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Dermatitis artefacta presenting as a basal cell carcinoma—an important clinical sign missed
  1. A T MURRAY,
  2. R GOBLE,
  3. G A SUTTON
  1. Birmingham and Midland Eye Centre, City Hospital NHS Trust, Dudley Road, Birmingham B3 2NS
  1. Mr Aidan Murray.

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Editor,—Dermatitis artefacta has not previously been reported presenting as a masquerade syndrome for basal cell carcinoma of the eyelid. We describe a patient who presented with a “typical” basal cell carcinoma of the lower eyelid, in whom the diagnosis only became apparent following its surgical excision.

CASE REPORT

A 43 year old right handed woman was referred by her general practitioner complaining of a 6 month history of a lesion on her left lower eyelid which had been increasing in size, and she had developed a red sticky eye. She had no ophthalmological history of note; however, she had previously worked in a beauty clinic and had used the sunbeds there with great regularity. She had a medical history of diverticular disease, anxiety, and was under investigation by a cardiologist for ectopic heart beats.

On examination she had a lesion which appeared typical of a basal cell carcinoma of her left lower eyelid with rolled edges, notching of the lid margin, and infiltration of the tarsal plate (Fig 1). The raised rolled edge of the lesion was indurated to palpation. In addition she had injection of the conjunctiva. She was referred to the oculoplastic clinic at Birmingham and Midland Eye Centre. At review the lesion appeared similar to Figure 1, although the conjunctival injection was absent. The lesion was excised with a 2 mm marginal clearance. The postoperative course was uneventful apart from the development of a mild papillary conjunctivitis—this was thought to be due to a chloramphenicol allergy and her topical antibiotic was discontinued, which led to resolution of this condition.

Figure 1

Dermatitis artefacta of the left lower eyelid imitating a basal cell carcinoma. Injection of the conjunctiva and the absence of subepithelial telangiectasia, in retrospect should have raised suspicion as to the certainty of the diagnosis of basal cell carcinoma.

Histology of the excised specimen revealed “...no evidence of neoplasm...”; there was what appeared to be a keratinous cyst. There was stromal scarring and active inflammation, and histiocytes and giant cells were seen, some of which were clearly a reaction to free lipid. There were, in addition, a number of conjunctival epithelial inclusion cysts.

A diagnosis of dermatitis artefacta was made.

COMMENT

In this case the “typical” features of what was thought to be a basal cell carcinoma of the lower eyelid overshadowed the subtle features in this patient’s medical history that may have aided the development of this rare diagnosis. More importantly the presence of a patient with a red eye with a coexisting lesion of the eyelid should have alerted us to the possibility of excessive scratching/digitation after exclusion of more obvious causes such as molluscum. Also, in retrospect, the absence of fine subepithelial telangiectasia should have raised added suspicion.

Had the possibility of dermatitis artefacta been mooted, a short period of occlusive bandaging with the use of steroid cream may have aided confirmation of the diagnosis.

Dermatitis artefacta or self inflicted factitial dermatitis forms one of the spectrum of self inflicted dermatoses and also represents one of the spectrum of obsessive compulsive disorders. Typically, patients deny the self inflicted nature of the disorder. The disorder is seen more commonly in women (male to female ratio of at least 1:4) and has a broad and variable age of onset (9–73 years).1 2Patients frequently have an impulsive personality disorder.

Skin lesions are produced or significantly exacerbated by self inflicted trauma.3 Recurrent excoriation produces inflammation and lichenification of the skin; the resultant irritation and pruritus leads to further self trauma and chronic dermatitis. The lesions have wide ranging morphological features and are often bizarre looking, with sharp geometric borders surrounded by normal looking skin.4 In the right handed person, the left side is usually involved,2 as in this case.

Self inflicted dermatoses vary greatly because of the wide range of methods that are used for inflicting the lesions: cutting, abrasion, burning applying chemicals, and injecting various products. This diversity makes it particularly difficult to diagnose dermatitis artefacta.5 Histopathological diagnosis consists of features of acute inflammation with increased polymorphonuclear leucocytes with scattered erythrocytes. There may also be areas of necrosis with areas of healing with fibrocystic reaction.6We believe the characteristic rolled edge of the lesion was from such healing areas.

Patients with dermatitis artefacta are particularly sensitive to hostile feelings in medical practitioners, to which they react with renewed self mutilation.7 The need for psychiatric referral should be balanced against the fact that the patient will interpret this referral as a rejection, which can intensify the self mutilation. Follow up studies have shown that most patients with dermatitis artefacta improve more significantly after changes in life situations and maturation than as a result of psychiatric treatment. In this case her continuing care was taken over by her general practitioner.

Acknowledgments

Our thanks to Mr Shun-Shin, Wolverhampton Eye Infirmary for his help in obtaining the documentation regarding this patient.

References

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