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Live Blog: Successfully Managing Delusions of Parasitosis, LSC, and Prurigo Nodularis – John Koo, MD

In this live blog from the 12th Annual SDPA conference in Indianapolis, John Koo, MD, spoke on the topic of Successfully Managing Delusions of Parasitosis, LSC, and Prurigo Nodularis.  Here are some of the highlights. 

Dr. John Koo started the lecture of treating psychotic patients by defining them as individuals presenting delusional criteria. The most common delusion seen by dermatologists is the delusion of parasitosis. These patients feel as if they have parasites, bugs, or objects coming out of the skin.  Koo explained the spectrum of delusion severity, noting that on the high end of the spectrum, patients do not have mental capacity to process that what they are feeling doesn’t exist. It is not a delusion for them: the bugs are real. Most delusional patients of this caliber get upset when a dermatologist tells them they cannot treat something that is not there. Some less delusional patients will want medication to get them out of the situation. Others are at the doctor to simply get validation that what they’re feeling is real.

It’s tempting to rationally argue with delusional patients but it is important to not try to convince them they’re wrong. They need to trust you first.

How to Approach to Delusional Patients

1) Pre-visit Provider Preparation

Take a moment to stop and enter in good spirits. They are not aware of social norms so they can talk for the whole session if you let them. It is important to give them a structured interaction with questions and answers. Give them VIP treatment in a sense to keep your patient happy and compliant.

2) Establishing Rapport

The more compassionate comments you make about their misery, the more they feel you understand and the more they trust you. If they bring in a specimen, it is important to still look at it, even if it’s just water or crumbs. It means a lot to them that you give them a chance and this builds trust. When suggesting medication, you can make them an offer, “We don’t know what is causing this, but I have an idea on how to make you feel better very soon.”

You can also prescribe parasitic creams. It’s not because they have parasites, but because you want to establish rapport. Dr. Koo tells them that if they use this “powerful medicine” anything living in their skin will die. If they still have the problem after use, it means that it’s not parasites. Then they may come back willing to hear about alternative treatments and potentially open to other meds.

3) History and Physical Exam

Ask about drug history and perform a full body skin check. Examine specimen samples presented by the patient under the microscope. Know that these patients don’t have an identifiable cause.

4) Initiating Therapy

Recommend medication on a “trial and error” basis. The classic medication Dr. Koo recommends for encapsulated delusional patients is Pimozide (Orap).  Pimozide has no psychiatric indication and is indicated for Tourette’s only. Let your delusional patients that this is what it is used for. Delusional patients like to know the details and if they hear the indication from you and the pharmacist, it will help compliance. Starting with a little dose (0.5 mg) will help “break the ice” and you can increase by 1 mg until 3-5 mg. Patients will only notice significant improvement when they reach the 3-5 mg dosing. When the medication kicks in, they will say that the bugs are leaving or dying; this is the cure from a dermatological point of view. To treat the side effect of stiffness or restlessness, Dr. Koo recommends Cogentin or Benadryl.

5) Maintaining Therapy

If you have established a good rapport, patients will have good compliance and follow-up. Dr. Koo’s long-term patients are often made up of the delusional population because he established rapport and gave them attention that no one else was willing to give.


Image: Caterina Appia


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