A 23-year-old woman with type 1 'brittle' diabetes of 12 years' duration, underwent a sural nerve biopsy which failed to heal for 3 months, but healed in 1 week under a tamper-proof dressing. She returned to clinic 3 months later with an ulcer on the dorsum of her foot. Parts of the ulcer bed had unusual morphometry with straight edges as shown in Fig. 4.40. It was thought that she might have an allergy to the dressing used and she was referred to the dermatologists. They did a patch test, tested the pH of the lesion on her foot and concluded that she had dipped a dressing in caustic lavatory cleaner and applied it to the foot. Following this episode she attended clinics at another hospital, had numerous admissions for infected skin lesions, developed end-stage renal failure and died aged 28 from sepsis.
• Morphologically unusual ulcers may be associated with artefactual disorder
• We consider the diagnosis of artefactual disorder in unusual ulcers and liaise with dermatologists and psychiatrists as necessary
• We do not 'confront' patients when artefactual disorder is suspected.
Many such patients have numerous admissions with severe foot infections or ketotic episodes related to foot infections. This is a difficult condition to treat and involvement of a psychiatrist with a special interest in artefactual disorders may be useful. Patients who cause their own ulcers or deliberately prevent their ulcers from healing are aware of what they are doing but have little insight into their motives. They can injure themselves with impunity because of their neuropathy (Fig. 4.41). Tamper-free dressings or unremovable casts probably provide the best means of achieving short-term healing, but the long-term outlook is poor. Confrontation and admonishment are unhelpful, as the patient will just go elsewhere for his care and will be at increased risk with
Fig. 4.41 This girl pulled skin off her foot and caused an ulcer which remained open for 3 years. It healed in 3 weeks when a tamper-free total-contact cast was applied.
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