Managing dermatitis simulata by bridging the dermatology-psychology gap

Dear Sir,

A 17-year-old girl came to us during the pandemic with itchy, blackish discoloration over her perioral and periorbital regions. As recommended by the government during the epidemic, the patient was inspected from a distance of two feet, and the results showed dark pigmentation. Under cross-examination, the patient revealed that she had previously seen numerous dermatologists but that the lesions had not been cured and had instead been becoming worse. She had presented all of the records of the numerous doctors who had treated her for lichen planus pigmentosus. Due to the lack of information on periorbital lichen planus pigmentosus in the literature, a suspicious skin inspection was conducted wearing gloves and double masks. During the evaluation, the patient showed symptoms of anxiousness, such as poor presentation, vague history-giving, and irritation when we asked about treatment history. Differentials such as chromhidrosis and pseudochromhidrosis were retained. Examination revealed well-to-ill-defined blackish spots on the tip of the nose, below the chin, and over the periorbital region [Figure 1a]. DermLite DL4 was used to do a dermoscopy inspection before cleaning the area. A deposit of black pigment was seen around the eccrine gland and perifollicular area [Figure 1b]. After obtaining consent, we started using cotton to wipe the area and noticed some black particles, but the lesion had not completely cleared. After wiping the area once more with cotton soaked in spirit, the lesions were erased entirely [Figure 1c and d]. Examinations of the hair, nails, mucosa, and other areas were normal. The patient was ashamed and depressed. We moved the patient to a different room and spoke with her one-on-one to get her background and reason. She agreed to act as though she had lesions. To make these areas look unattractive, she had applied kajal over them. This time, however, she applied more and was caught. The patient was transferred to the psychiatric department for further evaluation.

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Figure 1:

A 17-year-old female presented with pigmentation over the periorbital and perioral area. (a) Pigmentation over the periorbital, chin, and tip of the nose area. (b) Dermoscopy shows dark color pigment deposits around the perifollicular area and the eccrine gland. (c) Clearance of pigmented area over the periorbital region by spirit cotton. (d) Blackish-stained cotton.

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Psychodermatology is a branch of dermatology that requires more research; diagnosing it usually requires a high level of suspicion, education, and exposure.^[1] Dermatitis artefacta, another name for factitious dermatitis, is a psychological disorder that manifests as a dermatological condition with the goal of creating a false illness to elicit sympathy, avoid accepting responsibility, or receive disability payments.^[2] Dermatitis simulata does not entail self-mutilation and has a better prognosis than dermatitis artefacta.^[3] These patients typically utilize readily removed cosmetics and crystallized sugar to simulate keratin crust.^[4] Chromhidrosis is a rare apocrine or eccrine gland disorder where colored sweat is produced. Pseudochromhidrosis is also a rare disorder in which certain bacteria, medications, dyes, or chemical agents that produce dyes are linked to colored sweat.^[5] Psycho-cutaneous issues were frequently overlooked. As medical information becomes more readily available to the general public, patients are getting increasingly skilled at hiding symptoms and indicators.