Hallucinatory Parasitosis: Addressing Both the Skin and Mind

A comprehensive review in the journal Clinical Infectious Diseases examines the diagnosis and management of hallucinatory parasitosis, also known as delusional infestation or Ekbom syndrome. The review discusses key diagnostic criteria, differential diagnosis, and pharmacological therapy, focusing on how dermatologists should approach patients with this psychotic disorder.
Hallucinatory parasitosis is characterised by a false belief that one is infested with living organisms, such as insects, parasites, or worms, or even objects like fibres. The review notes that the most effective treatment occurs in psychodermatology centres, where both skin and psychological symptoms are addressed.
Empathy Is Crucial
“I really liked how the authors emphasised communication with these patients,” said Anna Graziella Burroni, president of the Italian Society of Psychosomatic Dermatology (SIDEP) and a lecturer at the University of Genoa, Italy, in an interview with Univadis Italy.
The review advocates for an empathetic, nonconfrontational approach. “If we tell patients with hallucinatory parasitosis that their condition isn’t dermatological and refer them to a psychiatrist, we risk alienating them and causing further distress,” Burroni explained. 
Instead, the recommended approach is more collaborative. Dermatologists should avoid immediately challenging the patient’s belief and instead say something like, ‘It’s possible that these parasites exist. Tell me where it bothers you the most, and we’ll do a biopsy.’ This allows the dermatologist to follow the patient’s narrative while also suggesting, ‘If we don’t find anything, we’ll need to explore other options.’ This method prioritises empathy and keeps patients engaged in their care.
The Dermatologist as a ‘Guide’
“When patients express their suffering through their skin, the treatment must begin there,” Burroni emphasised. “You cannot immediately refer them to a mental health specialist. The dermatologist must interact with them. Once trust is built, patients may be more open to consulting a psychiatrist on their own. However, if you refer them right away, failure is almost certain.”
Some doctors might feel unprepared to manage such complex patients. In such situations, Burroni advised a different approach. “You can say, ‘I’m sending you to a colleague who specialises in this condition,’ without directly mentioning psychiatry. A dermatologist with psychoanalytic training can guide the patient appropriately, leading them to the necessary care—psychiatry—when the time is right. We’re not replacing one professional with another; we’re helping the patient take the right steps,” she explained.
Psychodermatology in Italy
“At the psychodermatology clinic at the San Martino University Hospital in Genoa, I care for patients facing more complex dermatological issues,” Burroni explained. “These aren’t just patients with severe conditions like delusional parasitosis; they include patients with atopic dermatitis who struggle with the impact on their body image.” Each visit can last up to 50 minutes—a notably long time in dermatology, due to the complexity of these cases. Patients travel across Italy for treatment. “These are very carefully selected cases, and with more resources and opportunities to train people, we could expand our reach,” Burroni noted.
Though psychodermatology is a relatively niche field, it has deep roots. The SIDEP, founded 26 years ago, organises an annual congress to highlight key topics for dermatologists. The next is scheduled for February 7-8, 2025, in Genoa. “In 2025, the congress will be titled ‘In the Skin of Others,’ focusing on challenges in understanding those who differ from us, whether in ethnicity or sexuality. Last year’s theme was ‘Psychodermatology and Social Media,’” said Burroni, who also coordinates the Psychosomatic Dermatology Group of the Italian Society of Medical, Surgical, and Aesthetic Dermatology and Sexually Transmitted Diseases.
The group organises online meetings every 2 months where colleagues present their cases, and they actively participate in congresses to discuss patient communication and care strategies. She described these activities as “seeds of psychodermatology” being planted in the scientific community.
This story was translated from Univadis Italy using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. 
 
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