Title : Interspecialty wound care: Case report of how psychiatry, dermatology, and plastic surgery managed a life-threatening forehead wound caused by delusional infestation and trigeminal trophic syndrome
Abstract:
Background/Significance: Delusional infestation (DI) is a somatic-type delusional disorder with dermatologic and psychological components, characterized by a fixed belief that one is infested by living or nonliving pathogens despite evidence to the contrary. Trigeminal trophic syndrome (TTS) is a rare cutaneous dysaesthesia that leads to self-induced ulcerations caused by repetitive skin-picking behavior in the trigeminal nerve distribution. Our case highlights the interplay between DI and TTS and how it can lead to severe clinical sequelae.
Case: A 60-year-old female with a history of depression and anxiety presented to our hospital with suicidal ideation and a self-inflicted 4.5cm x 1.5cm central forehead wound with exposed brain tissue and underlying infection. This severe head wound developed over nine months by use of topical salicylic acid, tweezers, and scissors to remove “sebaceous plugs,” a “dripping rhinophymatous tumor,” and “layers of bacteria” located on the nose and forehead. Dermatology diagnosed TTS based on location of the wound and history of Chiari Malformation surgery but felt that the behaviors were driven primarily by the patient’s delusions. They started carbamazepine as treatment, which is thought to reduce aberrant nerve ending paresthesias. Psychiatry was consulted and started treatment with olanzapine, and later memantine, which reduced picking behavior and urges, but not insight into the condition. The patient ultimately underwent successful flap reconstructive surgery with plastic surgery prior to discharge to a skilled nursing facility.
Discussion: Patients with TTS typically present with crescent-shaped ulcerations in the nasal ala and forehead ulcerations. In unique cases, the dysesthesia may manifest as formication, or the sensation of insects crawling on or in the skin, which can precipitate the development of DI. The incidence of DI is rare alone, and the incidence of DI co-occurring with TTS is even more rare. A literature review revealed only one case report describing two patients with co-occurrence. TTS is typically caused by nerve injury from surgical procedures, herpes zoster, trauma, brainstem infarcts, or tumors. Our patient’s corrective Chiari Malformation surgery in 2013 is presumed to have led to TTS. Case reports support the efficacy of antipsychotics, N-acetylcysteine, gabapentin, carbamazepine, and physical barriers in treating the concomitant conditions, but currently, there is no formal guideline for treatment. It is only through a multidisciplinary treatment model that patients with both conditions can reach maximal improvement.
Conclusion/Implications: This case highlights a rare co-occurrence of DI and TTS and underlines the importance of collaboration between psychiatry and dermatology in the management of these complex clinical phenomena.
