The skin is an important organ of communication and plays an important role in socialization throughout life. The skin is the interface between the individual and the physical and social environment and an important medium for communication. The self-inflicted ulcerations are the type of ulcerations which are caused by repeated injuries by patients themselves knowingly or unknowingly. It may masquerade as numerous dermatological disorders and should be considered after exclusion of other skin diseases. The self-inflicted dermatoses are a chronic heterogeneous group of disorders, reported to be more common among females and are generally associated with different classes of psychopathology. Knowledge of these disorders is important in the evaluation of any psychiatric patient as these disorders are essentially a cutaneous sign of psychopathology. Psychocutaneous conditions are difficult to diagnose and a challenge to treat. A study conducted in community setup in Ireland showed that 4 % wounds were pressure ulcers, 2.9 % as leg ulcers, 2.2 % as self-inflicted ulcerations, and 1.7 % as surgical wounds [1].

There are three major self-inflicted dermatoses, namely, dermatitis artefacta, neurotic excoriations, and trichotillomania or traumatic alopecia. Psychiatric intervention is often the most crucial element in the treatment of these patients [2].

Dermatitis artefacta is a factitious disorder and represents an obsessive compulsive spectrum disorder. Dermatitis artefacta has a much more wide ranging age of onset and is associated with a more heterogeneous group of psychiatric disorders, but it is most frequently encountered among individuals with immature personalities in the face of a stressful life situation. The patient creates skin lesions to satisfy an internal psychological need. There are cutaneous lesions that are wholly self-inflicted. The patients typically deny the self-inflicted nature of these lesions. It is more common among females, with a male-to-female ratio of at least 1–4 in the various studies. The age at onset of symptoms spans a broad range from 9 to 73 years. Typically, bizarre-looking necrotic lesions appear rather suddenly in areas that are easily accessible to the patient. In the right-handed person, the left side is usually involved. The lesions have wide-ranging morphologic features and are often bizarre looking with sharp geometric borders surrounded by normal-looking skin. They may occur at any site but are mainly confined to the patients hand, periocular skin, arms, legs, and breast. They may present as blisters, purpura, ulcers, erythema, edema, sinuses, or nodules, depending upon the means employed by the patient to create the lesions such as deep excoriation by fingernails or other sharp object and chemical and thermal burns. The lesions are usually asymmetric and may appear singly or in crops, with no history of a primary papule or vesicle. The patients are typically not able to describe how the lesions evolved. Self-inflicted dermatologic lesions have been associated with mental retardation, psychosis, Münchausen syndrome, and malingering. Loss or threatened loss, marital difficulties, and increased social isolation, especially among the elderly, may precede dermatitis artefacta [3, 4].

Early diagnosis is important as this may prevent unnecessary surgery and chronic morbidity. Diagnosis is usually confirmed by biopsy which indicates lack of a primary disease process. Treatment is a supportive and empathic approach. In some instances, recovery occurs after the initial psychiatric contact, whereas in other cases, the disorder may persist for decades. The prognosis is reported to be better in the younger age group where symptoms arise primarily in the context of a disturbed home situation.

Neurotic excoriations are lesions produced by the patient as a result of repetitive self-excoriation which may be initiated by an itch, “a disturbing sensation” in the skin distinct from pruritus, or because of an urge to excoriate a benign irregularity on the skin. This initiates and perpetuates the “itch-scratch” cycle, which in some patients becomes a true compulsive ritual. Neurotic excoriation is the most common self-inflicted dermatosis and has been associated with suicide. Unlike dermatitis artefacta, the patients typically acknowledge the self-inflictive nature of their lesions. It is mainly among females, ranging from 52 to 92 % in the various studies with a mean age between 30 and 45 years. Unlike the frequently bizarre-looking lesions of dermatitis artefacta, the lesions in neurotic excoriations do not stand out as being unusual and do not have the potential to mimic other dermatologic disorders. They are typically a few millimeters in diameter, weeping, crusted, or scarred, with postinflammatory hypopigmentation or hyperpigmentation. The lesions may range in number from 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 reach, typically affected regions being the upper and lower extremities, face, and upper back. The repetitive self-excoriation can also exacerbate a preexisting dermatosis [5, 6].