Ekbom Syndrome, also known as Delusional Parasitosis (DP), is considered a rare psychiatric condition. Based on diagnostic criteria, it is characterized by the strong belief of being infested with various parasites, as well as the presence of perceptual disturbances, usually tactile and/or visual hallucinations. The syndrome can manifest idiopathically or in connection with other medical conditions and substance use. Diagnosis is challenging, as patients tend to pursue dermatological care initially. This case report describes an 81-year-old female diagnosed with Ekbom Syndrome, presenting with severe anxiety, insomnia, and persistent delusions of infestation. Initial treatment with low-dose Risperidone (2 mg/day) was ineffective, requiring a dose escalation to 4 mg/day. However, the patient's nonadherence to follow-up limited the assessment of long-term outcomes. This case highlights key clinical challenges in elderly patients, particularly dose titration, treatment response, and adherence issues. Comparative analysis with prior case reports suggests that higher doses of Risperidone (3-6 mg/day) may be required for symptom remission, but long-term outcomes remain uncertain. Additionally, nonadherence remains a major barrier, underscoring the need for structured monitoring and caregiver involvement. These findings offer insights into antipsychotic strategies for Ekbom Syndrome, highlighting individualized pharmacotherapy, long-term follow-up, and adherence support in elderly patients.

This letter provides a concise review of the pertinent literature on visual and tactile hallucinations in elderly patients. The discussion addresses differential diagnoses and potential underlying mechanisms, as well as the psychopathology associated with tactile hallucinations, and emphasizes the necessity for investigation into the possibility of coexisting delusional infestation (parasitosis). These symptoms frequently manifest in patients with primary psychotic disorders, organic mental disorders, and substance use disorders. The proposed pathophysiological mechanisms may involve dopaminergic imbalances and dysfunction of the striatal dopamine transporter.

Ekbom syndrome, also known as delusional parasitosis (DP) or delusional infestation, is an uncommon psychiatric disorder distinguished by an enduring conviction of parasitic infestation, persisting notwithstanding the presence of medical evidence to the contrary. Primarily affecting middle-aged women, DP can manifest either as isolated psychological distress or as a component within a more intricate psychiatric framework, substantially influencing the quality of life for affected individuals. Its pathophysiological mechanism involves uncertain dopaminergic imbalances and dysfunction in the dopamine transporter system. Dermatologists often play a pivotal role in diagnosis, as patients first seek dermatological assessments of their signs and symptoms. However, DP frequently originates from underlying psychiatric disorders or medical variables, manifesting with neurological and infectious causative factors. The diagnostic complexity is attributed to patients' resolute convictions, leading to delayed psychiatric intervention. First-line DP treatment involves antipsychotics, with newer agents demonstrating promising prospects, but the lack of standardized protocols poses a significant therapeutic challenge. In this narrative review, both a comprehensive approach to this uncommon pathology and an update on the state of knowledge in this medical subfield focused on optimizing the management of DP are provided. The complexity of DP underlying its uncommon nature and the incomplete understanding of its pathophysiology highlight the need for further research through multicenter studies and multidisciplinary teams to enhance therapeutic efficacy and safety.

Delusional parasitosis is not a common presentation in hospital-based geriatric units. Our aim was to review the presentation of a sudden onset of parasitosis in an older patient who had no prior psychiatric history, and its management. This case report describes an 82-year-old man who presented with delusions of parasitosis for the past three years of his life. The report includes a longitudinal description of the patient's symptoms, signs, and manifestations during his stay at an inpatient senior mental health service center, emergency department (ED) visits, and medical floor stay along with medication management of his psychiatric symptoms with concomitant medical issues. Presentation of delusional parasitosis poses a special challenge not only psychiatrically but also medically and dermatologically. The unique difficulty of finding appropriate antipsychotics for not only the symptoms of parasitosis but also the compulsive behavior that follows a deeply ingrained belief of being infested must be carefully managed, especially in the elderly. Somatic delusions that resemble a plausible but inaccurate reality of infestations could delay treatment as well.

Ekbom's syndrome represents a relatively uncommon neuropsychiatric condition characterized by the recurrent and bizarre fixed delusional belief to be infested by small organisms or even unanimated materials ('Morgellons disease'), without any objective evidence of infestation/parasitosis. The condition, mainly diagnosed in a nonpsychiatric setting, is supposed to be largely underestimated and, hence, undermanaged. The present comprehensive review aims at investigating Ekbom's syndrome, from a historical, epidemiological, clinical and therapeutic perspective, by providing diagnostic-treatment strategies in managing this condition in routine psychiatric clinical settings. The prototypical patient is a middle-aged woman (or a younger subject in those cases in which substance and/or alcohol abuse is implicated), often single, divorced or widowed (loneliness component and social withdrawal), who has already consulted several specialists due to skin lesions associated with a firm and delusional belief to be infested. The identification and diagnosis are challenging due to poor patient's insight, poor knowledge and collaboration between specialists and differential diagnoses to be considered before asking for a psychiatric referral. Management and treatment strategies mainly derive from isolated case reports or observational studies with a small sample size. Further randomized clinical trials should be performed to evaluate the efficacy of newer antipsychotic drugs, including long-acting injectable formulations.

Dementia with Lewy bodies (DLB) is characterized by fluctuating cognitive impairments, recurrent visual hallucinations, the motor symptoms of parkinsonism and REM sleep behavior disorder. Various neuropsychiatric symptoms including hallucination and delusions occur frequently; however, delusional parasitosis is rare in DLB. Here, we report a case of DLB patient with delusional parasitosis.

The patient was an 89-year-old woman. At the age of 88, she began to complain her oral cenesthopathy, and developed cognitive decline, delusional parasitosis and parkinsonism. As a result of examination, she was diagnosed as DLB and treated with combination of donepezil 5 mg/day and aripiprazole 1.5 mg/day, and her complaint was disappeared.

Further studies are needed to investigate the association between delusional parasitosis and underlying pathophysiology of DLB, and the utility of antipsychotics for delusional parasitosis in DLB has to be examined through more cases.