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Yan BY, Jorizzo JL. Management of Morgellons Disease With Low-Dose Trifluoperazine. JAMA Dermatol. 2018;154(2):216–218. doi:10.1001/jamadermatol.2017.5175
Morgellons disease is a poorly understood condition characterized by delusions of cutaneous infiltration by microbes and/or inanimate materials. Current management involves building a strong therapeutic alliance, treating cutaneous lesions, and using low-dose antipsychotics.1-3 Our study examines the novel use of low-dose trifluoperazine, a high-potency typical antipsychotic, in this patient population.
This is a Weill Cornell Medical College institutional review board–approved retrospective medical record review of adult patients with Morgellons disease who presented to our dermatology department between September 1, 2006, to August 31, 2016. Inclusion criteria included age 18 years or older and at least 2 visits with a single investigator (J.L.J.). Patients with clinicopathological evidence of another dermatologic process were excluded.
The main outcomes examined were clinical response, time to remission, and adverse effects. Partial remission was defined as patient-reported improvement, and at least 50% lesion clearance as determined by the same physician. Baseline function was defined as at least 90% lesion clearance and no patient-reported distress from perceived skin infiltrates.
Patients received empathetic counseling concordant with published recommendations,3 including using formication as a dermatologic sign. Trifluoperazine was initiated at 1 mg/d at bedtime, with uptitration of 1 mg/d every month according to the clinical picture. Patients were assessed for extrapyramidal findings and mood changes during follow-up visits.
Twenty-four patients met inclusion criteria (Table 1). Four patients were excluded; Table 2 provides a clinical overview. The mean (range) follow-up time was 11.2 (0.9-39.8) months.
With our management approach, 7 patients (29%) returned to baseline function. Fifteen patients (63%) achieved at least 50% improvement. The average dosage for 50% to 90% and at least 90% improvement was 1.9 mg/d and 2.3 mg/d, respectively. Four patients (17%) reported minor adverse effects, with the most common being drowsiness (2 patients), which resolved with time.
The mean (range) time to at least 50% and 90% disease control was 2.4 (0.9-5.0) months and 6.6 (3.2-13.1) months, respectively. Of patients who achieved baseline function, all had median dosages of 2 mg/d and remained in remission at their last visit, with a mean (range) remission time of 10.0 (3.0–18.2) months.
When comparing patients receiving median dosages of 1 mg/d and 2 mg/d, the median time to partial remission for both groups was 2.1 months, with a median (interquartile range [IQR]) duration of response of 2.3 (1.9-2.6) months and 4.7 (2.9-12.6) months, respectively. Of patients with median dosages of 1 mg/d, 50% achieved partial responses. Among patients with median dosages of 2 mg/d, 10 (71%) achieved at least partial responses and 7 (50%) achieved baseline function, with a median (IQR) duration of remission of 9.9 (3.7-15.4) months.
Research on antipsychotic therapies for Morgellons disease remains limited. Pimozide, a typical antipsychotic, was historically favored, partly because of its antipruritic properties.1 Nowadays, as with other medications, the decision between pimozide and other antipsychotics involves considering their efficacy and profiles of adverse effects.1,4
Our findings, with 63% of patients achieving partial or full remission, are concordant with published results using pimozide and atypical antipsychotics, although direct comparisons are difficult owing to heterogeneity of the studies.1 Moreover, our finding that a higher dosage of trifluoperazine is associated with a longer duration of response and a greater percentage of patients achieving remission suggests a positive dose-response relationship.
Similar to the antipruritic effects of pimozide, low-dose trifluoperazine has analgesic effects from its opioid-receptor system interactions.5 Moreover, consistent with our observations, trifluoperazine at low dosages up to 4 mg/d has limited to no adverse effects.6 Given the comparative safety, cost-effectiveness, and clinical efficacy, we propose the use of low-dose trifluoperazine for Morgellons disease. Future studies comparing various typical and atypical antipsychotics in a controlled setting are needed.
Corresponding Author: Bernice Y. Yan, BS, Department of Dermatology, Weill Cornell Medical College, 1305 York Ave, 9th Floor, New York, NY 10021 (email@example.com).
Correction: This article was corrected on February 14, 2018, to fix errors in data in the last paragraph of the Results section.
Published Online: January 10, 2018. doi:10.1001/jamadermatol.2017.5175
Author Contributions: Ms Yan and Dr Jorizzo had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Both authors.
Acquisition, analysis, or interpretation of data: Both authors.
Drafting of the manuscript: Yan.
Critical revision of the manuscript for important intellectual content: Both authors.
Statistical analysis: Both authors.
Administrative, technical, or material support: Both authors.
Study supervision: Jorizzo.
Conflict of Interest Disclosures: Dr Jorizzo has served on the Advisory Board and received honoraria from Amgen. No other conflicts are reported.