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 Table of Contents    
Year : 2019  |  Volume : 61  |  Issue : 1  |  Page : 101-102
Eyelid petechiae as a window to relapse in a case of purging-type anorexia nervosa

1 Department of Dermatology and STD, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India
2 Department of Psychiatry, Dr. BSA Medical College and Hospital, New Delhi, India

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Date of Web Publication9-Jan-2019

How to cite this article:
Agrawal M, Yadav P, Kumari R, Chander R. Eyelid petechiae as a window to relapse in a case of purging-type anorexia nervosa. Indian J Psychiatry 2019;61:101-2

How to cite this URL:
Agrawal M, Yadav P, Kumari R, Chander R. Eyelid petechiae as a window to relapse in a case of purging-type anorexia nervosa. Indian J Psychiatry [serial online] 2019 [cited 2022 Nov 28];61:101-2. Available from:


Dermatological signs and symptoms have often aided in the diagnosis of psychiatric disorders. Cutaneous manifestations in eating disorders have been classified into four groups: those caused by starvation or malnutrition, due to self-induced vomiting, due to drug consumption, and finally, caused by concomitant psychiatric illness.[1],[2] Herein, we report a case of a young girl who presented to dermatology with eyelid petechiae, which seized the diagnosis of relapse in a psychiatric disorder.

A 22-year-old unmarried girl presented to the dermatology outpatient department with tiny, asymptomatic, irregular, nonpalpable purpuric lesions on and around the eyelids for 3–4 days [Figure 1]. She did not give any history of trauma or easy bruisability. History of multiple episodes of vomiting was present in the past month, and the last episode had occurred 2 days back. There were no knuckle calluses or enamel erosions. An interview with the mother revealed a history of sudden weight loss 2 years back which was treated by the psychiatry department, after which her condition had gradually improved and she seemed to be “doing fine” since then. This prompted us to evaluate the history of vomiting in detail, which is when the patient revealed that she was inducing vomiting for nonspecific reasons.
Figure 1: Multiple discrete, pinpoint-to-pinhead sized, irregular, nonpalpable purpura in bilateral periorbital distribution

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Psychiatric consultation revealed that her symptoms had started 2 years back after starting college, causing her to become “self-conscious” as her friends were thinner than her. She started restricting her food intake and invested most of her time in diet and fitness regimens and remained preoccupied with her waist fat. This even hampered her routine and she gradually became irritable and started missing classes. Her food intake reduced to once a day with predominant water intake. She lost almost 40 kg of weight in 3–4 months. Her mother became concerned about changes in behavior and took her to a psychiatrist who diagnosed her as anorexia nervosa (AN) (restrictive type) with major depressive episode. She received fluoxetine (40 mg for 6 months) and cognitive behavioral therapy (18 sessions) and showed improvement in symptoms with complete remission. She resumed her college schedules after 1 month of regular treatment and even started meeting family members and friends. She maintained well for almost 1 year and regained her weight of 65 kg.

Recently, for the last 4 months, she had joined a new center for Journalism. She was initially very enthusiastic but gradually became critical of it. She again began to reduce her food intake, but this time she used to repeatedly indulge in binge eating followed by self-induced vomiting with occasional laxative use. She started developing thoughts of low self-worth and avoided meeting people. This time she hid her symptoms to avoid consultation for “psychological symptoms” and felt she could manage this herself.

Family history of major depressive disorder was found in her brother. Mental status examination revealed that she was conscious, alert, and oriented. Her psychomotor activity was reduced with decreased speech output, affect sad, thought content revealed preoccupation with body shape, low confidence level, and feeling of worthlessness. She was found to be thin-built with BMI 18.4 kg/m2 weighing 50 kg. Her blood parameters revealed leukopenia, microcytic anemia, and thrombocytopenia. Rest of the biochemical evaluation was within normal limits. Electrocardiography revealed sinus bradycardia.

Based on this, a diagnosis of purging-type of AN and major depressive episode with postemetic facial purpura was made, and the patient was counseled regarding the self-resolving nature of the petechiae. The lesions disappeared in a week, and the patient is regularly following up in the psychiatry department and receiving both pharmacotherapy and psychotherapy.

Eyelid petechiae have been commonly described due to raised intravascular pressure secondary to vomiting, severe bouts of cough, and Valsalva maneuver among other causes.[3] It is also considered a cutaneous feature of bulimia nervosa and purging-type AN. The rich blood supply of the face and lose adipose tissue makes the eyelids a vulnerable site for the rupture of thin blood vessels. It is often a clinical diagnosis and management solely needs reassurance. It has also been labeled as “mask phenomenon” when petechiae appear suddenly on the face and neck after a prolonged bout of vomiting.[4]

It is important for physicians to be aware of these cutaneous markers of various eating disorders as these patients often have a tendency to be shy of their practices and hide them. They may present to other specialties with indicators suggestive of these disorders. Moreover, like in this case, these signs may serve as early pointers and unmask an evolving or a full-blown relapse.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Strumia R. Eating disorders and the skin. Clin Dermatol 2013;31:80-5.  Back to cited text no. 1
Gupta MA, Gupta AK, Haberman HF. Dermatologic signs in anorexia nervosa and bulimia nervosa. Arch Dermatol 1987;123:1386-90.  Back to cited text no. 2
Ota M. A rash localised around the eyes. BMJ 2017;358:j3148.  Back to cited text no. 3
Alcalay J, Ingber A, Sandbank M. Mask phenomenon: Postemesis facial purpura. Cutis 1986;38:28.  Back to cited text no. 4

Correspondence Address:
Pravesh Yadav
Department of Dermatology and STD, Lady Hardinge Medical College and Associated Hospitals, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/psychiatry.IndianJPsychiatry_107_18

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