Psychocutaneous Disorder

The Current Management of Delusional Parasitosis and Dermatitis Artefacta

Caroline S. Koblenzer, MD

Skin Therapy Letter. 2010


Introduction:

Patients who present with delusional parasitosis or dermatitis artefacta are not easy for dermatologists to work with, whose treatment requires the use of drugs unusual to the dermatologist and a significant investment of the clinician's time.

Each is a skin manifestation of a psychiatric disorder that represents a psychological defense - a way for the patient to avoid the acknowledgment of psychiatric pathology.

Delusions of Parasitosis

The delusions seen in dermatology are "systematized" or non-bizarre - i.e., they are fixed beliefs that, though false, control the patient's feelings and behavior in ways that are wholly consistent with the content of those beliefs. Delusions of parasitosis associated with cutaneous dysesthesia.

The delusional patient is often defensive, angry, and distrusting. The patient desperately wants answers. "We do not know the cause, but we have treatments that are effective" or "We have seen other patients with similar symptoms, and whatever is the cause, there are changes in the skin that we can treat" are possible answers.

Intensive topical measures are helpful (e.g., tar or bleach baths, emollients, and antibiotics as indicated). Topical agents, such as pramoxine hydrogen chloride cream or lotion, may be used to provide temporary relief of any dysesthesia.

Antipsychotic drugs are the first-line treatment (Much smaller doses than those used). Pimozide has long been the drug of choice. Risperidone and aripiprazole are preferable to olanzapine.

50–90% of patients are reported to have near or full symptom resolution, with improved functioning and any psychiatric and physical comorbidities tend to improve in parallel.

Dermatitis Artefacta

Dermatitis artefacta refers to skin lesions produced by the patient, under the veil of secrecy, to satisfy an unconscious need to be taken care of.

Lesions that are morphologically bizarre, often geometric in outline, destructive, and reportedly of sudden, mysterious yet fully formed appearance. Patients with neurotic excoriations usually have depression or anxiety with obsessive-compulsive features; those with Munchausen's syndrome have a sociopathic personality, while patients with dermatitis artefacta are most commonly diagnosed with the borderline personality disorder.

Dermatologic support is important, borderline patients are best treated psychiatrically, though a recommendation for psychiatric referral must be approached very judiciously. The antipsychotics are the drugs of choice and aripiprazole has an advantage in that it also has antidepressant properties.

Discussion:

Because patients with delusional parasitosis and dermatitis artefacta do not accept the need for psychiatric treatment, they fall either to the lot of the dermatologist or receive no help at all.

An optimal approach includes frequent short clinic visits, expression of empathy, affirmation that the skin itself is involved, and low dose antipsychotic drugs. With compliance, remissions of varying length occur, but both disorders are likely to last life-long.

Rebound of plasma viremia following cessation of antiretroviral therapy despite profoundly low levels of HIV reservoir

Chun T-W et al. Rebound of plasma viremia following cessation of antiretroviral therapy despite profoundly low levels of HIV reservoir: Implications for eradication. AIDS 2010 Oct 19.

The persistence of HIV in CD4 cells despite full virologic suppression in plasma renders the prospect of viral eradication highly unlikely, at least with present strategies. However, initiation of antiretroviral therapy (ART) very early during acute HIV infection limits the size of the viral reservoir, and some studies suggest that it may deplete the pool of HIV-infected CD4 cells over time. In this study, researchers further explore whether early, long-term administration of potent ART might eliminate viral reservoirs.

Using quantitative real-time polymerase chain reaction, the researchers measured genomic HIV DNA in highly purified CD4 cells obtained from 44 patients who had achieved long-term suppression on ART without any episodes of detectable viremia.

Nine of the patients had started ART <6 months after acquiring HIV. These patients were found to have significantly lower levels of HIV proviral DNA (mean, 4.6 copies per million CD4 cells) than the patients who started ART later, and four of them had no proviral DNA detected.

One such patient was found to have an extremely low level of virus after 10.5 years of ART (1 infected cell per 1.7 billion CD4 cells). Under close follow-up, this patient discontinued ART. For 7 weeks, he had no virus detected in his plasma, but then his plasma HIV RNA level rebounded to 1593 copies/mL.

It spontaneously returned to an undetectable level for a brief period, only to rebound again during week 20, reaching 8684 copies/mL. At that time, ART was restarted.

Comment:

In this study and others, initiating long-term effective ART very early rather than later was associated with lower levels of residual HIV. Nonetheless, this seemingly favorable combination of very early ART, long-term consistent virologic suppression, and a very limited viral burden in the reservoir of CD4 cells did not prevent HIV recurrence after withdrawal of ART.

Although reemergence of the virus took longer in the patient described here than in patients in other studies who had less favorable circumstances, viral rebound still occurred in <2 months. Long-term virologic suppression without ART will require novel strategies to target the rare infected cells that rekindle the infection systemically.