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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 22  |  Issue : 2  |  Page : 126-128

Dermatitis artefacta: A consequence of self-mutilating behavior in a girl with intellectual disability


1 Department of Psychiatry, King George's Medical University, Lucknow, Uttar Pradesh, India
2 Department of Dermatology and Venerology, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India

Date of Web Publication2-Apr-2018

Correspondence Address:
Sujita Kumar Kar
Department of Psychiatry, King George's Medical University, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmhhb.jmhhb_4_17

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  Abstract 


Intellectual disability (mental retardation) is a common mental health morbidity, worldwide. These groups of individuals are often a neglected cluster in the society. Intellectual disability often disables their ability to express their needs and distress, which becomes more evident with increasing severity of intellectual disability. Individuals with intellectual disability may show challenging behaviors such as self-injurious behavior. Dermatitis artefacta may result from repeated self-injurious behavior, which may mimic with various dermatologic conditions. Improvement in self-injurious behavior may bring improvement in the skin lesions.

Keywords: Dermatitis artefacta, intellectual disability, self-injurious behavior


How to cite this article:
Das A, Kar SK, Sahu P. Dermatitis artefacta: A consequence of self-mutilating behavior in a girl with intellectual disability. J Mental Health Hum Behav 2017;22:126-8

How to cite this URL:
Das A, Kar SK, Sahu P. Dermatitis artefacta: A consequence of self-mutilating behavior in a girl with intellectual disability. J Mental Health Hum Behav [serial online] 2017 [cited 2018 May 20];22:126-8. Available from: http://www.jmhhb.org/text.asp?2017/22/2/126/229104




  Introduction Top


Intellectual disability is widely seen across the globe with a prevalence of 18.3 per 1000 population with the highest prevalence in low- to middle-income countries.[1] Challenging behavior is seen in more than half individuals with intellectual disability.[2] Various risk factors (male gender, lack of communication skills, and strong need for care) attribute to the development of challenging behavior in intellectual disability. The majority of the challenging behavior are situational, which depends on the extent of interaction between the individual and environment.[2] Challenging behaviors are frequently seen in the context of sensory impairments and in the presence of comorbid psychiatric disorders.[3] The challenging behavior may be of self-injurious type, aggressive type, or stereotyped type.[3]

Self-mutilating behavior may be seen in healthy children during infancy and early childhood; its persistence after the age of 3 years is considered as pathological.[4] Self-injurious behavior may be of various forms, of which, biting is a common type of behavior. Self-injurious behaviors are mostly reported during adolescence and commonly associated with female gender.[4] A study reported the prevalence of dermatitis artefacta in 3.7% individuals with intellectual disability.[5] Other dermatoses associated with intellectual disability were trichotillomania and onychophagia.[5]

The nosological status of the self-inflicted skin lesions in dermatology is debatable. Dermatitis artefacta is often seen in the light of factitious disorder;[6] however, it may be the result of self-injurious behavior seen in individuals with intellectual disability.


  Case Report Top


An 18-year-old female from rural background was brought for psychiatric consultation to a tertiary care hospital with the chief complaints of inability to take proper care of herself and frequent self-injurious behavior. The patient was born at home by normal vaginal delivery with a history of delayed cry. No history of any need of ventilatory support or hyperbilirubinemia or prolonged fever reported in the postnatal period. All developmental milestones (motor, language and social) were delayed. She had started walking at around 6 years of age. On sociodevelopmental ground, the patient could dress herself and feed herself when provided with food. She did not have any toilet training, could not handle money, and could not identify colors. There had been no history of seizure. Her family history was insignificant for any psychiatric illness. The patient had behavior of harming herself. She used to bite her right hand especially the first web space, which started from the age of 4 years. The injured part would heal in due course of time, which was subsequently followed by self-injury by the patient in the same area. The parents of the patient consulted several doctors for the treatment of the recurrent cutaneous lesion. There was no history of other significant behavioral disorders like harming others or getting irritated on unprovoked trivial issues. The sleep and other vegetative functions of the patient were adequate. The patient was advised for the assessment of her intellectual functioning (intelligence quotient assessment) which came around 35–40 suggestive of moderate mental retardation.

On dermatological/cutaneous examination, there was a non-itchy thickened plaque of size 5 cm × 6 cm with central depigmentation and peripheral hyperpigmentation present on first web space of the right hand [Figure 1]. In addition to this, there were some raw areas suggesting of recent self-injurious behavior. A biopsy was advised by the dermatologist with the differential diagnosis of hypertrophic scar and hypertrophic lichen planus. Histopathological examination was suggestive of hypertrophic scar. She was also started with tablet risperidone (0.5 mg/day) for her behavioral problems with topical 3% salicylic acid ointment on the cutaneous lesions. Expectations of the family members were addressed; behavioral modifications were suggested.
Figure 1: Three hyperpigmented plaques with central depigmentation and scaling present on the first web space on dorsum of the right hand extending up to the right wrist

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  Discussion Top


Self-mutilation is often seen in the context of mental illness and may be the manifestation of aggression directed toward self.[7] The psychological distress resulting from any cause in individuals with intellectual disability may be manifested as self-directed aggression. The skin lesions in dermatitis artefacta are often located in the approachable sites of the body and can be manifested in the form of keloid and hypertrophied scar.[8],[9] In our patient, the self-induced callous and associated skin changes are a component of dermatitis artefacta.

There are limited evidence regarding the use of pharmacological intervention in the management of behavioral problems associated with intellectual disability; however, various medications such as risperidone, lithium, methylphenidate, antiepileptic drugs, naltrexone, glutamatergic agents, and acetylcholinesterase inhibitors have been tried with variable success.[9],[10],[11] These medications have been used in various clinical or syndromal subtypes of intellectual disabilities. Our patient was prescribed risperidone to curtail her self-injurious behavior.

The clinician should be judicious in prescribing psychotropic medications in individuals with intellectual disability. Use of psychotropic medication without clear indications may cause drug-related problems, which may be as high as 34%. Structured medication review focusing on the assessment of the need of medication, dose of medication, and monitoring of adverse drug events regularly may be beneficial in individuals with intellectual disability.[12] Dermatological lesions often improve with improvement in self-injurious behavior. Topical keratolytic agents may be beneficial.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Maulik PK, Mascarenhas MN, Mathers CD, Dua T, Saxena S. Prevalence of intellectual disability: A meta-analysis of population-based studies. Res Dev Disabil 2011;32:419-36.  Back to cited text no. 1
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2.
Dworschak W, Ratz C, Wagner M. Prevalence and putative risk markers of challenging behavior in students with intellectual disabilities. Res Dev Disabil 2016;58:94-103.  Back to cited text no. 2
    
3.
Poppes P, van der Putten AJ, Vlaskamp C. Frequency and severity of challenging behaviour in people with profound intellectual and multiple disabilities. Res Dev Disabil 2010;31:1269-75.  Back to cited text no. 3
    
4.
Baguelin-Pinaud A, Seguy C, Thibaut F. Self-mutilating behaviour: A study on 30 inpatients. Encephale 2009;35:538-43.  Back to cited text no. 4
    
5.
Dimoski A, Duricic S. Dermatitis artefacta, onychophagia and trichotillomania in mentally retarded children and adolescents. Med Pregl 1991;44:471-2.  Back to cited text no. 5
    
6.
Gieler U, Consoli SG, Tomás-Aragones L, Linder DM, Jemec GB, Poot F, et al. Self-inflicted lesions in dermatology: Terminology and classification – A position paper from the European Society for Dermatology and Psychiatry (ESDaP). Acta Derm Venereol 2013;93:4-12.  Back to cited text no. 6
    
7.
Broniarczyk-Dyla G, Pajor A. Skin self-injuries in psychodermatological aspect. Wiad Lek 2011;64:142-6.  Back to cited text no. 7
    
8.
Choudhary SV, Khairkar P, Singh A, Gupta S. Dermatitis artefacta: Keloids and foreign body granuloma due to overvalued ideation of acupuncture. Indian J Dermatol Venereol Leprol 2009;75:606-8.  Back to cited text no. 8
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9.
Kumaresan M, Rai R, Raj A. Dermatitis artefacta. Indian Dermatol Online J 2012;3:141-3.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Ji NY, Findling RL. Pharmacotherapy for mental health problems in people with intellectual disability. Curr Opin Psychiatry 2016;29:103-25.  Back to cited text no. 10
    
11.
Deb S, Unwin GL. Psychotropic medication for behaviour problems in people with intellectual disability: A review of the current literature. Curr Opin Psychiatry 2007;20:461-6.  Back to cited text no. 11
    
12.
Scheifes A, Egberts TC, Stolker JJ, Nijman HL, Heerdink ER. Structured medication review to improve pharmacotherapy in people with intellectual disability and behavioural problems. J Appl Res Intellect Disabil 2016;29:346-55.  Back to cited text no. 12
    


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