Approach to Patients With Delusions of Parasitosis

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Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of The Dermatologist or HMP Global, their employees, and affiliates. 

Cultivate a Trusting Therapeutic Alliance
A potentially ineffective approach to the patient with delusional parasitosis among some physicians seems to be to become a bit frustrated if the patient is not immediately willing to start an antipsychotic, dismissing them as “difficult.” However, because this patient population has such low illness insight, they may be completely convinced that their issue is a dermatologic one, as op- posed to psychiatric, and not immediately receptive to believing they are delusional or require antipsychotic therapy.

A more effective strategy may be to spend time cultivating a trusting therapeutic alliance and making sure to validate the patient’s distress and suffering while taking care not to validate their delusional thoughts. If the patient feels they are being listened to and their symptoms are being taken seriously, they may be more receptive to potential treatment recommendations. This can be followed up with a careful explanation of the benefits of an antipsychotic, perhaps mentioning that other patients with their condition have benefited from therapy with antipsychotic or similar drugs. Of course, a robust patient-physician relationship is important with all patients, but it may be especially important in this patient population because the initiation of proper therapy can depend on it.

Esther A. Balogh, MD
Winston Salem, NC

Dupilumab for Atopic Neurodermatitis From Retinoids
Consider using dupilumab for drug-induced atopic neurodermatitis caused by acitretin and isotretinoin. This will allow for a higher systemic retinoid dose and better outcomes. I have a patient with severe Hailey-Hailey disease. The skin weeps, gets infected, and itches. She does well on prednisone, but flares with tapering. She does not do well on methotrexate, cyclosporine, naltrexone, glycopyrrolate, or magnesium chloride. She was well managed on low-dose acitretin 10 mg daily when living in California. She does not respond to this dose of acitretin in Hawaii due to the increased heat and humidity. Higher doses of acitretin 25 mg daily or twice a day trigger severe atopic neurodermatitis. By adding dupilumab to the acitretin treatment, I can push the acitretin dose to 25 to 50 mg daily and clear the Hailey-Hailey disease. Dupilumab could also be used with isotretinoin for patients who cannot tolerate the 1 mg/kg dose.

Wayne Fujita, MD
Aiea, HI

Liquid Nitrogen Precision
To direct liquid nitrogen to a pinpoint area, use a small plastic cone or a plastic funnel, which will direct the cryotherapy to that area and protect surrounding skin.

Ron Vender, MD
Hamilton, ON, Canada

Learn From Your Staff
Email staff periodically to ask: “What are 2 things we do great and 2 things we can do better?” Give a tight deadline and consider offering prizes. Your staff members will feel appreciated and listened to, and a prize can lead to more and higher quality responses from the front lines.

Benjamin Barankin, MD
Toronto, ON, Canada