Morgellons disease: a narrative review.

Morgellons disease is characterized by the persistent delusion of skin infestation, ultimately inflicting wounds and impairing quality of life. There is insufficient and conflicting research pertaining to this condition, imposing challenges on clinicians in understanding, diagnosing, and treating it. In this review, we summarize the available literature on Morgellons disease including its historical evolution, epidemiology, proposed pathophysiology, underlying structural and functional brain pathologies, typical and atypical clinical presentations, diagnosis, and treatment. A comprehensive review of the literature was conducted on PubMed, Embase, and Scopus using specified keywords. Selected articles were screened by two independent reviewers based on set inclusion and exclusion criteria. Conflicts were resolved by a third reviewer as needed. No limit to the date of selected articles was set due to the scarce literature available on the subject. Morgellons disease is an underdiagnosed entity, owing mostly to the lack of an established pathophysiology and treatment guidelines. While many authors classify it as a type of delusional infestation (DI), others correlate MD with an underlying spirochetal infection, namely Lyme disease. Neuroimaging studies have revealed abnormalities in the "fronto-striato-thalamo-parietal network", a finding common to patients with DI, in addition to alterations in structures related to the "Itch Processing Pathway". Patients tend to extract fibers from their skin lesions and place them in a match box hence the term "match box sign". The diagnosis is that of exclusion, requiring extensive work up to rule out secondary causes and differential diagnoses. Treatment is largely based on the use of antipsychotics, with or without cognitive behavioral therapy. Despite being a diagnosis of exclusion, clinicians must be aware of this entity and have a profound understanding of the pathogenesis underlying it. Upon clinical suspicion, secondary Morgellons should always be ruled out through a thorough history taking, physical examination, and laboratory exams. Despite the challenges brought by the heterogeneous presentation of the condition and the paucity of research revolving around it, the great impact that Morgellons disease has on patients' quality of life forms a pressing need for its adequate detection, diagnosis, and treatment.

The Koo-Brownstone staging system as a tool to assist in the management of patients with a possible diagnosis of dermatological delusions: an experts suggestion.

BACKGROUND: Delusional infestation (DI) is one of the most challenging situations dermatologists and other dermatology providers may face in their practice. Dermatologists must know how to properly communicate with these patients. The process of acquiring delusional states can be a gradual development and not all delusional patients in dermatology are the same. OBJECTIVE: The objective of this manuscript is to introduce the 'Koo-Brownstone Staging System' for Delusional Infestation (Morgellons disease) with the goal of improving communication and management for these patients. METHODS: This staging system has been derived based on more than three decades of experience of the senior author supported by additional years of experience of the first author. RESULTS: The following stages are presented and explained: formication only (stage 1), overvalued ideation of parasitosis (stage 2), pre-delusional (stage 3), delusional (stage 4) and terminally delusional (stage 5). LIMITATIONS: This staging system has been derived based on expert clinical experience rather than a direct reporting from this patient population themselves. CONCLUSIONS: This staging system will enhance awareness on the part of the health providers to enable them to categorize a given patient, which becomes critical in optimizing communications and management.

The challenge of Morgellons disease: A patient with clinicopathologic correlation.

Morgellons disease is a rare condition characterized by patient-reported multicolored fibers and other nonorganic particles or organic particles embedded in and protruding from diffuse skin ulcerations. Although the scientific community is prone to believe that Morgellons disease is a psychiatric disorder, an infectious pathogenesis associated with Borrelia burgdorferi in the setting of Lyme disease has also been proposed. The histopathology is usually considered as nonspecific. To illustrate this condition, we present the case of an adult woman with significant ulcerative skin lesions and cicatricial changes on the face, trunk, and arms. After multiple biopsies and successful microscopic visualization of the fibers, she received a diagnosis of Morgellons disease in the setting of delusional infestation. No evidence of Borrelia infection was found. Treatment with antipsychotics was initiated, but the patient was lost to follow-up, as is often the case with patients with Morgellons disease.

Morgellons disease etiology and therapeutic approach: a systematic review.

Morgellons disease is characterized by patient reports of fibers embedded in and protruding from the skin. Etiologies from infection to delusion have been endorsed, and treatment guidelines are not well-defined. The objective of this manuscript is to evaluate the existing evidence regarding the etiology and treatment of Morgellons disease in an effort to better inform clinical management. A PubMed search including key words "Morgellons," "delusional parasitosis and fibers," "delusions of parasitosis and fibers," or "delusional infestation and fibers" was completed. Original publications directly assessing etiology or treatment methods of Morgellons disease published between January, 2010 and the time of manuscript preparation were reviewed and evaluated. Sixteen articles regarding etiology were reviewed. All studies were correlative in nature with various limitations. Support for a psychiatric etiology was more widespread than support for an infectious etiology. Eleven articles regarding treatment efficacy were reviewed. Antipsychotic regimens have the most evidence of efficacy. Existing data regarding Morgellons disease suggests a psychiatric etiology and supports treatment with a low-dose antipsychotic agent once non-psychiatric causes have been excluded.

Treatment of Oral Mucosal Lesions Associated With Overlapping Psychodermatologic Disorders.

Delusional infestations are psychodermatologic disorders in which those affected have a false belief they are infested by parasites and/or "growing" inanimate objects from cutaneous surfaces. Individuals with delusional parasitosis (DP) believe parasites, bacteria, worms, mites, or other living organisms are the source of cutaneous symptoms, while those with Morgellons disease (MD) attribute their symptoms to growth of small fibers or inorganic material. In both DP and MD, self-inflicted, non-healing cutaneous lesions caused by scratching at the affected areas to alleviate symptoms are commonly observed. This report describes a case of oral mucosal lesions in a patient demonstrating overlapping symptoms of DP and MD. It is important for oral healthcare providers to recognize oral signs and symptoms that may be associated with psychodermatologic disorders.

Review of epidemiology, clinical presentation, diagnosis, and treatment of common primary psychiatric causes of cutaneous disease.

Approximately half of all patients presenting to dermatologists exhibit signs and symptoms of psychiatric conditions that are either primary or secondary to cutaneous disease. Because patients typically resist psychiatric consult, dermatologists often are on the front line in evaluating and treating these patients. Accordingly, distinguishing the specific underlying or resulting psychiatric condition is essential for effective treatment. The etiology, epidemiology, clinical presentation, diagnosis, and first-line treatment of specific primary psychiatric causes of dermatologic conditions, including delusional infestation, Morgellons syndrome, olfactory reference syndrome, body dysmorphic disorder, excoriation disorder, trichotillomania, and dermatitis artefacta are discussed here, followed by a discussion of the recommended treatment approach with an overview of the different first-line therapies discussed in this review, specifically cognitive behavioral therapy, atypical antipsychotics, selective serotonin reuptake inhibitors, and tricyclic antidepressants. Included is a guide for dermatologists to use while prescribing these medications.

Delusional Infestation: State of the Art.

Patients with a delusional infestation (DI) have an overwhelming conviction that they are being infested with (non) pathogens without any medical proof. The patients need a systematic psychiatric and dermatological evaluation to assess any possible underlying cause that could be treated. Because they avoid psychiatrists, a close collaboration of dermatologists and psychiatrists, who examine the patient together, seems to be a promising solution. It helps to start a trustful doctor-patient relationship and motivates the patient for psychiatric treatment. We here review diagnostic criteria, classification of symptoms, pathophysiology and treatment options of DI. Antipsychotic medication is the treatment of choice when any other underlying cause or disorder is excluded. Further research is needed to assess the pathophysiology, and other treatment options for patients with DI.

Morgellons Disease Presenting As an Eyelid Lesion.

Morgellons disease is characterized by complaints of uncomfortable skin sensations and fibers emanating from nonhealing skin lesions. Morgellons disease is well-known in the dermatology and psychiatry literature, where it is typically considered a subtype of delusional parasitosis, but it has not yet been described in the ophthalmology literature. A patient with self-reported Morgellons disease is presented, who was referred for evaluation of left lower eyelid ectropion. She reported that her skin was infested with fibers that were "trying to get down into the eyelid." On examination, she had ectropion of the left lower eyelid, broken cilia, and an ulcerated left upper eyelid lesion concerning for carcinoma. Biopsy of the lesion was consistent with excoriation. Treatment of her ectropion was deferred out of concern for wound dehiscence, given the patient's aggressive excoriation behavior. This case is presented to make the ophthalmologist aware of this disorder and to highlight the appropriate clinical management.

A case report highlighting the growing trend of Internet-based self-diagnosis of "Morgellon's disease".

"Morgellon's Disease" is a term used to describe a bizarre condition characterized by the belief that strange sensations in the skin are due to filaments called "Morgellon's Bodies."' The focus of this case report is to inform readers of the growing incidence of this psychosomatic condition. Unfortunately, self-diagnosis has become increasingly common because of the widespread coverage on the Internet. While the validity of the diagnosis is in question, the impact on patient's lives is real, often debilitating, and bears more examination.

Dermatologic infestations.

Head lice are transmitted by head to head contact. Optimal therapy includes malathion lotion 0.5% repeated in one week left on for 30 minutes to 8 hours. Spinosad topical suspension 0.9% repeated in one week left on for 10 minutes is another option. Scabies is transmitted mainly by direct contact but also via heavily infested fomites due to crusted scabies. Permethrin 5% cream to the body repeated in four days is often sufficient; however, scalp treatment with malathion lotion 0.5% is helpful in crusted scabies and in infested children. Oral ivermectin 200 mcg/kg is another option, repeated in four days. For scabies more than lice, fomites should be placed in a drier at 60 °C for 10 minutes to kill the arthropods. Treatment of close contacts in both cases will control outbreaks and repeated infestations. Both have been associated with methicillin-resistant Staphylococcus aureus infection. Bed bugs are a common cause for papular urticaria. Identification of the insect in the mattress or bedding confirms the diagnosis. Prevention involves encasing the mattress in a sealed plastic cover and extermination. Delusions of parasitosis is a diagnosis of exclusion that is best treated with an antipsychotic.

Variable clinical presentations of secondary delusional infestation: an experience of six cases from a psychodermatology clinic.

OBJECTIVE: Delusional Infestation (DI) is a relatively rare condition with a fixed belief of being infested with living organisms, despite a lack of medical evidence of such infestation. Although it seems to be a psychiatric disease, patients commonly are admitted to dermatology clinics because of skin findings. Psychiatrists can underestimate its prevalance, whereas dermatologists can miss the diagnosis. It should be managed as a psychodermatological disease. Our aim in the study was to evaluate six patients with different clinical presentations of DI and to emphasize some clinical features. METHOD: All patients were internalized in the psychodermatology clinic for this study. Medical history and clinical data from dermatologic and psychiatric examinations were noted; Mini International Neuropsychiatric Interview (MINI-Plus) and laboratory investigations including blood and urine analyses, microscopic analysis of so-called pathogens, and skin biopsy if needed, were performed. The diagnosis was made based on detailed history, dermatologic and psychiatric examinations, and laboratory investigations. RESULTS: All patients had symptoms of itching, burning, or crawling sensations dermatologically and thus were admitted to dermatology clinic. They were all considered secondary DI to another medical condition or to psychiatric illness. Vitamin B12 deficiency, diabetes, and hypothyroidism were the underlying medical conditions. Related psychiatric illnesses were trichotillomania and schizoaffective disorder, schizophrenia, shared pychotic disorder, and brief psychotic disorder. Two patients had delusions of inanimate materials; four patients had partial and complete remissions; and two patients have dropped out. CONCLUSION: Each patient had different clinical characteristics creating diagnostic challenges. All complaints were related to the infestation of the skin. The presence of different psychiatric comorbidities is remarkable. It seems that both psychiatrists and dermatologists can face diagnostic and therapeutic challenges of this complex disease in clinical settings, particularly if there are unusual clinical features of DI. Therefore, both psychiatrists and dermatologists should be well aware of DI.

Delusional infestation with unusual pathogens: a report of three cases.

Delusional infestation (DI) is a psychiatric disorder characterized by a fixed, false belief that the patient is infested with extracorporeal agents. It is known by several names, including the more commonly used term 'delusional parasitosis'. The psychiatric disease is responsible for the cutaneous pathology. About 90% of patients with DI seek help from dermatologists, and most reject psychiatric referral. Thus, effective management requires incorporation of psychiatric principles. We report three cases of DI with inanimate materials, and examine 'Morgellons' disease. We believe that patients with unusual presentations of DI are likely to be seen more commonly in the future. These patients appear to be a subgroup of DI, and may be even more difficult to treat than other patients with DI.

An oral ulceration associated with Morgellons disease: a case report.

Morgellons disease is a psycho-dermatologic condition in which patients report fibers or filaments "growing" out of their skin. This case report highlights an oral ulceration in a young woman associated with Morgellons disease, a condition that has not been previously described in the dental literature. An increasing number of individuals are self-reporting this condition and oral health care providers must be familiar with this disorder.

Morgellons disease and delusions of parasitosis.

Morgellons disease is a controversial and poorly defined symptom cluster of skin lesions and somatic symptoms, most notably 'fibers' in the skin. Because of widespread coverage in the media and on the Internet, there are an increasing number of patients presenting to dermatologists. We present three patients who believed that they had fibers in their skin. We offer a discussion of delusions of parasitosis to demonstrate similarities between these conditions. It has been suggested by a limited number of healthcare providers that an unknown infectious agent underlies this symptom complex yet no available evidence supports this assertion. Laboratory values that would be reflective of an infectious process (e.g. elevated white blood cells, sedimentation rate, C reactive protein) are routinely normal and biopsies often reflect only nonspecific findings such as acute and chronic inflammation with erosion or ulceration. Patients with Morgellons disease generally lack insight into their disease and reject the need for psychiatric help. The goal is to build trust and refrain from minimizing what the patient experiences. Attentive examination of the patient's skin and fragments they present is necessary to rule out a true underlying pathologic process and to establish a trusting relationship. A supportive, non-confrontational approach is ideal. The patient is best treated by a team of practitioners of several specialties, including dermatologists, psychiatrists, and counselors.