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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 20  |  Issue : 2  |  Page : 134-137

Factitious disorders in children: A diagnostic labyrinth of cases


Department of Skin and VD, Institute of Medical Sciences and SUM Hospital, Kalinga Nagar, Bhubaneswar, Odisha, India

Date of Web Publication29-Mar-2019

Correspondence Address:
Dr. Chinmoy Raj
Department of Skin and VD, Institute of Medical Sciences and SUM Hospital, Kalinga Nagar, Bhubaneswar - 751 003, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.IJPD_4_18

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  Abstract 


Factitious disorders are among the most underdiagnosed and less explored group of disorders in pediatric patients. Studies from different parts of the world have reported varying prevalence rates. In this article, we present a series of nine cases of factitious disorders that we encountered in the pediatric age group. Factitious disorder remains highly elusive in developing countries like India. It is highly necessary to remain vigilant to clinch an early diagnosis and manage appropriately.

Keywords: Dermatitis artefacta, factitious disease, pediatric, psychocutaneous disorders


How to cite this article:
Raj C, Panda M, Behera D, Kar BR. Factitious disorders in children: A diagnostic labyrinth of cases. Indian J Paediatr Dermatol 2019;20:134-7

How to cite this URL:
Raj C, Panda M, Behera D, Kar BR. Factitious disorders in children: A diagnostic labyrinth of cases. Indian J Paediatr Dermatol [serial online] 2019 [cited 2019 Jun 25];20:134-7. Available from: http://www.ijpd.in/text.asp?2019/20/2/134/255203




  Introduction Top


Factitious disorders in dermatology manifest as self-inflicted skin lesions. It involves the creation of physical or psychiatric symptoms in oneself or other reference persons. While it is a difficult diagnosis to make in adults, it is much more difficult to diagnose in children; hence, these disorders are a frequently misdiagnosed or underdiagnosed entity by dermatologists and pediatricians.

Factitious disorders have been reported in very young children, but it is more commonly seen in adolescent females.[1] There has been increasing recognition in the pediatric literature for the past 20 years that illness falsification by caregivers must be included in the differential diagnosis of children presenting with persistent, unexplained symptoms, or inconclusive laboratory findings. The patients may exhibit both physical and psychological symptoms. Children and adolescents can fabricate illness themselves or participate in the illness falsification by caregivers.[2] The issue of motive remains a major cause of debate.[3]

Drawing attention and care toward self seems to be the motive in majority patients.[4] There have been published literature suggesting an underlying psychiatric disorder, particularly personality disorder in children diagnosed with factitious disorders.[1]

It is essential to identify cases of factitious disorders in the pediatric age group to prevent further mental disability and to curb the disease chronicity which is associated with considerable physical and psychological morbidity. Here, we present a series of nine cases of factitious disorders in the pediatric age group.


  Case Reports Top


Case 1

A 6-year-old boy was brought by his parents with complaints of thickening and darkening of the knuckles. On examination, there was a single hyperkeratotic thick plaque over dorsum of left thumb. The right thumb was completely spared. The parents gave a history of the boy having attention deficit hyperactivity disorder. We made a diagnosis of knuckle-biting leading to pseudo-knuckle pads.

Case 2

A 13-year-old girl was brought by her parents with complaints of patchy loss of hair over the occipital area. They also brought a tuft of hair with them. On examination, there were short, broken, irregular in length, and distorted hair on the scalp in the absence of scarring with negative hair-pull test and potassium hydroxide mount. Dermoscopy revealed irregular lengths of hair shafts, coiled hair, and scratching and bleeding points. A diagnosis of trichotillomania was made [Figure 1].
Figure 1: (a and b) Trichotillomania

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Case 3

A 14-year-old boy was brought by his parents with complaints of multiple painful nodular lesions appearing in crops on his right leg. On examination, there were multiple circular lesions in various stages of evolution. The lesions varied from tender punched-out nodules to healed areas with scarring and hyperpigmentation. The boy had a history of poor performance in school due to which he faced constant nagging by parents and teachers. He even had a poor relationship with classmates and friends. The parents were asked to leave the room, and on further questioning, the boy admitted to creating the lesions with the pointed end of a rounder! This case was diagnosed as a case of dermatillomania [Figure 2].
Figure 2: Dermatillomania

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Case 4

A 14-year-old girl studying in class 9 was brought by her parents with complaints of a nonhealing ulcer. On examination, there was a single well-defined spindle-shaped deep laceration with few healed hesitation cuts on the same arm. When we isolated her from her parents, she told us that she was in love with a boy from her class. However, the boy used to ignore her and gave his attention to another girl. Hence, she was doing this to forget the pain of heartbreak! This was a case of self-mutilation.

Case 5

A 14-year-old girl was brought by her parents with complaints of spontaneous appearance of fluid-filled blisters on the right leg. On examination, there were multiple bullae with clear fluid and few deroofed bullae with superficial ulceration localized to middle 1/3rd of the right leg. Her erratic behavior in our OPD aroused our suspicion. On much probing, she admitted to creating the blisters with lit incense sticks and further rupturing the blisters and further scratching the eroded areas to make deeper ulcers! We made a diagnosis of dermatitis artefacta [Figure 3].
Figure 3: Dermatitis artefacta

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Case 6

A 8-year-old boy was brought by his brother and sister-in-law with complaints of painful circular lesion on the left cheek. On examination, there was a single ill-defined patch with charring of skin and atrophied scarring at places. On questioning, the boy broke down and started crying. He was an orphan and was adopted by his cousin brother. As both his brother and sister-in-law were working people, he felt neglected and alone. He was probably doing this subconsciously to gain attention. The nature of the substance used could not be elicited. We made a diagnosis of dermatitis artefacta.

Case 7

A 14-year-old girl studying in class 9 was brought by her elder sister with complaints of spontaneously appearing blisters which rupture and leave behind scars on healing. On examination, there were symmetric healed linear scars on the extensor surface of lower limbs and flexural aspect of the upper limbs. There were also two fresh linear wounds with crusting, one on each extensor aspect of thigh. All the lesions were on easily self-accessible areas. The girl would not answer a single question, avoided eye contact and kept mum the whole time she was in our outpatient department. We made a provisional diagnosis of dermatitis artefacta and sent her for a psychiatric evaluation. There she confessed to creating the lesions herself with incense sticks and knives! She did not want to study in a residential school and wanted to go home.

Case 8

A 8-year-old girl was brought by her mother with complaints of redness, swelling, and peeling of skin of face. On examination, there was diffuse edema of face with necrotic crusted areas and superficial fissuring localized to face and neck. The girl was very shy and apprehensive. The mother gave a history of the father not being happy with a girl child and used to ignore both mother and child in the process. When we confronted the mother directly, she admitted to applying topical plant products thus causing the lesions! She was doing this to gain attention of the family members. A diagnosis of Munchausen syndrome by proxy (MSBP) was made. With symptomatic treatment from our side and psychiatric consultation and counseling, the girl was able to make a complete recovery [Figure 4].
Figure 4: (a) First visit, (b) full recovery after counseling and treatment

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Case 9

A 10-year-old girl was brought by her mother with complaints of sudden pain and auto-avulsion of nail with severe bleeding. On examination, the nails and nail folds were at different stages of healing. The right toe nail was completely avulsed with frank bleeding. The proximal and lateral nail folds were torn with jagged edges which showed evidence of some kind of shearing force having been applied. (The nail was forcibly pulled out.) The girl was emotionally labile and only cried uncontrollably on asking any questions. On repeatedly questioning the mother, she admitted to pulling the nails from the girl herself with a set of pliers! She gave a further history of a strenuous relationship with her alcoholic husband. A diagnosis of MSBP was made [Figure 5].
Figure 5: (a-d) Sequence of events in a case of Munchausen syndrome by proxy

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  Discussion and Review of Literature Top


Factitious skin disorders are a group of psychiatric disorders with intentional and conscious execution of creating self-inflicted lesions on the skin, hair, nails, or mucosa with a motive to assume the sick role or gain attention and care. The diagnosis is often bewildering and history is misleading, which leads to a battery of investigations and procedures to rule out the organic causes. The classification of psychodermatologic conditions are shown in [Table 1].[5]
Table 1: Classification of psychodermatologic disorders

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Pseudo-knuckle pads are a form of callosity that appears due to repeated trauma. It has been described in children with obsessive behavior as chewing pads.[6] Trichotillomania is a form of traumatic alopecia caused by an irresistible compulsion to pull one's own hair. This has been described in children as young as 2 years.[7] Dermatillomania may be obsessive or compulsive skin picking to the point where it causes visible wounds. The patient has an intense urge to pick the skin following which the patient experiences a sense of relief.[8] Self-mutilation is an impulsive disorder which offers rapid, but short-lived relief from a variety of intolerable conditions and acute emotional stress. The lesions of dermatitis artefacta are caused by fully aware patients. These patients hide the responsibility for their actions from the doctor while patients of self-mutilation own up to their actions.[8],[9]

In case of factitious disorders in pediatric population, most cases are MSBP where the parents or close relatives consistently fabricate history and clinical evidence. This makes the clinical assessment and management to be more confusing and challenging. It is a form of child abuse. Clinical suspicion is pertinent in cases of irrelevant and incoherent history described as “hollow history” lacking details, multiple consultations, and disproportionate signs and symptoms.[8],[9] Keen observation of the child's behavioral pattern such as being wary of physical contact, lying very still while surveying the environment, a lack of appropriate reaction to adverse stimuli such as pain, injury, or frightening events, and apparent fear of parents or going home, should arouse clinical suspicion.

It is of paramount importance to understand the psyche of the patient and the motive behind the fabricated illness rather than focusing on how the lesions were caused. In the pediatric age group, a nonconfrontative and holistic approach involving dermatologist, pediatrician, proper evaluation, and counseling by psychiatrist and medical psychologist is necessary to manage such cases and prevent further psychological disability as they attain adulthood.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s)/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jaghab K, Skodnek KB, Padder TA. Munchausen's syndrome and other factitious disorders in children: Case series and literature review. Psychiatry (Edgmont) 2006;3:46-55.  Back to cited text no. 1
    
2.
Krishnan R, Russell PS. Clinical presentation and approach to management of Factitious Disorder in adolescents – A case report. J Indian Assoc Child Adolesc Ment Health 2017;13:208-24.  Back to cited text no. 2
    
3.
Bass C, Adshead G. Fabrication and induction of illness in children: The psychopathology of abuse. Adv Psychiatr Treat 2007;13:169-77.  Back to cited text no. 3
    
4.
Libow JA. Child and adolescent illness falsification. Pediatrics 2000;105:336-42.  Back to cited text no. 4
    
5.
Jerajani H, Jerajani R. Psychocutaneous disorders. Indian J Dermatol 2006;51:5-7.  Back to cited text no. 5
  [Full text]  
6.
Calikoǧlu E. Pseudo-knuckle pads: An unusual cutaneous sign of obsessive-compulsive disorder in an adolescent patient. Turk J Pediatr 2003;45:348-9.  Back to cited text no. 6
    
7.
Parmar NV, Kuruvila S, Thilakan P. Early-onset trichotillomania: A case report with dermoscopic findings. Indian J Paediatr Dermatol 2016;17:65-7.  Back to cited text no. 7
  [Full text]  
8.
Ring HC, Smith MN, Jemec GB. Self-inflicted skin lesions: A review of the terminology. Acta Dermatovenerol Croat 2014;22:85-90.  Back to cited text no. 8
    
9.
Bewley A, Taylor RE. Psychodermatology and psychocutaneous disease. In: Griffiths C, Barker J, Bleiker T, Chalmers R, Creamer D, editors. Rook's Textbook of Dermatology. 9th ed. United Kingdom: John Wiley & Sons Ltd.; 2016. p. 86.1-86.40.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1]



 

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