A 22 year old gulf returnee presented with a history of crusted lesions over the extensor aspect of left arm and fore arm of one month duration.

The lesions started one month after his reaching the Middle East for a job. Unfortunately he could not find a suitable job and he wanted to come back. On further questioning he admitted that the lesions are produced by touching with a cigarette butt.

A diagnosis of dermatitis artefacta was made and he was sent for psychological evaluation. The psychological evaluation revealed that he was having severe depressive illness and he was put on anti depressants. Along with this he was given antibiotic and saline compresses followed by topical steroid. With these treatments he improved very well.

One month later he presented again with erythematous, oedematous plaque with tenderness.

A biopsy of the lesion was done and it showed the following picture in H&E staining.

What is the diagnosis?

The examination at the second presentation revealed that he was having an erythematous tender scaly oval plaque of 20x5 cm. The cold, touch and pain sensations were impaired. The hair was absent over the plaque. There was neither nerve thickening nor tenderness. The slit skin smear examination for AFB was negative. The histopathology of the lesion showed features of Hansen’s disease – Borderline Tuberculoid.

Retrospectively the patient didn’t feel the pain while he burnt the lesion with cigarette. So he continued the act which he used for his escape from a foreign country where he was unhappy.

The case is an eye opener because 1. the patient should be examined thoroughly before we make a diagnosis 2. the psychological disturbance should not be a hindrance to make an organic disease.