|

Received: 22 July 2020    Accepted: 5 October 2020

DOI: 10.1111/jocd.13786

REVIEW ARTICLE

Delusional infestation: Clinical presentations, diagnosis, and

management

Julio Torales MSc1  | Oscar García MD1 | Iván Barrios BSc1 | Marcelo O’Higgins MD1 |

João Mauricio Castaldelli-Maia PhD2,3 | Antonio Ventriglio PhD4 |
Mohammad Jafferany MD5

1
Department of Psychiatry, School of
Medical Sciences, National University of Abstract
Asunción, San Lorenzo, Paraguay Background: Delusional infestation is a primary psychiatric disorder characterized
2
Department of Neuroscience, Medical
by a somatic-type delusional disorder (primary delusional infestation) that may lead
School, Fundação do ABC, Santo André,
Brazil to self-induced cutaneous lesions which are often difficult to recognize and treat
3
Department of Psychiatry, Medical School, properly. It may be also secondary to other psychiatric disorders, medical diseases,
University of São Paulo, São Paulo, Brazil
4
or substance abuse.
Department of Clinical and Experimental
Medicine, University of Foggia, Foggia, Italy Aims: This review will describe prevalence, common clinical features, different clini-
5
Department of Psychiatry, Central cal presentations, differential diagnoses, and treatment recommendation. Special
Michigan University, Mount Pleasant, MI,
focus has been put on psychological aspects.
USA
Methods: We conducted a literature search on PubMed from January 2001 to June
Correspondence
2020 with the search terms of delusional parasitosis, delusional infestation, psycho-
Mohammad Jafferany, Department of
Psychiatry, Central Michigan University, logical, Reference lists of identified articles were examined for further relevant stud-
Mount Pleasant, MI, USA.
ies. The search was limited to English language articles. No specified quality criteria
Email: [email protected]
were used for study inclusion.
Results: The clinical manifestations of delusional infestation are very important
in the differential diagnosis and its psychological implications and management
perspectives.
Conclusion: This article presents an update regarding the clinical aspects and treat-
ment options of delusional infestation in order to provide an up-to-date review for
dermatologists and general practitioners.

KEYWORDS

antipsychotics, delusional disorder, delusional infestation, psychocutaneous,

psychodermatology

1 |  I NTRO D U C TI O N Patients usually present intense skin picking and self-harm behaviors
to get rid of the pathogens.1,2
Delusional infestation (DI) is a medical condition in which the patient The typical DI patient is generally female, middle-aged, with lim-
delusionally believes that his or her body, mainly the skin, is infested ited social contacts, with no previous psychiatric history and pre-
by small pathogens, alive or not, in absence of any medical evidence. served cognitive functioning. Affected body regions may include

J Cosmet Dermatol. 2020;00:1–6. wileyonlinelibrary.com/journal/jocd© 2020 Wiley Periodicals LLC     1 |

 |
2       TORALES et al.

TA B L E 1   Clinical subtypes of DI13,16,17

Subtype Characteristics

Primary, autochthonous DI is independent of any other medical condition

or associated psychiatric disorder. Likewise,
there is no additional decline in basic mental
functioning.
Secondary, functional DI is associated with other psychiatric disorders
(schizophrenia, depression, among others)
Secondary, organic DI is caused by an underlying medical condition or
substance abuse.

skin, hair, and natural orifices, among others. The prognosis of DI It is of note that DI is not a medical condition per se, and it is
depends on the duration of untreated psychosis and how timely the not classified in the fifth edition of the Diagnostic and Statistical
treatment is, including the chance to be assessed by a dermatologist, Manual of Mental Disorders (DSM-5) or in the eleventh edition of
or psychiatrist, or general practitioner. In primary DI, antipsychotics the International Classification of Diseases (ICD-11); it is included in
are considered the first-line treatment. When appropriately treated, the broader category of somatic delusional disorder, described both
DI shows a favorable prognosis, with possible remission in 75% of in ICD-11 and DSM-5 within the “delusional disorders” section.11,12
1,2
the cases. DI affects both women and men, with a 3:1 sex ratio.13 This dif-
ference increases proportionally with age, and it may be due to the
aging and cognitive impairment, as suggested by Ekbom.14
2 |  C L A S S I FI C ATI O N A N D E PI D E M I O LO G Y It is difficult to estimate the prevalence of DI. DI annual inci-
dence rates vary between 2.37 and 17 for per 1 million inhabitants
DI is a clinical condition classified by Koo and Lebwohl3 as a primary per year.5 The illness onset occurs between 55 and 68 years old.7,8
psychiatric disorder leading to self-induced cutaneous lesions. It is Nonetheless, it may occur in adolescents and young adults (between
characterized by the presence of a delusional idea in which the body, 20 and 40 years), mostly secondary to substance abuse.7,8
mainly the skin, is infested by small pathogens, alive or not, in ab- There are no evidences about possible association between eco-
sence of any dermatological o microbiological evidence.1,2,4-8 nomic or social factors with the onset of the syndrome13,15; never-
This delusional idea may include abnormal cutaneous sensations theless, some social and demographical factors may have a role in
(tactile or coenesthetic hallucinations), such as itching, tingling, or the outcome of the disease. Also, most of patients show a baseline
biting sensations. Patients show self-destructive behaviors in effort high personal functioning and many of them may be even physicians
to get rid of skin pathogens, generating excoriations, ulcerations, and or psychologists.13
7
severe secondary infections. They also seem to be reluctant to seek
help from psychiatrists and usually consult first their general practi-
tioner or dermatologist or even a microbiologist.8 This approach may 3 | PATH O PH YS I O LO G Y
add delay in the correct diagnosis and may lead to initial inadequate
treatments. DI can start with a cutaneous sensorial misinterpretation that turns
In 1938, Ekbom described with detail a clinical condition into a tactile hallucination and consolidates into a delusional idea.13
named with the German term Dermatozoenwahn (from Old There may be a set of clinical presentations as classified by Le
Greek “derma” = skin, “zoon” = living creature/animal and the and Gonski16 and Hinkle.17 Table 1 reports three clinical subtypes of
German word “wahn” = delusional idea). Since this term was dif- DI, differentiating the primary form from secondary forms such as
ficult to be employed in others languages, the disorder was re- functional and due to other organic illness.13,16,17
named as “Ekbom Syndrome,” becoming an eponymous disease. DI etiology is multifactorial. It has been proposed, by Huber and
Nonetheless, many authors pointed out that “Ekbom syndrome” colleagues,18 that a decrease in dopamine transport within the stri-
is not appropriate because it may also refer to the homonymous atum, with the consequent rise of its extracellular levels, may con-
restless leg syndrome. 8,9 tribute to the onset of delusional condition. The above-mentioned
In 1946, Wilson and Milner introduced the term “delusional par- model was supported by Millard and Millard,19 who proposed that DI
10
asitosis” and this became the most common term to indicate the may happen in patients with higher dopamine levels, either because
DI. Nonetheless, patients may report different forms of infestation, of consumption of dopamine transporter inhibitors (cocaine, pemo-
so the name “delusional parasitosis” has the disadvantage of indicat- line, bupropion, amphetamines, among others) or due to secondary
4
ing those form supposed to be caused by parasites, whereas the disfunction of dopamine transporter (which is observed in traumatic
broader term “delusional infestation” highlights the delusional core brain injury, Parkinson's disease, schizophrenia, depression, alcohol-
of this syndrome and may represent all possible pathogens consid- ism, Huntington's disease, human immunodeficiency virus infection,
ered to be responsible of the current “infestation”.1 iron deficiency, among others).19-21 It should be noted here that
TORALES et al. |
      3

antipsychotics could improve the symptoms of DI in the majority of pathogen to the physician was recognized as a pathognomonic sign
1,2,4,5,7-9,13
patients by improving the altered dopamine transmission. named “matchbox sign” in The Lancet. 28 However, Freudenmann and
Likewise, the aging process can trigger the development of DI, Lepping have proposed to use the name “specimen sign,” since it is
through a multifactorial mechanism as summarized in Table 2.13,17 more appropriate to point the “pathogen” than the container.5
Regarding the secondary organic DI, studies conducted with Dangerous behaviors, such as setting fire at furniture in the house
structural magnetic resonance have demonstrated the importance or burning clothes, as well as fleeing their houses29 to avoid more in-
18
of striatum lesions (mainly putamen) in its etiopathogenesis. These festations, have been described in the literature. Furthermore, and
lesions generate alterations in the putamen functioning (which me- as previously mentioned, some other patients may burn their own
diates motor and visual-tactile perception) and in the function of skin using abrasive detergents to “kill the bugs”.17 Often, patients
cerebral regions associated with striatal-thalamic-cortical dorsal develop secondary depressive symptoms in the context of their de-
somatic gyrus. In addition, the involvement of the of fronto-stria- lusional state. Occasionally, suicide and suicide attempts have been
to-thalamo-parietal brain circuits and the efficacy of antipsychotics reported.30
in the treatment of DI, as previously mentioned, may add evidence Up to 15% of patients can present shared delusional ideas of in-
22,23
on the hypothesis of a dopaminergic dysfunction. festation with a relative or a close friend. 21 This shared psychosis
may involve two or more individuals of the family: folie à deux (two
people), folie à trois (three), folie à plusieurs o folie à famille (many peo-
4 | C LI N I C A L PR E S E NTATI O N ple or the entire family).31,32 Recently, it has been observed that the
media and the internet may play a role in the development of shared
As discussed, according to the literature, the average patient is gen- psychotic disorders (folie à Internet). 21
erally a female, middle-aged with limited social contacts, and no pre- Several studies have shown that risk factors for the development
vious psychiatric story and with preserved cognitive functioning. 24 of shared psychotic disorders are related to common characteris-
We have also reviewed that DI may occur in individuals with any tics of the individuals developing shared symptoms. They may have
personality type, but it is more frequent in those with obsessive or genetic or environmental factors in common or may live in close co-
paranoid characteristics.1,2,7-9 habitation (which is an essential factor in the shared psychoses).33
Affected body sites include skin, hair, and natural orifices. DI Patients’ and families’ quality of life are both severely compromised.
onset can be sudden or progressive, and it is generally characterized
by severe pruritus, followed by intense scratching.16,17,19,25,26
Patients may use fingers or nails, but also scissors, needles, 4.1 | DI variants and related conditions
razors, and tweezers in order to alleviate pruritus. In some severe
cases, it has been reported the employment of rocks, kitchen uten- According to the reviewed literature, clinical variants and related
sils, surgical instruments, chemical and corrosive agents, and pesti- conditions to DI may be summarized as following34-37:
cides. Many patients end up with mutilations and cutaneous lesions
such as lichenification, ulcers, or scabs.17,26 • Orificial delusional infestation: DI variant that involves body's
When patients are able to delusionally “catch some insects,” they natural orifices.
bring them to the physician as proof of infestation. This “specimens” • Delusory cleptoparasitosis: The patient believes the pathogen is
are usually presented in small containers, paper envelopes, or plastic infesting his/her own house.
bags. The “proof” is usually dandruff, scabs of cutaneous lesions, hair, • Morgellons disease: It includes DI with cognitive defects, behav-
strands, dirt, or sand. 27 Nowadays, and with a growing frequency, ioral changes, and fatigue.
patients may present videos or digital pictures of the sites in which • Formication: perception of walking ants on the skin (from Latin
they believe to be infested.1,2,4 The presentation of the supposed “formica” which means ant). It is a very common symptom, al-
though unspecific and does not define the diagnosis of DI, if not
associated with the delusion of being infested.
TA B L E 2   Multifactorial contribution of aging in DI
pathophysiology13,17 • Illusory Parasitosis: produced by real physical causes such as
static electricity, allergens or formalin, which produce dermati-
• Presence of senile pruritus
tis. Affected patients are not delusional and are easily convinced
• Increased incidence of diabetic neuropathy
• Decreased visual acuity when their condition is technically explained.
• Reduction of blood flow due to arterial stenosis, which generates
paresthesia DI can also occur in the context of other diseases, such as stroke
• Loss of autonomy, consequently generating depression, and
that affects the nondominant hemisphere.1,2 Structural brain abnor-
decreases in self-esteem
• Polypharmacy malities that have been reported in these cases may include sub-
• Frequent consumption of over-the-counter drugs/supplements/ cortical vascular encephalopathy and right temporo-parietal cortex
herbs lesions.13 Furthermore, there are several mental disorders that can
• Other medical conditions
be accompanied by DI, such as schizophrenia, depression, anxiety,
 |
4       TORALES et al.

and dementia. Secondary organic DI is associated with hypothyroid- 7 | TR E ATM E NT O P TI O N S

ism, anemia, vitamin B12 deficiency, hepatitis, severe renal disease,
diabetes, and infections (HIV, syphilis). 21 In adolescents and young Some authors have proposed that, when possible, treatment for DI
adults, it may be related to concomitant substance abuse.38 patients should be administered in dermatology clinics, in coopera-
tion with the local liaison psychiatry department.39 This approach
could be seen as friendlier and help overcome patients' reluctance
5 |  D I AG N OS I S to seek help from mental health professionals.8 Firstly, DI should
be diagnosed, excluding differential diagnoses and, secondarily, the
Freudenmann and Lepping5 have proposed minimum criteria for the disease nature (primary, secondary organic, secondary functional)
diagnosis of DI, taking into account that the disorder is not classified should be recognized.39
as an independent entity neither in ICD nor DSM (Table 3). Therapeutic approach in primary DI is mostly based on antipsy-
chotic medications.1,2,7-9,21-24,40-44 Secondary DI may benefit from
treating the underlying disease, besides antipsychotics. For example,
5.1 | Differential diagnosis DI secondary to a psychotic depression may benefit from the treat-
ment of depressed mood with antidepressants and antipsychot-
Primary and secondary variants, as previously described, should ics.7,8,43 Occasionally, a major depressive disorder with concomitant
be recognized and differentiated. Then, DI should be differenti- symptoms of DI may respond to an antidepressant therapy on its
ated from other psychiatric conditions (Table 4) such as schizo- own, without needing an antipsychotic treatment.1,2 Selective sero-
phrenia, major depressive disorder with psychotic symptoms, tonin reuptake inhibitors are usually first-line agents. 21
obsessive-compulsive-related disorders, factitious disorders, medi- Atypical antipsychotics are highly recommended. Risperidone
cal or substance related disorders (general medical diseases, brain (1-8  mg/d) and olanzapine (5-10  mg/d) are mostly used with posi-
disorders, medication/illicit substances, such as cocaine), and from tive outcomes in 69% and 72% of treated DI patients, respectively.41
1,2,5,7,8,12,13
formication. Some authors described a successful outcome associated with trials
with aripiprazole,45 ziprasidone,46 or quetiapine.4 Some other stud-
ies have reported a remission rate of 90% with pimozide,47 even if
6 |  O U TCO M E A N D PRO G N OS I S it should not be considered as a first option because of its safety
problems.8,9 First-generation antipsychotics in general should be
DI clinical course may vary depending on the clinical type presented. considered as a second-line option.
Primary DI has an insidious onset and a chronic course. This type of As DI is a type of delusional disorder, we recommend an adju-
chronic course is also observed in patients with DI secondary to a vant psychological approach. Cognitive behavioral therapy (CBT)
medical condition (mostly among elders). On the contrary, substance focusing on different aspects of delusions (anxiety, reasoning biases,
induced DI has an abrupt onset and its symptoms may only last hours, faulty logic, among others) has shown efficacy in improving symp-
days or weeks.5 Prognosis relies on the promptness of diagnosis and toms in the short-term.48 Furthermore, depressive symptoms might
treatment and on different pathways to care (dermatology or psy- be secondary to DI. Before starting any antidepressant treatment,
chiatry). Dermatologists might pay attention to cutaneous disorders patients with mild depressive symptoms should try CBT as well. 21 It
strongly associated with psychological factors and may involve men- should be noted that suicide is a risk in patients with severe DI.1,2 We
tal healthcare professionals in their daily practice. Up to 75% of the strongly recommend that such cases should be admitted to the hos-
cases of primary DI show a good prognosis with remission with ap- pital and carefully monitored. Finally, secondary scratching lesions,
propriate treatments. Outcome may be poor in case of concomitant ulcers, and infections should be treated with accordingly dermato-
organic disease with higher probability of chronic course. 2 logical therapy.1,2

1. Presence of a belief of being infested with pathogens (small, alive, unanimated, many times TA B L E 3   Criteria for the diagnosis of
“new for science”) without medical or microbiological evidence that supports this. This belief DI5
can range from an overvalued idea to a delusional, unwavering, idea
2. Presence of abnormal, usually qualitative, cutaneous sensations, explained by the first
criteria
Additional symptoms Additional psychotic or nonpsychotic symptoms may be present, such
as visual illusions or hallucinations
Localization Skin (“in,” “on top of,” “inside,” “underneath”), but all body parts can be
infested
Duration Typically, months or years (chronic cases), although it can vary from
minutes (in the case of DI secondary to delirium or substance
induced) to many years
TORALES et al. |
      5

TA B L E 4   Differential diagnosis of
Diagnosis Characteristics
DI1,2,5,7,8,12,13
Schizophrenia Delusional ideas and behavior in schizophrenia are usually bizarre,
contrasting with ideas in delusional disorders, which is the case
in primary DI
Major depression Patients with major depressive disorder with psychotic symptoms
disorder with psychotic usually present guilt delusional ideas or hypochondriac ideas,
characteristics while other psychotic symptoms in the spectrum of DI are rare
complications
Excoriation Disorder Skin manipulation and lesions observed in excoriation disorder
can be like those observed in DI, but they are not caused by the
presence of imaginary pathogens in the skin
Dermatitis artefacta Dermatitis artefacta is a variety of factitious skin disorders.
Skin lesions are self-inflicted and seek secondary gain such as
arousing sympathy or evading some form of responsibility. Such
lesions are not due to the presence of delusions of infestation
Formication As previously mentioned, the symptom of feeling “ants walking on
the skin” (from Latin “formica” = ant) is very common, although
unspecific and does not sustain the DI diagnosis. The absence of
a delusional idea of being infested indicated the absence of DI

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