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Diagnosis and Management of Delusional Parasitosis Diagnosis and management of delusional parasitosis Elliott H. Campbell, BSc,a Dirk M. Elston, MD,b James D. Hawthorne, MD,c and David R. Beckert, MDd Lexington, Kentucky, and Charleston, South Carolina Delusional parasitosis is a monosymptomatic hypochondriacal state that causes great suffering for the patient and great suffering for those around them. Dermatologists are experts in the diagnosis of cutaneous disease and frequently encounter such patients. This review provides an overview of the diagnosis and management of delusional parasitosis and the differential diagnosis. ( J Am Acad Dermatol 2019;80:1428-34.) Key words: chronic tactile hallucinosis; delusional parasitosis; delusions of parasitosis; delusory parasitosis; Ekbom syndrome; psychogenic parasitosis. elusional parasitosis (DP), also commonly parasitosis, mood episodes have been brief relative D referred to as delusions of parasitosis, to the duration of the delusional period(s), and delusional infestation, or Ekbom syndrome, where the disturbance is not attributable to medical is a monosymptomatic hypochondriacal psychosis in conditions, substances, or another disorder.4 which affected individuals have a fixed, false belief We summarize the current literature regarding that they are infested with living organisms. The epidemiology, diagnosis, and management in this German term Dermatozoenwahn (parasitosis) was review. Evidence-based recommendations for phar- originally cited in 1938 by Karl Axel Ekbom to macologic management and side effect profiles of describe this disorder. The name Ekbom syndrome the available agents are discussed in the context of was later used to describe this disorder; however, this the authors’ experience. eponym is ambiguous because it can also be used to refer to restless leg syndrome.1 Morgellons disease is METHODS a condition in which a patient perceives fibers or The PubMed database was queried for relevant threads emerging from or attached to the skin. Many articles using the following search terms: delusional of these patients demonstrate fixed ideation of parasitosis OR delusions of parasitosis OR delusional infestation that affects their work and relation- infestation OR delusory parasitosis OR psychogenic shipsdmanifestations that are typical of delusional parasitosis OR chronic tactile hallucinosis OR Ekbom parasitosis.2,3 syndrome (NOT restless leg). The search produced a DP is a type of delusional disorder, somatic type total of 597 articles, 122 case reports, 22 case series, (Diagnostic and Statistical Manual of Mental 58 reviews, 2 systematic reviews, 1 randomized Disorders, Fifth Edition code 297.1 F22).4 Previous controlled trial, and 1 metaanalysis. Articles were editions of the Diagnostic and Statistical Manual of selected for review based on their relevance to the Mental Disorders required individuals with this presentation, differential diagnosis, evaluation, and diagnosis to have nonbizarre delusions, which is management of DP. Side effect profiles were ex- no longer a requirement. Criteria include the pres- tracted from the results of pharmaceutical trials ence of a delusion for $1 month where the criteria included in the product labeling. Recommendations for schizophrenia have not been met, the patient is are based on the published literature and the authors’ functioning in general outside of the delusion of experience in managing the disorder. From the University of Kentucky College of Medicinea and the Accepted for publication December 3, 2018. Department of Psychiatry,c University of Kentucky, Lexington, Reprint requests: Elliott H. Campbell, BSc, 2011 Madison Rd, and the Departments of Dermatology and Dermatologic Cincinnati, Ohio 45208. E-mail: [email protected]. Surgeryb and Psychiatry,d Medical University of South Carolina, Published online December 11, 2018. Charleston. 0190-9622/$36.00 Funding sources: None. Ó 2018 by the American Academy of Dermatology, Inc. Conflicts of interest: None disclosed. https://doi.org/10.1016/j.jaad.2018.12.012 1428 JAM ACAD DERMATOL Campbell et al 1429 VOLUME 80, NUMBER 5 DISCUSSION often have atypical presentations, and burrows may Presentation not be evident. Some patients actually isolate indi- The mean age of patients with DP is 57 years, vidual scabies, zoonotic, or environmental mites, there is a roughly 3:1 female:male ratio, and females and it pays to examine the specimens that the patient may have a longer duration of symptoms compared provides. Bites and infestations may produce clini- with males.5 Past or comorbid psychiatric conditions cally nonspecific lesions, and obtaining a biopsy are reported in roughly 80% of patients with DP.6,7 specimen can help rule out genuine arthropod The most common comorbid reactions. Wedge-shaped psychiatric illness was perivascular polymorphous CAPSULE SUMMARY depression (74%), followed infiltrates often with eosino- by substance abuse (24%) phils and endothelial d Delusional parasitosis can be effectively and anxiety (20%).6 Patients swelling are characteristic of managed with second-generation are often highly distressed the latter. antipsychotic agents. and the condition dominates Mites, both scabetic and their lives, disrupting per- d Extrapyramidal and metabolic side nonscabetic, are the most sonal and professional rela- effects are major limiting factors in the common causes of cryptic tionships. Some remain choice of therapy. arthropod-induced pruritus. tremendously successful at d Based on the published data on efficacy, Theyrangeinsizefrom0.1 work while their private lives the incidence of side effects, and to2mmandmaybedifficult are consumed by the delu- attributable risk, risperidone (0.5-4 mg/ to see without magnifica- sions. Many of the patients day) is a reasonable first-line choice for tion. Many lack host speci- have read extensively about pharmacotherapy. ficity, and avian mite- the parasites they believe induced dermatitis may infest them. They typically result from contact with bring ‘‘specimens’’ as proof of their infestation and either birds or rodents, including pet gerbils and may relate accounts of failed drastic measures to hamsters. Mites are widely distributed in nature, and eradicate the infestation. The ‘‘matchbox sign’’ is the conditions such as ‘‘grocer’s itch’’ may be related to classic presentation of various materials that have a wide variety of agricultural products. Pet-induced been collected by the patient as evidence of infesta- dermatitis and natural fillings for pillows and tion, including anything from dust/dirt, plant or mattresses have also been associated with cryptic animal fibers, scabs and skin debris to photographs mite-induced dermatoses. Caterpillars and moths of old/previous lesions or parasites. One can often often appear in great numbers, and their dislodged find real insects/arthropods in the matchbox, but hairs can cause urticaria and pruritus. they are typically innocent peridomestic organisms. Formication and pruritus caused by medica- Patients may describe an exposure to a dirty envi- tions, such as amphetamines (both illegal and ronment or a sexual encounter that they believe to be prescription), dopamine agonists,9 opioids, top- the origin of the infestation. In some cases, they iramate,10 cocaine,11 or alpha-adrenergic agents believe family members are also affected and may must also be considered. Pruritus related to sys- expose them to significant risk in their attempts to temic diseases, including hyperthyroidism and cure them. Folie a deux, a condition in which a renal and liver disease, may present with general- psychiatric condition (delusion or hallucination) is ized itch or a crawling sensation in the skin. transferred from one individual to another, is not Exposure to fiberglass may produce itching of uncommon in this setting.8 Patients experience unknown etiology, and fiberglass-contaminated formication, hallucinatory crawling sensations on clothing placed in the laundry can result in itching the skin attributed to the presence of the alleged in an entire family. parasites. Other psychiatric disorders should also be consid- ered, including schizophrenia spectrum disorders, dementia, affective psychoses, substance-induced Differential diagnosis psychoses, and psychoses caused by a general A thorough evaluation is required, including a medical condition (eg, iron deficiency anemia). complete history and physical examination. Table I Anxiety disorders, obsessive compulsive disorder, lists some of the more common diseases on the and somatoform disorders should be carefully distin- differential diagnosis. It is important to rule out guished from delusional states and may be comorbid genuine parasitosis. Older patients with scabies with delusional disorder. 1430 Campbell et al JAM ACAD DERMATOL MAY 2019 Evaluation Table I. Differential diagnosis of delusional A complete blood cell count, metabolic panel, parasitosis thyroid-stimulating hormone, obtaining a biopsy Scabies specimen of lesional skin, and perilesional skin Avian mite-induced dermatitis for direct immunofluorescence may help to rule out Grocer’s itch organic disease and help to establish an effective Pet-induced dermatitis e physician patient relationship. Dermatologists can Caterpillar and moth dermatitis use adhesive tape, cyanoacrylate stripping of skin, Fiber glass dermatitis and dermoscopy to detect evidence of mites. Substance-induced (amphetamines, opioids, cocaine, etc) Patients and exterminators can examine the house Pruritus related to systemic diseases and office for evidence of nesting birds
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