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SummaryForty-three patients, 38 women and 5 men, with selfinflicted skin lesions were studied. Thirty-three were followed up for up to 22 years. In most cases dermatitis artefacta was only one incident in a long history of psychogenic illness. Of the 43 patients, 13 (30%), 12 women and one man, continued to produce lesions or were disabled with other psychiatric disorders more than 12 years after the onset of symptoms. Prognosis was difficult but recovery seemed to occur when the patient's life circumstances changed rather than as a result of treatment. IntroductionSkin disease is never simple to treat even when the patient wishes to recover. It becomes far more difficult when the patient (usually female) deliberately manufactures lesions. Such patients present a double challenge-that of diagnosis, and that of management, since once detected they usually refuse to discuss the underlying problem and cease to attend. As early as 1907, Towle' described 49 cases of gangrena cutis hysterica, and in 1917 Simpson2 pointed out the need to recognize such lesions in young girls. The shape of artefact lesions is usually bizarre3; they have linear or geometric outlines, and superficial necrosis is common. The handedness of the patients is a factor determining the sites of the lesions. Many patients have a "Mona-Lisa-like" expression of artful innocence.4 Lyell5 reviewed the whole problem of the diagnosis of self-inflicted

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