Trichotillomania: a case report with clinical and dermatoscopic differential diagnosis with alopecia areata

ABSTRACT Trichotillomania is a psychodermatologic disorder characterized by uncontrollable urge to pull one's own hair. Differential diagnoses include the most common forms of alopecia such as alopecia areata. It is usually associated with depression and obsessive-compulsive disorder. Trichotillomania treatment standardization is a gap in the medical literature. Recent studies demonstrated the efficacy of N-acetylcysteine (a glutamate modulator) for the treatment of the disease. We report the clinical case of a 12-year-old female patient who received the initial diagnosis of alopecia areata, but presented with clinical and dermoscopic features of trichotillomania. She was treated with the combination of psychotropic drugs and N-acetylcysteine with good clinical response. Due to the chronic and recurring nature of trichotillomania, more studies need to be conducted for the establishment of a formal treatment algorithm.

Management of Delusions of Parasitosis in Dermatology: A 3-year Retrospective Study of 32 Cases / 대한피부과학회지

BACKGROUND: Delusions of parasitosis (DOP) is a psychiatric disorder in which patients have a fixed, false belief that they are infested by parasites. Management of patients with DOP presents a challenge to dermatologists, because such patients usually refuse to see a psychiatrist. OBJECTIVE: The aim of this study was to investigate the clinical manifestations and responses to treatment in DOP patients. METHODS: Between January 2010 and December 2012, the medical records of 32 DOP patients were reviewed to obtain data on clinical presentation, family history, accompanied psychiatric disorders, and treatments. RESULTS: The male-to-female ratio was 1:4.3. Twenty-two patients (68.8%) had symptoms for over 6 months. Seven patients (21.9%) had apparent skin lesions. Eighteen patients (56.3%) had a positive specimen sign. Three patients had depression, 4 had insomnia, and 2 had other delusional disorders. Eight patients (25%) reported that their family members were also experiencing itching. Six patients underwent skin biopsies, the results of which were consistent with chronic dermatitis. With pimozide treatment, 6 patients (18.8%) achieved complete remission, 17 (53.1%) showed a partial response, and 9 (28.1%) showed no response. CONCLUSION: Because DOP patients depend on dermatologists for treatment, it is crucial for dermatologists to be prepared for the proper management of this condition. This study expands our understanding of the disease and suggests the optimal methods of treatment. Further studies on socioeconomic data and selection of effective antipsychotics are needed.

Síndrome de Ekbom secundária a transtorno orgânico: relato de três casos / Secondary Ekbom Syndrome to organic disorder: report of three cases

A Síndrome de Ekbom, também conhecida como delírio de parasitose ou acarofobia, é um estado fóbico obsessivo no qual o paciente pensa, imagina ou acredita que está infestado por parasitas na pele. Em estado alucinatório, retira fragmentos de pele, identificando-os como parasitas. Pode tratar-se de um quadro psiquiátrico primário ou secundário a outros transtornos orgânicos. Geralmente, esses pacientes demoram a procurar ajuda médica, e o dermatologista, quase sempre, é o primeiro profissional procurado. Descrevemos o caso de três pacientes dos quais apresentaram delírio de parasitose, associados a transtornos orgânicos.

The Ekbom syndrome, also known as delusion of parasitosis or acarophobia is an obsessive phobic state in which the patient thinks, imagines or believes that his or her skin is infested by parasites. In the hallucinatory state, he/she removes parts of the skin, identifying them as parasites. It can be primary or secondary to other organic or psychiatric diseases. Generally speaking these patients take a long time to seek for medical support and the dermatologist is almost always the first physician to see them. Here we describe three patients with delusional parasitosis associated with organic disorders.

Delirio de parasitosis: a propósito de doce casos / Delusion of parasitosis: report of twelve cases

En el presente trabajo se da cuenta de la historia del síndrome delirante crónico conocido como "delirio de parasitosis o síndrome de Ekbom", sus principales características clínicas, evolutivas, la ubicación nosográfica y las estrategias terapéuticas utilizadas. Los hallazgos de la principal literatura publicada se comparan con la experiencia de los autores al haber estudiado doce pacientes portadores de esta sintomatología. Asimismo, se indaga acerca de la posible conexión con otros cuadros psicopatológicos, más específicamente con el espectro obsesivo-compulsivo.

In this paper, the history of the chronic delusional syndrome known as delusional parasitosis or Ekbom syndrome is reviewed as well as its main clinical characteristics, evolution, nosographic position and therapeutic approaches. The findings in the published literature are compared with the clinical experience of the authors who have studied twelve cases. The possible connection with other mental diseases, specifically Obsessive Compulsive Spectrum, is evaluated.

Effects of psychotropic drugs on the thrombin-induced liberation of arachidonate in human platelets

To compare the effects of chlorpromazine [CPZ], prochlorperazine [PCP], trifluoperazine [TFP], clozapine [CLO], haloperidol [HPD], quetiapine [QTP], pimozide [PMZ], and olanzapine [OLP] as well as the tricyclic antidepressants amitriptyline AMI, imipramine IMI, and nortriptyline NTP on thrombin-induced liberation of arachidonic acid AA in platelets. This work was carried out at the Department of Biomedicine, University of Bergen, Norway in 2006-2007. Human platelets pre labelled with [3H] arachidonate were incubated with thrombin in the absence and presence of the drugs, and the amount of free [3H] arachidonate liberated was determined. Myosin light chain [MLC] phosphorylation was determined in [32P] phosphate-labelled platelets after sodium dodecyl sulfate polyacrylamide gel electrophoresis. The effects of the drugs on the molecular area and surface pressure of phospholipid monolayers were determined in the Langmuir apparatus. All drugs reduced arachidonate liberation with the ranking order of increasing potency: OLP. The mechanisms for reduction of arachidonate liberation is thought to interfere with activation of cytosolic phospholipase A2 [cPLA2] by alteration of the PLA2 phospholipid substrate structure in platelet membranes

Tratamento famacológico da neuralgia do trigêmeo: revisão sistemática e metanálise / Pharmacological treatment of trigeminal neuralgia: systematic review and metanalysis

JUSTIFICATIVA E OBJETIVOS: A neuralgia do trigêmeo é uma síndrome de dor crônica, caracterizada por paroxismos de dor excruciante que afeta de maneira dramática a qualidade de vida dos pacientes acometidos. A terapia medicamentosa sistêmica é considerada o tratamento de primeira linha para esta doença. Este estudo teve como objetivo avaliar a eficácia, a segurança e a tolerabilidade dos diversos tratamentos farmacológicos oferecidos aos pacientes com neuralgia do trigêmeo, visando fornecer evidências para as recomendações da prática clínica e identificar as necessidades de pesquisas adicionais. MÉTODO: Foram analisados ensaios clínicos aleatórios e controlados, publicados até julho de 2003, sobre o efeito analgésico das drogas prescritas no tratamento da neuralgia do trigêmeo. A análise estatística foi realizada com o auxilio do programa Review Manager 4.2.2 (Colaboração Cochrane, 2003). RESULTADOS: Os resultados da metanálise sugerem que a carbamazepina é mais eficaz que o placebo. Em três estudos controlados comparando a lamotrigina, o topiramato e o cloridrato de proparacaína ao placebo, somente a lamotrigina mostrou-se superior a ele. O dextrometafano foi comparado ao lorazepam em baixas doses, havendo aumento da dor com o uso daquele fármaco. Três estudos compararam a carbamazepina com a tizanidina, a tocainida e a pimozida, mostrando-se apenas a pimozida superior à carbamazepina. CONCLUSÕES: A carbamazepina continua como droga de escolha para o tratamento da neuralgia do trigêmeo, estando a lamotrigina e a pimozida indicadas em casos refratários à terapia convencional. Além disso, estudos adicionais são necessários para o estabelecimento de futuras opções terapêuticas.

Diagnosis and Treatment of Tic Disorders

Tics are brief, rapid and repetitive movement and sounds that are either simple or complex in presentation. Tics can be preceded by a premonitory urge (sensation) that decreases after tic is completed. The fourth edition of Diagnostic Statistical Manual of Mental Disorder (DSM- IV) includes diagnoses for Tourettes disorder, chronic motor or vocal tic disorder, transient tic disorder and tic disorder not otherwise specified (Table 1) according to the duration of tic symptoms and degree of complexity. The purposes of treatment of tic disorders must be set up based on the comprehensive evaluation of developmental profiles, strength, weakness, family situation, and school adaptation status. The family education must be included early in treatment process and psychosocial treatment including the cognitive behavioral therapy will be needed to develop and maintain the self-efficacy in controlling the tic symptoms. The most effective and efficient method for the reduction of tic symptoms, however, are drug treatment. The pharmacotherapy is usually one component of treatment for chronic tic disorder and Tourettes disorder. The gold standard for tic reduction is the dopaminergic receptor blocking agent (or antipsychotic agent, neuroleptics). The primary drugs are haloperidol, pimozide, and risperidone. Among theses, risperidone will be the primary choice because of its low side effect profiles, esp, neurologic side effects. In the near future, the studies on the efficacy of the olanzapine, quetiapine and ziprasidone will be more reported. As second line drugs, clionidine, guanfacine, nicotine related drugs can be considered.

Effect of Ca2+-channel Blockers on Norepinephrine Release in the Rat Hippocampal Slice and Synaptosome

The aim of this study was to investigate the role of Ca2+-channel blockers in norepinephrine (NE) release from rat hippocampus. Slices and synaptosomes were incubated with [3H]-NE and the releases of the labelled products were evoked by 25 mM KCl stimulation. Nifedipine, diltiazem, nicardipine, flunarizine and pimozide did not affect the evoked and basal release of NE in the slice. But, diltiazem, nicardipine and flunarizine decreased the evoked NE release with a dose-related manner without any change of the basal release from synaptosomes. Also, a large dose of pimozide produced modest decrement of NE release. omega-conotoxin (CTx) GVIA decreased the evoked NE release in a dose-dependent manner without changing the basal release. And omega-CTxMVIIC decreased the evoked NE release in the synaoptosomes without any effect in the slice, but the effect of decrement was far less than that of omega-CTxGVIA. In interaction experiments with omega-CTxGVIA, omega-CTxMVIIC slightly potentiated the effect of omega-CTxGVIA on NE release in the slice and synaptosomal preparations. These results suggest that the NE release in the rat hippocampus is mediated mainly by N-type Ca2+-channels, and that other types such as L-, T- and/or P/Q-type Ca2+-channels could also be participate in this process.

Trigeminal neuralgia: current concepts and management.

Trigeminal neuralgia is the most frequent cranial neuralgia, the incidence being 1 per 1,000,00 persons per year. It presents with stabbing pain often in the distribution of the mandibular and maxillary divisions of the trigeminal nerve. An accurate history of pain is important in the diagnosis of trigeminal neuralgia. A patient with tic douloureux and no neurological abnormality on clinical examination does not need diagnostic tests. The available options for management of trigeminal neuralgia are: Pharmacotherapy, destructive procedures and non-destructive procedures. The pharmacotherapy includes (i) monotherapy with one anticonvulsant, (ii) combined therapy with more than one anticonvulsant, (iii) add-on therapy with newer drugs and (iv) polytherapy with anticonvulsant + add-on drugs + antidepressants/anxiolytics. Destructive procedures include (i) non-surgical methods--injections along trigeminal pathways, percutaneous trigeminal radiofrequency thermocoagulation and (ii) surgical methods--trigeminal branch avulsion or peripheral neurectomy, avulsion of trigeminal nerve, trigeminal tractotomy, radiosurgery. Though various modalities of treatment are available for the management of trigeminal neuralgia, pharmacotherapy with carbamazepine still remains the first line of treatment. The alternative approach followed at most centres is percuatenous Gasserian rhizolysis (chemical/radiofrequency thermal) or microvascular decompression.

Correlación entre niveles plasmáticos de pimozida y psicopatología del trastorno delirante / Correlation between plasmatic pimozide levels and psychopathology of delusional disorder

Se estudió la correlación entre niveles plasmáticos de pimozida y la psicopatología del trastorno delirante. Método: en un estudio doble ciego, cruzado con un esquema ABA; se administró pimozida(2-12 mg/día) por 6 semanas, a siete pacientes con trastorno delirante según criterios del DSM-III-R, luego placebo por cuatro semanas y nuevamente pimozida por otras seis semanas. Semanalmente fueron evaluados mediante BPRS y se determinaron los niveles plasmáticos de pimozida semanales mediante cromatografía líquida de alta resolución(HPLC). En tres de los siete pacientes la administración de pimozida se correlacionó significativamente con la mejoría clínica medida según el BPRS. La pimozida sólo produjo una mejoría discreta en los pacientes con trastorno delirante. La determinación de niveles plasmáticos es una estrategia útil en el estudio de la terapéutica farmacológica de estos trastornos

Síndrome de Gilles de La Tourette / Gilles de La Tourette's syndrome

Relata-se caso de criança cuja evoluçäo com tiques, distúrbio comportamental e coprolalia permitiu o diagnóstico de síndrome de Gilles de la Tourette. Filha adotiva, com história de ascendentes naturais desconhecida. Exames complementares sem alteraçöes específicas (EEG, tomografia computadorizada e ressonância magnética do encéfalo). Resposta clínica satisfatória à terapêutica com clonidina e haloperidol, associada à psicoterapia de apoio. Conclui-se que pacientes com idade inferior a 18 anos, apresentando sintomas de doença obsessivo-compulsiva ou hiperatividade com déficit de atençäo, associados a tiques, deveräo ser considerados como possíveis portadores de síndrome de Gilles de la Tourette

Terapéutica farmacológica del trastorno delirante / Pharmacologic treatment of delusional disorder

La literatura disponible acerca de la terapéutica del trastorno delirante sugiere que esta entidad no responde bien a los tratamientos neurolépticos habituales. Varios trabajos informan de casos que responden a pimozida, luego de no haber respondido a otros antipsicóticos. No obstante, se carece de estudios controlados. Por este motivo no es posible llegar a conclusiones definitivas al respecto

A Case of Delusions of Parasitosis Responsive to Pimozide / 대한피부과학회지

Delusions of parasitosis is a type of monosymptomatic hypochondrial psychosis and is defined as the fixed belief that one is infested with living organisms, in t.he abscence of any objective evidence that such infestation exists. A 43 year-old woman had a 2-month history of generalized pruritus and skin ulceration on the buttock representing dermatitis artefacta. She also complained of seeing small black insects crawling on her whole body skin, especially on the pubic area without evidence of cutaneous invasion by the parasites. She had no evidence of other medical diseases. She was treated with oral pimozide, starting with 1mg/day to 3mg/day. In two weeks, clinical symptoms and false belief that she is infested with parasites subsided.

Trastorno delirante con delirio de tipo somático / Delusional disturbance with delirium of somatic type

The delusional disturbance is characterized by the presence of persistent delusions that are not bizarre, which cannot be attributed to schizophrenia, mood state disorders, substance abuse or ornagic brain disease. We report a 37 years old male that presented the disease during tha last seven years and had very little response to a 2 months course of pimozide, a neuroleptic whose effectiveness in this disease has been suggested

Neurolépticos: os legítimos e verdadeiros antimanicomiais / Neuroleptic: the real antimanicomial drug

O autor analisa o advento dos neurolépticos e suas conseqüências. Faz ampla revisão do tema abordando a farmacologia destas substâncias, os aspectos clínicos, principais indicações e efeitos colaterais. Conclui mostrando o verdadeiro alcance antimanicomial dos neurolépticos

Effect of pimozide on the increase of muscarinic receptors caused by mazindol and apomorphine in the rat cerebral motor cortex

The effects of pimozide, mazindol and apomorphine on muscarinic receptors in homogenates of rat cerebral motor cortex were measured by binding assays, using 3H-N-methylscopolamine (3H-NMS) alone as ligand (for the measurement of M1- and M2-like receptors) or in the presence of carbachol or pirenzepine for determination of M1- and M2-like receptors, respectively. Female Wistar rats (150g) were treated daily for one week with pimozide, a dopaminergic antagonist (10 and 20 mg/Kg, po, by gavage), or with apomorphine (1mg/Kg,ip). In another ser of experiments, animals were treated with pimozide and 30 min later with mazindol (10 mg/Kg, po, by gavage) or apomorphine. The drugs were administered daily for one week. Controls received the same volume of saline. 3H-NMS binding was increased from the control value of 418 ñ 17 ñ 42 fmol/mg protein by administration of mazindol (10mg/Kg) but binding was reduced to 360 ñ 11 fmol/mg protein upon administration of pimozide (20mg/Kg) plus mazindol (10mg/Kg. Similarly 10 mg/ Kg pimozide reduced the increase in M1-like receptors caused by mazindol from 262 ñ to 220 ñ 20 fmol/mg protein. Although 20 mg/Kg pimozide alone produced a decrease in M1-plus M2-like receptors (from 418 ñ 17 to 348 ñ 22 fmol/mg protein), its action was preferentially on M2-like receptors, decreasing them from 148 ñ 10 to o ñ 15 fmol/mg protein in the control and treated groups, respectively. At the higher dose, 20 mg/Kg pimozide also inhibited the 3 H-NMS binding (M1-plus M2-like receptors) in the presence of apomorphine (263ñ25 vs 418 ñ 17 fmol/mg protein...

Delusional parasitosis--study of 3 cases.

Delusional disorder-somatic (parasitosis) type is a rare psychiatric disorder which poses a challenge to diagnostic and therapeutic skills. Pimozide, a highly specific dopamine blocker has shown promising results in the 3 cases illustrated here. These cases were seen over a period of 3 years. All the three patients believed that an insect has entered through the ear and is burrowing tracts/laying multiple eggs. They approached the ENT surgeons or neurosurgeon with a fear that their brain will be invaded. On psychiatric evaluation, no past or present history of major psychiatric illness was found. Premorbid personalities were well adjusted. Only for two patients, acute moderate stressors were detected. Delusions disappeared by the end of 2 wks but therapy was continued for 5 months.

Síndrome de Gilles de la Tourette e seu tratamento farmacológico: relato de dois casos / Tourette syndrome and its pharmacological treatment: two case reports

A síndrome de Gilles de la Tourette (SGT) é um distúrbio de caráter flutuante e crônico, caracterizado por tiques motores e vocais involuntários. A SGT tem sido subdiagnosticada devido à ênfase em uma etiologia exclusivamente psicológica, bem como a critérios imprecisos. O haloperidol é seu tratamento habitual desde aproximadamente 1961. O pimozide vem sendo apontado como mais efetivo na SGT, devido a uma quantidade menor de efeitos sedativos e extrapiramidais, e assim proporcionando maior aderência ao tratamento. Apresentamos dois casos de SGT onde säo discutidos aspectos terapêuticos