Dermatitis artefacta in an intellectually disabled man with monosymptomatic hypochondriacal delusion of HIV infection

To the Editor

The prevalence of psychiatric disorders occurring in dermatology outpatient clinics was estimated to be around 30% (Hughes et al., 1983). A range of psychiatric disorders has been reported from an outpatient setting; these include neurotic excoriation, trichotillomania, monosymptomatic hypochondriacal psychosis (MHP), and dermatitis artefacta (Ehsani et al., 2009). MHP, also known as delusional disorder-somatic type is a form of psychosis characterized by a delusion about a particular somatic or hypchondriacal concern. Although the main type of MHP reported in the literature is delusional parasitosis, other forms have also been reported (Wang and Lee, 1997). Dermatitis artefacta is a psychocutaneous disorder in which patients deliberately inflict cutaneous lesions of almost all kinds. It is often associated with childhood sexual abuse, obsessive compulsive disorder, depression, psychosis, intellectual disability, malingering, and factitious disorder (Gupta and Gupta, 1996). We present a case of a 28-year-old male with mild intellectual impairment who presented with dermatitis on his hands and face secondary to a delusion of being infected with HIV.

“Mr L” was a 28-year-old man who presented to the hospital emergency department with infected erythematous skin rashes on the dorsum of his hands and face. He claimed that “HIV was coming out of the hand lesions” and his “blood needed to be drained”. He also reported that he had unprotected sex with two women about 3 weeks prior to the onset of the skin rash. On physical examination, he was afebrile and had normal vital functions. The routine blood tests, HIV serology, anti-double-stranded DNA antibodies, extractable nuclear antibody, and antineutrophil cytoplasmic antibodies tests were all negative and an MRI brain scan showed no abnormalities. The rashes on the dorsum of the hands and face were warm, tender, and red while some areas displayed signs of infection. He also had erythematous rashes on his face. A diagnosis of dermatitis was made and he was given intravenous flucloxacillin 2 g at the emergency department cubicle. About few hours later, he removed the intravenous line by himself and wanted to leave the hospital. A psychiatric opinion was sought and he was subsequently admitted to an acute psychiatric unit under an involuntary treatment order for further assessment and treatment. Of note, there was no past or family history of any psychiatric disorders. He lived independently with some support and never had any behavioural problems associated with his intellectual disability.

On mental state examination, he appeared as a skinny young man, with poor personal hygiene. His behaviour was characterized by an over-concern with his hands, looking constantly at them and shaking and frequently raising them in the air. He appeared anxious and perplexed with his speech rapid and slightly pressured. He had a severe morbid belief of being infected with HIV and was not amenable to any reasoning. He was not relieved despite repeatedly washing his hands and he did not have the characteristic resistance against a subjective compulsion. Our patient clearly had a well-systematized hypochondriacal delusion of acute onset, which may have been triggered by the fear and anxiety following unprotected sexual contacts. His mild intellectual disability might have been a predisposing factor. His delusional belief of being infected with HIV resulted in repeatedly washing and rubbing his hands to get rid of the virus leading to the development of severe dermatitis affecting initially his hands and later his face.

He was started on olanzapine 10 mg daily and continued on oral flucloxacillin. He responded well to olanzapine 15 mg per day with significant improvement in his skin condition and delusion at discharge. Following his discharge from the hospital, he was assessed by the community mental health service on two occasions reporting good remission.

The most commonly used pharmacological treatment for MHP is the antipsychotic medication pimozide. However, there have been many reported side effects with this medication including cardiac (Q-T interval prolongation) and extrapyramidal symptoms. Several case studies have shown good results with atypical antipsychotics such as risperidone, quetiapine, and olanzapine. Olanzapine has been reported to be effective in previous case reports on MHP (Weintraub and Robinson, 2000; Fawcett, 2002). We chose olanzapine for its immediate sedative effect due to our patient’s agitation.

To summarize, early detection and treatment of the primary psychiatric condition can have a significant impact on the positive outcome of comorbid cutaneous disorders.