This 95 year-old woman presented with a non-healing left nasal ulcer involving the alar rim. She compulsively picks at her left nostril until it bleeds. The nose itches terribly, but does not hurt. Thirty years ago, she had undergone a left suboccipital craniotomy for the removal of a brain tumor. Following that operation, she developed a left facial paralysis, complete anesthesia of the left side of the face and lost her hearing in the left ear.
Factitial ulcers are self-induced skin lesions resulting from habitual rubbing, scratching or hair-pulling. They are usually associated with trigeminal trophic syndrome, but could also be caused by malingering, or mental disturbance.
Trigeminal trophic syndrome is a unilateral, frequently crescent-shaped neurotrophic ulceration of the face occurring after injury to the trigeminal nerve. The appearance of the ulcers resembles other disease entities such as granulomatous disease, neoplasm, vasculitis, infection, and factitial dermatitis.
Sadeghi et al. (1) reported on 4 cases and reviewed the litterature. They found 60 cases of trigeminal trophic syndrome reported from 1982 to 2002. The age at presentation ranged from 14 months to 93 years. Time of onset from injury to the trigeminal ganglion or its branches and the development of the ulcers ranged from 2 weeks to 30 years. One-third of the patients had undergone trigeminal nerve ablation for the treatment of trigeminal neuralgia and another third had a history of stroke. Other causes included craniotomy, head trauma, herpes infection.
(1)Sadeghi, Parrish, Papay, Francis A. & Vidimos, Allison T. (2004)
Trigeminal Trophic Syndrome Report of Four Cases and Review of the Literature.
Dermatologic Surgery 30 (5), 807-812.