The challenge of Morgellons diseaseREFERENCESCOMMENTARYThe challenge of Morgellons diseaseCaroline S. Koblenzer, MDPhiladelphi a, PennsylvaniaTwo letters that describe patients with ‘‘Mor-gellons disease,’’ appearing in this month’sissue of the Journal, serve to remind us thatthe spectrum of those with cutaneous dysesthesia isbroad indeed. Though we cannot yet delineate thepathway exactly, some of the mechanisms by whichthe itch sensation is generated and transmitted are nowunderstood,1-3andwefeelthatwehavesomesortofagrip on winter itch, itching in the elderly, the infantwith atopic dermatitis,4,5or urticaria, lichen planus,and others of the recognized pruritic dermatoses.Less well understood are other sensations thatpatients may describe to us, such as crawling, biting,stinging, pricking, burning, shooting, and so forth.These sensations may be focal or generalized, andwhile some patients may present to us with no visiblechange in the skin—those with brachioradial pruri-tus,6for example—others, reporting that the discom-fort is relieved only by picking, squeezing, or pullinghair, present with neurotic excoriations, prurigonodularis, or trichotillomania.7,8A separate group of patients are those unfortunatefew who have an inherent need to ‘‘know’’ and tounderstand what is going on with their skin. Thesepatients, made very anxious by the vacuum in theirknowledge, and perhaps also by their inability toattain relief from professionals will, with great inge-nuity, ‘‘create’’ a ‘‘cause’’ for their symptoms, whichmakes logical sense to them, and with which theycan be comfortable. Because of the nature of thesensation, many of these patients believe themselvesto have an infection or infestation, and we are ofcourse all familiar with the syndrome of delusions ofparasitosis, or Ekbom’s disease,6,9-12as is describedin the two letters.This condition12has recently reverted to the namegiven by Sir Thomas Browne in 1674, to anapparently identical symptom complex, Morgellonsdisease.15What is remarkable in Sir ThomasBrowne’s description, in the literature referencesover the past 75 years,6,11-14and in the complaints ofour patients today, is the extraordinary similaritiesthat they all describe—in the quality of the sensorychanges experienced, in the level of the patient’sdistress, in the various and ingenious interpretationsof what may be happening in the skin, and in theongoing and desperate search for relief. The patientsare virtual carbon copies, one of the other.The clinical picture is unmistakable. The patient isintensely anxious, is obsessively focused on his orher symptoms, brings ‘‘specimens’’ of the offendingagent, or agents, and is unshakable in his or her beliefas to the cause. Usually there will be a logicalexplanation of exactly how the infection or infestationwas contracted, and the patient will have resorted tothe most extreme measures both to eradicate it andto prevent contagion.6,9-12Furniture is discarded,clothing burned, and close physical contact denied.Tragically, grandmothers will not touch their grand-children—for although the condition may occur atany age, and in both sexes, elderly women livingalone are the most common demographic.It is important for us to realize that, just as thepatient describes, the sensation that is experienced isin the skin. It is understandable, therefore, that thepatient is not open to the idea of pathology in themind, the nervous system, or the brain. It is alsoimportant for us to distinguish delusional beliefs fromphobic concerns or obsessional worries, a distinctionthat caused some confusion in the past13and that isimportant, because both the psychopathology andthe treatment are different between the three.11The syndrome may be seen in association with anumber of psychiatric conditions, including bipolardisorder, paranoia, schizophrenia, depression, andabuse of drugs, such as cocaine, amphetamines, orritalin. In the past, a delusion of parasitosis was oftenconsidered to be a monosympomatic hypochodria-cal psychosis,13but it has been my experience thatthis is a rather restricted view, and that psychiatric co-morbidity, such as depression, anxiety, or personalitydisorder, can usually be uncovered during a carefulinterview, when more florid psychopathology is notFrom the Department of Dermatology, University of Pennsylvania.Funding sources: None.Conflicts of interest: None identified.Correspondence to: Caroline S. Koblenzer, MD, 1812 Delancey Pl,Philadelphia, PA 19103. E-mail: [email protected] Am Acad Dermatol 2006;55:920-2.0190-9622/$32.00ª 2006 by the American Academy of Dermatology, Inc.doi:10.1016/j.jaad.2006.04.043920evident. The syndrome has also been reported inassociation with a number of medical conditions thatare characterized by itching, such as renal disease,malignant lymphoma, hepatic disease, etc.6,11Today, the informed dermatologist may be any-where from doctor number five to number ten ormore in this patient’s search for relief, and the patientwill, in the interim, have raised both heaven and hellin a frantic attempt to solve the problem that hasliterally taken over his or her life. Today, the internetfurther complicates an already difficult situation, aswe see in the two letters in this Journal,asourpatients share every facet of their condition, everytheory as to cause, and every attempt at relief,however far-fetched, with their fellow sufferers.This sharing, and a tremendous amount of suffer-ing, have given rise to the formation of ‘‘TheMorgellons Research Foundation,’’ an organizationdevoted to ‘‘researching an emerging infectious dis-ease,’’16with a medical board that boasts five MDsand an RN. Interestingly, none are dermatologists. Aninternet search for ‘‘bugs in the skin’’ will bring one tothe Foundation’s Web site,16and as Murase et al17point out, the information therein may be verymisleading to someone who suffers from delusionsof parasitosis. One reads of cellulose fibers, fiberswith ‘‘autofluorescence,’’ fuzz balls, specks, granules,strongyloides stercoralis, cryptococcus neoformans,‘‘alternative cellular energy pigments,’’ and varioustypes of bacteria for which potent antibiotics areprescribed, in the ever broadening spectrum ofpossible ‘‘pathogens.’’ In no case does one read ofpositive confirmatory tests, though many tests areundertaken. As Murase et al17note, one also reads ofnumerous associated medical and