Dermatitis artefacta in children and adolescents

Dermatitis artefacta (DA) is skin damage caused deliberately and secretly by the patient, and presented as skin disease, for covert secondary gain. In children DA must be distinguished from skin damage inflicted by others (abuse and fabricated or induced illness). Excluding the possibility of rare skin disease is difficult for paediatricians, who may feel unable to dismiss other dermatological diagnoses with authority. However there are usually positive diagnostic clues in the history, such as previous unexplained illness or psychosocial difficulties alleviated by the DA. Examination may reveal either a characteristic distribution or particular morphology of the lesions which will suggest the diagnosis. Most of the published cases are adults, in whom DA usually reflects significant psychological needs, or conscious deception for material gain. Children with DA have psychological needs too, but the spectrum of causes is different. At one end, normal children sometimes inflict lesions on themselves experimentally or in response to peer pressure, then find themselves caught up in a medical scenario. At the other, children trapped in an intolerable situation may resort to DA as a cry for help. Skill and sensitivity are required to provide an “exit strategy” or to divert a dermatological presentation to the appropriate agency such as clinical psychology or child protection.