Morgellons? I Made the Diagnosis of DP. Now I Have to Figure Out How to Manage it.

Sometimes you learn about a disease just before you run into it for the first time. That has happened again and again in my career.

After I published my post about bot fly infections, a commenter asked if I had seen the larvae and suggested it might have been a case of Morgellons disease. I had never heard of that one, so I read up on it. Morgellons is a subtype of delusional parasitoses (DP), which can have many etiologies.

My own patient’s larvae were well documented by others and I think I saw them during our telemedicine visits.

A few days later I had reason to remember my impromptu research.

Gail is a woman in her forties with anxiety disorder and fibromyalgia. She came in with a concern about parasites under her skin and told me two of her girlfriends and her next door neighbor also had them.

Each one of them had seen several providers including the emergency room and basically had been told they might have scabies but probably didn’t. They had all tried and failed topical permethrin.

But Gail gave me a vivid description of all the teeny-tiny parasites she saw in the bottom of the tub after she bathed off the permethrin the morning after her treatment.

She also described, in excited and dramatic language, how scraping the skin where she saw a little black “thing” would make her suddenly itch or bleed some distance away. She used descriptions like “they get angry” and “they are clever”.

I looked and I looked. I took off my -10 diopter glasses and placed my eyeballs 4 inches from her skin, spotted with blemishes of different age and size. I saw nothing that looked like insects, burrows or bites.

I offered to do some skin scrapings. Gail was pleased. As I did it, I did see her unusually thin skin start bleeding very slightly half an inch away from my sampling here and there and she said, “see, they’re on the move”.

I submitted my sample and as I wait for the path report I am thinking about what to say next.

Here is what I have learned from UpToDate:

Delusional parasitosis can be associated with a host of psychiatric conditions but can also have its root cause in tingling sensations caused by medications, from ciprofloxacin to topiramate, amantadine, ketoconazole and many others. It can be related to diseases that cause paresthesias, from Lyme disease to restless leg syndrome (Ekbom’s disease, which can be linked to iron deficiency) to diabetes and many others.

Regarding Morgellons, which my commenter suggested, UpToDate writes:

Morgellons is a syndrome characterized by symptoms that appear to be identical to delusional infestation or very similar, but with the addition of the affected patient’s beliefs that inanimate objects (such as colored strings or fibers) were present in the lesion as well.

UpToDate and many other sites, including Wikipedia, point out that one (possibly increasing) common cause of delusional parasitosis, or formication, is methadone or cocaine abuse:

Some users also report formication: a feeling of a crawling sensation on the skin also known as “coke bugs“. These symptoms can last for weeks or, in some cases, months.

So now my question is: How do I tactfully explore if the cluster of cases in my community has anything to do with meth or coke when so many other things theoretically could cause these symptoms?

10 Responses to “Morgellons? I Made the Diagnosis of DP. Now I Have to Figure Out How to Manage it.”


  1. 1 Felicity May 17, 2021 at 5:23 am

    Good morning, Doctor,
    It might be wise to speak with this foundation before you venture further.
    https://thecehf.org
    The last thing patients need is to not be believed, they can get that attitude from numerous medics but from what I’ve read having followed your blog, I’m sure you have a more open approach and willingness to learn regarding conditions you hadn’t learned about in medical school.

  2. 5 aptroed May 22, 2021 at 10:38 pm

    It’s a psychiatric disease. This does not mean I do not look very carefully, but after ruling out organic disease, it is what you are left with. An exceptional case to bring up the point: a young woman was raped at college. After a thorough sex abuse exam, with no STD’ noted, she returned to her home state. She was convinced she had contacted a disease and or parasites. She went to an OBGYN doctor and two different ID doctors, who did not find anything, but one gave her Doxycycline, just in case. After not getting any relief, she came to my practice. I could not find anything on exam and repeat STD testing. I tried to gently explain to her there was nothing there. Then she asked me for a referral to Mayo, which I gave. She needed Psychiatric help, but dismissed me as being like all the other doctors. I have treated other patients, two, but found it only reinforces their belief and delays them from Psychiatric help.

    • 6 acountrydoctorwrites May 22, 2021 at 11:37 pm

      Where I work, there are 2 (two) psychiatrists within a 200 mile radius…

      • 7 Tony Glaser May 23, 2021 at 11:56 am

        I guess you have to manage it the way you manage this lady’s fibromyalgia and her anxieties in the absence of local specialists (none of whom would likely be very helpful!) – a reasonable workup (which you have done), reassurance, supportive attitude, perhaps medications for symptomatic relief (whether for anxiety, pruritus or whatever). I try to support the patient but not the symptoms – eg. with anxious patients who keep calling with palpitations, after an EKG/Holter and whatever else may be appropriate, I tell them that the definition of palpitations is that there is a sensation of the heart beating abnormally – and once we have ruled out an abnormal heart, what we are left with is an abnormal sensation, which is a much preferable conclusion, even though the sensations may be troubling and anxiety arousing. Do tell us what the Mayo says (which department did you refer her to? Psychiatry, dermatology, ID?).

  3. 8 Mamadoc May 25, 2021 at 1:08 pm

    Have seen this a couple of times and it is VERY difficult.

  4. 9 Christopher Guzik May 31, 2021 at 7:36 am

    In my 20+ years of Family Practice, I too have had three patients with DP. All were women between 50-70 years old, all had anxiety disorder, one was also treated for ADHD, all had degenerative OA. All had a traumatic life event. All had polypharmacy with an opioid, benzodiazepine, and a psychostimulant medications. Could DP be a a form of medication induced psychosis ?


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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

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