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What’s up with people who think they’re infested with bugs?

Dear Cecil:

I do HIV testing and counseling and recently had a client come in for testing who had sores all over his body. He said he wanted to rule out AIDS but acknowledged that it was the least of his concerns right now. Said he has bugs crawling in his skin and nobody believes him. I wrote him off as a lunatic. What do you think?

Norm Fones, Portland, Oregon

Illustration by Slug Signorino

Cecil replies:

Well, assuming he didn’t actually have bugs — can appreciate your not wanting to check too closely — I agree with you. However, he’s a lunatic with a cool-sounding problem: delusional parasitosis, the conviction that one is infested with bugs. Some clinicians distinguish DP, also known as Ekbom’s syndrome, from entomophobia, fear of bugs without necessarily thinking they’re crawling on you, and illusions of parasitosis, an apparent bug infestation actually caused by something else (see

As one would expect in our advanced age, people with delusional parasitosis have their own support groups and Web sites, such as the one run by the National Unidentified Skin Parasite Association at and the Cutaneous Parasite Home Page at (site now defunct). The prevailing attitude at both sites is: Who you calling delusional? These suckers are real. Read these comments from the CPHP guest book and judge for yourself:

  • “On occasion I notice spiders dangling from my hair. The same type and often enough to think they be living up there. Are there any type of spiders like that? I also have a specimen that I caught alive.”
  • “I was infected with a black fly from Bolivia. I was injected with the eggs of the fly when I received infected collagen injections in my face. The collagen was not pasteurized enough to kill the organisms. I have a doctor but hasn’t got a clue what to treat it with, Filarias exit my skin looking like very fine hairs and I’ve even seen them reproduce in front of my eyes.”
  • “Have found a way to get specimens of black dots, etc. Have also found that black dots are black if they have been moving around on the floor. They are white if they have been moving around on your bed linens. They are red if they have been moving around on red fabric. I finally cleaned and cleaned until they had no dust left to hide in, and they are little black bugs with wings. They come alone or in clusters. I have been using alcohol to kill them, and when I feel them moving around in my hair, I spray my hair with alcohol and comb it. I repeat this process two or three times, and in four or five minutes they will jump out of my hair onto the table in front of me, or my bed linens, depending on where I am. Then I take Scotch tape or a Ziploc bag and collect them. I have some very good specimens now.” (Keeping collections of alleged pests in small containers — the “matchbox sign” — is considered diagnostic of DP by some dermatologists.)
  • “Hello! Can you help my wife and I, please? We have a worm that attaches to our bones. Mainly our lower spinal column. Goes in our ears, under the skin to our brain, mostly at night, and has come to our eyes and turned them bloodshot. Apple cider vinegar makes them move. . . . We can’t stand more than a day of Mintezol but it drives the worms crazy. Please help!” Sounds like a typical folie a deux, or shared delusion, which accounts for roughly one case in eight.
  • “The little uninvited guests seem to have a puzzling life cycle. . . . The ulcers have a flat, red center which looks like a skull shape (or a diamond, sometimes a circle). A scaly flake appears around the perimeter. When scratched (and it is VEEEEERRRRYYY itchy), the center does some interesting things. It moves, changes shape, opens and closes, and does not like to be poked. They ooze a serous fluid whenever you rub the skin anywhere nearby. When trying to remove one of the ‘crusts,’ whatever it is tries to pull back into the skin. A piece can be removed, but never the entire thing. Under just a magnifying glass, the excoriated chunk appears to be some kind of insect/mite holding a clear worm.”

The bane of most dermatologists’ existence, delusional parasitosis is difficult to treat. Patients tend to fall into two groups: socially isolated elderly women and a younger, more heterogeneous crowd that includes alcoholics and drug abusers suffering from “cocaine bugs.” Most refuse to see a psychiatrist and many won’t take antipsychotic drugs that have been shown to be effective, such as pimozide.

Then again, maybe they’re not cooperating because they’re not having delusions. One woman claimed that for a year she’d felt something moving in her mouth — she even had specimens. Sure, her doctor thought. Then she brought one in. It was an adult female Gongylonema (gullet worm). Even lunatics sometimes have real parasites.

Cecil Adams

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