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

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

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352

©2006 American Medical Association. All rights reserved.

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,
his dermatitis had improved, but he continued to be-
lieve that he had a fungal infection. His wife stated that
he had purchased a “Hazmat suit” for the purpose of ster-
ilizing their house, at a cost equivalent to their monthly
income. The dosage of olanzapine therapy was in-
creased to 10 mg/d, and a psychiatric referral was made,
which the patient did not pursue. He did not like the idea
of the stigmata that are often associated with psychiatric
referral. At the 3-month follow-up visit, the rash had
cleared, and the patient no longer voiced any concern
about fungal infection. He only asked about treatment
for a plantar wart.
CASE 2
A 56-year-old healthy Hispanic woman with a several-
year history of depression complained of intense pruri-
tus on the posterior aspect of her neck that had been pres-
ent for approximately 2 months. She described the
sensation as “bugs crawling.” Her itching was recalci-
trant to treatment with several topical steroids and an-
tipruritic agents. Her medications included paroxetine
for depression.
Physical examination revealed a localized plaque of
excoriated, crusted papules and nodules at the nape of
her neck. The findings of microscopic examination of skin
scrapings using a potassium hydroxide mount were nega-
tive for organisms, as were those of a scabies prepara-
tion. Impetiginized prurigo nodularis with delusions of
parasitosis was diagnosed.
Intralesional triamcinolone acetonide was adminis-
tered to the largest nodules, and the patient was told to
apply clobetosol cream to the nape of her neck twice daily
and to begin a 10-day course of oral cephalexin therapy.
At a follow-up visit, she was tearful and stated that she
was increasingly frustrated and unable to sleep as a re-
sult of her recalcitrant condition. She brought in the
“bugs” that she had found along the posterior hairline
area, and they were found to be dried peas (Figure 1).
Olanzapine therapy (5 mg/d) was initiated, and the par-
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Figure 1. This pea was brought in by patient 2, who complained that it was
the “bug” that was causing the itching sensation along the posterior aspect
of her hairline.
oxetine therapy was discontinued because her primary
problem was not depression. At her 1-month follow-up
visit, she showed dramatic improvement, with resolu-
tion of all symptoms. She no longer had any delusions
of parasitosis. She left for Puerto Rico to visit her mother
soon afterward, a trip she had delayed for several months
owing to her condition.
CASE 3
A 54-year-old man with a history of work-related back
injury presented with a more than 1-year conviction that
“larva are being injected into me by insurance audi-
tors.” He explained that these auditors would sneak into
his house at night and hold him down as they injected
larva into his skin and sinuses because he was receiving
workers’ compensation. He would subsequently at-
tempt to kill the larva by burning them with cigarettes
or pulling them out with tweezers, which he physically
demonstrated during the interview. He claimed that the
larva matured into flies, which then flew away. He was
taking no medications.
Physical examination revealed several erosions with
a honey-colored crust and scars on his face. His hands
had several deep, irregularly shaped, crusted ulcer-
ations (Figure 2). His ulcers and impetiginization were
treated with cephalexin and mupirocin ointment. His de-
lusions of parasitosis were treated with olanzapine (5
mg/d) and psychiatric referral. He did not return to our
clinic because of the significant distance he had to travel.
Follow-up telephone conversations with his local psy-
chiatrist revealed that he had markedly improved, with
only a few excoriations remaining. When contacted by
telephone he spoke in a rational manner, never mention-
ing any infestation. He stated that his sores were healing
and that he wanted a prescription for more olanzapine,
which he agreed to obtain from his psychiatrist.
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Figure 2. Patient 3 presented with these irregularly shaped crusted
ulcerations on his hands.
COMMENT
Typical antipsychotic agents block both mesolimbic and
striatal dopamine receptors, causing extrapyramidal ad-
verse effects at therapeutic doses.3 The newer atypical an-
tipsychotics have a more benign adverse effect profile,
perhaps owing to decreased occupancy of striatal dopa-
mine receptors.4 The atypical antipsychotic olanzapine
was therefore considered as an alternative therapeutic ap-
proach to pimozide. In the 3 patients described herein,
treatment consisted of olanzapine therapy started at a dos-
age of 5 to 10 mg/d.
In the literature, DP can also be referred to as mono-
symptomatic hypochondriacal psychosis, psychogenic para-
sitosis, or Ekbom syndrome, which was named after the
psychiatrist who summarized the first 22 case reports in
1938.5 Patients often present with specimens of “para-
sites” they have collected, the so-called matchbox sign,
which is considered by some authors to be pathogno-
monic.6 In some cases, the delusion is shared by a sig-
nificant other, and this is termed a folie à deux.7 Patients
may resort to self-mutilation in an effort to rid them-
selves of parasites, and insomnia is a common com-
plaint.8 Several steps are useful in approaching patients
with DP.8 A true infestation must first be ruled out. Wet
preparations of skin scrapings and skin biopsy can be use-
ful and can help the physician establish trust with the
patient. Empathetic listening, expressing concern about
how the problem is affecting the patient’s life, and es-
tablishing rapport are also helpful in preventing “doctor
hopping.”8
It is also important to rule out any systemic disorder
or unrecognized cutaneous disease. Careful history tak-
ing can help establish whether the delusions might be
associated with alcoholism or drug addiction. Both co-
caine and amphetamine abuse have been associated with
the sensation of formication. Kidney, liver, thyroid, and
endrocrine abnormalities and lymphomas may cause sec-
ondary generalized pruritus. It is essential to distin-
guish a shakable belief of infestation from an unshak-
able belief; during discussion, some patients are receptive
to testing results that reveal no active infestation.9 A psy-
chiatric referral is useful, but not always accepted by pa-
tients,8 who may perceive an associated stigma. Like-
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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-
roleptic drugs, pimozide has adverse effects, including
parkinsonism, tardive dyskinesia, and neuroleptic ma-
lignant syndrome (fever, muscle rigidity, confusion, and
dysrythmias). Electrocardiographic changes have also
been observed; therefore, baseline and serial electrocar-
diograms are required for patients using pimozide.
Atypical antipsychotic agents have been suggested as
potential alternatives for DP treatment owing to their more
favorable benefit-risk ratio.15 A limited number of case
reports have documented the effectiveness of risperi-
done,16,17 sulpiride,18 and sertindole19 in the treatment of
DP. To our knowledge, this series of 3 case reports rep-
resents the first documentation of olanzapine’s effective-
ness in treating DP in the English-language dermatol-
ogy literature. Previous reports either have been single
case reports in German20,21 or have been published in the
psychiatry literature and have used the term monosymp-
tomatic hypochondriacal psychosis, which is not as well
recognized by dermatologists.22-24 Olanzapine, which was
introduced by Eli Lilly in 1997, acts as a potent antago-
nist at dopaminergic and serotonergic receptors, with
weaker antagonism at ␣-adrenergic and muscarinic re-
ceptors.25 Olanzapine shows selectivity for mesolimbic
and mesocortical over striatal dopamine tracts, thereby
minimizing extrapyramidal adverse effects.25
Atypical antipsychotic agents can cause adverse ef-
fects, but the effects are considered less severe than those
associated with typical antipsychotic agents. Olanzapine
use has been associated with sedation, hyperlipidemia,
weight gain, and insulin-resistant diabetes.26,27 Patients
should be educated regarding these potential adverse ef-
fects. Fasting blood glucose and lipid determinations can
be used to monitor for adverse effects, especially in the pres-
ence of additional risk factors such as obesity, advancing
age, hypertension, a family history of diabetes, and a low
level of physical activity. Although the incidence of tar-
dive dyskinesia and neuroleptic malignant syndrome is con-
siderably less than with the use of traditional antipsy-
chotic agents, at high doses the possibility of their
occurrence should be taken into consideration.28 Evi-
dence is growing that monitoring the blood levels of atypi-
cal antipsychotics in patients may improve efficacy and
safety; however, further investigation is necessary before
therapeutic drug monitoring can be implemented.29
At present, olanzapine is prescribed predominantly by
psychiatrists for patients with schizophrenia at a dosage
of 20 mg/d. However, there are reports of success at a
WWW.ARCHDERMATOL.COM
dosage as low as 1.25 mg/d in cases of mild DP.30 We sug-
gest initiating therapy at a dosage of 2.5 to 5 mg/d and
then seeing the patient in 6 weeks. If there is little im-
provement, the dosage is increased. In our experience of
treating several other patients with DP, no more than 10
mg/d is usually necessary for monosymptomatic hypo-
chondriacal psychosis.
Because patients are often hesitant to try a psychiat-
ric medication, some encouragement may be needed. For
example, we often state that there is “no evidence of in-
festation today,” which establishes no confirmation of the
delusion but also demonstrates to the patients that you
trust them. Then, we suggest that although olanzapine
is a psychiatric medication, patients with similar symp-
toms have had remarkable improvement. In summary,
our experience suggests that olanzapine should be con-
sidered as first-line therapy for DP.
Accepted for Publication: July 17, 2005.
Correspondence: Christine L. Mackley, MD, Depart-
ment of Dermatology, PO Box 850 HU 14, Penn State Mil-
ton S. Hershey Medical Center, Hershey, PA 17033
(cmackley@psu.edu).
Author Contributions: Study concept and design: Mack-
ley. Acquisition of data: Mackley and Badreshia. Analysis
and interpretation of data: Mackley. Drafting of the manu-
script: Meehan. Critical revision of the manuscript for im-
portant intellectual content: Badreshia and Mackley. Ad-
ministrative, technical, and material support: Mackley. Study
supervision: Mackley.
Financial Disclosure: None.
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