Reflex sympathetic dystrophy with mutilating ulcerations suspicious of a factitial origin

Reflex sympathetic dystrophy (RSD) is a poorly understood posttraumatic pain syndrome associated with dysfunction of the sympathetic nervous system. Pain is often out of proportion to the extent of injury. Progression of the disease may lead to dystrophic and atrophic changes resulting in total disability of an affected limb. Skin findings are highly variable and nonspecific and may rarely include bullae and ulcerations. We describe a mutilating case of RSD with unusual and severely disfiguring ulcerations that necessitated amputation of the right arm. Shortly after the amputation, ulcerations began appearing on the left arm. We suspect a factitial component but have been unable to prove or disprove it. We propose that some ulcerations in patients with RSD may be factitial in origin.