A caution in the evaluation of scar revision
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Journal of the American Academy of Dermatology Volume 28, Number 2, Part I A caution in the evaluation of scar revision Brief communications 269 Duane C. Whitaker, MD, and Ann C. Smith, MD Iowa City, Iowa A request for scar revision or correction of a cu- taneous defect is common. Some patients request surgery for a cutaneous disease when, in fact, med- ical treatment is appropriate. Most patients when so informed accept proper treatment. However, some persist in their desire for surgery and are convinced that this is the only effective treatment. Nonhealing cutaneous processes or diseases and unstable, hy- pertrophic, contracted, or depressed scars are prob- lems for which surgical correction may be appropri- ate. Surgical correction in patients with unrealistic or illusory expectations should be avoided. Patients with self-induced disease may benefit from a psy- chotherapeutic program if they are compliant with this mode of treatment. 1 However, improper moti- vations and lack of insight can complicate diagnosis and therapy. We discuss two patients in whom sur- gical scar revision would be inappropriate. CASE REPORTS Case 1 A 32-year-old woman requested scar revision of the left malar region and the forehead (Fig. 1). She said she had had recurrent infected acne in these areas for 3 years. According to· her, a biopsy specimen and cultures were nondiagnostic. Her facial lesions finally healed during a prolonged hospitalization for a complicated pregnancy. The patient seemed unconcerned about the possibility of recurrence of the underlying process. She was accompa- nied by her spouse who was unable to provide additional details about her facial scarring. We recommended pho- tographic documentation and requested previous medical records to determine the cause. The patient agreed to this and was scheduled for reevaluation in 3 months. She failed to keep this appointment; no medical records were received. Attempts to contact the patient failed because the family had moved and left no forwarding address. Case 2 A 62-year-old married woman was referred by her physician for surgical closure or grafting of a nonhealing From the Department of Dermatology, University of Iowa Hospitals and Clinics. Reprint requests: Duane C. Whitaker, Department of Dermatology, University of Iowa, Hospitals and Clinics, Iowa City, IA 52242. JAM ACAD DERMATOL 1993;28:269-70. Copyright @ 1993 by the American Academy of Dermatology, Inc. 0190-9622/93 $1.00 +.10 16/54/41477 Fig. 1. Case 1. A 32-year-old woman presented with facial scars she attributed to acne. ulcer on the left side of the neck (Fig. 2, A). She had had the ulcer for nearlya year. She described herself as a ner- vous person and said she picked the area but denied caus- ing the ulcer. She was taking an antihypertensive medi- cation but was otherwise healthy. The patient had used a variety of topical over-the-counter ointments on her wound. She had an anxious manner with pressured speech but was in no acute distress. The patient stated her will- ingness to cooperate with any medical or surgical treat- ment recommended. A dressing of antibiotic ointment with petroleum jelly gauze was placed on the wound. The patient was in- structed that it was important that the dressing remain undisturbed until her next visit. The dressing was then changed 3 days later in our clinic. She agreed to have all wound care done in the clinic; the bandages remained in place for 5 to 7 days. The wound soon began to show healthy granulation with no evidence of infection. On re-
Transcript of A caution in the evaluation of scar revision
Journal of the American Academy of DermatologyVolume 28, Number 2, Part I
A caution in the evaluation of scar revision
Briefcommunications 269
Duane C. Whitaker, MD, and Ann C. Smith, MD Iowa City, Iowa
A request for scar revision or correction of a cutaneous defect is common. Some patients requestsurgery for a cutaneous disease when, in fact, medical treatment is appropriate. Most patients when soinformed accept proper treatment. However, somepersist in their desire for surgery and are convincedthat this is the only effective treatment. Nonhealingcutaneous processes or diseases and unstable, hypertrophic, contracted, or depressed scars are problems for which surgical correction may be appropriate. Surgical correction in patients with unrealisticor illusory expectations should be avoided. Patientswith self-induced disease may benefit from a psychotherapeutic program ifthey are compliant withthis mode of treatment. 1 However, improper motivations and lack of insight can complicate diagnosisand therapy. We discuss two patients in whom surgical scar revision would be inappropriate.
CASE REPORTSCase 1
A 32-year-old woman requested scar revision ofthe leftmalar region and the forehead (Fig. 1). She said she hadhad recurrent infected acne in these areas for 3 years.According to· her, a biopsy specimen and cultures werenondiagnostic. Her facial lesions finally healed during aprolonged hospitalization for a complicated pregnancy.The patient seemed unconcerned about the possibility ofrecurrence of the underlying process. She was accompanied by her spouse who was unable to provide additionaldetails about her facial scarring. We recommended photographic documentation and requested previous medicalrecords to determine the cause. The patient agreed to thisand was scheduled for reevaluation in 3 months. Shefailed to keep this appointment; no medical records werereceived. Attempts to contact the patient failed becausethe family had moved and left no forwarding address.
Case 2
A 62-year-old married woman was referred by herphysician for surgical closure or grafting of a nonhealing
From the Department of Dermatology, University of Iowa Hospitalsand Clinics.
Reprint requests: Duane C. Whitaker, Department of Dermatology,University of Iowa, Hospitals and Clinics, Iowa City, IA 52242.
JAM ACAD DERMATOL1993;28:269-70.Copyright @ 1993 by the American Academy of Dermatology, Inc.0190-9622/93 $1.00 +.10 16/54/41477
Fig. 1. Case 1. A 32-year-old woman presented withfacial scars she attributed to acne.
ulcer on the left side of the neck (Fig. 2, A). She had hadthe ulcer for nearly a year. She described herself as a nervous person and said she picked the area but denied causing the ulcer. She was taking an antihypertensive medication but was otherwise healthy. The patient had used avariety of topical over-the-counter ointments on herwound. Shehad an anxious manner withpressured speechbut was in no acute distress. The patient stated her willingness to cooperate with any medical or surgical treatment recommended.
A dressing of antibiotic ointment with petroleum jellygauze was placed on the wound. The patient was instructed that it was important that the dressing remainundisturbed until her next visit. The dressing was thenchanged 3 days later in our clinic. She agreed to have allwound care done in the clinic; the bandages remained inplace for 5 to 7 days. The wound soon began to showhealthy granulation with no evidence of infection. On re-
270 Briefcommunications
Fig. 2. Case 2. This patient was referred for grafting orclosure of this nonhealing wound on the left side of herneck. B, Same patient 5 weeks after occlusive dressings.
turn visits, the patient described a feeling of "healing" inthewound site and believed thatshe was making progress.Fig. 2, B shows the wound 5 weeks after her first clinicvisit. Complete healing was achieved with treatment thatprevented patient manipulation ofthe wound. The patientwas seen monthly and remained healed more than a yearlater.
DISCUSSION
Our patients had different clinical presentations.However, both had a self-inflicted injury and wereeither unaware or not forthright about their role in
Journal of the American Academy of DermatologyFebruary 1993
causing the problem. This self-induced disease hasbeen called dermatitis artefacta or factitial dermatitis.2 Dermatitis artefacta generally refers to denialof the self-inflicted nature of the cutaneous injury.This may not always be clear clinically. Patients maybe vague or evasive regarding details of the cutaneous injury without complete denial of their involvement in the injury. Ifdisease is self-induced, manyphysicians recommend a psychiatric consultation.However, some patients refuse this and adhere totheir belief that the problem is entirely physical.Fruensgaard has found that patients who acceptpsychotherapeutic referral do benefit.! Some patients with self-injury will be clinically depressed andrequire treatment.2, 3 When these patients urgentlypress for immediate surgical intervention, the physician should recognize that this is inappropriate.When psychiatric consultation is sought, it may beimportant for the dermatologist to manage thephysical problem because the patient may lackinsight regarding the emotional cause of his or herdisease.4 Cosmetic revision is not recommended unless the patient meets the following criteria: (1) prolonged period of remission (at least 2 years) withoutreinjury, (2) expressed desire for behavior modification, and (3) insight regarding the cause achievedthrough a therapeutic relationship.
REFERENCES1. Fruensgaard K. Psychotherapy and neurotic excoriations.
Int J DermatolI991;30:262-5.2. Gupta MA, Gupta AK. Haberman HF. Neurotic excoria
tions: a review and some new perspectives. Compr Psychiatry, 1986;27:381-6.
3. Munro A, Chmara J. Monosymptomatic hypochondriacalpsychosis: a diagnostic checklist based on 50 cases of the disorder. Can J Psychiatry 1982;27:374-6.
4. Koo JYM, Strauss GD. Psychopharmacologic treatment ofpsychocutaneous disorders: a practical guide. Semin DermatolI985;6:780-4.
