ARTEFACTUAL SKIN LESIONS: A TRAP FOR RHEUMATOLOGISTS

Background: Dermatitis artefacta (DA) refers to deliberate and conscious self-inflicted skin lesions to satisfy an unconscious psychological or emotional need. It is an unusual condition often described in women, and rarely reported in children. The disorder is often misdiagnosed and needs to be distinguished from organic illness, Munchausen’s by proxy syndrome, and from illicit, nontherapeutic drugs or overdose of medications. Objectives: We report three paediatric cases with a long medical hystory characterized by many laboratory and radiological exams, and mistaken etiologies. Methods: Case 1. An 11-year-old female was referred to our Rheumatology Department for a second opinion about a suspicion of Behcet’s disease based on her cutaneous manifestations. Clinical examination was unremarkable except for bluish ecchymoses, and linear cutaneous abrasions and scars located in accessible areas of her skin ( Figure 1 , Figure 2 and Figure 3 ). Extensive laboratory tests and radiological exams were normal. Case 2. A 14-year-old female was admitted to our pediatric hospital for a 1 month history of fever, malaise and multiple purpuric lesions. The patient referred a 3 year history of similar recurrent episodes characterized by abrupt onset of fever, arthralgia and purpuric lesions for which she already received the diagnosis of urticarial vasculitis. The girl was in good general conditions, without fever. Violaceous ecchymotic lesions were evident on her left forearm. Exhaustive laboratory tests, chest X-ray, and abdomen ultrasound were within normal limits. Case 3. A 14-year-old female was referred to our Pediatric Rheumatology department for a 6 month history of musculoskeletal pain, recurrent shoulder and hip dislocations, and spontaneous ecchymosis on her neck and face. Except for joint hypermobility (Beighton score 7/9), physical examination was normal. At a careful orthopedic evaluation and after shoulder and hip imaging the history of dislocations appeared to be inconsistent. Blood and radiologic tests, cardiological and genetic evaluations for Elher-Danlos syndrome were negative. Results: In Case 1, dermatitis artefacta was suspected and the patient was referred to our mental health colleagues that confermed a severe psychological stress in a basal condition of psychiatric disorder. In Case 2, an in-depth psychological evaluation highlighted a depressive status for personal and familiar suffering. The patient was therefore referred to our mental health department for assessment and management. In Case 3 , eventually a psychiatric interview oriented the diagnosis to a major depressive disorder. Conclusion: DA is a rare condition that should be evaluated in the differential diagnosis, in the presence of unexplained cutaneous lesions without an apparent identifiable cause. Association with various psychological disturbances is the mainstay for this diagnosis, and a careful psychiatric history represents the essential diagnostic key to identify this disorder. REFERENCES: [1] Alcántara Luna S, et al. Dermatitis Artefacta in childhood: a retrospective analysis of 44 patients, 1976-2006. Pediatr Dermatol2015;32:604-8. [2] Ring HC, et al. Artefactual skin lesions in children and adolescents: review of the literature and two cases of factitious purpura. Int J Dermatol2015, 54, e27–e32. [3] Finore ED, et al. Dermatitis artefacta in a child. Pediatr Dermatol2007;24:E51-6. Abstract AB0972 Figure 1 Abstract AB0972 Figure 2 Abstract AB0972 Figure 3 Disclosure of Interests: Lisa Gamalero: None declared, Ilaria Pagnini: None declared, Gabriele Simonini Grant/research support from: Abbvie, Speakers bureau: Abbvie, Rolando Cimaz: None declared, Teresa Giani: None declared DOI: 10.1136/annrheumdis-2019-eular.4312Citation: Ann Rheum Dis, volume 78, supplement 2, year 2019, page A1952Session: Paediatric rheumatology (Scientific Abstracts)