C a s e r e p o r t
Factitious genital ulcer
Self-inflicted non-healing genital ulcer: a rare form offactitious disorder
A. Feily, M. R. Namazi, M. Saboktakin, M. Mehri, J. Lotfi, A. Ayoobi,
S. Ghadakzadeh, and N. Karimian
- S U M M A R Y
Dermatitis artefacta is a factitious dermatological disorder with many forms of presentation that may occur on any part of the body. A diagnosis of dermatitis artefacta is often reached after rigorous and repeated investigations. Here we present the case of a 49-year-old single man complaining of a 4-month history of ulceration on the dorsal surface of the glans penis. In view of the unusual appearance of the lesion and the negative findings from clinical investigations, a diagnosis of dermatitis artefacta was made and the patient was referred for psychiatric evaluation. He was started on 20 mg/day of citalopram and titrated up to 40 mg/day by the 4th week, leading to complete remission in the following weeks. Thus, although rare, artefactual dermatitis should be considered in the differential diagnosis of unusual penile lesions.
Introduction
KEY
WORDS
self-inflicted, genital ulcer, factitious disorder
A 49-year-old single man presented with a 4-month history of ulceration on the dorsal surface of the glans penis. He reported pruritus on the site followed by the appearance of a flaccid blister that ruptured easily to create the ulcer. He denied picking or scratching the wound, and was examined by several dermatologists and general practitioners for his condition. He mentioned severe nail biting, quarrelsomeness, anxiety, and obsessive behavior since childhood, but had no history of medication use or hospital admission for these problems. He stated that he was lonely and could not marry because of psychological disturbances. Cutaneous examination showed fresh, sharply demarcated, 0.8 x 2 cm superficial ulceration on the dorsal surface of the glans without any discharge or inflammation (Fig. 1).
Nail and dental examinations revealed loss of about a quarter of the distal parts of all fingernails (Fig. 2) and anterior teeth (Fig. 3) due to nail biting. The general examination did not reveal any other abnormalities: the VDRL was negative and histopathologic study of a biopsy taken from the genital lesion revealed fibro-connective tissue with loss of epithelial lining, sparse inflammatory cell infiltration, and capillary proliferation with no evidence of malignancy. In view of the unusual appearance of lesions localized to the glans penis, a clinical diagnosis of dermatitis artefacta was made. The patient was referred to a psychiatrist for further evaluation; psychiatric assessment revealed depression and obsessive compulsive disorder. The patient also admitted that he himself induced the ulcer by picking and
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C a s e r e p o r t
Fig. 1. Fresh, sharply demarcated, superficial ulceration on the dorsal surface of the glans of penis without any discharge or inflammation.
Fig. 2. Loss of about a quarter of distal parts of finger nails due to nail biting.
scratching the site. He was started on citalopram 20 mg/day and titrated up to 40 mg/day by the 4th week, and complete remission was seen in the following weeks.
Genital ulcers may be due to a number of causes, with the most frequent ones being infections - including sexually transmitted diseases - as well as tumors and mechanical causes. These conditions need to be excluded before a diagnosis of dermatitis artefacta is
Fig. 3. Abreaded teeth due to nail biting.
R EFER EN CE S
made (1). Successful management of genital ulcer disease depends on accurate diagnosis corroborated by appropriate laboratory tests when required (2).
Dermatitis artefacta is a factitious disorder and may represent an obsessive-compulsive spectrum disorder. It has been associated with depression, psychosis, and severe personality disorders featuring immature coping mechanisms (3). The clinical presentation of self-inflicted dermatitis varies widely in morphology and distribution, and may be difficult to recognize. Individual lesions are often bizarre, with irregular rectilinear outlines and geographical patterning not conforming to any spontaneous pathological process (4). The lesions in dermatitis artefacta may occur at any site, but are mainly confined to areas easily accessible to the patient's hands, such as the face, periocular skin, arms, legs, and breasts (5). Interestingly, Hernandez-Gil (1) describes the occurrence of simultaneously appearing artefactual genital ulcers in a couple (1), but we could not find any other report of artefactual genital ulcers in the medical literature. Our patient's lesion was an odd, perfectly demarcated ulcer. These clinical features are typically observed in dermatitis artefacta. Management of such patients is often challenging, and requires close cooperation between medical and mental health professionals.
In conclusion, although rare, artefactual dermatitis should be considered in the differential diagnosis of unusual penile lesions.
1.	Hernandez-Gil J, Guióte MV, Vilanova A, Mendoza F, Linares J, Naranjo R. Genital artefact ulcers appearing simultaneously in a couple. Actas Dermosifiliogr. 2006 Mar;97(2):122—5
2.	Mroczkowski TF, Martin DH. Genital ulcer disease. Dermatol Clin. 1994 Oct;12(4):753-64.
3.	Soong TK, Soong V, Samsudin A, Soong F, Sharma V, O'Donnell N. Periocular dermatitis artefacta in a child. J AAPOS. 2006 Dec;10(6):585-6.
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4.	Gregurek-Novak T, Novak-Bilic G, Vucic M . Dermatitis artefacta: unusual appearance in an older woman. J Eur Acad Dermatol Venereol. 2005 Mar;19(2):223-5.
5.	Zalewska A, Kondras K, Narbutt J, Sysa-Jedrzejowska A. Dermatitis artefacta in a patient with paranoid syndrome. Acta Dermatovenerol Alp Panonica Adriat. 2007 Mar;l6(1):37-9.
AUTHORS' ADDRESSES
Mohammad Reza Namazi, MD, Assistant Professor of Dermatology, Faghihi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran, corresponding author, E-mail: namazi_mr@yahoo.com Amir Feily, MD, Resident of Dermatology, Department of Dermatology, Jondishapur, University of Medical Sciences, Ahvaz, Iran, E-mail: Dr.feily@yahoo.com
Mehdi Saboktakin, Resident of Dermatology, Department of Dermatology, same address, E-mail: Saboktakin2005@yahoo.com Majid Mehri, Resident of Dermatology, Department of Dermatology, same address, E-mail: majidmehri@gmail.com Jalal Lotfi, Resident of Dermatology, Department of Dermatology, same address, E-mail: sjlotfi@yahoo.com
Arash Ayoobi, Resident of Dermatology, Department of Dermatology, same address, E-mail: 94126@irimc.org Saber Ghadakzadeh, MD, Faculty of Medicine, same address, E-mail: Saber_721@yahoo.com
Negar Karimian, MD, Faculty of Medicine, same address, E-mail: Negar_k_md@yahoo.com
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