Chronic Scattered Skin Lesions Present for Over 5 Years
The most likely diagnosis in a patient with multiple scattered wounds/lesions over the entire body present for over 5 years is dermatitis artefacta (factitious dermatitis), particularly given the chronic, persistent nature and widespread distribution that defies typical organic dermatologic disease patterns.
Key Diagnostic Considerations
Primary Diagnosis: Dermatitis Artefacta
Dermatitis artefacta characteristically presents as self-inflicted skin lesions that persist chronically, often with polymorphic appearance and distribution patterns that do not conform to recognized dermatologic diseases 1, 2
The 5-year duration is highly consistent with dermatitis artefacta, as these patients typically have chronic, relapsing courses driven by underlying psychiatric conditions including depression, anxiety, obsessive-compulsive disorder, or impulse control disorders 2, 3
Lesions in dermatitis artefacta commonly appear on accessible body areas (upper body, face, extremities) where patients can reach to inflict injury, and the "scattered" distribution across the entire body fits this pattern 2, 4
The condition predominantly affects females and can occur at any age, including elderly patients, with underlying emotional distress serving as the primary driver 1, 2
Critical Exclusions Required
Stevens-Johnson syndrome/toxic epidermal necrolysis must be excluded but is highly unlikely given the 5-year duration, as SJS/TEN progresses rapidly over 5-7 days with widespread purpuric macules, positive Nikolsky sign, mucosal involvement, and skin tenderness 5, 6, 7
Any cutaneous ulcer or wound persisting longer than 2 weeks requires tissue biopsy to exclude malignancy, making histopathologic evaluation mandatory in this case 6
Baseline laboratory investigations should include complete blood count, fasting blood glucose, HIV antibody testing, and syphilis serology to identify underlying systemic conditions that may contribute to chronic wounds 6
Diagnostic Approach
Clinical Assessment Features
Look for lesions with bizarre, geometric, or linear patterns that do not follow dermatomal or vascular distributions 1, 2
Assess for sharp demarcation between affected and unaffected skin, with lesions appearing in areas easily accessible to the patient's dominant hand 2, 4
Evaluate for evidence of mechanical trauma (excoriations, ulcerations) or chemical injury patterns, as these are the most common methods used to produce dermatitis artefacta lesions 2, 8
Document patient's emotional state, history of psychiatric disorders, and any pattern of denial regarding self-infliction of lesions 1, 2, 3
Psychiatric Comorbidities to Screen For
Depression, anxiety disorders, obsessive-compulsive disorder, personality disorders, and impulse control disorders are commonly associated with dermatitis artefacta and require systematic evaluation 2, 3
Dissociative identity disorder may present as dermatitis artefacta, with patients inflicting lesions during dissociative episodes and having no conscious memory of self-injury 4
Patients typically deny self-infliction and refuse dialogue with physicians about the psychological origins of their lesions, making diagnosis particularly challenging 2, 3
Management Strategy
Multidisciplinary Team Approach
A psychodermatology multidisciplinary team involving dermatology, psychiatry, and psychology achieves 93% successful management rates (resolution or remission) for dermatitis artefacta 3
Dermatological input is essential to make the diagnosis and exclude organic disease through appropriate biopsy and laboratory testing 3
Psychiatric intervention is required to manage concomitant mental health disease, which is present in 46% of patients at presentation 3
Psychological therapy addresses the underlying emotional precipitants and provides coping mechanisms to replace self-injurious behavior 3
Common Pitfalls to Avoid
The polymorphic nature and rarity of dermatitis artefacta often leads to misdiagnosis and multiple unnecessary investigations, imposing significant economic burden 1
Failure to recognize the psychiatric nature of the condition results in repeated dermatologic treatments that inevitably fail, as the underlying psychological drivers remain unaddressed 2, 3
Confronting patients directly about self-infliction typically results in denial and disengagement from care; a non-judgmental, supportive approach is essential 2, 3
In pediatric or vulnerable adult cases, consider whether child protection or safeguarding services referral is appropriate, as was necessary in 32% of pediatric cases in one series 3