A 60-year-old man presents with a 1 1/2 year history of an expanding lesion on the scalp. He has seen several other health care providers, none of whom have been able to provide any effective therapy.
Key point: This pathology is clearly outside the “normal” realm. A biopsy should been done to rule out extensive non-melanoma skin cancer and cultures should be obtained to identify infectious pathogens that are amenable to antimicrobial intervention. If the foregoing diagnostic maneuvers are unproductive, then it is important to remember that self-induced (factitious) disease may be responsible.
Treatment: The patient needs immediate attention by a qualified mental health professional to address psychological issues underlying this type of self-mutilation.
Note: After extensive counseling, the patient admitted that he was using a blunt letter opener to create and expand the skin lesion. He was extremely stressed at his workplace and was fearful of being fired.