gellons disease,’’ appearing in this month’s
issue of the Journal, serve to remind us that
Browne’s description, in the literature references
the spectrum of those with cutaneous dysesthesia is
over the past 75 yearsand in the complaints of
broad indeed. Though we cannot yet delineate the
our patients today, is the extraordinary similarities
pathway exactly, some of the mechanisms by which
that they all describe—in the quality of the sensory
the itch sensation is generated and transmitted are now
changes experienced, in the level of the patient’s
understoodand we feel that we have some sort of a
distress, in the various and ingenious interpretations
grip on winter itch, itching in the elderly, the infant
of what may be happening in the skin, and in the
with atopic dermatitis,or urticaria, lichen planus,
ongoing and desperate search for relief. The patients
and others of the recognized pruritic dermatoses.
are virtual carbon copies, one of the other.
Less well understood are other sensations that
The clinical picture is unmistakable. The patient is
patients may describe to us, such as crawling, biting,
intensely anxious, is obsessively focused on his or
stinging, pricking, burning, shooting, and so forth.
her symptoms, brings ‘‘specimens’’ of the offending
These sensations may be focal or generalized, and
agent, or agents, and is unshakable in his or her belief
while some patients may present to us with no visible
as to the cause. Usually there will be a logical
change in the skin—those with brachioradial pruri-
explanation of exactly how the infection or infestation
tus,for example—others, reporting that the discom-
was contracted, and the patient will have resorted to
fort is relieved only by picking, squeezing, or pulling
the most extreme measures both to eradicate it and
hair, present with neurotic excoriations, prurigo
to prevent contagionFurniture is discarded,
clothing burned, and close physical contact denied.
A separate group of patients are those unfortunate
Tragically, grandmothers will not touch their grand-
few who have an inherent need to ‘‘know’’ and to
children—for although the condition may occur at
understand what is going on with their skin. These
any age, and in both sexes, elderly women living
patients, made very anxious by the vacuum in their
alone are the most common demographic.
knowledge, and perhaps also by their inability to
It is important for us to realize that, just as the
attain relief from professionals will, with great inge-
patient describes, the sensation that is experienced is
nuity, ‘‘create’’ a ‘‘cause’’ for their symptoms, which
in the skin. It is understandable, therefore, that the
makes logical sense to them, and with which they
patient is not open to the idea of pathology in the
can be comfortable. Because of the nature of the
mind, the nervous system, or the brain. It is also
sensation, many of these patients believe themselves
important for us to distinguish delusional beliefs from
to have an infection or infestation, and we are of
phobic concerns or obsessional worries, a distinction
course all familiar with the syndrome of delusions of
that caused some confusion in the pastand that is
parasitosis, or Ekbom’s disease,as is described
important, because both the psychopathology and
the treatment are different between the three.
This conditionhas recently reverted to the name
The syndrome may be seen in association with a
given by Sir Thomas Browne in 1674, to an
number of psychiatric conditions, including bipolardisorder, paranoia, schizophrenia, depression, andabuse of drugs, such as cocaine, amphetamines, or
From the Department of Dermatology, University of Pennsylvania.
Funding sources: None.
ritalin. In the past, a delusion of parasitosis was often
Conflicts of interest: None identified.
considered to be a monosympomatic hypochodria-
Correspondence to: Caroline S. Koblenzer, MD, 1812 Delancey Pl,
cal psybut it has been my experience that
this is a rather restricted view, and that psychiatric co-
morbidity, such as depression, anxiety, or personality
2006 by the American Academy of Dermatology, Inc.
disorder, can usually be uncovered during a careful
interview, when more florid psychopathology is not
evident. The syndrome has also been reported in
Murase et al, with the patient’s pain and discomfort,
association with a number of medical conditions that
their anger and frustration with dismissive doctors,
are characterized by itching, such as renal disease,
and the devastating changes wrought by the condition
in the patient’s life, and so develop a therapeutic rela-
Today, the informed dermatologist may be any-
tionship. With regard to causation, Morgellons disease
where from doctor number five to number ten or
may be an acceptable appellation, but it may also be
more in this patient’s search for relief, and the patient
that the touted ‘‘mysteries’’ of this disease only prove
will, in the interim, have raised both heaven and hell
stimulus for further research by the patient. So, perhaps
in a frantic attempt to solve the problem that has
without going too far into the difference between a
literally taken over his or her life. Today, the internet
disease with a definite cause and a syndrome that may
further complicates an already difficult situation, as
have different ones, it may be reasonable for us to refer
we see in the two letters in this Journal, as our
to the symptom complex in question as ‘‘Morgellans
patients share every facet of their condition, every
theory as to cause, and every attempt at relief,
My own approach has been to explain to the
however far-fetched, with their fellow sufferers.
patient that from my examination, biopsy, and tests, I
This sharing, and a tremendous amount of suffer-
have been unable to find evidence to support any of
ing, have given rise to the formation of ‘‘The
the possible causes put forth by either the patient or
Morgellons Research Foundation,’’ an organization
the Web site, though I in no way doubt the patient’s
devoted to ‘‘researching an emerging infectious dis-
experience. I explain that though we cannot explain
ease,’’with a medical board that boasts five MDs
exactly what is going on, we believe that, in part,
and an RN. Interestingly, none are dermatologists. An
certain neuropeptides are involved. This then opens
internet search for ‘‘bugs in the skin’’ will bring one to
the way either to refer the patient to a psychiatrist
the Foundation’s Web and as Murase et al
with whom one can work—as someone familiar with
point out, the information therein may be very
these specialized pathways—or to prescribe appro-
misleading to someone who suffers from delusions
priate medication oneself. It is very important also,
of parasitosis. One reads of cellulose fibers, fibers
I believe, to pay attention to the skin in a positive
with ‘‘autofluorescence,’’ fuzz balls, specks, granules,
way, with baths, emollients, and the like. Of the
strongyloides stercoralis, cryptococcus neoformans,
psychotropics, I still find that pimozide, in a dose
‘‘alternative cellular energy pigments,’’ and various
of anywhere from 0.5 mg to 2 mg once daily, works
types of bacteria for which potent antibiotics are
more quickly and more reliably than others of the
prescribed, in the ever broadening spectrum of
atypical antipsychotics, perhaps because of its known
possible ‘‘pathogens.’’ In no case does one read of
action on opioid pathways,although risperidone
positive confirmatory tests, though many tests are
and aripiprazole are also reportedly effectivIt is
undertaken. As Murase et alnote, one also reads of
very important to tell the patient at the outset that
numerous associated medical and psychiatric disor-
medication may be needed for months to years, and
ders that are attributed to, rather than co-existent
to stress the need not to discontinue, unilaterally—so
with, or causative of the distressing symptoms.
often once control has been lost, it is hard to regain
Frustration is extreme and suicidality is not unknown.
it. Coexisting psychomorbidities such as anxiety and
Clearly, as more and more of our patients discover
this site, there will be an ever greater waste of
Although it is clear that one must always keep an
valuable time and resources on fruitless research
open mind, it would seem to me to be appropriate
into fibers, fluffs, irrelevant bacteria, and innocuous
for the treating physician to wait until the tried and
worms and insecIt behooves us, therefore, as
true drugs, such as those mentioned above, pre-
dermatologists, not only to be aware of this phe-
scribed in an adequate dose, and for an adequate
nomenon, but also each to develop an effective way
period of time, have failed in a particular case, before
to work with these patients, and so enable the
one becomes too involved in ascribing a pathogenic
patients to be able to accept one of the medications
function to cellulose fibers and the like, as is cur-
that we know to be effective. This is a challenge
indeed—so often the patient, feeling ‘‘brushed off’’or not understood, simply does not follow through
either with medication or with psychiatric referral.
1. Greaves MW, Khalifa N. Itch: more than skin deep. Int Arch
If one is to succeed in helping these patients, it is
2. Ward JR, Bernhard JD. Willan’s itch and other causes of
important that one acknowledge to the patient that
pruritus in the elderly. Int J Dermatol 2005;44:267-73.
what the patient describes is exactly what that patient
3. Schmeltz M, Handwerker HO. Neurophysiologic basis of itch.
is experiencing. One can then empathize, as did
In: Yosipovitch G, Greaves MW, Fleischer AB, McGlone F,
editors. Itch: basic mechanisms and therapy. New York: Marcel
12. Ekbom KA. Der presenile dermatozoenwahn. Acta Psychiatri
4. Stander S, Steinhoff M, Luger TA. Pathophysiology of pruritus.
13. Obermeyer M. Psychocutaneous medicine. Springfield, IL:
In: Bieber T, Leung DYM, editors. Atopic dermatitis. New York:
Charles C. Thomas; 1955. pp. 148-63.
Marcel Dekker, Inc; 2002. pp. 183-216.
14. Munro A. Delusional parasitosis: a form of monosymptomatic
5. Pallanti S, Lotti T, Urpe M. Psychoneuroimmunodermatology
hypochondriacal psychosis. Semin Dermatol 1983;2:197-202.
of atopic dermatitis: from empiric data to the evolutionary
15. Kellett CE. Sir Thomas Browne and the disease called the
hypothesis. Dermatol Clin 2005;23:695-701.
Morgellons. Ann Med Hist 1935;7:467-79.
6. Wallengren J, Dahlback K. Familial brachoradial pruritus. Br J
16. Murase JE, Wu JJ, Koo J. Morgellons disease: a rapport-
enhancing term for delusions of parasitosis. J Am Acad
7. Koblenzer CS. Psychocutaneous disease. New York: Grune and
17. Morgellons Research Foundation Web site. Available at:
8. Koblenzer CS. Neurotic excoriations and dermatitis artefacta.
18. Lee CS, Koo JYM. The use of psychotropic medications in
9. Musalek M. Delusional parasitosis. In: Koo JYM, Lee CS, editors.
dermatology. In: Koo JYM, Lee CS, editors. Psychocutaneous
Psychocutaneous medicine. New York: Marcel Dekker, Inc;
medicine. New York: Marcel Dekker, Inc; 2002. pp. 427-51.
19. Koblenzer CS. Psychotropic drugs in dermatology. In: James
10. Munro A. Delusional disorder. Cambridge: Cambridge Univer-
WD, Cockerell CJ, Dzubow LM, Paller AS, Yancey KB, editors.
Advances in dermatology (vol 15). St Louis: Mosby, Inc; 2000.
11. Arnold LM. Psychocutaneous disorders. In: Sadock BJ, Sadock
VA, editors. Kaplan and Sadock’s comprehensive textbook of
20. Savely VR, Leitao MM, Stricker RB. The mystery of Morgellons
psychiatry. 7th ed. Philadelphia: Lippincott, Williams and
disease. Infection or delusion? Am J Clin Dermatol 2005;7:
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