Dermatitis Artefacta: A Multidisciplinary Approach

Introduction

Dermatitis artefacta is a psychocutaneous disorder characterized by self-induced skin lesions, typically triggered by chronic pruritus [1]. Diagnosing dermatitis artefacta remains clinically challenging due to its frequent mimicry of other chronic ulcerative conditions, such as pyoderma gangrenosum and cutaneous malignancies, often leading to delayed diagnosis and prolonged patient morbidity [2]. The self-perpetuating itch-injury cycle, whereby pruritus induces scratching that exacerbates tissue damage, creates a significant barrier to healing. This case offers an unusual case of refractory dermatitis artefacta involving the scalp and auricle, a rarely reported location that further complicated the diagnostic process. This report demonstrates the effectiveness of a structured outpatient multidisciplinary approach specifically targeting the itch-injury cycle, providing a clinically actionable management framework.

Case Report

A 59-year-old man presented with a progressively enlarging, intensely pruritic ulcer over the right temporal scalp, which had persisted for 3 years. The ulcer eventually extended to the auricle. Upon examination, a solitary, sharply demarcated ulcer with an erythematous border and serous exudate was observed (Figure 1). The patient had received multiple treatments with oral antihistamines (including ebastine) and topical corticosteroids (including mometasone furoate), all of which provided minimal relief.

Histopathological examination (hematoxylin and eosin staining) revealed epidermal hyperkeratosis, acanthosis, and mild perivascular lymphocytic infiltration (Figure 2). Immunohistochemistry was positive for AE1/AE3 cytokeratins and p63 (indicating epithelial origin) and negative for cluster of differentiation 31, cluster of differentiation 34, D2–40 (podoplanin), Ber-EP4, and periodic acid–Schiff staining, effectively excluding infectious, vascular, and neoplastic causes. Formal psychiatric assessment did not identify major mood or psychotic disorders that would preclude a mechanism-based dermatologic approach. The discordance between the chronic, destructive clinical presentation and the relatively nonspecific histopathologic findings was a key feature prompting reconsideration of the underlying disease mechanism.

Based on the working diagnosis of dermatitis artefacta within an itch-injury cycle framework, a multidisciplinary management plan was initiated. This included gabapentin 300 mg 3 times daily for neuropathic itch modulation, topical tacrolimus for barrier repair, simple protective dressings to prevent mechanical trauma, and behavioral counseling to interrupt the itch-scratch cycle.

Over the course of 8 weeks, the ulcer healed completely (Figure 3), with no adverse reactions reported. The patient successfully controlled scratching behavior, and there were no signs of relapse during follow-up.

Discussion

The rapid resolution of a 3-year-old ulcer following a coordinated intervention underscores the central role of addressing the itch-injury cycle in dermatitis artefacta management. Compared with cases in the literature, our case demonstrates the efficacy of a structured outpatient protocol. For instance, although 59% of patients in a recent severe dermatitis artefacta cohort required psychiatric hospitalization, our patient achieved remission through coordinated outpatient care, highlighting that early, targeted intervention addressing neurocutaneous (gabapentin) and behavioral components may prevent more intensive psychiatric management [3].

This case also exemplifies diagnostic stewardship. The observed 8-week healing period was notably shorter than the median 14-week period reported in refractory cases [2], a difference potentially attributable to our early and sequential blockade of the itch-injury pathway. A key diagnostic step was recognizing the marked clinicopathologic discordance—a feature emphasized by Conde-Salazar et al—which redirected focus from purely organic etiologies to the self-perpetuating itch-injury cycle [4]. Our diagnostic reasoning systematically progressed from, first, excluding mimics via histopathology and immunohistochemistry, to, second, identifying this discordance, and finally, third, integrating findings within the itch-injury framework.

The following 3 key insights emerge. (1) Feasibility of outpatient management: Rigorous outpatient coordination can yield favorable outcomes, even in cases where literature suggests a high need for psychiatric co-management [3]. (2) Temporal advantage of early intervention: The shorter healing time suggests that prompt interruption of the itch-injury cycle may accelerate recovery [2]. (3) Diagnostic refinement: Clinicopathologic discordance can be operationalized as a positive diagnostic marker, building upon established criteria [4].

Conclusions

This case highlights the value of a multidisciplinary, mechanism-based approach targeting the itch-injury cycle for managing dermatitis artefacta. Sequential integration of gabapentin for itch modulation, barrier repair, mechanical protection, and behavioral intervention achieved significant clinical improvement in this chronic, refractory case. This framework, which demonstrates the efficacy of coordinated outpatient management, advances clinical practice through a structured pathway and promotes diagnostic stewardship by reducing ambiguity and unnecessary investigations. Prospective studies are warranted to validate efficacy and long-term outcomes in larger cohorts.