The incidence of dermatitis artefacta (DA) among dermatologic patients has been reported to be 0.3 % [3]. The skin lesions are known as a ‘defense’ in that they distract the patient from the underlying psychiatric problem [7]. It has been observed that either the patient or a close relative has been associated with some aspect of healthcare [8].

The age at onset of symptoms can broadly range from 9 to 73 years [2], with the highest prevalence being in adolescents and adults under the age of 30 [9]. Females are predominantly affected; the ratio of female to male varies from 20:1 to 4:1 [9]. Self-mutilating behavior has been observed in 10–15 % of healthy children, especially between the ages of 9 and 18 months. These self-mutilations are considered pathological after the age of 3. DA has been noted to develop among psychiatric inpatients [10], and in older males [8, 11–13]. The male to female ratio is 2:1 in the latter category of the population, and patients are more likely to produce subtle cutaneous lesions, and often have a past history of somatizing illnesses (pseudo-seizures, abdominal pain, syncope, chronic fatigue, backache) [9]. In a follow up study of 43 patients, an 81 year old female (diagnosed with senile dementia) had a forgotten rubber band around her leg, and an 80 year old female had a rubber band under her wedding ring [14].

The lesions have wide-ranging, morphologic features that are often bizarre with sharp, distinct, geometric margins surrounded by normal skin. Weeping, crusted, or scarred lesions, with post inflammatory hypopigmentation or hyperpigmentation can be seen. The lesions may range in number from single or a few to several hundred, and in chronic cases, scarring may be the only sign. The lesions are distributed in areas that the patient can easily access (e.g. the face, extensor surfaces of extremities, and upper back). Repetitive self-excoriation can also exacerbate a preexisting dermatosis [2]. The morphology of individual lesions is determined by the manner in which they are created, do not conform to the pattern of any known dermatoses and are non-healing. Blisters, purpura, ulcers, erythema, edema, sinuses, or nodules, deep excoriation by fingernails or other sharp object, chemical and thermal burns, occlusion of circulation around the limbs or digits [2, 8] can be seen. Thus factitial lesions may be very destructive.

A “hollow history” is a part of the clinical presentation. The patients usually insist that the lesions appeared mysteriously, even overnight, or over a short period of time [8, 15]. The patient typically appears unconcerned, while family members are very disturbed, often angry and confronting. Generally, patients and their family members have consulted multiple physicians of various specialties, with numerous tests [8].

Weber-Christian syndrome, bullous pemphigoid, cellulitis, vasculitis, pyoderma gangrenosum, deep fungal infection, arthropod bites and collagen vascular disease [2, 8].

Psychological stress has been associated with the onset or exacerbation of a wide range of cutaneous disorders [16, 17]. In the literature, the term, ‘stress,’ is used to address the sequel of major catastrophes in the lives of individuals. These include natural or accidental events such as major earthquakes or life threatening accidents. Psychological stress, which focuses on patients’ subjective evaluations of their capacity to cope with life circumstances (e.g. the stress induced by the social stigma of having a skin disorder or the unexpected death of a loved one) [17]. Physical trauma represents a more severe form of stress. Such events include war, torture, concentration camp experiences, severe accidents or illness, child abuse, rape, violence in the family, personal assault/physical abuse [17].

Biological factors, such as stress-induced activation of the hypothalamic-pituitary-adrenal axis [17] commonly found in depression, likely has an important role given that skin disorders are more prevalent in depressed individuals. Due to difficulties in insight and body-image, DA has been compared with anorexia nervosa as it often coexists with this condition [10]. DA patients tend to have introverted personalities, self-centered attitudes and emotional immaturity. Subsequently, adults may respond to stressful circumstances in an impulsive manner [11], due to an immature personality style [2]. These patients experience difficulty when stressed and their discomfort is further aggravated because of poor communication skills [7, 18]. A background of emotional disturbance has been noted to be present during formative years, leading to feelings of insecurity and isolation in later life. The onset of DA has been closely associated with the psychological stress of a major life event. The visible lesions represent an attempt at nonverbal communication which is similar to an appeal [7].

Patients with factitious disorder usually have an affinity with the medical system, and have maladaptive coping skills. This behavior often occurs in the setting of a loss such as the death of a relative or an occupational loss. Securing the attention of family, friends, medical professionals is likely a way of obtaining emotional solace. There is a motivation to assume the sick role, which initially evolves within the family and then with health care providers. Behavioral theories postulate that in early life these individuals received reinforcement of the sick role. Patients can have self-hate and guilt, and an illness which allows inappropriate regression and avoidance of adult responsibilities [9]. The psychological trauma of sexual abuse has been reported to precipitate DA [9, 10, 19]. Factitious illness can also symbolize anger and conflict with authority figures (school phobia being a case in point). They usually experience emotional deprivation during childhood, resulting in an unstable body image, and a need to be cared for [7]. Children and adolescents often develop anxiety and immaturity of coping styles in response to a dysfunctional parent-child relationship (e.g. rejecting mother, absent father), bullying, physical changes in the body and substance use [9]. The sensation of self-induced pain and physical lesions may relieve their isolation and distress, and even help them establish a sense of identity [1]. Chronically affected patients generally have comorbid personality disorders, especially borderline and hysterical in women and paranoid personality disorder in men [7, 9].