Sanrısal Parazitoz Tanı ve Tedavisinde Güncel Gelişmeler: Bir Gözden Geçirme

Abstract

Sanrısal parazitoz (SP), bireyin deri ya da mukozalarında parazit, böcek veya benzeri organizmaların bulunduğuna dair sarsılmaz inançla karakterize, nadir ancak klinik açıdan oldukça karmaşık bir psikotik bozukluktur. Hastalık genellikle yoğun kaşıntı, dokunsal halüsinasyonlar ve “kibrit kutusu işareti” olarak tanımlanan sahte kanıt sunumlarıyla ortaya çıkar. Hastaların dermatoloji ve enfeksiyon hastalıkları gibi branşlara tekrarlayan başvurularda bulunması, buna karşın psikiyatrik değerlendirmeyi reddetmesi tanıda gecikmeye ve sekonder cilt lezyonları, işlev kaybı ve sosyal izolasyon gibi ciddi sonuçlara yol açabilir. SP çoğunlukla ileri yaşta ve özellikle kadınlarda görülür; bazı olgularda paylaşılan sanrısal bozukluk (folie à deux) şeklinde de seyredebilir. Primer SP’de altta yatan bir psikiyatrik ya da organik neden bulunmazken, sekonder form depresyon, demans, Parkinson hastalığı, madde kullanımı ve bazı ilaçlarla ilişkilidir. Etiyopatogenezde dopaminerjik sistemde bozulma ve somatik uyaranların yanlış yorumlanması önemli rol oynar. Tanı, gerçek paraziter enfestasyonların dışlanması ve psikiyatrik değerlendirmenin birlikte yürütülmesiyle konur. Tedavide ikinci kuşak antipsikotikler (risperidon, aripiprazol, olanzapin) ön plandadır; Bilişsel Davranışçı Terapi (BDT) tedaviye uyumu ve içgörüyü artırabilir. Multidisipliner yaklaşım, empatik iletişim ve güvene dayalı terapötik ilişki, SP yönetiminin temelini oluşturur. Bu derleme, klinik zorlukları ve güncel tanı-tedavi stratejilerini özetleyerek sağlık profesyonellerine bütüncül bir bakış açısı sunmayı amaçlamaktadır.

Keywords

• Antipsikotik ajanlar
• Morgellon hastalığı
• paylaşılan paranoid bozukluk
• sanrısal parazitoz

Recent Advances in the Diagnosis and Treatment of Delusional Parasitosis: A Review

Abstract

Delusional parasitosis (DP) is a rare yet clinically challenging psychotic disorder characterized by the unwavering belief that parasites, insects, or similar organisms inhabit the skin or mucosal surfaces. The condition typically manifests with intense pruritus, tactile hallucinations, and the submission of pseudoevidence, commonly referred to as the “matchbox sign.” Patients frequently present to dermatology or infectious diseases clinics while persistently declining psychiatric evaluation, which may delay diagnosis and result in secondary skin lesions, functional impairment, and social withdrawal. DP is more commonly observed in older individuals, particularly women, and may occasionally occur as shared psychotic disorder (folie à deux). The disorder is classified into primary and secondary forms: primary DP lacks identifiable psychiatric or organic etiologies, whereas secondary DP is associated with depression, dementia, Parkinson’s disease, substance use, and certain medications. Pathophysiologically, dysregulation within the dopaminergic system and the misinterpretation of somatic stimuli are considered central mechanisms. Diagnosis requires the exclusion of true parasitic infestation and the integration of dermatological and psychiatric assessments. Second-generation antipsychotics, including risperidone, aripiprazole, and olanzapine, constitute first-line pharmacological therapy; Cognitive Behavioral Therapy (CBT) may further enhance insight and adherence. A multidisciplinary approach, empathetic communication, and a strong therapeutic alliance are essential to successful management. This review synthesizes current evidence on the diagnosis, treatment, and follow-up of DP, aiming to provide healthcare professionals with a comprehensive and clinically relevant overview of this complex condition.

Keywords

• Antipsychotic agents
• delusional parasitosis
• Morgellons disease
• shared paranoid disorder

References

1. 1. Lu J D, Gotesman R D, Varghese S, Fleming P, Lynde C W. Treatments for Primary Delusional Infestation: Systematic Review. JMIR Dermatol. 2022; 5: e34323.
2. 2. McPhie M L, Kirchhof M G. A systematic review of antipsychotic agents for primary delusional infestation. J Dermatol Treat. 2022; 33: 709-721.
3. 3. Mindru F M, Radu A-F, Bumbu A G, Radu A, Bungau S G. Insights into the Medical Evaluation of Ekbom Syndrome: An Overview. Int J Mol Sci. 2024; 25: 2151.
4. 4. Mumcuoglu K Y, Leibovici V, Reuveni I, Bonne O. Delusional Parasitosis: Diagnosis and Treatment. 2018
5. 5. Reich A, Kwiatkowska D, Pacan P. Delusions of Parasitosis: An Update. Dermatol Ther. 2019; 9: 631-638.
6. 6. Kemperman P M J H, Bruijn T V M, Vulink N C C, Mulder M M C. Drug-induced Delusional Infestation. Acta Derm Venereol. 2022; 102: adv00663.
7. 7. Marquez-Grap G, Kranyak A, Brownstone N, Koo J. Can pimozide kill parasites? Surprisingly, the most honest answer is ‘yes’. J Dermatol Treat. 2025; 36(1).
8. 8. Torales J, García O, Barrios I, ve ark. Delusional infestation: Clinical presentations, diagnosis, and management. J Cosmet Dermatol. 2020; 19: 3183-3188.

9. 9. Mendelsohn A, Sato T, Subedi A, Wurcel A G. State-of-the- Art Review: Evaluation and Management of Delusional Infestation. Clin Infect Dis. 2024; 79: e1-e10.
10. 10. O’Connell J E, Jackson H J. Delusional infestation: the case for improved mental state testing. Australas Psychiatry. 2016; 24: 462-465.
11. 11. WILSON J W, MILLER H E. DELUSION OF PARASITOSIS (Acarophobia). Arch Dermatol Syphilol. 1946; 54: 39-56.
12. 12. Freudenmann R W, Lepping P. Delusional Infestation. Clin Microbiol Rev. 2009; 22: 690-732.
13. 13. Kohorst J J, Bailey C H, Andersen L K, Pittelkow M R, Davis M D P. Prevalence of Delusional Infestation—A Population- Based Study. JAMA Dermatol. 2018; 154: 615-617.
14. 14. Millard L G, Millard J. Psychocutaneous Disorders. Rooks Textb Dermatol. 2010; 1-55.
15. 15. Bewley A P, Lepping P, Freundenmann R W, Taylor R. Delusional parasitosis: time to call it delusional infestation. Br J Dermatol. 2010; 163: 1-2.
16. 16. Freudenmann R W, Kühnlein P, Lepping P, Schönfeldt-Lecuona C. Secondary delusional parasitosis treated with paliperidone. Clin Exp Dermatol. 2009; 34: 375-377.
17. 17. Koo J, Lee C S. Delusions of Parasitosis: A Dermatologist??s Guide to Diagnosis and Treatment. Am J Clin Dermatol. 2001; 2: 285-290.
18. 18. Hirjak D, Huber M, Kirchler E, ve ark. Cortical features of distinct developmental trajectories in patients with delusional infestation. Prog Neuropsychopharmacol Biol Psychiatry. 2017; 76: 72-79.
19. 19. Huber M, Kirchler E, Karner M, Pycha R. Delusional parasitosis and the dopamine transporter. A new insightof etiology? Med Hypotheses. 2007; 68: 1351-1358.
20. 20. Huber M, Karner M, Kirchler E, Lepping P, Freudenmann R W. Striatal lesions in delusional parasitosis revealed by magnetic resonance imaging. Prog Neuropsychopharmacol Biol Psychiatry. 2008; 32: 1967- 1971.
21. 21. Freudenmann R W, Kölle M, Huwe A, ve ark. Delusional infestation: Neural correlates and antipsychotic therapy investigated by multimodal neuroimaging. ProgNeuropsychopharmacol Biol Psychiatry. 2010; 34: 1215- 1222.
22. 22. Wolf R C, Huber M, Depping M S, ve ark. Abnormal gray and white matter volume in delusional infestation. Prog Neuropsychopharmacol Biol Psychiatry. 2013; 46: 19-24.
23. 23. Beuerlein K G, Balogh E A, Feldman S R. Morgellons disease etiology and therapeutic approach: a systematic review. Dermatol Online J. 2021; 27(8).
24. 24. Barsky A J, Borus J F. Functional Somatic Syndromes. Ann Intern Med. 1999; 130: 910-921.
25. 25. Flann S, Shotbolt J, Kessel B, ve ark. Three cases of delusional parasitosis caused by dopamine agonists: Delusional parasitosis caused by dopamine agonists. Clin Exp Dermatol. 2010; 35: 740-742.
26. 26. Kidder G W, Montgomery C W. Oxygenation of frog gastric mucosa in vitro. Am J Physiol. 1975; 229: 1510-1513.
27. 27. Garcia-Mingo A, Dawood N, Watson J, Chiodini P L. Samples From Cases of Delusional Parasitosis as Seen in the UK Parasitology Reference Laboratory (2014–2015). Open Forum Infect Dis. 2019; 6: ofz440.
28. 28. Maher S, Hallahan B, Flaherty G. Itching for a diagnosis - A travel medicine perspective on delusional infestation. Travel Med Infect Dis. 2017; 18: 70-72.
29. 29. Troublesome disguises: Managing challenging disorders in psychiatry. 2014
30. 30. Lee W R. MATCHBOX SIGN. The Lancet. 1983; 322: 457-458.
31. 31. Wykoff R F. Delusions of Parasitosis: A Review. Clin Infect Dis. 1987; 9: 433-437.
32. 32. Brownstone N, Howard J, Koo J. Management of delusions of parasitosis: an interview with experts in psychodermatology. Int J Women’s Dermatol. 2022; 8: e035.
33. 33. Cordeiro Júnior Q, Corbett C E P. Delírio de infestação parasitária e folie à deux: relato de caso. Arq Neuropsiquiatr. 2003; 61: 872-875.
34. 34. Sawant N, Vispute C. Delusional parasitosis with folie à deux: A case series. Ind Psychiatry J. 2015; 24: 97.
35. 35. Harth W, Hermes B, Freudenmann R W. Morgellons in dermatology. JDDG J Dtsch Dermatol Ges. 2010; 8: 234-242.
36. 36. Hinkle N C. Ekbom Syndrome: The Challenge of “Invisible Bug” Infestations. Annu Rev Entomol. 2010; 55: 77-94.
37. 37. Kim C, Kim J, Lee M, Kang M. Delusional Parasitosis as “Folie a Deux”. J Korean Med Sci. 2003; 18: 462.
38. 38. Le L, Gonski P N. Delusional parasitosis mimicking cutaneous infestation in elderly patients. Med J Aust. 2003; 179: 209-210.
39. 39. Trenton A, Pansare N, Tobia A, Bisen V, Kaufman K R. Delusional parasitosis on the psychiatric consultation service – a longitudinal perspective: Case study. BJPsych Open. 2017; 3: 154-158.
40. 40. Lepping P, Aboalkaz S, Squire S, ve ark. Later Age of Onset and Longer Duration of Untreated Psychosis are Associated with Poorer Outcome in Delusional Infestation. Acta Derm Venereol. 2020; 100: adv00261.
41. 41. Grant M. Between a Rock and a Hard Place: Balancing Physician Deception and Patient Self-Harm in the Management of Delusional Infestation. Am J Trop Med Hyg. 2020; 102: 3-4.
42. 42. Muralidharan V, Zahedi D, Kaur B, Goulding J M R. Diagnosis and management of psychodermatological problems: confidence levels among dermatologists and psychiatrists. Clin Exp Dermatol. 2020; 45: 482-483.
43. 43. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 2013
44. 44. Campbell E H, Elston D M, Hawthorne J D, Beckert D R. Diagnosis and management of delusional parasitosis. J Am Acad Dermatol. 2019; 80: 1428-1434.
45. 45. Lepping P, Freudenmann R W. Delusional parasitosis: a new pathway for diagnosis and treatment. Clin Exp Dermatol. 2008; 33: 113-117.
46. 46. Bransfield R C, Friedman K J. Differentiating Psychosomatic, Somatopsychic, Multisystem Illnesses and Medical Uncertainty. Healthcare. 2019; 7: 114.
47. 47. Wong J, Koo J. Delusions of parasitosis. Indian J Dermatol. 2013; 58: 49.
48. 48. Al-Imam A M L. A systematic literature review on delusional parasitosis. J Dermatol Dermatol Surg. 2016; 20: 5-14.
49. 49. Freudenmann R W, Lepping P. Second-Generation Antipsychotics in Primary and Secondary Delusional Parasitosis: Outcome and Efficacy. J Clin Psychopharmacol. 2008; 28: 500-508.
50. 50. Lepping P, Russell I, Freudenmann R W. Antipsychotic treatment of primary delusional parasitosis: Systematic review. Br J Psychiatry. 2007; 191: 198-205.
51. 51. Reszke R, Pacan P, Reich A, Szepietowski J. Delusional infestation in clinical practice over a period of two decades. Adv Dermatol Allergol. 2021; 38: 144-150.
52. 52. Çınar M, Kutlutürk P, Ertek İ E, Coşar B. Aripiprazole as a treatment option for delusional parasitosis: case series of 8 patients. Psychiatry Clin Psychopharmacol. 2019; 29: 794-797.
53. 53. Guedes N L K O, Dwan A J, Gerlero P, Nico M M S. Delusional infestation treated with risperidone: a series of 27 patients. Clin Exp Dermatol. 2024; 49: 364-367.
54. 54. Tang P K, Lepping P, Lepping S G, ve ark. Efficacy of antipsychotics in delusional infestation. J Eur Acad Dermatol Venereol. 2025; 39: 815-822.
55. 55. Roulet T, Zdanowicz N. Delusional parasitosis treated by atypical antipsychotic and selective serotonin reuptake inhibitor: a case report. Psychiatr Danub. 2017; 29(Suppl 3): 219-221.
56. 56. Akhoundi M, Bosc N, Benamari E, Brun S, Durand R, Izri A. Delusional infestation syndrome: first retrospective study on a case series in France. Clin Exp Dermatol. 2025; 50: 1566-1570.
57. 57. Hutchison E, Angus J, Davies J. Delusional infestation: a retrospective cohort study of 49 patients over a 6-year period. Clin Exp Dermatol. 2024; 49: 146-148.
58. 58. Her Y-N, Chang H-A, Wan F-J, Tzeng N-S. Lurasidone Treatment for Delusional Infestation in a Patient with Dementia. J Med Sci. 2023; 43: 79-83.
59. 59. Bak R, Tumu P, Hui C, Kay D, Peng D. A Review of Delusions of Parasitosis, Part 2: Treatment Options.
60. 60. Freudenmann R W, Schönfeldt-Lecuona C, Lepping P. Primary delusional parasitosis treated with olanzapine. Int Psychogeriatr. 2007; 19: 1161-1168.
61. 61. Shen Y-C, Hsiao C-Y. Brexpiprazole for a Patient with Ekbom Syndrome with Intolerable Side Effect of Aripiprazole. Psychiatry Clin Psychopharmacol. 2024; 34: 272-274.
62. 62. Singh A, Shah R, Cholera R, Mulky P. Treatment of Ekbom Syndrome With Clozapine and Electroconvulsive Therapy. Cureus. 2022.
63. 63. Kalovidouri C, Kowalewski L, Mos D V, Waqar M U. A Case of Delusional Parasitosis With Folie à Deux Treated With Low-Dose Quetiapine. Cureus. 2022.
64. 64. McKinnon A I, Dow R. Brief cognitive behavioural therapy for post-stroke ‘delusional infestation’ in a 71-year-oldman: a single case experimental design. Behav Cogn Psychother. 2020; 48: 717-724.
65. 65. Shenoi S, Soman S, Munoli R, Prabhu S. Update on pharmacotherapy in psychodermatological disorders. Indian Dermatol Online J. 2020; 11: 307.
66. 66. Schuyler M, Zakhary L. Treating delusional parasitosis with the antidepressant sertraline. JAAD Case Rep. 2023; 33: 20-22.
67. 67. Hylwa S A, Foster A A, Bury J E, Davis M D P, Pittelkow M R, Bostwick J M. Delusional Infestation is Typically Comorbid with Other Psychiatric Diagnoses: Review of 54 Patients Receiving Psychiatric Evaluation at Mayo Clinic. Psychosomatics. 2012; 53: 258-265.
68. 68. Kimsey L. Delusional Infestation and Chronic Pruritus: A Review. Acta Derm Venereol. 2016; 96: 298-302.
69. 69. Schwartz E, Witztum E, Mumcuoglu K Y. Travel as a Trigger for Shared Delusional Parasitosis. J Travel Med. 2006; 8: 26-28.
70. 70. Fowler E, Maderal A, Yosipovitch G. Treatment-induced Delusions of Infestation Associated with Increased Brain Dopamine Levels. Acta Derm Venereol. 2019; 99: 327-328.
71. 71. González-Rodríguez A, Monreal J A, Natividad M, Seeman M V. Collaboration between Psychiatrists and Other Allied Medical Specialists for the Treatment of Delusional Disorders. Healthcare. 2022; 10: 1729.
72. 72. Rodríguez-Alonso B, Álvarez-Artero E, Martínez-Goñi R, ve ark. Delusional parasitosis. A multicenter retrospective study in Spanish infectious disease services. Enfermedades Infecc Microbiol Clínica. 2021; 39: 223-228.
73. 73. González-Rodríguez A, Seeman M V, Izquierdo E, ve ark. Delusional Disorder in Old Age: A Hypothesis-Driven Review of Recent Work Focusing on Epidemiology, Clinical Aspects, and Outcomes. Int J Environ Res Public Health. 2022; 19: 7911.
74. 74. D’Auria A, Wiseman T, Varghese A, Espiridion E D. Refractory Delusional Parasitosis in a 70-year-old Woman. Cureus. 2018.
75. 75. Cipriani G, Lucetti C, Danti S, Ulivi M, Nuti A. Uncommon and/or bizarre features of dementia. Acta Neurol Belg. 2015; 115: 19-25.
76. 76. Romanov D, Lepping P, Bewley A, ve ark. Longer Duration of Untreated Psychosis is Associated with Poorer Outcomes for Patients with Delusional Infestation. Acta Derm Venereol. 2018; 98: 848-854.
77. 77. Fisher J D. Emergency department presentation of‘delusional parasitosis by proxy’. Delusional parent, injured child. Am J Emerg Med. 2019; 37: 1806.e1-1806.e2
78. 78. Giam A, Tung Y L, Tibrewal P, Dhillon R, Bastiampillai T. Folie à deux and Delusional Parasitosis. Asian J Psychiatry. 2017; 28: 152-153.
79. 79. Hylwa S A, Ronkainen S D. Delusional infestation versus Morgellons disease. Clin Dermatol. 2018; 36: 714-718.
80. 80. Sandhu R K, Steele E A. Morgellons Disease Presenting As an Eyelid Lesion. Ophthal Plast Reconstr Surg. 2016; 32: e85-e87.
81. 81. Davis J L, Kurek J A, Sethi K D, Morgan J C. Delusional Infestation in Parkinson’s Disease. Mov Disord Clin Pract. 2017; 4: 111-115.
82. 82. Oh M, Kim J W, Lee S-M. Delusional parasitosis as premotor symptom of parkinson’s disease: A case report. World J Clin Cases. 2022; 10: 2858-2863.
83. 83. Mendonça F J P D, Teixeira I A, Marinho V. Ekbom Syndrome associated with Lewy Body Dementia: A case report. Dement Neuropsychol. 2020; 14: 83-87.
84. 84. Ochiai S, Sugawara H, Kajio Y, ve ark. Delusional parasitosis in dementia with Lewy bodies: a case report. Ann Gen Psychiatry. 2019; 18: 29.
85. 85. Taomoto D, Kanemoto H, Satake Y, ve ark. Case report: Delusional infestation in dementia with Lewy bodies. Front Psychiatry. 2022; 13: 1051067.
86. 86. Christensen R E, Jafferany M. Unmet Needs in Psychodermatology: A Narrative Review. CNS Drugs. 2024; 38: 193-204.
87. 87. Martins A C G P, Mendes C P, Nico M M S. Delusional infestation: a case series from a university dermatology center in São Paulo, Brazil. Int J Dermatol. 2016; 55: 864- 868.
88. 88. Wong S, Bewley A. Patients with delusional infestation (delusional parasitosis) often require prolonged treatment as recurrence of symptoms after cessation of treatment is common: an observational study. Br J Dermatol. 2011; 165: 893-896.
89. 89. Knapp B, Tito D, Espiridion E D. Delusional Parasitosis in a Patient with Alcohol-induced Psychotic Disorder. Cureus. 2019.
90. 90. Marques J G, Brissos S. Normal Pressure Hydrocephalus Following Ekbom Syndrome. J Neuropsychiatry Clin Neurosci. 2015; 27: e91-e91.
91. 91. Sekhon S, Jeon C, Nakamura M, Koo J. Delusional parasitosis secondary to severe iron deficiency anemia. JAAD Case Rep. 2017; 3: 390-391.
92. 92. Tampa M, Sârbu M I, Matei C, Mihăilă D E, Potecă T D, Georgescu S-R. Kyrle’s Disease in a Patient with Delusions of Parasitosis. Rom J Intern Med. 2016; 54: 66-69.
93. 93. Tan G, Zhang H, Feng W, Liu Z. A patient with delusional parasitosis secondary to herpes zoster and comorbid depression: a case report. Psychogeriatrics. 2020; 20: 941-943.
94. 94. Tsai S-J, Yeh C-B, Wang C-W, ve ark. Delusional infestation in a patient with posterior reversible encephalopathy syndrome. Aust N Z J Psychiatry. 2016; 50: 1212-1213.
95. 95. Yang C, Brandenburg J, Mozingo E B. Delusional Infestation: A Case of Ekbom Syndrome in an HIV-Infected Patient. Prim Care Companion CNS Disord. 2016.
96. 96. Howes C F, Sharp C. Delusional infestation in the treatment of ADHD with atomoxetine. Drug Ther Bull. 2019; 57: 93- 95.
97. 97. Naber D, Lambert M. The CATIE and CUtLASS Studies in Schizophrenia: Results and Implications for Clinicians. CNS Drugs. 2009;PAP.
98. 98. Solmi M, Murru A, Pacchiarotti I, ve ark. Safety, tolerability, and risks associated with first- and second-generation antipsychotics: a state-of-the-art clinical review. Ther Clin Risk Manag. 2017; 13: 757-777.