‘Awful, isn’t it, doctor?’
The patient’s partner indicates a lesion on his other half’s hand, which he has just freed of bandages for me to inspect. And it does look pretty nasty.
According to the patient, the ulcer on the back of her hand had developed quickly – over the last couple of days – and was painless. There was no history of trauma and she had no comparable lesions elsewhere on her body, or any history of similar problems.
But, her medical summary was extensive. This 28-year-old woman had a history of type 1 diabetes, asthma, eating disorders, ulcerative colitis and obsessive compulsive disorder. Her current medication comprised insulin, salbutamol, mesalazine and corticosteroid inhalers. Despite this she was physically quite well, though her partner mentioned that she had been suffering stress because her mother was dying of cancer.
My immediate reaction – given the speed of onset and the appearance – was that this ulcer had been caused by trauma, possibly a burn. Though she couldn’t recall any specific injury, perhaps a diabetic-related neuropathy meant that she had been unaware of the original insult.
However, the diagnosis was far from clear, and her past medical history raised a number of other possibilities.
- Pyoderma gangrenosum
- Necrobiosis lipoidica
- Dermatitis artefacta
- Malignant skin ulcer
Pyoderma gangrenosum is associated with inflammatory bowel disease and can develop rapidly – though the ulcer was not particularly purulent, nor gangrenous-looking. Necrobiosis lipoidica was another possibility, particularly given her diabetes, and can cause ulceration. But the site of the lesion was not typical and the onset was unusually rapid. Plus, with both of these differentials there is usually considerable pain.
A vasculitis can cause strange ulcers, but she seemed otherwise well at presentation, and the lesion was solitary which made a vasculitis unlikely.
Malignancy did cross my mind – as it always does when examining any otherwise inexplicable ulcerated lesion – but her young age and the short history were, obviously, against this.
Her past medical history and current period of stress put dermatitis artefacta on the agenda – though she instantly refuted the gentle suggestion that the problem might have been self inflicted. So trauma, probably a burn, remained my favoured differential.
The hidden clue
We decided to live with the uncertainty, apply proper dressings from our practice nurse and reassess in a week, provided she remained well. At review, the lesion was much better. Two weeks later, having not worn a dressing, she was back to square one. This cycle repeated itself.
This healing under occlusion was one major clue. The other clue was her apparent complete lack of concern for the problem – in stark contrast to her partner, who was very worried and eventually, understandably, insisted on referral to a dermatologist.
Getting on the right track
The dermatologist confirmed dermatitis artefacta and subsequently we arranged for her to have formal psychiatric help. Her ulcerated hand fluctuated in severity, usually reflecting her prevailing mental state, but eventually it healed for good. At no point did she accept that the lesion was self inflicted – although her partner did.
Dr Keith Hopcroft is a GP in Laindon, Essex