Summary
The Psychodermatology service at Bart’s Health has transformed the way in which patients with Delusional Infestation (DI) are managed. DI is a rare, primary psychiatric condition, that presents primarily to dermatologists because of its cutaneous nature. Patients believe they have living organisms, or non-living objects, emanating from their skin. There is a high disease burden and low social functioning, making this a very debilitating condition with which to live. Screening blood and urine tests were introduced to investigate the primary and secondary causes of DI. A serum prolactin monitoring system was used to ascertain and monitor treatment adherence. In addition, a patient information leaflet was developed for people with DI. This is being refined based on patient feedback, which has been positive to date. A database of over 1000 patients has been compiled, which has enabled Bart’s Health to evaluate the outcomes of the patients seen and conduct further research into this cohort of patients. Guidelines for managing DI, led by Dr Ahmed, were published as a Cochrane review in 2019.
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Method
Developing a holistic management programme for DI required a multifaceted approach. A combined assessment model was instituted, whereby the psychiatrist and dermatologist consulted with the patient in the same space. New patients were allocated a 45-minute consultation and a follow-up of 30 minutes (both carry an MDT tariff). The team looked out for iatrogenic causes of DI, based on an observational study conducted in 2016. The study indicated that DI was brought about by a prescribed treatment in some patients. Baseline blood investigations were organised for all patients (pruritis screen/to rule out undiagnosed chronic kidney/liver disease/thyroid disorders). Urine toxicology screening was conducted for all individuals. Evidence published by Bart’s Health demonstrated that patients might not declare their use of recreational drugs, which could precipitate and exacerbate DI. Serum prolactin testing was introduced as a baseline, along with monitoring, as over 90% of individuals experienced raised prolactin levels on antipsychotics. Devising the patient information leaflet required a multi-centre collaboration with dermatologists and psychiatrists. Patient involvement was sought through surveys to understand their existing knowledge of the condition and the questions they had.
Results
Robust monitoring systems have been developed to monitor and manage the DI patients. Pharmacological treatment of DI is effective, particularly in a combined dermatology/psychiatry clinic. Most treated patients have a good prognosis, and a remission period can be expected. However, more than 25% of patients may relapse when they stop treatment, the greatest risk being within the first few months of discontinuation. These patients may require longer treatment courses, or long-term maintenance therapy for symptom control, although further studies are needed to provide recommended guidelines on drug and dosing regimen. Patients maintained in a psychodermatology setting that recognises the condition and provides holistic care have better long-term outcomes.
Sustainability and Spread
The holistic management service for patients with DI is delivered as part of the psychodermatology clinic at the Royal London Hospital. This clinic has been established for over a decade, with ongoing and dedicated funding for one consultant psychiatrist and three consultant dermatologists. It is a national, tertiary referral centre that accepts patients from anywhere in the United Kingdom. This clinic has been used as a service model and there are now two other established national referral centres for psychodermatology that offer similar holistic management for patients with DI. The main findings from the service and the cumulative service experience are being translated into guidelines for the management of DI that will be made accessible to dermatologists. This process has involved engagement with stakeholders, as well as patient involvement. The guidelines will allow the holistic approach to be communicated to dermatologists and psychiatrists and support their learning in this area. The service is subject to annual performance audits to ensure continual improvement of service delivery. The service is well known to dermatologists and psychiatrists, with a high acceptance rate of referral, and it is valued in its expertise in managing a complex group of patients.
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