Extensive Cutaneous Ulceration of the Scalp - Unknown Disease Entity or Dermatitis Artefacta?

Psychological disturbances and emotional stress events may elicit a wide spectrum of skin disturbances which are classified as dermatitis artefacta. This diagnosis should be taken into consideration when symptoms coexist in a bizarre pattern or indicate at least several distinct skin pathologies while laboratory tests remain inconclusive. We present a case of dermatitis artefacta which produced very extensive loss of the scalp. Our intention was to show difficulties in diagnostic management of this recurrent and complex psychiatric disorder which may inconvenience clinicians. Neither laboratory tests (including bacteriology) nor X-ray of the skull identified any significant pathology. Although histopathology excluded skin malignancy, it showed an unspecific pattern not attributable to the most probable skin conditions like pyoderma gangrenosum or infection. Psychiatric consultation was inconclusive. Despite undetermined diagnosis, the patient was eligible for reconstructive surgery, which restored his scalp coverage. Different skin conditions may share very similar spectra of clinical symptoms, and even deep medical investigation does not always enable us to define the observed condition. However, both laboratory and imaging tests are necessary to exclude infections or potential malignancies before the diagnosis of dermatitis artefacta is established, whereas psychiatric consultation may or may not identify mental issues.