British Association of Dermatologists (BAD) guidelines for managing adults with delusional infestation (DI) 2022 was developed for the BAD Clinical Standards Unit. The overall objective of the guideline is to provide up-to-date, evidence-based recommendations for managing DI in adults.

The guidelines recommend to:

• Engage with patients, family/caregivers and undertake entire history and physical examination.
• Undertake appropriate investigations to screen for an underlying organic condition. Look for a neurological disorder, substance use or another specific systemic disease. Assess for signs of psychiatric disorder or significant psychological distress and risk of harm to self and others.
• Treat the index case first in the case of shared delusion. For adults with DI, offer antipsychotics early. Tailor the choice of treatment as per the patient’s need.
• Consider referral to a psychodermatology service, where available. Undertake regular reviews to evaluate treatment response, side effects and adherence. Offer treatments of at least 1 year after the symptom has resolved, and restart treatment if symptoms recur following treatment cessation.

First-line antipsychotic recommendations include amisulpride, olanzapine and risperidone. These medications have the most available evidence for efficacy and a better side-effect profile than first-generation antipsychotics, especially in the elderly. Treatment with antipsychotics is recommended until symptoms have resolved, and then continue up to 1 year before slow dose reduction. Consider referral to a psychodermatology service, where available. 

Although the guidelines provide guidance for management for adults with suspected DI, it is necessary to conduct epidemiological studies (to assess the incidence and prevalence), clinical trials (to establish the effectiveness of psychological therapies), investigate the etiopathogenesis and establish cost-effectiveness in the future.

Source: Ahmed A, Affleck AG, Angus J, et al; British Association of Dermatologists′ Clinical Standards Unit. British Association of Dermatologists guidelines for the management of adults with delusional infestation 2022. Br J Dermatol. 2022;187(4):472-80.