Self-inflicted pathological cutaneous disorders. Part II.

Self-inflicted skin disorders are artefact diseases inflicted by the use of multiple different means, for various different purposes. They account for about 2% of dermatology patient visits, and include disorders with a denied or hidden pathological behavior (factitious disorders) and disorders with a non-denied and non-hidden pathological behavior (compulsive disorders). In turn, factitious skin disorders are subdivided into 2 groups: factitious disorders without an external incentive (considered in a preceding work) and factitious disorders with external incentives. In the second eventuality, the simulator is motivated by illicit intent, wishing to evade civil duties or a prison sentence, for instance, or to exploit situations of an occupational nature, and is fully aware of his action and his intention. Apart of the two groups of pathomimic artefacts and malingering, some self-inflicted dermatoses are due to behavioral disorders involving compulsive habits (tics, psychological excoriations). The great majority of subjects suffering from the latter disturbances are quick to confess their urge to self-inflict lesions. The management, including both psychiatric and dermatological assessment, concludes this second part of the work regarding the self-inflicted cutaneous diseases.

Therapeutic Potential of Curcumin in Reversing the Depression and Associated Pseudodementia via Modulating Stress Hormone, Hippocampal Neurotransmitters, and BDNF Levels in Rats.

Depressive state adversely affects the memory functions, especially in the geriatric population. The initial stage of memory deficits associated with depression is particularly called as pseudodementia. It is the starting point of memory disturbance before dementia. The purpose of this research was to study depression and its consequent pseudodementia. For this purpose 24 male albino Wistar rats were divided into four groups. Depression was induced by 14 days of chronic restraint stress (CRS) daily for 4 h. After developing a depression model, pattern separation test was conducted to monitor pseudodementia in rats. Morris water maze test (MWM) was also performed to observe spatial memory. It was observed that model animals displayed impaired pattern separation and spatial memory. Treatment was started after the development of pseudodementia in rats. Curcumin at a dose of 200 mg/kg was given to model rats for one week along with the stress procedure. Following the treatment with curcumin, rats were again subjected to the aforementioned behavioral tests before decapitation. Corticosterone levels, brain derived neurotrophic factor (BDNF) and neurochemical analysis were conducted. Model rats showed depressogenic behavior and impaired memory performance. In addition to this, high corticosterone levels and decreased hippocampal BDNF, 5-HT, dopamine (DA), and acetylcholine (ACh) levels were also observed in depressed animals. These behavioral biochemical and neurochemical changes were effectively restored following treatment with curcumin. Hence, it is suggested from this study that pseudodementia can be reversed unlike true dementia by controlling the factors such as depression which induce memory impairment.

Gardner-Diamond Syndrome in an Adolescent With Suicidal Ideation: A Case Report.

Gardner-Diamond syndrome (GDS) is a rare disease often seen in young women involving painful localized inflammation and ecchymosis. Ecchymosis usually develops spontaneously after emotional stress. The pathophysiology of the disease is not fully understood, and little is known about management modalities for this syndrome. The primary approach of health professionals in the evaluation of this rare condition should involve identification of cases and investigation of potential accompanying psychiatric pathologies. The case presented here highlights the importance of assessing for GDS and reviews descriptions of GDS in the context of the existing literature.

[Self-inflicted lesions in the context of hidradenitis suppurativa: Pathomimicry]. / Lésions auto-provoquées dans un contexte d'hidradénite suppurée : un cas de pathomimicrie.

BACKGROUND: Factitious disorders constitute a complex pathology for the dermatologist. Although a diagnosis is often indicated, it is difficult to confirm and treatment is complicated. Dermatitis artefacta is the somatic expression of an often serious psychiatric disorder consciously created by patients on their own cutaneous-mucosal surfaces but the motivation is unconscious and no secondary benefits are sought (in contrast to simulation). Pathomimicry represent a specific entity: the provocation of outbreaks of a known disease, triggered by voluntary exposure to a causative agent. Herein we report on a case of pathomimicry in a context of hidradenitis suppurativa. PATIENTS AND METHODS: A teenage girl whose main previous medical history consisted of grade-2 obesity and an episode of pubic abscess was seen at our clinic for axillary lesions. She presented in a state of negligence, was suspicious and aggressive, and refused to undress. After gaining her trust, clinical examination revealed prominent ulcerations (each with a granulated base) at a distance from the folds in the axillary areas, as well as typical hidradenitis lesions of Hurley Grade 2 with purulent openings and rope-like scars from the inguinal folds. Hospitalization was recommended and a positive outcome was achieved under antibiotic therapy with doxycycline, topical alginate and hydrocellular dressings. A psychiatric evaluation concluded that the patient was presenting dysmorphophobic narcissistic weakness, probably in reaction to recurrent harassment at school since childhood. Once she developed trust with us, which was difficult to establish, the patient admitted to having caused the lesions herself. Given the history and clinical data, as well as the negative laboratory tests, a diagnosis of pathomimicry was made. DISCUSSION: Several cases of dermatological pathomimicry (sustainment by the patient of an ulcer with a known cause, contact with an allergen found in eczema, or renewed use of a medication implicated in toxiderma) or systemic disease (insulin injection in a diabetic patient) have been reported. To the best of our knowledge, this is the first description of pathomimicry associated with hidradenitis suppurativa. Regarding therapy, aftercare should be multidisciplinary. Confessions should not be forced and confrontations, which risk serious psychiatric collapse, should be avoided. A reassuring attitude enables psychiatry to be applied once trust has been sustainably established, hence the crucial role of the dermatologist.

Histopathological patterns in dermatitis artefacta.

BACKGROUND: Dermatitis artefacta is a relevant and frequently unrecognized clinical condition associated with self-harming behavior, in which unconscious manipulation causes skin lesions. While atypical lesions and an unusual disease course may give rise to clinical suspicion of a self-induced disorder, questioning and examining these patients usually fails to confirm or clarify this suspicion. In this setting, the dermatopathologist may be faced with the question whether there are any histological signs corroborating the diagnosis of dermatitis artefacta. METHODS: We conducted a Pubmed search (without time frame) using the terms "dermatitis artefacta", "factitious/factitial dermatitis", "artefactual skin" in combination with "histology" or "pathology". Given the low number of hits, we extended the search by adding terms related to certain types of injuries (for example, "burn" or "cold") in order to identify specific patterns. RESULTS: In general, there are only few studies investigating the histological features of factitious skin disorders. Another problem arises from the fact that, even if clinical and histological findings are suggestive of dermatitis artefacta, subsequent confirmation of the exact mechanism of injury is frequently not possible, thus leaving room for speculation. This complicates defining specific histological patterns based on the various types of injuries. Overall, the results of the present study suggest that a factitious disorder should be considered if histological findings include blistering with a mild inflammatory infiltrate, rupture of collagen fibers, multinucleated keratinocytes, or elongated and vertically aligned keratinocytic nuclei.

[Gardner-Diamond syndrome in a young man: A case report and literature review]. / Syndrome de Gardner-Diamond : à propos d'un cas chez un homme jeune et revue de la littérature.

INTRODUCTION: Gardner-Diamond syndrome is a rare condition secondary to a sensitization to self-erythrocytes. It is predominantly seen in women and presents as a painful ecchymotic disorder. An underlying psychiatric disease or a triggering psychological stress is of important diagnostic value. CASE REPORT: We report a 24-year-old patient who presented with intermittent spontaneous painful ecchymosis since 5 years. Complementary investigations failed to identify an organic disorder. Gardner-Diamond syndrome was retained because of the clinical presentation, the negativity of diagnostic work-up and the identification of a psychological trauma. Patient management (pain, psychological support) is difficult, justifying a multidisciplinary approach. CONCLUSION: Gardner-Diamond syndrome is a rare and unrecognized disorder, which should be discussed in the presence of ecchymotic or purpuric lesions that do not have a diagnostic orientation. Early recognition of this disorder enables initiation of an appropriate management, but also limits unnecessary additional explorations.

Gardner-Diamond syndrome.

Gardner-Diamond syndrome, which also is knownas autoerythrocyte sensitization disorder, is a raresyndrome of inflammatory, edematous papulesthat evolve into painful ecchymoses on the trunkand lower legs after a period of stress with no priorhistory of trauma. This syndrome usually occurs inwomen with a history of psychiatric disorders, themost common one being depression. Although theexact mechanism of injury is not well understood,it is hypothesized that these patients haveautoantibodies to phosphatidylserine, which is aphospholipid membrane component in erythrocytes.Treatment for this disorder includes symptomatictherapies and psychotropic medications to treat theunderlying psychiatric disorder.

Integrating Neuropsychology and Brain Imaging for a Referral of Possible Pseudodementia: A Case Report.

The study aimed to highlight the importance of interdisciplinary collaboration and the value for combining normative neuropsychological and neuroradiological measures for clinical purposes. We present the case of "CL," a 65-year-old, right-handed, Caucasian female referred for a neuropsychological evaluation of memory difficulties and depression with the rule-out of pseudodementia. A brain magnetic resonance imaging (MRI) scan was conducted within 24 hours of the neuropsychology exam. Mood measures showed elevated depression and apathy symptoms. The neuropsychological profile showed variable effort, intact comprehension but compromised confrontation naming and verbal memory deficits. Using normative references from 20 female age- and education-matched healthy control peers, CL showed significantly reduced temporal cortex thickness with reduced bilateral hippocampal, right amygdala, and right caudate volumes. Combined data were supportive of a diagnosis of semantic dementia. Examining neuropsychological profiles in combination with neuroimaging standardized metrics relative to peers improved case conceptualization. Standard measures of effort and malingering examined alone and without MRI for the diagnosis of pseudodementia have questionable validity and rationale. We additionally discuss the advantages and limitations/challenges for integrating neuropsychological assessments with normative based MRI brain metrics.