BAD GUIDELINES Rui Baptista Gonçalves

MANAGEMENT OF ADULTS WITH ST3 Dermatology

DELUSIONAL INFESTATION ELHT
 STRUCTURE OF THE
PRESENTATION

1. PURPOSE AND SCOPE & METHODOLOGY

2. DEFINITIONS
3. DIAGNOSIS AND INVESTIGATION
4. RECOMMENDATIONS FOR MANAGEMENT OF ADULTS WITH DI
5. ANTIPSYCHOTICS

Ahmed, A. et al. (2022) British Association of Dermatologists Guidelines for the management of adults with
delusional infestation 2022, British Journal of Dermatology 187, 472-480
BACKGROUND
 PURPOSE, SCOPE &
METHODOLOGY
• Need for up-to-date evidence-based recommendation for management of adults with DI
• Appraisal of the literature (inc. systematic review)
• Address important practical and clinical questions
• Methods used: AGREE II and GRADE
• Guideline Development Group: consultant dermatologists, consultant psychiatrists, clinical
psychologists, patient representatives and a technical team
• REVIEW QUESTION: in people with DI, what is the clinical effectiveness and safety of
interventions compared with each other, placebo or no treatment?
 DEFINITIONS

Delusional infestation (delusional parasitosis or Ekbom syndrome)

“fixed false belief of pathogenic infestation of the skin or body, without
objective medical evidence.”
- Two forms: Primary and Secondary
- Living organism or an inanimate object (threads, fibers)
- Very debilitating – severely affects the person’s quality of life (high disease
burden)
- Dermatologists and GPs often preferred first contact physicians
 DELUSIONAL
INFESTATION
PRIMARY
- monosymptomatic hypochondrial psychosis
- delusions, somatosensory abnormality, behavioural alteration, cognitive dysfunction
- no definitive cause or underlying illness – persistent delusional disorder (ICD10, DSM 5)
- should be present for more than one month without diagnosis of schizophrenia, the patient
should be able to function despite the delusion, and it should not be secondary to any
pathology or substance use
SECONDARY
- caused by another defined organic or pre-existing psychiatric condition or by substance use.
 DELUSIONAL
INFESTATION
Most common monosymptomatic delusional disorder presenting to dermatologists
Lack of epidemiological data / likely under-reported condition
Incidence: 1.9 in 100 000 person-years
Mean disease duration: 3.13 years (days - >30 years)
Female predominance in over 50 years old, equal sex incidence in those under 50
More common in whites
Unclear aetiology: genetic susceptibility, life events, dopamine pathway, abherrant itch pathway,
brain damage. Secondary: substance use, medications, MS.
 DIAGNOSIS AND
INVESTIGATIONS
Highly distressed patients
Common complaints:
- being infested with a living or non-living pathogen
- pruritis, crawling, biting sensation + skin changes
- sensations in ears, eyes, potentially affecting all organs
- concerns for surrounding environment / multiple decontamination attempts
- attempt to isolate source of infestation – provision of specimens (the specimen sign)
- poor quality of life, self-isolation, concerns of infesting others (follie à deux/DI by proxy)
 DIFFERENTIAL
DIAGNOSES
SCHIZOPHRENIA
PSYCHIATRIC
DEPRESSION

TRUE INFESTATION
NEUROLOGICAL DISORDERS
MEDICAL
DEMENTIA
PRURITUS OF SYSTEMIC DISEASE
SUBSTANCE

ANTIBIOTICS
DOPAMINERGIC MEDICATIONS
ANTIPSYCHOTICS
DI IS A DIAGNOSIS OF EXCLUSION!
ANTI PARKINSONIAN
 INVESTIGATIONS
- PRURITUS SCREEN
- DEMENTIA SCREEN
- HIV, INFECTIOUS DISEASE SCREEN
- SEROLOGICAL MARKERS OF INFLAMMATION
- METABOLIC PANEL: LIVER, HBA1C, LIPIDS
- MICROBIOLOGICAL ANALYSIS OF SPECIMENS
- URINE TOXICOLOGY
- THYROID FUNCTION
- CT/MRI BRAIN
- SKIN BIOPSY (questionable)
RECOMMENDATION
S
 RECOMMENDATION
S
INITIAL PRESENTATION (45 minutes new patients/30 min follow up)
- Engage with patients and family/carers
- Full history (psych, medical, travel, substance use)
- Full physical examination, inc. neurological
- visual inspection of specimens, preferably using microscope
- proceed with investigations
 RECOMMENDATION
S

INVESTIGATIONS
- Screening diagnostic tests (urine, blood)
- Validated psychiatric tools (HADS, GAD, DLQI)
- Assess the risk of harm to self and others
 MANAGEMENT &
FOLLOW-UP
 EARLY REFERRAL TO A SPECIALIST PSYCHODERMATOLOGY CLINIC
 PSYCHIATRIC AND PSYCHOLOGICAL SUPPORT IN ADDITION TO DERMATOLOGICAL
TREATMENT (if acceptable to the patient)
 ANTIPSYCHOTIC MEDICATION – early in the management, tailored to the patient’s
characteristics
 TREATMENT FOR PSYCHOLOGICAL COMORBIDITIES
 Shared DI: index case is priority
Regular reviews to assess response to treatment (include measurement of adherence)
 Proactive communication & continuity of care
 Offer treatment for at least one year after symptoms have resolved (restart treatment if recurs)
 ANTIPSYCHOTICS
Suggested duration:
Up to 1 year after symptoms
resolve

Small dose to begin with

Monitoring for side effects

Pimozide is suggested as first

line therapy by Brownstone
et al (2022)

“uniquely acceptable to
those patients who intensely
oppose any psychiatric
medication”
 ANTIPSYCHOTICS
 Screen for risk factors that make experiencing side effects more likely: female, CV risk, liver
disease, poor nutrition, interactions with concomitant drugs;
 monitoring adjusted to antipsychotic side effect profile (ECG, FBC, CRP, Prolactin)
 Serum levels of the drug as an indicator of adherence
 Start on the lowest dose and treat up to one year after symptoms resolved
 If symptoms recur – up-titration of dose
 Discuss with GP or local psychiatric service if not comfortable with managing prescription
and monitoring.
REFERENCES
o Ahmed, A et al. (2022) British Association of Dermatologists Guidelines for the
management of adults with delusional infestation 2022, BJD 187, 474-480
o Freudenmann R, Lepping P (2009) Delusional infestation, Clinical Microbiological
Review, 22, 690-732
o Brownstone, N, Thibodeaux, Q, Koo, J (2022) Delusions of parasitosis, Ch 5 of
Treatment of Skin Disease 6th Ed, pp 193-195
 THANK
YOU!!

BAD GUIDELINES Rui Baptista Gonçalves

MANAGEMENT OF ADULTS WITH ST3 Dermatology
DELUSIONAL INFESTATION ELHT