12/11/13

Delusions of Parasitosis

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Delusions of Parasitosis
Author: Noah S Scheinfeld, MD, JD, FAAD; Chief Editor: Dirk M Elston, MD more... Updated: Feb 8, 2013

Background
Delusions of parasitosis manifest in the patient's firm belief that he or she has pruritus due to an infestation with insects. Patients may present with clothing lint, pieces of skin, or other debris contained in plastic wrap, on adhesive tape, or in matchboxes. They typically state that these contain the parasites; however, these collections have no insects or parasites. This presentation is called the matchbox sign, or what the authors term the "Saranwrap sign." The patients have no obvious cognitive impairment, and abnormal organic factors are absent. True infestations and primary systemic diseases that cause pruritus are not involved. Primary skin lesions are not present. Physical examination may reveal no lesions, but only linear erosions with crusts, prurigo nodularis, and/or ulcers. The classification of delusions of parasitosis is complicated. It is considered primarily a monosymptomatic hypochondriacal psychosis and has been associated with schizophrenia, obsessional states, bipolar disorder, depression, and anxiety disorders. Delusions of parasitosis occur primarily in white middle-aged or older women, although the condition has been reported in all age groups and in men. Savely et al[1] introduced the term Morgellon disease to describe a condition characterized by fibers attached to the skin. The entity appears to be little more than a new designation for delusions of parasitosis. Koblenzer[2] and Waddell and Burke[3] have discussed the utility of the term, with Murase et al[4] finding the term useful for building a therapeutic alliance with patients with delusions of parasitosis. The Centers for Disease Control and Prevention Ads not by this site is currently investigating Morgellon disease.[5] William Harvey [6] of the Morgellons Research Foundation Medical Advisory Board states the following: "All patients with Morgellons carry elevated laboratory proinflammatory markers, elevated insulin levels , and verifiable serologic evidence of 3 bacterial pathogens. They also show easily found physical markers such as peripheral neuropathy , delayed capillary refill, abnormal Rombergs sign, decreased body temperature, and tachycardia. Most importantly they will improve, and most recover on antibiotics directed at the above pathogens." The author of this article has not found reliable data to back up William Harvey's claims, but they are included here to comprehensively address this issue. Walling and Swick [7] suggest abandoning 3 the diagnostic terms trichotillomania, delusions of parasitosis, and neurotic excoriation, which they believe have become barriers to treatment. Instead, they suggest using the alternative patient-centered nomenclature of neuromechanical alopecia, pseudoparasitic dysesthesia, and (simply) excoriation. It is important to note that many patients with psychopathology complain of delusions of parasitosis, but the coexistence of delusions of parasitosis and another condition, the author thinks, is independent of pure delusions of parasitosis without other symptoms.[8, 9] One study of 47 patients reported that those noting bugs appeared to be more likely to be diagnosed with of delusional disorder or to have a medical diagnosis, as opposed to those noting fibers, who were more likely deemed to possess a somatoform disorder. Patients referred to a medical setting for delusions of parasitosis were 300 times more likely to require a physician to engage the hospital's legal counsel versus other patients in the same clinical setting.[10] European researchers reported a series of 148 delusions of parasitosis patients. None of the patients possessed genuine infestation, as was shown by thorough examinations. Thirty-five percent of the patients believed
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themselves to be parasite infested. Most patients in this series noted a significant number of other living or inanimate (17%) pathogenic agents. Seventy-one (48%) of the 148 patients presented to doctors with proof of their infestations. These specimens were, for the most part, skin bits or hair and rarely insects. Only a few of these insects were anthropophilic or of human pathogenicity. No insects could be linked to the clinical presentations.[11]

Pathophysiology
The cause of delusions of parasitosis is unknown. It appears related to neurochemical pathology. This concept is underlined by its induction by psychoactive agents (eg, amphetamines, cocaine, and methylphenidate) and its coincidence with depression, schizophrenia, social isolation, and sensory impairment. Some reports have linked delusions of parasitosis to hyperthyroidism, which was deemed a secondary type of delusions of parasitosis, because it resolved with pimozide therapy and thyroid medications.

Epidemiology
Frequency
United States The exact prevalence of delusions of parasitosis is unknown. International The exact prevalence of delusions of parasitosis is unknown.

Mortality/Morbidity
The literature includes one report of suicide in a 40-year-old man with delusions of parasitosis.[12]

Race
Delusions of parasitosis appear to be more common in whites than in people of other races.

Sex
Delusions of parasitosis occur primarily in white middle-aged or older women, although the condition has been reported in all age groups and in men. The female-to-male ratio is approximately 2:1. More specifically, this ratio is 1:1 in people younger than 50 years and 3:1 in those older than 50 years.

Age
Delusions of parasitosis are more common in middle-aged and elderly persons than in others. The female-to-male ratio is 1:1 in people younger than 50 years and 3:1 in those older than 50 years.[13, 14]

Contributor Information and Disclosures

Author Noah S Scheinfeld, MD, JD, FAAD Assistant Clinical Professor, Department of Dermatology, Weil Cornell Medical College; Consulting Staff, Department of Dermatology, St Luke's Roosevelt Hospital Center, Beth Israel Medical Center, New York Eye and Ear Infirmary; Assistant Attending Dermatologist, New York Presbyterian Hospital; Assistant Attending Dermatologist, Lenox Hill Hospital, North Shore-LIJ Health System; Private Practice Noah S Scheinfeld, MD, JD, FAAD is a member of the following medical societies: American Academy of Dermatology Disclosure: Optigenex Consulting fee Independent contractor Specialty Editor Board Franklin Flowers, MD Chief, Division of Dermatology, Professor, Department of Medicine and Otolaryngology, Affiliate Associate Professor of Pediatrics and Pathology, University of Florida College of Medicine Franklin Flowers, MD, is a member of the following medical societies: American College of Mohs Micrographic Surgery and Cutaneous Oncology
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Disclosure: Nothing to disclose. David F Butler, MD Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa Disclosure: Nothing to disclose. Jeffrey Meffert, MD Assistant Clinical Professor of Dermatology, University of Texas School of Medicine at San Antonio Jeffrey Meffert, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Association of Military Dermatologists, and Texas Dermatological Society Disclosure: Nothing to disclose. Catherine M Quirk, MD Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology Disclosure: Nothing to disclose. Chief Editor Dirk M Elston, MD Director, Ackerman Academy of Dermatopathology, New York Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology Disclosure: Nothing to disclose.

References
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37. Szepietowski JC, Salomon J, Hrehorow E, Pacan P, Zalewska A, Sysa-Jedrzejowska A. Delusional parasitosis in dermatological practice. J Eur Acad Dermatol Venereol. Apr 2007;21(4):462-5. [Medline]. 38. Elmer KB, George RM, Peterson K. Therapeutic update: use of risperidone for the treatment of monosymptomatic hypochondriacal psychosis. J Am Acad Dermatol. Oct 2000;43(4):683-6. [Medline]. 39. Friedmann AC, Ekeowa-Anderson A, Taylor R, Bewley A. Delusional parasitosis presenting as folie trois: successful treatment with risperidone. Br J Dermatol. Oct 2006;155(4):841-2. [Medline]. 40. Meehan WJ, Badreshia S, Mackley CL. Successful treatment of delusions of parasitosis with olanzapine. Arch Dermatol. Mar 2006;142(3):352-5. [Medline]. 41. Freudenmann RW, Schnfeldt-Lecuona C. Delusional parasitosis: treatment with atypical antipsychotics. Ann Acad Med Singapore. Jan 2005;34(1):141-2; author reply 142. [Medline]. 42. Atilganoglu U, Ugurad I, Arikan M, Ergun SS. Monosymptomatic hypochondriacal psychosis presenting with recurrent oral mucosal ulcers and multiple skin lesions responding to olanzapine treatment. Int J Dermatol. Oct 2006;45(10):1189-92. [Medline]. 43. van Vloten WA. Pimozide: use in dermatology. Dermatol Online J . Mar 2003;9(2):3. [Medline]. 44. Fellner MJ, Majeed MH. Tales of bugs, delusions of parasitosis, and what to do. Clin Dermatol. Jan-Feb 2009;27(1):135-8. [Medline]. 45. Bennassar A, Guilabert A, Alsina M, Pintor L, Mascaro JM Jr. Treatment of delusional parasitosis with aripiprazole. Arch Dermatol. Apr 2009;145(4):500-1. [Medline]. 46. Lim GC, Chen YF, Liu L, Huang SC, Lin KK, Hsiao CH. Camphor-related self-inflicted keratoconjunctivitis complicating delusions of parasitosis. Cornea. Dec 2006;25(10):1254-6. [Medline]. 47. Gee SN, Zakhary L, Keuthen N, Kroshinsky D, Kimball AB. A survey assessment of the recognition and treatment of psychocutaneous disorders in the outpatient dermatology setting: how prepared are we?. J Am Acad Dermatol. Jan 2013;68(1):47-52. [Medline]. Medscape Reference 2011 WebMD, LLC

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