OBSERVATION

Successful Treatment of Delusions of Parasitosis

With Olanzapine
William J. Meehan, MD, PhD; Sonia Badreshia, MD; Christine L. Mackley, MD

Background: Delusional parasitosis is a rare disorder in (5 mg/d). Olanzapine has a more benign adverse effect
which patients have a fixed, false belief of being infested profile than typical antipsychotic agents and eliminates
with parasites. It is often accompanied by a refusal to seek the need for electrocardiographic monitoring. Olanza-
psychiatric care. Delusions of parasitosis is classically treated pine therapy has been associated with such adverse ef-
with typical antipsychotic agents, the traditional derma- fects as sedation, hyperlipidemia, weight gain, and insu-
tologic choice being pimozide. However, pimozide’s ad- lin resistance, all of which were infrequent in our patients.
verse effect profile and the need for frequent electrocar-
diographic monitoring make such treatment less practical. Conclusion: Olanzapine is an atypical antipsychotic agent
that can be used as a first-line agent in delusional para-
Observation: We describe 3 patients who were diag- sitosis as a safer therapeutic option without a special-
nosed as having delusional parasitosis that was success- ized monitoring regimen.
fully treated with a recently Food and Drug Administra-
tion–approved atypical antipsychotic agent, olanzapine Arch Dermatol. 2006;142:352-355

I
N DELUSIONAL PARASITOSIS (DP), We describe 3 patients who were diag-
patients have a fixed, false belief nosed as having delusions of parasitosis
that they are infested with that were successfully treated with a newer,
parasites. This relatively rare atypical antipsychotic, olanzapine, which
psychiatric disorder most often has a safer adverse effect profile than its
presents as a monosymptomatic hypo- classic antipsychotic counterparts. This ar-
chondriacal psychosis, in which no other ticle represents the first documentation,
thought disorders exist and delusions are to our knowledge, of olanzapine effective-
not secondary to an additional psychiat- ness in the treatment of delusions of para-
ric illness.1 It is essential that dermatolo- sitosis in the English-language dermatol-
gists are well versed in diagnosing and ogy literature.
treating this psychiatric disorder, as the de-
lusional nature of the disease is often ac- REPORT OF CASES
companied by a refusal to seek psychiat-
ric care.2 CASE 1
For editorial comment A 53-year-old male chemical engineer pre-
see page 362 sented with a 5-month history of a pru-
ritic rash that was characterized by pink
In the dermatology literature, DP has patches with excoriations on his upper and
lower extremities. His rash began after he
classically been treated with the antipsy-
cleaned out the house of his recently de-
chotic pimozide. However, pimozide, like
ceased mother. He stated that the house
other typical or classic antipsychotic medi- smelled “damp” and that there was a black
cations, is associated with extrapyrami- mold in the basement. About 2 weeks af-
dal adverse effects, including irreversible ter cleaning, he became increasingly itchy
tardive dyskinesia, which can occur with over his upper extremities and trunk. He
long-term use. Also, pimozide therapy can persisted in cleaning his body to rid him-
cause a prolonged QT interval, requiring self of any suspected exposure. He be-
Author Affiliations:
baseline and periodic electrocardio- lieved that he had inhaled “mold spores”
Department of Dermatology, graphic monitoring. A safer therapeutic op- that, after having infected his entire body,
Penn State Milton S. Hershey tion without specialized monitoring re- were causing the pruritus. He subse-
Medical Center, Hershey, Pa. quirements is needed. quently removed some of his skin with a

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sharp blade and examined it under a microscope, reveal-
ing white spots that he believed were “fungus.” He was
able to maintain his chemical engineering job and out-
side hobbies. Outside dermatologists had attempted tra-
ditional treatments with topical steroids, prednisone
tapers, and antihistamines. He presented to our clinic with
photographs on his laptop in presentation format.
On presentation, he had rushed, pressured speech. He
also had extensive excoriations and scaling patches over
both of his arms, his trunk, and the upper part of his
thighs. Skin scrapings from his arms were examined with
a potassium hydroxide mount and were negative for or-
ganisms. He viewed the slide and conceded that there was
no evidence of fungal infection. He was diagnosed as hav-
ing delusions of infestation and irritant dermatitis caused
by frequent washing.
His treatment regimen consisted of clobetasol pro-
pionate ointment for his hands, 0.1% triamcinolone ace-
tonide ointment to be applied twice a day to his thighs
and abdomen, and oral olanzapine (5 mg/d). He was given
a listing of local psychiatrists, and one particular doctor
was recommended to him. At the 1-month follow-up visit, Figure 1. This pea was brought in by patient 2, who complained that it was
his dermatitis had improved, but he continued to be- the “bug” that was causing the itching sensation along the posterior aspect
lieve that he had a fungal infection. His wife stated that of her hairline.
he had purchased a “Hazmat suit” for the purpose of ster-
ilizing their house, at a cost equivalent to their monthly oxetine therapy was discontinued because her primary
income. The dosage of olanzapine therapy was in- problem was not depression. At her 1-month follow-up
creased to 10 mg/d, and a psychiatric referral was made, visit, she showed dramatic improvement, with resolu-
which the patient did not pursue. He did not like the idea tion of all symptoms. She no longer had any delusions
of the stigmata that are often associated with psychiatric of parasitosis. She left for Puerto Rico to visit her mother
referral. At the 3-month follow-up visit, the rash had soon afterward, a trip she had delayed for several months
cleared, and the patient no longer voiced any concern owing to her condition.
about fungal infection. He only asked about treatment
for a plantar wart. CASE 3

CASE 2 A 54-year-old man with a history of work-related back

injury presented with a more than 1-year conviction that
A 56-year-old healthy Hispanic woman with a several- “larva are being injected into me by insurance audi-
year history of depression complained of intense pruri- tors.” He explained that these auditors would sneak into
tus on the posterior aspect of her neck that had been pres- his house at night and hold him down as they injected
ent for approximately 2 months. She described the larva into his skin and sinuses because he was receiving
sensation as “bugs crawling.” Her itching was recalci- workers’ compensation. He would subsequently at-
trant to treatment with several topical steroids and an- tempt to kill the larva by burning them with cigarettes
tipruritic agents. Her medications included paroxetine or pulling them out with tweezers, which he physically
for depression. demonstrated during the interview. He claimed that the
Physical examination revealed a localized plaque of larva matured into flies, which then flew away. He was
excoriated, crusted papules and nodules at the nape of taking no medications.
her neck. The findings of microscopic examination of skin Physical examination revealed several erosions with
scrapings using a potassium hydroxide mount were nega- a honey-colored crust and scars on his face. His hands
tive for organisms, as were those of a scabies prepara- had several deep, irregularly shaped, crusted ulcer-
tion. Impetiginized prurigo nodularis with delusions of ations (Figure 2). His ulcers and impetiginization were
parasitosis was diagnosed. treated with cephalexin and mupirocin ointment. His de-
Intralesional triamcinolone acetonide was adminis- lusions of parasitosis were treated with olanzapine (5
tered to the largest nodules, and the patient was told to mg/d) and psychiatric referral. He did not return to our
apply clobetosol cream to the nape of her neck twice daily clinic because of the significant distance he had to travel.
and to begin a 10-day course of oral cephalexin therapy. Follow-up telephone conversations with his local psy-
At a follow-up visit, she was tearful and stated that she chiatrist revealed that he had markedly improved, with
was increasingly frustrated and unable to sleep as a re- only a few excoriations remaining. When contacted by
sult of her recalcitrant condition. She brought in the telephone he spoke in a rational manner, never mention-
“bugs” that she had found along the posterior hairline ing any infestation. He stated that his sores were healing
area, and they were found to be dried peas (Figure 1). and that he wanted a prescription for more olanzapine,
Olanzapine therapy (5 mg/d) was initiated, and the par- which he agreed to obtain from his psychiatrist.

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 wise, managed care has limited the availability of
psychiatric care for many patients.
Patients with shakable beliefs of infestation are not truly
delusional. Nondelusional patients with depression can
be effectively treated with selective serotonin reuptake
inhibitors, tricyclic antidepressants, and electroconvul-
sive therapy.10-13 Alternatively, patients with a fixed false
belief of infestation are best treated with antipsychotic
agents. Pimozide was the first antipsychotic drug that was
broadly used to treat DP, and a meta-analyisis of 1223
case reports demonstrated a full remission rate of 50%
with pimozide treatment, compared with a 30% remis-
sion rate in patients treated before pimozide was used.14
These data caused pimozide therapy to become the stan-
dard of care for patients with DP. Like many older neu-
Figure 2. Patient 3 presented with these irregularly shaped crusted
ulcerations on his hands.
roleptic drugs, pimozide has adverse effects, including
parkinsonism, tardive dyskinesia, and neuroleptic ma-
lignant syndrome (fever, muscle rigidity, confusion, and
COMMENT dysrythmias). Electrocardiographic changes have also
been observed; therefore, baseline and serial electrocar-
Typical antipsychotic agents block both mesolimbic and diograms are required for patients using pimozide.
striatal dopamine receptors, causing extrapyramidal ad- Atypical antipsychotic agents have been suggested as
verse effects at therapeutic doses.3 The newer atypical an- potential alternatives for DP treatment owing to their more
tipsychotics have a more benign adverse effect profile, favorable benefit-risk ratio.15 A limited number of case
perhaps owing to decreased occupancy of striatal dopa- reports have documented the effectiveness of risperi-
mine receptors.4 The atypical antipsychotic olanzapine done,16,17 sulpiride,18 and sertindole19 in the treatment of
was therefore considered as an alternative therapeutic ap- DP. To our knowledge, this series of 3 case reports rep-
proach to pimozide. In the 3 patients described herein, resents the first documentation of olanzapine’s effective-
treatment consisted of olanzapine therapy started at a dos- ness in treating DP in the English-language dermatol-
age of 5 to 10 mg/d. ogy literature. Previous reports either have been single
In the literature, DP can also be referred to as mono- case reports in German20,21 or have been published in the
symptomatic hypochondriacal psychosis, psychogenic para- psychiatry literature and have used the term monosymp-
sitosis, or Ekbom syndrome, which was named after the tomatic hypochondriacal psychosis, which is not as well
psychiatrist who summarized the first 22 case reports in recognized by dermatologists.22-24 Olanzapine, which was
1938.5 Patients often present with specimens of “para- introduced by Eli Lilly in 1997, acts as a potent antago-
sites” they have collected, the so-called matchbox sign, nist at dopaminergic and serotonergic receptors, with
which is considered by some authors to be pathogno- weaker antagonism at ␣-adrenergic and muscarinic re-
monic.6 In some cases, the delusion is shared by a sig- ceptors.25 Olanzapine shows selectivity for mesolimbic
nificant other, and this is termed a folie à deux.7 Patients and mesocortical over striatal dopamine tracts, thereby
may resort to self-mutilation in an effort to rid them- minimizing extrapyramidal adverse effects.25
selves of parasites, and insomnia is a common com- Atypical antipsychotic agents can cause adverse ef-
plaint.8 Several steps are useful in approaching patients fects, but the effects are considered less severe than those
with DP.8 A true infestation must first be ruled out. Wet associated with typical antipsychotic agents. Olanzapine
preparations of skin scrapings and skin biopsy can be use- use has been associated with sedation, hyperlipidemia,
ful and can help the physician establish trust with the weight gain, and insulin-resistant diabetes.26,27 Patients
patient. Empathetic listening, expressing concern about should be educated regarding these potential adverse ef-
how the problem is affecting the patient’s life, and es- fects. Fasting blood glucose and lipid determinations can
tablishing rapport are also helpful in preventing “doctor be used to monitor for adverse effects, especially in the pres-
hopping.”8 ence of additional risk factors such as obesity, advancing
It is also important to rule out any systemic disorder age, hypertension, a family history of diabetes, and a low
or unrecognized cutaneous disease. Careful history tak- level of physical activity. Although the incidence of tar-
ing can help establish whether the delusions might be dive dyskinesia and neuroleptic malignant syndrome is con-
associated with alcoholism or drug addiction. Both co- siderably less than with the use of traditional antipsy-
caine and amphetamine abuse have been associated with chotic agents, at high doses the possibility of their
the sensation of formication. Kidney, liver, thyroid, and occurrence should be taken into consideration.28 Evi-
endrocrine abnormalities and lymphomas may cause sec- dence is growing that monitoring the blood levels of atypi-
ondary generalized pruritus. It is essential to distin- cal antipsychotics in patients may improve efficacy and
guish a shakable belief of infestation from an unshak- safety; however, further investigation is necessary before
able belief; during discussion, some patients are receptive therapeutic drug monitoring can be implemented.29
to testing results that reveal no active infestation.9 A psy- At present, olanzapine is prescribed predominantly by
chiatric referral is useful, but not always accepted by pa- psychiatrists for patients with schizophrenia at a dosage
tients,8 who may perceive an associated stigma. Like- of 20 mg/d. However, there are reports of success at a

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dosage as low as 1.25 mg/d in cases of mild DP.30 We sug- 6. Lee WR. Matchbox sign. Lancet. 1983;2:457-458.
7. Kim C, Kim J, Lee M, Kang M. Delusional parasitosis as “folie a deux.” J Korean
gest initiating therapy at a dosage of 2.5 to 5 mg/d and
Med Sci. 2003;18:462-465.
then seeing the patient in 6 weeks. If there is little im- 8. Aw DC, Thong JY, Chan HL. Delusional parasitosis: case series of 8 patients and
provement, the dosage is increased. In our experience of review of the literature. Ann Acad Med Singapore. 2004;33:89-94.
treating several other patients with DP, no more than 10 9. Slaughter JR, Zanol K, Rezvani H, Flax J. Psychogenic parasitosis: a case series
mg/d is usually necessary for monosymptomatic hypo- and literature review. Psychosomatics. 1998;39:491-500.
10. Zanol K, Slaughter J, Hall R. An approach to the treatment of psychogenic
chondriacal psychosis.
parasitosis. Int J Dermatol. 1998;37:56-63.
Because patients are often hesitant to try a psychiat- 11. Lyell A. The Michelson Lecture: delusions of parasitosis. Br J Dermatol. 1983;108:
ric medication, some encouragement may be needed. For 485-499.
example, we often state that there is “no evidence of in- 12. Reilly TM, Batchelor DH. The presentation and treatment of delusional parasit-
festation today,” which establishes no confirmation of the osis: a dermatological perspective. Int Clin Psychopharmacol. 1986;1:340-
delusion but also demonstrates to the patients that you 353.
13. Morris M. Delusional infestation. Br J Psychiatry Suppl. 1991;(14):83-87.
trust them. Then, we suggest that although olanzapine 14. Trabert W. 100 years of delusional parasitosis: meta-analysis of 1,223 case reports.
is a psychiatric medication, patients with similar symp- Psychopathology. 1995;28:238-246.
toms have had remarkable improvement. In summary, 15. Wenning MT, Davy LE, Catalano G, Catalano MC. Atypical antipsychotics in the
our experience suggests that olanzapine should be con- treatment of delusional parasitosis. Ann Clin Psychiatry. 2003;15:233-239.
sidered as first-line therapy for DP. 16. Elmer KB, George RM, Peterson K. Therapeutic update: use of risperidone for
the treatment of monosymptomatic hypochondriacal psychosis. J Am Acad
Dermatol. 2000;43:683-686.
Accepted for Publication: July 17, 2005. 17. De Leon OA, Furmaga KM, Canterbury AL, Bailey LG. Risperidone in the treat-
Correspondence: Christine L. Mackley, MD, Depart- ment of delusions of infestation. Int J Psychiatry Med. 1997;27:403-409.
ment of Dermatology, PO Box 850 HU 14, Penn State Mil- 18. Takahashi T, Ozawa H, Inuzuka S, Harada Y, Hanihara T, Amano N. Sulpiride for
ton S. Hershey Medical Center, Hershey, PA 17033 treatment of delusion of parasitosis. Psychiatry Clin Neurosci. 2003;57:552-
553.
([email protected]). 19. Yorston G. Treatment of delusional parasitosis with sertindole. Int J Geriatr
Author Contributions: Study concept and design: Mack- Psychiatry. 1997;12:1127-1128.
ley. Acquisition of data: Mackley and Badreshia. Analysis 20. Kumbier E, Kornhuber M. Delusional ectoparasitic infestation in multiple sys-
and interpretation of data: Mackley. Drafting of the manu- tem atrophy [in German]. Nervenarzt. 2002;73:380-383.
script: Meehan. Critical revision of the manuscript for im- 21. Freudenmann RW. A case of delusional parasitosis in severe heart failure: olanza-
pine within the framework of a multimodal therapy [in German]. Nervenarzt. 2003;
portant intellectual content: Badreshia and Mackley. Ad- 74:591-595.
ministrative, technical, and material support: Mackley. Study 22. Weintraub E, Robinson C. A case of monosymptomatic hypochondriacal psy-
supervision: Mackley. chosis treated with olanzapine. Ann Clin Psychiatry. 2000;12:247-249.
Financial Disclosure: None. 23. Fawcett RG. Olanzapine for the treatment of monosymptomatic hypochondria-
cal psychosis. J Clin Psychiatry. 2002;63:169.
24. Nakaya M. Olanzapine treatment of monosymptomatic hypochondriacal psychosis.
REFERENCES Gen Hosp Psychiatry. 2004;26:166-167.
25. Bymaster FP, Rasmussen K, Calligaro DO, et al. In vitro and in vivo biochemistry
1. Munro A. Monosymptomatic hypochondriacal psychosis. Br J Psychiatry Suppl. of olanzapine: a novel, atypical antipsychotic drug. J Clin Psychiatry. 1997;
1988;(2):37-40. 58(suppl 10):28-36.
2. Koo J, Lee CS. Delusions of parasitosis: a dermatologist’s guide to diagnosis 26. Casey DE. Dyslipidemia and atypical antipsychotic drugs. J Clin Psychiatry. 2004;
and treatment. Am J Clin Dermatol. 2001;2:285-290. 65(suppl 18):27-35.
3. Serretti A, De Ronchi D, Lorenzi C, Berardi D. New antipsychotics and schizo- 27. Ananth J, Parameswaran S, Gunatilake S. Side effects of atypical antipsychotic
phrenia: a review on efficacy and side effects. Curr Med Chem. 2004;11:343- drugs. Curr Pharm Des. 2004;10:2219-2229.
358. 28. Kogoj A, Velikonja I. Olanzapine induced neuroleptic malignant syndrome–a case
4. Grunder G, Carlsson A, Wong DF. Mechanism of new antipsychotic medica- review. Hum Psychopharmacol. 2003;18:301-309.
tions: occupancy is not just antagonism. Arch Gen Psychiatry. 2003;60:974- 29. Hiemke C, Dragicevic A, Grunder G, et al. Therapeutic monitoring of new anti-
977. psychotic drugs. Ther Drug Monit. 2004;26:156-160.
5. Ekbom KA. Der prasenile dermatozoenwahn. Acta Psychiatr Neurol Scand. 1938; 30. Guttman C. Olanzapine safe choice for delusions of parasitosis. Dermatology Times.
13:227-259. March 2001:21.

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