Les lésions cutanées auto-infligées sont une forme particulière de troubles factices provoqués par le patient lui-même sur son revêtement cutanéomuqueux ou ses phanères, de manière volontaire, consciente et dissimulée. La lecture psychiatrique des lésions cutanées auto-infligées s’avère complexe. Elle ne se résume à aucun cadre nosographique prédéterminé. Les diagnostics évoqués sont multiples.

Nous rapportons un cas complexe de trouble factice chronique et récurrent impliquant la peau. Il s’agissait d’une femme de 48ans, diabétique depuis son jeune âge, avec de nombreux événements de vie stressants, un trouble de l’adaptation ainsi qu’un trouble de personnalité borderline sous-jacent. Le début des troubles aurait coïncidé avec la découverte de l’adultère de son mari. Le trouble factice a été diagnostiqué après de vastes investigations et des traitements dans plusieurs services de dermatologie, ainsi que de multiples hospitalisations. Le retard diagnostique de cinq ans avait facilité la survenue de complications somatiques graves, notamment une amputation de jambe. La prise en charge de la patiente était très difficile malgré l’établissement et le maintien d’une bonne alliance thérapeutique. Les poussées de la maladie étaient rythmées par les conflits avec le conjoint. Une provocation des lésions cutanées au cours d’épisodes dissociatifs a été suspectée chez elle, et une approche thérapeutique ciblée a été adoptée.

La provocation des lésions au cours des épisodes dissociatifs est une hypothèse d’autant plus intéressante qu’elle permet d’engager avec le patient, au sein d’une relation thérapeutique confiante, une discussion sur son comportement.

Factitious disorders in dermatology consist of intentionally self-inflicted skin lesions that vary in morphology and distribution and occur on surfaces readily accessible to the patient's hands. They tend to be a chronic condition that waxes and wanes according to the circumstances of the patient's life. Patient management poses a particular challenge to the clinician and the prognosis is considered poor. The aetiopathogenesis of factitious disorders in dermatology is not completely understood. We present a case in which we suggested the occurrence of factitious behaviour during a dissociative state, and we briefly describe our diagnostic and therapeutic approach.

A 48-year-old unemployed woman was referred to our department of psychiatry by her dermatologist for suspected factitious disorder. The patient was diagnosed with diabetes mellitus type 1 and had been hospitalized repeatedly for confirmed diabetic ketoacidosis. The onset of the disease was related to marital discord with her spouse. Numerous skin lesions had appeared on her face, arms, legs, neck and back. These lesions resulted in multiple hospital admissions and in amputation of her left leg. The condition had worsened considerably after her separation from her husband. During the initial conversation, the patient was unable to provide a clear history of the disease. She denied any knowledge of the circumstances in which these skin lesions appeared, and she did not admit self-infliction. Her mood was depressed and her speech was slow. We suspected that our patient was herself causing her skin lesions while in a dissociative state. Several arguments militate in favour of our hypothesis, particularly her history of childhood maltreatment and the association of traumatic life events with simultaneous deterioration of the skin. The explanation of the dissociative mechanism helped us to strengthen the therapeutic relationship. Within a few days, we noted a slow regression of the lesions, but the patient was still unable to explain how the lesions had occurred.

The pathophysiology of factitious disorders in dermatology is poorly understood. It has strong ties with other psychiatric disorders, and according to several authors, skin lesions occur in dissociative states, after which patients do not remember how the skin change started. Management of this disease is challenging. An improved understanding of its mechanisms may enhance the prognosis for this particular group of patients.