My plane doesn’t leave till 2:30. Glad I cut off seeing patients at 11, which should give me plenty of time. I’m getting smarter in my old age.
Smooth morning, paperwork pretty much done. Just one patient left. Look, a nice little old man. He has such a sweet smile.
“How can I help you, Mr. Goldfarb?”
“It’s complicated. This letter explains everything that’s happened the past 3 years,”
Oh-oh, that doesn’t sound good. “OK, let’s have a look.”
“My, you read fast, Doctor.”
When the first line says, ‘The lice all over my body don’t go away even after I apply bug shampoo every day,’ I’m pretty much done.
“Doctor, this bag has everything I’ve used: lice shampoo, insect spray, itch lotion. I forgot to bring in all the little bugs I collected from my combs and sheets.”
No! This can’t be happening! How do I negotiate with a delusion and still make my plane?
“Sometimes it feels like bugs are crawling on my skin.”
“Itching often feels that way ... ”
“I brought pictures. Want to see?”
No! Not an album! Snap after snap: scabs on the scalp, scaling at the corners of the mouth, linear scratches on the extremities.
“You know, Mr. Goldfarb – maybe firm confidence will let me regain control of this interview – what you’re describing does not sound like lice or bugs of any kind ... ”
“But Doctor, how do you explain this?” Another photo, this of a comb filled with brownish epidermal fragments. “I meant to bring some in, but I forgot.”
Enough. Time to look grim and speak briskly. “Mr. Goldfarb, this cannot be lice because ... ”
“I see them coming out of all my pores ... ”
“Mr. Goldfarb!” Now it’s my turn to interrupt. “I would appreciate it if you would let me finish my sentence.”
“Yes, Doctor. If it’s not lice, what do you think it is?”
Must think fast. “Sensitivity. Sensitive skin, especially if you’ve scratched it, can certainly feel as though there are things crawling on you. Patients often say that the skin feels this way. I will therefore treat this sensitivity with anti-inflammatory creams and lotion you will apply to the scalp, face, and the rest of your body respectively.”
Goldfarb is still listening. I’m almost there.
“I want you to use this medication for 2 weeks without stopping, and not use any more of the bug shampoos and creams because they can be irritating and increase itch and sensitivity. Please call me on my private extension at that point with your progress.” Easier to deny a delusion when not standing face to face.
“That’s good news, Doctor. I’ll pick up the medication and let you know.”
At most, he’ll stop scratching for a while. By the time he starts again, I’ll have made my plane and come back to the office. Meantime: Depart exam room briskly!
I can still make it if I leave right away. One last check of my office e-mail. There’s one from Zelda. She has a small scaly patch on one forearm. Claims it’s responded neither to topical antifungals nor steroids.
Here’s the text of her e-mail: “Doctor, I showed my rash to my neighbor Mary. She did some Internet research, and she’s convinced it’s chromoblastomycosis. I’m pretty sure she’s right. What do you think?”
I think I better leave right now.
My reply: “Dear Zelda, pretty unlikely. Try the new cream I’m going to prescribe for 2 weeks, and let me check on how you’re doing.”
How does evil dermatologic karma know that I’m trying to leave town? Parasitosis and chromoblastomycosis! Can this be a bad dream? If so, why don’t I wake up?
Mr. Goldfarb, still looking sweet and mild, sits in the waiting room, awaiting the elder shuttle to take him home.
Walk fast. Do not smile and meet his gaze. This is no time for politeness.
No, sir. I am outta here.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Write to him at firstname.lastname@example.org.