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Treatment of delusions of parasitosis
772
Journal of the American Academy of Dermatology
Correspondence
First, there is nothing "insidious" about a statement to the effect that the currently available literature on PUVA and carcinogenicity clearly indicates that certain patients who have been exposed to known carcinogens (e.g., x-ray and arsenic) have developed cutaneous malignancy while on PUVA. This is a reported fact, and until Dr. Halprin or others produce a control group treated only with the known carcinogen and no PUVA, with comparative malignancy figures over the same period of time, the question mark over the total ineffectiveness of PUVA either as an initiator or, more likely, a promoter of carcinogenesis will and should remain. The second non sequitur comes from Dr. Halprin's comparison of arsenic and x-rays, both recognized carcinogens, with methotrexate, which, compared with other cytotoxic drugs, seems remarkably safe in this respect. The point that we wish to make, and clearly must make more forcibly, is that the whole principle of initiation and promotion in the induction of carcinogenesis is that neither initiator nor promoter alone will induce malignancy but that the two together do. Thus we suggest that methotrexate and PUVA given simultaneously may possibly act in this manner. Genetic predisposition to skin cancer is frequently associated with recognizable defects in deoxyribonucleic acid (DNA) repair. On intensive in vitro studies of unscheduled DNA repair (results to be reported elsewhere) neither of our patients demonstrated such defects. Further, neither patient has the striking Celtic or Caledonian phenotype of fair skin, freckles, red hair, and poor tanning ability with which we are very well acquainted in this part of the world. Dr. Halprin's statement on bowenoid changes observed in skin following methotrexate therapy is in fact referenced by an article referring to similar changes seen during PUVA therapy. Perhaps he could clarify this area of confusion for his readers. Both our patients have clear invasive squamous carcinoma, not bowenoid change. The lack of progression of new lesions following withdrawal of PUVA therapy but continuing administration of methotrexate encourages us in our belief that the two given simultaneously may be additive as far as induction of cutaneous malignancy is concerned. It is important to emphasize once more that our patients received simultaneous methotrexate and PUVA, and the two were not given sequentially as Dr. Halprin suggests. The recent clear report of topical 5-methoxysoralen (5-MOP)-induced malignancy in animals treated with ultraviolet B (UVB) published in this JOURNALt is food for thought in this respect. Animals receiving only UVB, the known carcinogen, did not develop malignancy during the time period studied.
This is strong evidence for a promotional effect 0f topical psoralen in this system. It will be of interest to see how safe and noncarcinogenic we believe PUVA to be in 5 years. The only way in which valid data can be accumulated for such facts to be established is careful and accurate documentation of patients such as the two we describe.
Rona M. MacKie, M.D. Clare P. Fitzsimons, M.B., Ch.B. University of Glasgow Department of Dermatology 56 Dumharton Rd. Glasgow Gl 1 6NU Scotland REFERENCE
1. Cartwright LE, Walter JF: Psoralen-containing sunscreen is tumorigenic in hairless mice. J AM ACADDERMATOL8; 830-836, 1983. T r e a t m e n t of d e l u s i o n s o f p a r a s i t o s i s
To the Editor: In my earliest clinical experience, [ spent a significant portion of time with that occasional patient suffering from delusions of parasitosis. I carefully examined the collected specimens which the patient brought in and calmly, then adamantly and more profusely, explained that there were no bugs to be found. My disbelieving patient would become agitated and angry, objecting to my fee and indicating that he (or she) would be seeing another doctor. I became wiser. Contrary to Dr. Lyell, the best formula is to examine the patient's specimens and to report that "the specimens have been carefully observed, confirming the patient's findings and a treatment is at hand which is virtually always effective (or similar phrasing but be definite)." I indicate that the medication I will prescribe has a particular odor which no bug or insect can withstand. The patient is told to use a capful of the special liquid in a shallow water tub bath each 2 or 3 days. Particularly, if the patient comes in with a friend or relative, I bring into the treatment room a bottle of crude coal tar and remove the cap, placing the opening under each of the noses, seeking the gratification and support of up-anddown moving heads. This therapy carries no complications, particularly as compared to pimozide, and has, practically without exception, removed the complaint for a period ranging from many months to years, and occasional reenforcement adds additional relief. On rare occasion, a patient has tried to thwart me by returning a few months later and indicating that the
Volume 9 Number 5 November 1983
Co~ respondence
bugs are now ' up m y nose" or " m my bowels (but off the skin) Undaunted, I md~cate the treatment should be increased (but not ingested) and now the effect will be internal also Slmdarly, the rewards for my pataents and I remain h~gh
Edward B Frankel M D 4322 Wdshtre Blvd Los Angeles', CA 90010
773
apy was difficult to duplicate I agree that plmoz~de as a potent antlpsycbouc drug and must be used with great care w~th attentaon to the dosage and s~de effects However, the dosage necessary to clear the delusions ts small, and, m consequence ~ts side effects also tended to be mlmmal
E E Duke M D F R C P ( C ) 770 Broadvtew Ave Suite 30/ Ottawa, Ontario K2A 3Z3 Canada
Reply To the Editor This Is a vahd point of view Fuller information about the patIents and the course of their Illnesses ts necessary The success claimed by Dr Frankel Is most unusual m patients who are genumely deluded It is open to question whether the success ~s due to appeasing the pataents While the therapist's objectwe is to keep m touch with the patient, to do so by th~s means ~s not recommended by others wiser than I nor does ~t accord with my own adea of what is a proper course of action, as 1 thank ~t would be hkely to compromise the relationship between me and m y patient whach is the rock upon which management ~s founded
Alan Lyell, M D Cratgathon, Skelmor&e Ayrshire PA 17 5DT Scotland
Reply To the Edttor Dr Frankel s letter tends to emphasize the difficulty that all of us have had with the disease "delusions of parasatosls " No matter how well one examines the patient or the spectmens that the patient brings In and no matter how reassurmg one Is, the patient cannot be conwnced that there are no bugs to be found I on the other hand could never bnng myself to tell the patient that bugs are present and thus to support the pataent's delusion My mare method of therapy for these patients ~s to support them and to attempt to avoid their mjunng themselves with the various treatments that they them selves would use Placebo therapy such as Dr Frankel describes was certamly many times part of that treat ment However I always found it to be temporary difficult to do, and requiring great reenforcement I also expect ~t requires a physician with a strong personality to carry out good placebo therapy on a patient w~th delusions Because of this most of us were unable to treat d~sease well The success that Dr Frankel has had w~th this ther
Thymopoletm pentapeptlde treatment of sarcoldos~s To the Editor We would hke to comment on the paper by Kang, Cooper and Harufin Thymopoletm Pentapept~de (TP-5) Improves Chmcal Parameters and Lymphocyte Subpopulat~ons an Atopac Dermatitis ' (J AM ACAD DERMATOL 8 372-377, 1983) W e have not had the opportumty to treat w~th TP-5 a s~mflar group of patients wzth atoplc dermatitis However, m an open study of patients with sarcoldosls treated with TP-5, we obtained beneficial chmcal effects and a progressive normahzatlon of cell-mediated ~mmunlty defects 1 Not otdy did erythema nodosum disappear m 3 weeks (three cases), but also hdar adenopathy disappeared and skan sarco~ds amproved or were cured (five cases) after 6 or 12 weeks of TP 5 treatment Patients lmtmlly had low levels of peripheral blood T cells ( O K T 3 + ) and suppressor T cells ( O K T 8 + ) There was a return to normal values w~th TP 5, a finding very s~mdar to that noted by Kang et a l m their atoplc dermatitis group Moreover, cutaneous anergy to skan muitltests was observed m seven pataents before treatment and was corrected with TP-5 These observations are further evidences for a stamu latlon of T cell functaons and/or T cell differentiation by the thymopotetm pentapepUde Chmcal results m pauents with atoplc dermatms or sarcotdos~s together w~th the modulatxon o f cell-mediated Immunity whach was noted could justify the use of TP-5 an patients with d~seases assocmted w~th T cell deficiencies
J Thtvolet, M D , and M Faure M D lnserm U 209, Laboratowe de Recherche Dermatologtque et lmmunologw Hbpttal E Hemot-Pav R 69374 Lyon Cedex 08 Ftance
Journal of the American Academy of Dermatology
Correspondence
First, there is nothing "insidious" about a statement to the effect that the currently available literature on PUVA and carcinogenicity clearly indicates that certain patients who have been exposed to known carcinogens (e.g., x-ray and arsenic) have developed cutaneous malignancy while on PUVA. This is a reported fact, and until Dr. Halprin or others produce a control group treated only with the known carcinogen and no PUVA, with comparative malignancy figures over the same period of time, the question mark over the total ineffectiveness of PUVA either as an initiator or, more likely, a promoter of carcinogenesis will and should remain. The second non sequitur comes from Dr. Halprin's comparison of arsenic and x-rays, both recognized carcinogens, with methotrexate, which, compared with other cytotoxic drugs, seems remarkably safe in this respect. The point that we wish to make, and clearly must make more forcibly, is that the whole principle of initiation and promotion in the induction of carcinogenesis is that neither initiator nor promoter alone will induce malignancy but that the two together do. Thus we suggest that methotrexate and PUVA given simultaneously may possibly act in this manner. Genetic predisposition to skin cancer is frequently associated with recognizable defects in deoxyribonucleic acid (DNA) repair. On intensive in vitro studies of unscheduled DNA repair (results to be reported elsewhere) neither of our patients demonstrated such defects. Further, neither patient has the striking Celtic or Caledonian phenotype of fair skin, freckles, red hair, and poor tanning ability with which we are very well acquainted in this part of the world. Dr. Halprin's statement on bowenoid changes observed in skin following methotrexate therapy is in fact referenced by an article referring to similar changes seen during PUVA therapy. Perhaps he could clarify this area of confusion for his readers. Both our patients have clear invasive squamous carcinoma, not bowenoid change. The lack of progression of new lesions following withdrawal of PUVA therapy but continuing administration of methotrexate encourages us in our belief that the two given simultaneously may be additive as far as induction of cutaneous malignancy is concerned. It is important to emphasize once more that our patients received simultaneous methotrexate and PUVA, and the two were not given sequentially as Dr. Halprin suggests. The recent clear report of topical 5-methoxysoralen (5-MOP)-induced malignancy in animals treated with ultraviolet B (UVB) published in this JOURNALt is food for thought in this respect. Animals receiving only UVB, the known carcinogen, did not develop malignancy during the time period studied.
This is strong evidence for a promotional effect 0f topical psoralen in this system. It will be of interest to see how safe and noncarcinogenic we believe PUVA to be in 5 years. The only way in which valid data can be accumulated for such facts to be established is careful and accurate documentation of patients such as the two we describe.
Rona M. MacKie, M.D. Clare P. Fitzsimons, M.B., Ch.B. University of Glasgow Department of Dermatology 56 Dumharton Rd. Glasgow Gl 1 6NU Scotland REFERENCE
1. Cartwright LE, Walter JF: Psoralen-containing sunscreen is tumorigenic in hairless mice. J AM ACADDERMATOL8; 830-836, 1983. T r e a t m e n t of d e l u s i o n s o f p a r a s i t o s i s
To the Editor: In my earliest clinical experience, [ spent a significant portion of time with that occasional patient suffering from delusions of parasitosis. I carefully examined the collected specimens which the patient brought in and calmly, then adamantly and more profusely, explained that there were no bugs to be found. My disbelieving patient would become agitated and angry, objecting to my fee and indicating that he (or she) would be seeing another doctor. I became wiser. Contrary to Dr. Lyell, the best formula is to examine the patient's specimens and to report that "the specimens have been carefully observed, confirming the patient's findings and a treatment is at hand which is virtually always effective (or similar phrasing but be definite)." I indicate that the medication I will prescribe has a particular odor which no bug or insect can withstand. The patient is told to use a capful of the special liquid in a shallow water tub bath each 2 or 3 days. Particularly, if the patient comes in with a friend or relative, I bring into the treatment room a bottle of crude coal tar and remove the cap, placing the opening under each of the noses, seeking the gratification and support of up-anddown moving heads. This therapy carries no complications, particularly as compared to pimozide, and has, practically without exception, removed the complaint for a period ranging from many months to years, and occasional reenforcement adds additional relief. On rare occasion, a patient has tried to thwart me by returning a few months later and indicating that the
Volume 9 Number 5 November 1983
Co~ respondence
bugs are now ' up m y nose" or " m my bowels (but off the skin) Undaunted, I md~cate the treatment should be increased (but not ingested) and now the effect will be internal also Slmdarly, the rewards for my pataents and I remain h~gh
Edward B Frankel M D 4322 Wdshtre Blvd Los Angeles', CA 90010
773
apy was difficult to duplicate I agree that plmoz~de as a potent antlpsycbouc drug and must be used with great care w~th attentaon to the dosage and s~de effects However, the dosage necessary to clear the delusions ts small, and, m consequence ~ts side effects also tended to be mlmmal
E E Duke M D F R C P ( C ) 770 Broadvtew Ave Suite 30/ Ottawa, Ontario K2A 3Z3 Canada
Reply To the Editor This Is a vahd point of view Fuller information about the patIents and the course of their Illnesses ts necessary The success claimed by Dr Frankel Is most unusual m patients who are genumely deluded It is open to question whether the success ~s due to appeasing the pataents While the therapist's objectwe is to keep m touch with the patient, to do so by th~s means ~s not recommended by others wiser than I nor does ~t accord with my own adea of what is a proper course of action, as 1 thank ~t would be hkely to compromise the relationship between me and m y patient whach is the rock upon which management ~s founded
Alan Lyell, M D Cratgathon, Skelmor&e Ayrshire PA 17 5DT Scotland
Reply To the Edttor Dr Frankel s letter tends to emphasize the difficulty that all of us have had with the disease "delusions of parasatosls " No matter how well one examines the patient or the spectmens that the patient brings In and no matter how reassurmg one Is, the patient cannot be conwnced that there are no bugs to be found I on the other hand could never bnng myself to tell the patient that bugs are present and thus to support the pataent's delusion My mare method of therapy for these patients ~s to support them and to attempt to avoid their mjunng themselves with the various treatments that they them selves would use Placebo therapy such as Dr Frankel describes was certamly many times part of that treat ment However I always found it to be temporary difficult to do, and requiring great reenforcement I also expect ~t requires a physician with a strong personality to carry out good placebo therapy on a patient w~th delusions Because of this most of us were unable to treat d~sease well The success that Dr Frankel has had w~th this ther
Thymopoletm pentapeptlde treatment of sarcoldos~s To the Editor We would hke to comment on the paper by Kang, Cooper and Harufin Thymopoletm Pentapept~de (TP-5) Improves Chmcal Parameters and Lymphocyte Subpopulat~ons an Atopac Dermatitis ' (J AM ACAD DERMATOL 8 372-377, 1983) W e have not had the opportumty to treat w~th TP-5 a s~mflar group of patients wzth atoplc dermatitis However, m an open study of patients with sarcoldosls treated with TP-5, we obtained beneficial chmcal effects and a progressive normahzatlon of cell-mediated ~mmunlty defects 1 Not otdy did erythema nodosum disappear m 3 weeks (three cases), but also hdar adenopathy disappeared and skan sarco~ds amproved or were cured (five cases) after 6 or 12 weeks of TP 5 treatment Patients lmtmlly had low levels of peripheral blood T cells ( O K T 3 + ) and suppressor T cells ( O K T 8 + ) There was a return to normal values w~th TP 5, a finding very s~mdar to that noted by Kang et a l m their atoplc dermatitis group Moreover, cutaneous anergy to skan muitltests was observed m seven pataents before treatment and was corrected with TP-5 These observations are further evidences for a stamu latlon of T cell functaons and/or T cell differentiation by the thymopotetm pentapepUde Chmcal results m pauents with atoplc dermatms or sarcotdos~s together w~th the modulatxon o f cell-mediated Immunity whach was noted could justify the use of TP-5 an patients with d~seases assocmted w~th T cell deficiencies
J Thtvolet, M D , and M Faure M D lnserm U 209, Laboratowe de Recherche Dermatologtque et lmmunologw Hbpttal E Hemot-Pav R 69374 Lyon Cedex 08 Ftance