Photo Essay: Factitious Dermatitis

Consultant for PediatriciansConsultant for Pediatricians Vol 5 No 4
Volume 5
Issue 4

Photo Essay: Factitious Dermatitis Lip Licker's Dermatitis Ecchymoses From Spoon Scratching Ecchymosis From Cupping

This 9-year-old girl had a slightly pruritic perioral rash for 6 months. The skin around her mouth was red, scaly, thickened, and hyperpigmented. She also had eczematous lesions in the antecubital and popliteal fossae.

The girl had not used any topical medications. However, she acknowledged that she licked her lips periodically throughout the day. She had had trichotillomania at age 7 years.

This is lip licker's dermatitis, caused by habitual licking of the lips and the skin around the mouth. The condition is an irritant contact dermatitis caused by saliva.1 The erythematous rash involves the perioral area and characteristically includes the vermilion border of the lips. Atopy and exposure to dry ambient air and wind are common predisposing factors. Lip licker's dermatitis may also be a manifestation of underlying stress.

Lip licker's dermatitis should be distinguished from perioral dermatitis. The latter presents as an erythematous eruption of tiny papules and papulovesicules; unlike lip licker's dermatitis, it typically spares a narrow zone immediately adjacent to the vermilion.2 Perioral dermatitis most often affects women in their third to fifth de- cades and may be caused by irritant chemicals in cosmetic preparations. Children also can be affected. Perioral dermatitis often follows the use of a potent topical corticosteroid.

The most important treatment of lip licker's dermatitis is to stop licking the lips. Regular use of a bland emollient is essential. Hourly application during the day may be necessary. Advise patients to apply a liberal amount at bedtime. A short course of a topical immunomodulator (tacrolimus ointment or pimecrolimus cream) can hasten resolution of the lesion if treatment with the emollient is not successful. When emotional stress is a precipitating factor, psychological counseling may be required.

A 7-year-old Chinese boy presented with fever, cough, and sore throat of 2 days' duration. His temperature was 38.3°C (101°F); heart rate, 85 beats per minute; and respiration rate, 26 breaths per minute. The throat was erythematous but without any exudate. There were small cervical lymph nodes bilaterally. The chest was clear.

Extensive ecchymoses were evident on his back and along his spine. The boy's mother acknowledged that the bruises were a result of spoon scratching, a Chinese folk remedy. An antipyretic medication was prescribed for the child. The fever subsided in 3 days and the sore throat in 5 days. Culture of a throat swab was negative for bacteria.

Spoon scratching (quat sha) is a Chinese folk dermabrasion therapy used to "scratch the wind" (to rid the body of "bad winds") and to relieve symptoms, such as fever and headache.1 Water or saline is applied to the site of scratching, which is usually the back. The area is then patted, pinched, or massaged until the skin turns red.1,2 The skin is then scratched with a porcelain spoon until bruises appear. The resulting ecchymoses often have a Christmas tree appearance. A similar procedure--coin rubbing (cao gio)--is popular in Vietnam, Cambodia, Thailand, Malaysia, and Indonesia.1,3 With coin rubbing, balsamic or mentholated oil replaces water or saline and a coin replaces a spoon.1

Spoon scratching is believed to improve health by blocking synaptic networks or by increasing circulation and relieving inflammation within the soft tissue.4 Regardless of whether spoon scratching has a scientific rationale, the procedure is practiced by caring families with good intentions; it has a low incidence of adverse events. As such, the practice is likely to continue.1,4 Failure to recognize the cultural origins of spoon scratching or coin rubbing may result in a false accusation of child abuse.1,4 Suicide was reported when a falsely accused Vietnamese father was jailed for child abuse.5 Awareness of folk medicine is essential for health care professionals who practice in a multicultural setting.2

A 14-year-old boy presented with a 3-day history of runny nose, cough, and fever. His temperature was 37.7°C (100ºF); heart rate, 78 beats per minute; and respiration rate, 26 breaths per minute. Several symmetric, circular ecchymotic lesions that measured 4 cm in diameter were noted on the upper chest. There was no evidence of external injury to other parts of the body. The child reported that the bruises resulted from cupping, performed by a Chinese practitioner in an attempt to relieve the fever.

In the Chinese literature, cupping therapy is reported to have a remarkable antipyretic effect.1 Cupping increases circulation in the treated area and theoretically eliminates toxins trapped in the tissue.2 The procedure involves heating the inside of a cup with a lighted cotton ball that has been soaked in alcohol.3 The cup is then firmly applied to the skin for 5 to 20 minutes.3 The vacuum produced by the combustion of the alcohol and consumption of oxygen draws the skin into the cup, and the negative pressure creates the characteristic circular ecchymotic lesions. These lesions have been mistaken for child abuse.4 Cupping may occasionally result in panniculitis or a thermal injury.5,6

This patient was treated with an antipyretic agent.



1. Watt CJ, Hong HC. Dermacase. Lip licker's dermatitis.

Can Fam Physician.

2002;48:1051, 1059.
2. Hafeez ZH. Perioral dermatitis: an update.

Int J Dermatol.



1. Leung AK. Ecchymoses from spoon scratching simulating child abuse.

Clin Pediatr (Phila).

2. Leung AK. Ecchymosis from spoon scratching.


3. Hulewicz BS. Coin-rubbing injuries.

Am J Forensic Med Pathol.

1994;15: 257-260.
4. Look KM, Look RM. Skin scraping, cupping, and moxibustion that may mimic physical abuse.

J Forensic Sci.

5. Anh NT. "Pseudo-battered child" syndrome.




1. Liu Y. Cupping therapy for 103 cases of high fever due to infection of the upper respiratory tract.

J Tradit Chin Med.

2. Look KM, Look RM. Skin scraping, cupping, and moxibustion that may mimic physical abuse.

J Forensic Sci.

3. Leung AK. Cupping.

Can J Diagn.

4. Asnes RS, Wisotsky DH. Cupping lesions simulating child abuse.

J Pediatr.

5. Lee JS, Ahn SK, Lee SH. Factitial panniculitis induced by cupping and acu- puncture.


6. Sagi A, Ben-Meir P, Bibi C. Burn hazard from cupping--an ancient universal medication still in practice.

Burns Incl Therm Inj.


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