Insights into the Medical Evaluation of Ekbom Syndrome: An Overview.

Ekbom syndrome, also known as delusional parasitosis (DP) or delusional infestation, is an uncommon psychiatric disorder distinguished by an enduring conviction of parasitic infestation, persisting notwithstanding the presence of medical evidence to the contrary. Primarily affecting middle-aged women, DP can manifest either as isolated psychological distress or as a component within a more intricate psychiatric framework, substantially influencing the quality of life for affected individuals. Its pathophysiological mechanism involves uncertain dopaminergic imbalances and dysfunction in the dopamine transporter system. Dermatologists often play a pivotal role in diagnosis, as patients first seek dermatological assessments of their signs and symptoms. However, DP frequently originates from underlying psychiatric disorders or medical variables, manifesting with neurological and infectious causative factors. The diagnostic complexity is attributed to patients' resolute convictions, leading to delayed psychiatric intervention. First-line DP treatment involves antipsychotics, with newer agents demonstrating promising prospects, but the lack of standardized protocols poses a significant therapeutic challenge. In this narrative review, both a comprehensive approach to this uncommon pathology and an update on the state of knowledge in this medical subfield focused on optimizing the management of DP are provided. The complexity of DP underlying its uncommon nature and the incomplete understanding of its pathophysiology highlight the need for further research through multicenter studies and multidisciplinary teams to enhance therapeutic efficacy and safety.

Psychological interventions in the treatment of delusional parasitosis: a brief review.

This review synthesized evidence on the most up-to-date treatment outcomes in patients with delusional parasitosis and examined the impact of incorporating psychological interventions in conjunction with psychiatric treatment. The reporting of this review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. PubMed and Google Scholar were searched between 2013 and 2023. Nine studies were included in this review. Partial remission was observed across all cases, irrespective of the treatment approach employed. Complete remission was limited to only three studies. No correlation was observed between the incorporation of psychological intervention in conjunction with psychotropic medication and an enhanced remission outcome. The findings underscore the importance of psychotropic medication as a fundamental component in the treatment of delusional parasitosis. The results highlight that although first- and second-generation psychotropic medications are the mainstay treatment options, they nevertheless play a limited role because of the patients' steadfast delusions of infestations.

How to improve the interface between dermatology and psychiatry: a review and expert suggestion regarding the management of delusional patients.

Psychodermatological problems are prevalent in dermatology practices. Among those, delusional infestation (DI) is the subject of one of the most challenging patient encounters practicing dermatologists may experience. This difficulty arises, at least partly, from the unavailability of psychiatric knowledge and skillset necessary to properly manage these patients, reflecting that most dermatology residency programs are unable to provide training in psychodermatology. This relates to the lack of faculty available with such expertise. This article reviews various suggestions made in the medical literature to try to improve this current unfortunate situation. However, the more common suggestion regarding organizing a multidisciplinary psychodermatologic clinic may be difficult to achieve as reflected by the scarcity of such clinics in the U.S. The authors offer alternative suggestions beyond the idea of organizing a multidisciplinary clinic.

Improving care for delusional infestation patients: What can dermatologists learn from an entomologist?

Delusional Infestation (DI), represents one of the most difficult patient encounters that dermatology practitioners may experience. It is common for DI patients to doctor shop. Thus, dermatologists are one of several disciplines that may encounter DI patients in their practices. Others include veterinarians, epidemiologists, emergency departments, mental health practitioners, and entomologists. In this article, entomologist, Dr. Gale E. Ridge, with extensive DI experience, was interviewed to find out what an entomologist's perspective has been and what we, the dermatology providers, can learn from that. This is followed by a discussion by the dermatology experts on how the experience of entomologists compares to our experience and what we can learn from them.

A case series of shared delusional infestation: folie à deux revisited.

Delusional infestation describes the unshakeable belief that one's skin is infected or infested with an external organism or inanimate material, in the absence of supportive medical evidence. It is one of the most challenging psychodermatological conditions to manage, given the rigidity of patients' physically focused health beliefs, and the competing need to introduce antipsychotic therapy to bring about resolution. This is rendered exponentially more complex when partners or family members are similarly afflicted. This situation is known as shared delusional infestation, shared psychotic disorder (SPD), or folie à deux. We present a series of three couples with SPD who were referred to our tertiary psychodermatology service during the same year. On examining the literature we were intrigued to discover that subtly different subtypes of SPD have been recognized since the late 1800s. These include folie simultanée, imposée, communiquée and induite. Our cases neatly demonstrate three of these variants, and highlight the difficulties in facilitating effective treatment.

[Ekbom syndrome or delusional parasitosis: Three cases in Ouagadougou (Burkina Faso)]. / Syndrome d'Ekbom ou parasitose délirante : trois cas à Ouagadougou, Burkina Faso.

INTRODUCTION: Ekbom syndrome is a rare disease characterized by a delusional conviction on the part of the patient of infestation with cutaneous parasites. It is rarely described in an African setting. Herein we report three cases observed in Ouagadougou. PATIENTS AND METHODS: Case 1: a 40-year-old housewife, living alone since her spouse left her, consulted for a feeling of insects under the skin and exulceration progressing over the previous year. A diagnosis was made of Ekbom syndrome in a depressed patient. Case 2: a 45-year-old bachelor, unemployed and with no children, consulted in dermatology for a sensation of continuous movement of insects under his skin, experienced over the previous six years. This sensation, which was worse in hair-covered areas, led to regular hair removal and untimely cleansing in a bid to dislodge them. Case 3: an 80-year-old patient, widowed for 3 years, consulted for a sensation of insects under her skin over the previous 2 years. This sensation was accompanied by intermittent pruritus and she removed the "insects" from her skin, which she brought to us in a sachet, but which in reality corresponded to debris of dead skin. We concluded on Ekbom syndrome in a depressive patient. CONCLUSION: These three cases of delusional parasitism observed in Ouagadougou, Burkina Faso, confirm the main clinical characteristics of Ekbom syndrome and underline the role of emotional and financial isolation, as well as pre-existing psychological difficulties, as potential triggers for this syndrome.

Delusional parasitosis as presenting symptom of occipital lobe cerebrovascular accident.

Delusional parasitosis manifests as a fixed, false belief that an individual is infested by living organisms. Primary delusional parasitosis is a psychiatric disorder with the delusion as an isolated manifestation, whereas secondary delusional parasitosis is a delusion occurring secondary to a psychiatric disorder, substance use, or medical illness. A 62-year-old woman with no psychiatric history presented to the Emergency Department with two to three months of "whole body itching" and seeing small insects crawling on her skin and in her hair. Exam of her skin and scalp was notable for no appreciable lesions, rashes, excoriations, or insects. Her neurologic exam was notable for full visual fields, and no localizing deficits. A non-contrast head CT demonstrated a nonspecific heterogeneous low-attenuation lesion within the medial right occipital lobe, and a follow up MRI confirmed a right posterior cerebral artery distribution subacute infarction. She was admitted for two days, and ultimately was discharged on aspirin and atorvastatin for secondary prevention. An emergency physician should remain vigilant in his/her assessment of patients with seemingly psychiatric symptoms, in particular elderly patients with no known psychiatric illnesses. Neuroimaging should be amongst studies considered in the evaluation of elderly patients presenting with new onset psychiatric complaints.

Emergency department presentation of 'delusional parasitosis by proxy'. Delusional parent, injured child.

We report a case of 'delusional parasitosis by proxy'. A sixyear old child was brought to the emergency department by a mother with concerns that her son had a skin and scalp infestation. Despite the absence of any clinical findings being found on exam, the mother remained disproportionately concerned. Follow up care was recommended with the child's primary care. The mother returned to the ED with her child three weeks later with concerns that her son had an inflamed scalp and eyes. The mother remained insistent that the child was infested with bugs and she had sought care at two other locations where the child was prescribed permethrin on both visits. She had been applying the medication repeatedly. On exam the boy's scalp had been shaved and was erythematous and irritated; his eyebrows and eyelashes had also been shaved off and likely contributed to an irritant conjunctivitis from repeated applications of topical permethrin lotion. No evidence of infestation was identified. We recruited the assistance of the maternal grandparents, child protective services and primary care pediatrics and the child was removed from the mother's custody and placed into the custody of the grandparents. Six weeks later with basic skin care and erythromycin ophthalmic ointment for the eyes, the child's hair, eyebrows and eyelashes grew had grown in, and the scalp irritation had resolved. The mother had sought and received psychiatric care and was improving.

A retrospective review of 12 patients with trichotillomania treated in a psychodermatology service.

Trichotillomania is a condition characterized by the pulling of hair from anywhere on the body and is classified as an obsessive-compulsive and related disorder. Patients with hair disorders are commonly referred to psychodermatology services, and can represent a management challenge. Few publications exist that report outcomes for patients with trichotillomania in real clinical practice. We report 12 such patients seen within our own psychodermatology service, who were managed using a variety of treatment strategies. The rate of defaulting of appointments was high, but improvements were seen in patients engaging with services.

Delusional infestation versus Morgellons disease.

Delusional infestation is the conviction that one is infested with pathogens-either animate or inanimate-despite medical or microbiologic evidence to the contrary. Infestation with inanimate pathogens, specifically fibers or filaments, has been controversially termed Morgellons disease by the patients themselves, who believe that this is not a psychiatric disease but rather a new organic condition or a skin manifestation of an infection, such as Lyme disease. A large-scale study by the Centers of Disease Control and Prevention on patients presenting with Morgellons clinical manifestations did not find evidence of fibers in the skin nor an association with any infection, including Lyme disease. Once the diagnosis of delusional infestation is made, the cornerstone of treatment is antipsychotics, although this is often quite challenging, as patients are reluctant to take these medications.

A patient with delusional infestation by proxy: Issues for vulnerable adults.

A 57-year-old Caucasian female presented to our clinic with her 23-year-old son, who was profoundly autistic. Our patient was convinced that her son had an infestation with fibers and believed that he had developed the condition as a young child. She described the symptoms of the infestation in her son's skin on his behalf, as he was not able to communicate. She identified dietary factors as a causative factor and wanted them removed from his diet. Her son had seborrhoeic dermatitis on examination, with no evidence of an infestation. Our patient later identified that fibers were coming out of her skin also. Her medical history included a road traffic accident resulting in back pain. Blood, urine, and microbiological investigations were normal. She was diagnosed with delusional infestation (DI) by proxy, and was started on risperidone. We present an interesting case of a patient with DI by proxy, in which the delusional beliefs of the mother have been projected onto her son. Issues of safeguarding vulnerable adults are raised in such cases, suggesting the crucial role of the physician in ensuring patient safety. DI by proxy has been reported in patients with children and animals, but we believe this is the first report of DI by proxy involving a vulnerable adult.

Longer Duration of Untreated Psychosis is Associated with Poorer Outcomes for Patients with Delusional Infestation.

We examined the association between the duration of untreated psychosis and outcome for patients with delusional infestation. This multi-centre international study included 211 consecutive patients. Illness severity was evaluated at first presentation and outcome was measured with the Clinical Global Impression scale (CGI) at baseline and follow-up. A regression analysis showed a clear clinical and statistically significant association between shorter duration of untreated psychosis and better outcome at follow-up. Patients with a duration of untreated psychosis of less than one year showed a CGI-S change from 5.37 to 2.07; those with a duration of untreated psychosis of 1-5 years a change from 5.48 to 2.59, and those with a duration of untreated psychosis of >5 years a change from 5.59 to 3.37. This difference of 1.1 CGI points between the groups resembles a clinically relevant difference in patient outcome. Our results suggest that longer duration of untreated psychosis in patients with delusional infestation is associated with significantly less favour-able clinical outcomes.

Delusional Infestation: Perspectives from Scottish Dermatologists and a 10-year Case Series from a Single Centre.

Perceptions of the clinical management of delusional infestation (DI) were compared with clinical outcomes in this 10-year case series from a single centre in Dundee, UK. An online questionnaire (survey-monkey, a TM brand of online survey available for free for basic use) was sent to Scottish Dermatologists to gauge their opinions and confidence in the management of DI. Also, a retrospective review of medical case notes of patients seen by dermatologists in one institution was undertaken and clinical outcomes were reported by patients' general practitioners (GP). The survey showed that 61% of responding dermatologists encountered 1-5 cases of DI per year. Twenty-four percent respondees were 'confident' in managing patients with DI, 54% were 'somewhat confident'. Forty-seven patients (62% female, 70% single) were seen over the 10 years; 43% brought a self-collected specimen to clinic, 68% of patients had a psychiatric comorbidity, 23% of patients had primary DI and 11/47 (23%) were seen by a psychiatrist. Clinical outcomes as rated by patients' GPs were reasonable or good in 2/3 patients. A poor outcome was seen in 12 patients and associated with chronic pain in 50% (p < 0.01) and psychiatric comorbidity in 100% (p < 0.01). We conclude that good outcomes can be achieved in some patients with DI without psychiatric input and without psychoactive treatment.

[Delusional parasitosis intestinal and dermatological: clinical cases]. / Parasitosis ilusoria intestinal y dermatológica: casos clínicos.

Illusory parasitosis, better known as delusional parasitosis, is a neuropsychiatric syndrome in which patients have the belief of suffering a parasitic disease, that can not be demonstrated after an exhaustive medical study. These patients are characterized by being polyconsultants in different medical specialties and, many of them, have antecedents of psychiatric disorders, some of them undiagnosed. Knowing the existence of the clinical picture, diagnosing early and empathizing with the patient, could give to clinician some clues for a timely and assertive psychiatric referral, and improve patient adherence to the proposed treatment.