Dermatitis artefacta
A 27-year-old lady presented to our OPD with a 6-month history of recurrent ulcers on extremities and upper back, the cause of which she could not explain. Her social and medical history revealed that her in-laws abandoned her after the death of her husband in a road traffic accident. On clinical examination, we found many symmetrical superficial excoriations on anterior aspect of both upper and lower extremities, which she claimed appeared overnight, interestingly many, as she narrated, appeared on her way to hospital. Almost all the lesions were similar in appearance (about 0.5 cm wide and 2.5 cm long), dimension and were positioned in a linear manner and all present only in accessible parts of body []. Though few were fresh erosions with little serous oozing, many were old marks indicating past healed-up lesions. Barring one or two over upper back and left flank [], almost all the lesions were on anterior aspect of lower limb and extensor aspect of forearm. DA was suspected and the patient was hospitalized for further evaluation and treatment.\nPhysical examination and laboratory work-up were negative. Fresh symmetrical and identical skin lesions started appearing while she was in hospital. Interestingly, patient could tell the exact time when a particular lesion appeared. Only occlusion dressing was advised with systemic antibiotics and lesions healed in 2 to 3 days. After repeated interviews, it became obvious that she was depressed following death of her husband and was in conflict with her parents and confessed to having produced the lesions by own nail. A clinical diagnosis of DA was made. No fresh lesions appeared during two days of observation. She was referred to a psychiatrist and few sessions of psychotherapy produced marked improvement. She was discharged and was advised by the psychiatrist for further sessions. At follow-up visit two weeks later, the ulcers had recurred and were still present at two subsequent visits. She refused further admission and did not return for follow-up visits.