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Successful Treatment of Morgellons Disease With Pimozide Therapy

Successful Treatment of Morgellons Disease With Pimozide Therapy Patients seen with complaints of fibers extruding from the skin associated with nonspecific dermatologic and neuropsychiatric symptoms have been diagnosed as having Morgellons disease. The cause of Morgellons disease and its relationship to delusional infestation (DI) remain controversial. A heterogeneous diagnosis, DI is the most common delusional disorder in dermatology and shares features with Morgellons disease.1 Report of a Case A 47-year-old woman with self-diagnosed Morgellons disease was seen for evaluation of facial sores. She reported pruritic and painful lesions over 4 months and also reported removing threadlike fibers from the lesions. Four months prior to her visit with us, she was hospitalized for sepsis of unknown origin and noted improvement in her skin after antibiotic and corticosteroid therapy but recurrence shortly after stopping that treatment. Her medical history included diabetes mellitus, restless leg syndrome, and fibromyalgia. On her initial visit, we noted multiple linear erosions with crusting on her cheeks and erythematous eroded papules on her chin (Figure 1). She presented a bag of blood-stained paper towels (Figure 2). Biopsy of a lesion on the cheek was performed, and the hemorrhagic debris was microscopically evaluated. The biopsy specimen revealed serohemorrhagic crust and changes suggestive of excoriation without signs of infestation or abnormal fibers. Figure 1 View LargeDownload Linear erosions with crusting on cheeks and erythematous eroded papules on chin. Figure 2 View LargeDownload Bloody paper towels presented by the patient. Because some of the lesions appeared infected, she was treated with azithromycin, 250 mg/d, and camphor-menthol lotion for pruritus. She experienced minimal improvement and requested a trial of prednisone because this had been helpful for her previously. The patient was prescribed prednisone, 10 mg/d, and lidocaine, 2.5%/prilocaine, 2.5%, cream as needed for pain. Over the following months, several visits and telephone calls revealed little improvement. She complained of feeling depressed and having difficulty thinking. She was extremely distressed by her skin condition and desperate for treatment. Other therapies including different antibiotics, phototherapy, antiparasitic agents, and pimozide were offered but refused. She was resistant to the idea of an antipsychotic medication, so minocycline was started at 100 mg twice daily. Two months later, she returned with multiple new lesions. She had been applying the lidocaine/prilocaine cream with symptomatic relief, but overall, her symptoms were not improved. She agreed to a trial of pimozide therapy when it was presented as a potential treatment for the itching and skin discomfort. A baseline electrocardiogram (ECG) was obtained, and after being counseled on the adverse effects of the drug, the patient was treated with pimozide, 2 mg twice daily. After 2 months, the patient returned in good spirits with complete resolution of the sores and complaining of new lesions only when she ran out of pimozide (Figure 3). She was very happy with the drastic improvement and requested to continue pimozide treatment. At last follow-up, her skin remained clear. Figure 3 View LargeDownload Resolution of lesions following treatment with pimozide. Comment Evidence supports the use of pimozide in the treatment of DI, but patients with Morgellons disease are often resistant to the diagnosis and to treatment for delusions.2-4 We found that presenting pimozide as an antipruritic agent destigmatized it sufficiently for patient compliance. The antipruritic effect of pimozide, possibly mediated by its antiopiate activity, is likely distinct from its antipsychotic effects.2,5 Atypical antipsychotic agents may be as effective as pimozide and with fewer side effects, but little evidence supports their specific use in DI and they exhibit no antipruritic mechanism.6 Pimozide has several potential adverse effects, the most worrisome of which are extrapyramidal symptoms including tardive dyskinesia, malignant neuroleptic syndrome, and dose-dependent prolongation of the QTc interval.7 The risk of QTc prolongation is theoretical, but pretreatment and periodic follow-up ECGs are typically recommended.6,8 Delusional infestation responds to low doses of pimozide for which the risk of movement disorder adverse effects is small.8 We suggest that a less stigmatizing framing of the drug treatment for Morgellons disease may lead to better compliance and more successful outcomes. Correspondence: Dr Lio, 676 N St Clair, Ste 1600, Chicago, IL 60611 (p-lio@northwestern.edu). Financial Disclosure: Dr Lio has consulted for 3M Corporation and has won a grant from the Association of Professors of Dermatology on an unrelated project. Additional Contributions: We are indebted to Anne Laumann, MBChB, MRCP(UK), for her encouragement. References 1. Harth WHermes BFreudenmann RW Morgellons in dermatology. J Dtsch Dermatol Ges 2010;8 (4) 234- 242PubMedGoogle ScholarCrossref 2. Johnson GCAnton RF Pimozide in delusions of parasitosis. J Clin Psychiatry 1983;44 (6) 233PubMedGoogle Scholar 3. Koblenzer CS Pimozide at least as safe and perhaps more effective than olanzapine for treatment of Morgellons disease. Arch Dermatol 2006;142 (10) 1364PubMedGoogle ScholarCrossref 4. Ungvári GVladár K Pimozide treatment for delusion of infestation. Act Nerv Super (Praha) 1986;28 (2) 103- 107PubMedGoogle Scholar 5. Lorenzo CRKoo J Pimozide in dermatologic practice: a comprehensive review. Am J Clin Dermatol 2004;5 (5) 339- 349PubMedGoogle ScholarCrossref 6. Freudenmann RWLepping P Delusional infestation. Clin Microbiol Rev 2009;22 (4) 690- 732PubMedGoogle ScholarCrossref 7. Drolet BRousseau GDaleau PCardinal RSimard CTurgeon J Pimozide (Orap) prolongs cardiac repolarization by blocking the rapid component of the delayed rectifier potassium current in native cardiac myocytes. J Cardiovasc Pharmacol Ther 2001;6 (3) 255- 260PubMedGoogle ScholarCrossref 8. Lee CSAccordino RHoward JKoo J Psychopharmacology in dermatology. Dermatol Ther 2008;21 (1) 69- 82PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Dermatology American Medical Association

Successful Treatment of Morgellons Disease With Pimozide Therapy

Archives of Dermatology , Volume 146 (10) – Oct 1, 2010

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Publisher
American Medical Association
Copyright
Copyright © 2010 American Medical Association. All Rights Reserved.
ISSN
0003-987X
eISSN
1538-3652
DOI
10.1001/archdermatol.2010.276
Publisher site
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Abstract

Patients seen with complaints of fibers extruding from the skin associated with nonspecific dermatologic and neuropsychiatric symptoms have been diagnosed as having Morgellons disease. The cause of Morgellons disease and its relationship to delusional infestation (DI) remain controversial. A heterogeneous diagnosis, DI is the most common delusional disorder in dermatology and shares features with Morgellons disease.1 Report of a Case A 47-year-old woman with self-diagnosed Morgellons disease was seen for evaluation of facial sores. She reported pruritic and painful lesions over 4 months and also reported removing threadlike fibers from the lesions. Four months prior to her visit with us, she was hospitalized for sepsis of unknown origin and noted improvement in her skin after antibiotic and corticosteroid therapy but recurrence shortly after stopping that treatment. Her medical history included diabetes mellitus, restless leg syndrome, and fibromyalgia. On her initial visit, we noted multiple linear erosions with crusting on her cheeks and erythematous eroded papules on her chin (Figure 1). She presented a bag of blood-stained paper towels (Figure 2). Biopsy of a lesion on the cheek was performed, and the hemorrhagic debris was microscopically evaluated. The biopsy specimen revealed serohemorrhagic crust and changes suggestive of excoriation without signs of infestation or abnormal fibers. Figure 1 View LargeDownload Linear erosions with crusting on cheeks and erythematous eroded papules on chin. Figure 2 View LargeDownload Bloody paper towels presented by the patient. Because some of the lesions appeared infected, she was treated with azithromycin, 250 mg/d, and camphor-menthol lotion for pruritus. She experienced minimal improvement and requested a trial of prednisone because this had been helpful for her previously. The patient was prescribed prednisone, 10 mg/d, and lidocaine, 2.5%/prilocaine, 2.5%, cream as needed for pain. Over the following months, several visits and telephone calls revealed little improvement. She complained of feeling depressed and having difficulty thinking. She was extremely distressed by her skin condition and desperate for treatment. Other therapies including different antibiotics, phototherapy, antiparasitic agents, and pimozide were offered but refused. She was resistant to the idea of an antipsychotic medication, so minocycline was started at 100 mg twice daily. Two months later, she returned with multiple new lesions. She had been applying the lidocaine/prilocaine cream with symptomatic relief, but overall, her symptoms were not improved. She agreed to a trial of pimozide therapy when it was presented as a potential treatment for the itching and skin discomfort. A baseline electrocardiogram (ECG) was obtained, and after being counseled on the adverse effects of the drug, the patient was treated with pimozide, 2 mg twice daily. After 2 months, the patient returned in good spirits with complete resolution of the sores and complaining of new lesions only when she ran out of pimozide (Figure 3). She was very happy with the drastic improvement and requested to continue pimozide treatment. At last follow-up, her skin remained clear. Figure 3 View LargeDownload Resolution of lesions following treatment with pimozide. Comment Evidence supports the use of pimozide in the treatment of DI, but patients with Morgellons disease are often resistant to the diagnosis and to treatment for delusions.2-4 We found that presenting pimozide as an antipruritic agent destigmatized it sufficiently for patient compliance. The antipruritic effect of pimozide, possibly mediated by its antiopiate activity, is likely distinct from its antipsychotic effects.2,5 Atypical antipsychotic agents may be as effective as pimozide and with fewer side effects, but little evidence supports their specific use in DI and they exhibit no antipruritic mechanism.6 Pimozide has several potential adverse effects, the most worrisome of which are extrapyramidal symptoms including tardive dyskinesia, malignant neuroleptic syndrome, and dose-dependent prolongation of the QTc interval.7 The risk of QTc prolongation is theoretical, but pretreatment and periodic follow-up ECGs are typically recommended.6,8 Delusional infestation responds to low doses of pimozide for which the risk of movement disorder adverse effects is small.8 We suggest that a less stigmatizing framing of the drug treatment for Morgellons disease may lead to better compliance and more successful outcomes. Correspondence: Dr Lio, 676 N St Clair, Ste 1600, Chicago, IL 60611 (p-lio@northwestern.edu). Financial Disclosure: Dr Lio has consulted for 3M Corporation and has won a grant from the Association of Professors of Dermatology on an unrelated project. Additional Contributions: We are indebted to Anne Laumann, MBChB, MRCP(UK), for her encouragement. References 1. Harth WHermes BFreudenmann RW Morgellons in dermatology. J Dtsch Dermatol Ges 2010;8 (4) 234- 242PubMedGoogle ScholarCrossref 2. Johnson GCAnton RF Pimozide in delusions of parasitosis. J Clin Psychiatry 1983;44 (6) 233PubMedGoogle Scholar 3. Koblenzer CS Pimozide at least as safe and perhaps more effective than olanzapine for treatment of Morgellons disease. Arch Dermatol 2006;142 (10) 1364PubMedGoogle ScholarCrossref 4. Ungvári GVladár K Pimozide treatment for delusion of infestation. Act Nerv Super (Praha) 1986;28 (2) 103- 107PubMedGoogle Scholar 5. Lorenzo CRKoo J Pimozide in dermatologic practice: a comprehensive review. Am J Clin Dermatol 2004;5 (5) 339- 349PubMedGoogle ScholarCrossref 6. Freudenmann RWLepping P Delusional infestation. Clin Microbiol Rev 2009;22 (4) 690- 732PubMedGoogle ScholarCrossref 7. Drolet BRousseau GDaleau PCardinal RSimard CTurgeon J Pimozide (Orap) prolongs cardiac repolarization by blocking the rapid component of the delayed rectifier potassium current in native cardiac myocytes. J Cardiovasc Pharmacol Ther 2001;6 (3) 255- 260PubMedGoogle ScholarCrossref 8. Lee CSAccordino RHoward JKoo J Psychopharmacology in dermatology. Dermatol Ther 2008;21 (1) 69- 82PubMedGoogle ScholarCrossref

Journal

Archives of DermatologyAmerican Medical Association

Published: Oct 1, 2010

Keywords: pimozide

References