Managing Delusional Parasitosis

Delusional parasitosis (DOP) is a psychiatric disorder where individuals falsely believe they are infested with parasites, leading to significant distress and repeated visits to dermatologists and primary care physicians. In a recent podcast, I had the pleasure of discussing this complex condition with Nicholas D. Brownstone, MD , a rising dermatologist and also host of another dermatology podcast called "Cutaneous Miscellaneous."

Understanding Delusional Parasitosis

Dr. Brownstone began by explaining that DOP can present as either primary or secondary. Primary DOP has no known origin, while secondary DOP is associated with substance intoxication or withdrawal, or as a manifestation of a greater psychiatric illness like schizophrenia. It’s crucial to distinguish between these to ensure proper treatment.

Patients with DOP typically report sensations of crawling, biting, or stinging on their skin. They may also describe seeing inanimate objects like fibers emerging from their skin. It's essential to rule out genuine skin conditions before diagnosing DOP, as patients can sometimes present with actual infestations like scabies. Dr. Brownstone shared a critical point: “You can’t just say, ‘Oh, the patient's crazy.’ Always do a bona fide skin exam.”

Diagnosing and Managing DOP

When diagnosing DOP, Dr. Brownstone emphasized the importance of conducting a thorough skin examination and possibly treating for scabies to rule out other conditions. He highlighted the necessity of scraping the skin and looking under the microscope to ensure no parasites are present. This not only helps in making an accurate diagnosis but also shows patients that their concerns are being taken seriously.

Patients often bring samples in Ziploc bags, referred to as the "matchbox sign," which can contain hair, lint, or skin cells they believe are parasites. Dr. Brownstone advised giving patients microscope slides to prepare their samples, which makes it easier to examine under a microscope.

Dr. Brownstone’s Journey

Dr. Brownstone shared his interest in this field, stemming from his background in psychology and his experiences during a dermatology research fellowship at UCSF. His mentor, Dr. John Koo, a pioneer in psychodermatology, greatly influenced his work with DOP patients. Dr. Brownstone explained, “I loved helping these patients that are difficult to treat, but you definitely help some people and save some people.”

Treatment Approaches

Treating DOP requires a sensitive approach. Dr. Brownstone recommended starting with simple treatments like permethrin cream, which has minimal side effects and can sometimes provide psychological relief. However, persistent cases may require antipsychotic medications like pimozide, a first-generation neuroleptic. Dr. Brownstone discussed the "trapezoid method" for titrating pimozide, which involves gradually increasing the dose until symptoms improve, maintaining it, and then slowly tapering off. This method leads to the best efficacy and safety.

He also mentioned the importance of ensuring patients are comfortable with the medication by explaining that pimozide is approved for Tourette's, a neurological condition, rather than a psychiatric one. This approach can make patients more willing to accept treatment.

Challenges and Future Directions

One significant challenge is addressing the stigma associated with psychiatric diagnoses. Dr. Brownstone advised using the term "Morgellons disease" as an alternative to DOP, as it is less stigmatizing and more acceptable to patients. He also highlighted the importance of research, mentioning the potential of medications like ozempic, which might impact dopamine levels and alleviate symptoms.

During our conversation, I proposed exploring ozempic's impact on DOP symptoms. Ozempic has shown benefits in other areas, such as reducing alcohol dependence, which might make it a valuable tool in managing DOP. This idea sparked excitement, indicating the continuous need for innovative research and treatments.

The Importance of Multidisciplinary Care

Dr. Brownstone and I both emphasized the importance of a multidisciplinary approach involving dermatologists and psychiatrists. These patients often require more than dermatological care, and collaborating with psychiatrists can ensure comprehensive treatment. However, it’s essential to be cautious with language when discussing psychiatric care with DOP patients, as they can be highly sensitive to any implication that their condition is purely psychological.

Communication and Empathy

Effective communication is crucial in managing DOP. Dr. Brownstone shared stories of patients reacting negatively to suggestions of psychiatric help, highlighting the need for careful, empathetic language. He stressed avoiding terms like “delusional” or “psychosis” in patient notes and conversations. Instead, using “Morgellons disease” can help patients feel understood and reduce the likelihood of them becoming defensive or distressed.

Our discussion emphasized the need for empathy, honesty, and a multidisciplinary approach in managing DOP. By improving communication and treatment strategies, dermatologists can significantly enhance patient outcomes.