A 48-Year-Old Woman with a Facial Lesion

The Resolution

 

Differential Diagnosis

• Acne excoriée
• Factitial ulcer
• Prurigo nodularis
• Neurogenic ulcer

Diagnosis

This patient was diagnosed with factitial ulcer. A manifestation of dermatitis artefacta, these occur secondary to a patient digging, excoriating, or generally manipulating their own skin—a psychiatric condition in and of itself, in which patients self-induce lesions in order to satisfy a need to assume the “sick role.”

 

Learnings/What to Look for

• Patients are unlikely to admit creating the lesions themselves
• Diagnosis of self-abuse tends to occur more frequently in women and in those working in healthcare
• Factitial ulcers should be differentiated from malingering, in which lesions are created deliberately for secondary gain, such as collecting disability or obtaining prescriptions

 

Pearls for Urgent Care Management and Considerations for Transfer

• Lesions are often produced by digging, picking, biting, cutting, injecting, and puncturing. Be vigilant for wounds that may be complicated by gangrene, abscess formation, or other life-threatening infections
• Treatment requires a multidisciplinary approach. In the urgent care setting, treat the wound according to its severity
• In patients for whom there is no known psychiatric diagnosis, recommend consultation with a mental health provider

 

Acknowledgment: Images courtesy of VisualDx (www.VisualDx.com/JUCM).

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