spurious x-ray ulcers were self-inflicted by means of hydrochloric acid.

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