How to Manage Patients with Dermatologic Delusional Disorders (Commentary)
Mio Nakamura, MD; John Y.M. Koo, MD
| Disclosures | August 11, 2015
Dermatologic delusional disorders are characterized by a fixed false belief that there are parasites or foreign objects on the skin, which manifest as cutaneous dysesthesia or abnormal sensations of the skin. The most common type of dermatologic delusional disorder is parasitosis, in which patients believe that there are parasites living on their skin. The delusion is associated with a sensation of stinging, biting, or crawling.
Patients often have skin findings consistent with scratching or manipulation of the skin. Many patients bring to the provider "evidence" of infestation, most commonly pieces of lint or dirt they have found on their skin that they believe are parasites. Most patients have gone to many doctors to find a cause of their skin disease, only to be discouraged at the lack of adequate treatment.
Although controversial, another example of a delusional disorder may be Morgellons disease. In this condition, patients believe that fibers are emerging from the skin, which in turn cause somatic, psychiatric, and neurologic symptoms. Some small studies have suggested that Morgellons disease may be an illness associated with spirochete infection[3,4]; however, many physicians, as well as the Centers for Disease Control and Prevention, believe that it falls in the realm of delusional disorder.[1,2]
Regardless of the controversy surrounding this issue, patients and providers can all agree that dermatologic delusional disorders can be extremely debilitating. As healthcare providers, the main goal should be to improve the well-being of the patients; therefore, it is essential that the practitioner and patient work together to find adequate treatment.
First, it is important to establish a strong therapeutic rapport between the dermatologist and the patient. When the patient presents to the dermatologist's office, it is highly likely that he or she has already been seen by other physicians, including dermatologists, and is disillusioned with the care received. It is very easy for the patient to project this negativity onto the new provider.
Therefore, it is helpful for the dermatologist to start the encounter with as much positive energy as possible. If the patient persists in harboring a negative perception of the provider, the dermatologist may need to clearly distinguish him- or herself from the previous providers.
Ultimately, the only therapy that has consistently been shown to work for dermatologic delusions in our experience, as well as in the literature, is antipsychotic medications.[1,2,5] However, it is very difficult to institute this therapy in reality. Patients may not be willing to see a psychiatrist for their presumed skin disease, and the responsibility to initiate therapy therefore probably lies with the dermatologist.
Until a good relationship is established, it is best for the provider not to put pressure on him- or herself or on the patient to discuss antipsychotic treatment options. It is absolutely critical to avoid confrontational and argumentative interactions. Patients are experiencing a "living hell" that is made worse by a lack of validation from healthcare providers who cannot appreciate their degree of suffering. They have probably encountered many care providers who have trivialized or invalidated their concerns.
It may take several interactions focused on support and empathy before the patient comes to trust the dermatologist, thereby making it possible to begin discussing therapeutic options. During this time of relationship-building, the dermatologist should be as enthusiastic as possible in conducting thorough skin examinations, as well as examination of any specimen brought in by the patient.
Initiating Antipsychotic Therapy
In our experience in treating patients with dermatologic delusional disease, the best way to discuss antipsychotic therapy is by a pragmatic, "trial and error" approach. The patient's top priority is usually relief from the present torment. The historical gold standard for the treatment of delusions of parasitosis is pimozide (Orap®). Pimozide has one major advantage over all other antipsychotic agents: The official US Food and Drug Administration indication is Tourette syndrome. With the wide resources now available on the Internet, patients are well aware that pimozide has no psychiatric indication, which makes it uniquely acceptable to them.
Pimozide is started at 0.5-1 mg per day and titrated upward by 0.5-1 mg every 2 weeks. It is important to tell the patient that therapeutic benefit may not be reached until the dosage is 3-5 mg per day, although a large proportion of patients experience therapeutic benefit with as little as 1 mg per day. Once the patient experiences significant improvement, the medication should not be stopped too soon. You may continue the effective dosage for at least 2-3 months before initiating a slow taper at a rate similar to uptitration.
Pimozide is very effective at a low dose, and thus side effects are rarely encountered in practice. The more common side effects are stiffness and restlessness (ie, extrapyramidal side effects), which can easily be controlled with use of over-the-counter diphenhydramine (Benadryl®) 25 mg up to four times per day as needed. If the patient has problems with the sedative side effects of diphenhydramine, benztropine (Cogentin®) 1 or 2 mg up to four times a day can be substituted. Tardive dyskinesia is a possible side effect but is rarely seen owing to the low dosage and short time course of treatment.
Alternatives to pimozide include newer antipsychotics, risperidone (Risperdal®), olanzapine (Zyprexa®), aripiprazole (Abilify®), and quetiapine (Seroquel®). The medication is slowly titrated up to the optimal dose, then maintained at that dose for 2-3 months even if symptoms are minimal or absent. It is slowly tapered off. With this regimen, it is possible to cure a large segment of these patients.
After complete remission, the recurrence of symptoms months or years later is extremely rare. Such recurrence can be effectively treated by following the same regimen outlined above.
It is unfortunate that delusional conditions, which clearly have a large negative impact on a patient's life, are undertreated despite the availability of safe therapeutic options. Like any other skill in our profession, once the dermatologist becomes familiar with the above art of medicine, it becomes much easier to handle these cases. Patients with delusional disease can be the most grateful patients you will ever have in your practice.