dermatitis artefactafactitiousself-inflictedMunchausen
Dermatitis Artefacta (Factitious Dermatitis)
דרמטיטיס ארטיפקטה
📖 מבוא
Dermatitis artefacta — נגעים עוריים self-inflicted שהמטופל מכחיש את מעורבותו. Factitious disorder imposed on self (Munchausen). Geometric/bizarre patterns, accessible areas only. DDx: neurotic excoriations (patient aware). Bologna Ch 159.
📝 אנמנזה
⚠️ גישה לא-שיפוטית, אמפתית. נגעים בצורות לא-טבעיות? מוגבל לאזורים נגישים? "הופיעו פתאום"? מהלך — נגעים חדשים כשישנים מחלימים? הנגעים מופיעים כשלא במעקב? לחץ נפשי, חרדה, דיכאון? היסטוריית hospitalization מרובה?
🔍 בדיקה
⚠️ "Hollow history" — patient cannot explain how lesions occurred. Geometric, angular, linear, bizarre shapes — NOT following anatomic/dermatologic patterns. Sharply demarcated borders. Location: accessible to dominant hand (face, arms, legs, trunk anterior). ⚠️ Sparing of areas difficult to reach (upper back center). Types: burns (cigarette, chemical), excoriations, purpura factitia, foreign body injection, panniculitis factitia.
📋 סיכום
נגעים עוריים שלא מתאימים לתבנית דרמטולוגית ידועה. בירור להשלמה.
💊 המלצות
🔬 בירור
-בירור: ביופסיה (often non-specific): necrosis, foreign body reaction, thermal injury, chemical burns — depends on mechanism. ⚠️ Wound cultures if infected. CBC, CMP, coagulation (r/o bleeding disorder for purpura). Consider: drug screen, dermatopathology review for "unknown" mechanism. Inpatient observation — lesions stop appearing when monitored (⚠️ may shift to other self-harm).
-DDx: Neurotic excoriations (patient acknowledges picking), Pyoderma gangrenosum (pathergy, undermined borders, biopsy: neutrophilic), Vasculitis (palpable purpura, systemic symptoms), Contact dermatitis (pattern matches exposure), Burns (accidental, history consistent), Bullous disorders (DIF positive).
💊 טיפול
-גישה: ⚠️ Do NOT confront/accuse patient directly — leads to flight and loss of therapeutic alliance. Avoid "factitious" in medical records if possible (use "non-physiologic pattern"). Acknowledge suffering: "I can see these lesions are causing you distress." Gentle exploration of psychosocial stressors. ⚠️ Munchausen by proxy (factitious disorder imposed on another) — mandatory reporting if child/elder involved.
-טיפול: Wound care — appropriate dressings, prevent infection. Psychiatry/psychology referral — essential but timing is critical (after rapport established). CBT (cognitive behavioral therapy) — effective. SSRIs for comorbid depression/anxiety. ⚠️ If personality disorder (borderline PD) — dialectical behavior therapy (DBT). Social work assessment. Minimize secondary gain (attention, disability).
📅 מעקב
-הפניה לפסיכיאטריה. ביקורת בעוד 2 שבועות.
⚗ מרשם
-Wound care: non-adherent dressings, mupirocin if secondary infection - OTC/1OP
-PO SERTRALINE 50-100 mg/d (comorbid depression/anxiety) - 1OP