A. Bewley

Maximizing patient adherence for optimal outcomes in psoriasis

Psoriasis is a chronic, disabling disease in which adherence to treatment is often poor. The aim of this article is to highlight the problem of adherence to long‐term treatment in psoriasis and the factors that contribute to it, and to discuss how adherence, and thus outcomes, can be improved. This article is based on a presentation given by the authors at a satellite symposium held during the 19th Congress of the European Academy of Dermatology and Venereology, 6–10 October, 2010, in Gothenburg, Sweden. Adherence to topical medication is a major problem in psoriasis. Not only are prescriptions not being filled by patients (primary adherence) but topical medications are not being used as recommended (secondary adherence). The issue is complex due to the many factors which affect adherence, including efficacy, ease of use and convenience of application, and the healthcare professional–patient relationship. Due to the nature of the disease, patients suffer poor self‐image and feel stigmatized, particularly when psoriasis is present on a visible part of the body. Consequently, the negative impact of psoriasis on patient quality of life underlies many adherence issues. It is therefore important for treatment to address the psychological aspects as well as the physical symptoms of psoriasis. Improvements in several areas of disease management may lead to benefits in medication adherence and hence clinical benefit. Prescribing therapy in line with patient preference for treatment vehicle and improving the healthcare professional–patient relationship may be key factors. Nurses have an important role in educating patients and delivering long‐term care. This individualized, personal, approach may help improve treatment adherence, outcomes, and the quality of life for patients with psoriasis.

Delusional parasitosis: time to call it delusional infestation

Delusional parasitosis (DP) is a term that was coined by Wilson and Miller in 1946 to describe a particular psychocutaneous clinical picture which had previously been called by various names. The well-recognized clinical picture of DP is reportedly an uncommon condition. Patients with DP hold a fixed belief that they are infected with organisms such as unicellular parasites, bacteria, viruses and worms; or infested with insects; or infiltrated by organic and nonorganic fibres, threads, ‘stealth viruses’ or other forms of inanimate particles known or unknown by medical science. We would like to support the change in the name proposed by Freudenmann and Lepping from ‘delusional parasitosis’ to the all-encompassing term ‘delusional infestation’ (DI). This term better reflects the growing number of patients who do not believe they are infested by ‘parasites’, covers any species blamed by patients for their symptoms, and includes the so-called ‘Morgellons syndrome’. The condition has been known by a variety of names since its initial description as ‘acarophobie’ in 1894 by Thieberge: these include ‘Dermatozoenwahn’ (Ekbom’s syndrome), delusion of infestation and parasitophobia. ‘Delusional parasitosis’ (the term preferred by many up until now) has been a more accurate term than parasitophobia as it is a true delusion, i.e. a fixed false belief, rather than a phobia (a persistent irrational fear). The diagnosis of DI can be subdivided into primary and secondary disorders. Primary functional delusional disorder is classified in DSM-IV-TR as delusional disorder somatic type and in ICD-10 as persistent delusional disorder. Nevertheless, the predominant delusional theme for most is that of an infestation. Some patients also see this as an infection or infiltration of one’s own body or immediate environment. We therefore prefer the term DI as it includes patients with a delusional belief that they are infected with any kind of vivid and inanimate pathogen. The basic phenomenology of the disease has remained unchanged for centuries, but as with most psychiatric disorders, the exact nature of the patients’ presentation is context dependent and changes over time. The term DI captures all the various presentations and, what is more, it is open to all future kinds of pathogens and infesting species which will (no doubt) emerge. Although reportedly uncommon, the average dermatologist will see two to three patients with DI every 5 years. The annual incidence of DI has been estimated at 20 cases per million. The female to male ratio under the age of 50 years is equal but over the age of 50 years the incidence is reported as 2 : 1. There is a bimodal distribution with a peak between 20–30 years and another at > 50 years, and there are frequent reports of the delusions being shared with a relative or close friend (folie à deux; 8–12% of cases of DI), and occasionally more than one person. It is likely that the incidence and prevalence of DI have been systematically under-reported. Clinicians who set up clinics for patients with DI and related disorders are soon inundated with patients who have hitherto been ‘held’ in primary care, or have ‘doctor-shopped’ so much that there is no one clinician who holds clinical responsibility for the patient. In many cases the aetiology is unknown. It may follow a real infestation, be associated with recreational drug use (especially alcohol, amphetamines, cannabis and cocaine), be a dementia-related psychosis in the elderly, and be associated with other organic disease. The management of patients with DI can be challenging. Treatment of secondary DI should begin with treating (where possible) underlying causes, in addition to treating the delusion itself. For example, it is important to treat any recreational drug and alcohol abuse as well as treating the patient’s skin and the delusion. Treatment of the skin as well as the psychiatric disease is crucial, not least because that is usually the patient’s main focus. Randomized controlled trials in the treatment of the delusion itself are lacking in part due to the nature of the condition and the obvious difficulty of recruiting patients for trials with informed consent. When referred to a purely psychiatric clinic, patients with DI will often default their appointments. Conversely, it is also difficult to manage these patients in a standard dermatology clinic as they often take considerable time and other resources to engage in therapeutic management. Lepping and coworkers conducted a systematic review of the effectiveness of antipsychotics in primary DI, and concluded that there was weak evidence that they are effective as there are no randomized controlled clinical trials. They describe the difficulties encountered by those trying to study pharmacological management of this group of patients. Healy et al. have reported a recent U.K. audit of the use of atypical antipsychotics in the treatment of DI. These authors report successful treatment of DI with atypical antipsychotics (often risperidone in surprisingly low doses, for example 0Æ5– 1 mg daily) in up to 75% of patients with DI. Patients who respond to second generation antipsychotics will usually start to describe benefit in their symptoms after 4–6 weeks of treatment, but the treatment will usually need to be continued for 6 months to 1 year. In the absence of evidence-based data there is some rationale in using atypical antipsycotics as first generation antipsychotics (for example, pimozide) may be

Updating the diagnosis, classification and assessment of rosacea: Recommendations from the global ROSacea COnsensus (ROSCO) panel

Rosacea is currently diagnosed by consensus‐defined primary and secondary features and managed by subtype. However, individual features (phenotypes) can span multiple subtypes, which has implications for clinical practice and research. Adopting a phenotype‐led approach may facilitate patient‐centred management.

Delusional infestation and the specimen sign: a European multicentre study in 148 consecutive cases.

Background  Systematic studies of delusional infestation (DI), also known as delusional parasitosis, are scarce. They lack either dermatological or psychiatric detail. Little is known about the specimens that patients provide to prove their infestation. There is no study on the current presentation of DI in Europe.

Successful treatment of a patient with octreotide–resistant necrolytic migratory erythema

We report a patient with the glucagonorna syndrome and octreotide‐resistant necrolytic migratory erythema (NME). The NME responded on two occasions to an intravenous infusion of essential fatty acids (EFA) and ammo acids (AA). A deficit of serum EFA prior to treatment was corrected following the infusion, whilst plasma AA were low before and after treatment. These findings indicate that NME, in the glucagonoma syndrome, may respond to correction of the EFA deficit, and that NME‐may be a disease of EFA deficiency.

Three cases of delusional parasitosis caused by dopamine agonists

We report three cases of delusional parasitosis (DP) in patients with well‐established Parkinson’s disease, all of whom were taking dopamine agonists. In all three cases, the DP resolved rapidly when the drug was withdrawn.

Delusional parasitosis presenting as folie à trois: successful treatment with risperidone

SIR, Delusional parasitosis (DP) is a condition that dermatologists find difficult to treat, predominantly as it is not a disease of the skin per se, but is a true psychotic delusion: a fixed false belief of infestation by organisms. It carries a high level of psychosocial morbidity and may even result in the patient’s suicide. Another individual may share the delusion—a phenomenon known as ‘folie à deux’. In very rare instances folie à trois may occur. Treatment in a joint dermatology/psychiatry environment has been advocated, and in the past, pimozide has been used successfully in the treatment of the condition. The side-effect profile of pimozide has necessitated the search for other, less dangerous treatments. Risperidone, an atypical antipsychotic that acts on serotonergic 5-HT2 and dopaminergic D2 receptors, has a much better safety profile than pimozide. We report its successful use in the treatment of a patient with DP and the subsequent resolution of symptoms of her husband and son who shared her delusions as folie à trois. A 35-year-old woman presented to her general practitioner (GP) on multiple occasions, originally to have her 6-year-old son treated for head lice. The boy was treated and referred to a paediatric dermatologist who found him to be clear of lice, and he was discharged. The woman continued to attend the GP and complained of itching. The GP treated her and the family for scabies and eczema on multiple occasions and eventually referred her to the dermatology clinic. After initially being treated for nodular prurigo, the patient was referred on to the joint liaison psychiatry/dermatology clinic at Barts and the Royal London Hospital. During this assessment she described a continuous sensation of itching and a conviction that there were small insects infesting her skin. She produced a specimen of nonspecific skin debris, which she insisted was examined microscopically. Her husband and son, who accompanied her, also complained of itching and shared the patient’s conviction that not only was she infested, but they were infested too. None of the family had any other health issues or was on any medication, and there was no family history of psychosis. Examination of the patient revealed widespread, symmetrical excoriated nodules with the appearance of nodular prurigo. There was no evidence of mite or louse infestation. Psychiatrically, she had mild signs of clinical depression and had reported the use of cocaine and amphetamines many years previously, but denied any current drug abuse—an aspect of the history which we could find no reason to doubt. The husband and son had no clinical signs. The patient was treated with risperidone 1Æ5 mg daily and within a month there had been a dramatic improvement in her symptoms and signs. She reported that she was no longer troubled by parasites and clinically, the excoriated nodules were improving. Remarkably, the husband and son also became asymptomatic during this period despite receiving no treatment. On subsequent visits, the patient was noncompliant with the medication, but gave no reason for her noncompliance. She reported a recurrence of the parasites but confirmed that her husband and son remained symptom free. When restarted on risperidone, there was another dramatic improvement, again within 4–6 weeks. It is not apparent why the patient insisted on stopping her medication, but it may be due to the fact that she ‘felt better’. To date, the patient is off medication and has not continued risperidone for any period greater than 3 months. She still complains of a sensation of itching from time to time but denies any further troubles with insect infestation. Thibierge initially described delusions of parasitosis in 1894, as ‘acarophobia’. The condition was later renamed ‘parasitophobia’ until Ekbom described a group of seven women with the condition in 1938 and it became known as Ekbom’s disease (not to be confused with Ekbom’s restless leg syndrome). In 1946, Wilson and Miller proposed the term ‘delusions of parasitosis’, which is a more appropriate name as the condition is a true delusion, a fixed, false belief, rather than a phobia, an abnormal fear response to a stimulus. DP occurs at a mean age of 59 years but the reported range is wide. In the over-50s, women are more commonly affected than men, with a ratio of 2 : 1, but this predilection is not seen in younger age groups. The prevalence of DP remains unknown, but in a survey by Reilly and Batchelor, 144 of 215 dermatologists who replied to a postal survey reported having seen at least one case in the last 5 years. DP has a high burden of psychosocial morbidity and sufferers may take extreme measures to rid themselves of parasites including self-harming behaviour and suicide. One man set fire to his house and later flooded it in an attempt to rid himself of the parasites. The clinical presentation is variable, ranging from a lack of cutaneous findings to multiple excoriations resembling nodular prurigo. There have been some case reports of patients

The efficacy and safety of apremilast, etanercept and placebo in patients with moderate-to-severe plaque psoriasis: 52-week results from a phase IIIb, randomized, placebo-controlled trial (LIBERATE).

Apremilast, an oral, small‐molecule phosphodiesterase 4 inhibitor, has demonstrated efficacy in patients with moderate‐to‐severe psoriasis.

Rosacea treatment update: Recommendations from the global ROSacea COnsensus (ROSCO) panel

Rosacea is currently treated according to subtypes. As this does not adequately address the spectrum of clinical presentation (phenotypes), it has implications for patient management. The ROSacea COnsensus panel was established to address this issue.

Labial fusion in children: a presenting feature of genital lichen sclerosus?

Abstract: Labial fusion is a common condition seen most frequently in infants and young children. While most cases are “physiological,” we believe it can occasionally be the presenting feature of genital lichen sclerosus.