Dermatitis Simulata mimicking malar rash

A 24‑year‑old female on imatinib therapy for chronic myelogenous leukemia (CML) presented with an asymptomatic intermittent rash involving her face. She complained of development of rash since 3 years after initiation of imatinib. She also complained of photosensitivity and occasional joint pains but denied fever, oral ulcers, Raynaud's phenomenon, and muscle weakness. The differentials of imatinib‑induced photosensitive rash and connective tissue disease‑associated malar rash were considered. On examination, well‑defined pink patches were noted over both cheeks and peri‑ocular area with similar pink patches in a linear distribution over abdomen and legs. On dermatoscopic examination, pinkish‑red exogenous pigment deposits, over perifollicular and eccrine gland openings were observed. A clinical possibility of dermatitis simulata was considered. The lesions were rubbed with an alcohol swab with which the artificial color was easily wiped off. On further questioning, the patient initially denied the application of cosmetics but later on she admitted to have self‑inflicted the lesions using lipstick. She was referred for further psychiatric evaluation to find the intention behind this behavior. She was advised for projective personality testing by psychiatry but the patient refused to participate in the test and didn't follow up.

Dermatitis artefacta or factitial dermatitis is a psychocutaneous disorder in which the patient intentionally self‑inflicts the signs of a dermatosis in an attempt to satisfy a conscious or unconscious desire to assume the sick role. Lesions are inflicted by sharp objects and irritant chemicals in a bizarre geometric pattern often over accessible sites with the surrounding skin being unaffected. Dermatitis simulata is a related entity where external agents like cosmetics which can be easily removed by spirit and crystallized sugar to simulate keratin crusts that can be dissolved in water are used to disguise the skin. In these patients, a detailed psychiatric evaluation is necessary to exclude malingering as a cause in which the patient may have a secondary material gain. Imatinib, a tyrosine kinase inhibitor for the treatment of CML has a plethora of cutaneous adverse effects including photosensitive rash and pseudoporphyria.

The knowledge of psycho‑cutaneous disorders among other specialties, namely family physicians and internist is limited leading to diagnostic delay or missed diagnosis. With the increasing ease of access to medical knowledge by common people patients are being more proficient in disguising signs and symptoms. The predominance of lesions over accessible sites, linear or punched out lesions, bizarre and angulated morphology, gaps in patient history, and lesional evolution are certain red flags, which point towards dermatitis artefacta.

A non‑confrontational approach by the dermatologist and allowing the patient to have the freedom to express their difficulties in a passive confidential environment by a psychiatrist will help towards exploring the complex personality and behavioral derangement that underlies this condition.

Source- Hanumanthu V, Kamat D, Vinay K. Dermatitis simulata: A curious case of photodistributed facial rash. Indian Dermatol Online J 2022;13:138-9.