Scabies

Scabies is an infestation by the mite Sarcoptes scabiei, usually spread by skin-to-skin contact,
characterized by generalized intractable pruritus often with minimal cutaneous findings. The
diagnosis may be easily missed and should be considered in a patient of any age with persistent
generalized severe pruritus.
Synonym: Chronic undiagnosed scabies is the basis for the colloquial expression, "the 7-year
itch."
Epidemiology and Etiology
Age of Onset
Young adults (usually acquired by body contact); elderly and bedridden patients in the hospital
(contact with mite-infested sheets); children (often 5 years). Nodular scabies more common in
children.
Etiology
S. scabiei var. hominis. Thrive and multiply only on human skin. Mites of all developmental
stages burrow/tunnel into epidermis shortly after contact, no deeper than stratum granulosum;
deposit feces in tunnels. Females lay eggs in tunnels. Burrow 2 to 3 mm daily. Usually burrow at
night and lay eggs during the day. Female lives 4 to 6 weeks, laying 40 to 50 eggs. Eggs hatch
after 72 to 96 h. In classic scabies, about a dozen females per patient are present. In
hyperkeratotic or crusted scabies, >1 million mites may be present, or up to 4700 mites/g skin.
Incidence
Estimated at 300 million cases/year worldwide. In the past, epidemics occurred in cycles every
15 years; the latest epidemic began in the late 1960s but has continued to the present.
Demography
Major public health problem in many less-developed countries. In some areas of South and
Central America, prevalence is about 100%. In Bangladesh, the number of children with scabies
exceeds that of children with diarrheal and upper-respiratory disease. In countries where human
T cell leukemia/lymphoma virus (HTLV-I) infection is common, generalized crusted scabies is a
marker of this infection, including cases of adult T cell leukemia/lymphoma.
Transmission

Mites transmitted by skin-to-skin contact as with sex partner, children playing, or health care
workers providing care. Mites can remain alive for >2 days on clothing or in bedding; hence,
scabies can be acquired without skin-to-skin contact. Patients with crusted scabies shed many
mites into their environment daily and pose a high risk of infecting those around them, including
health care professionals.
Risk Factors
In nursing homes, risk factors include age of institution (>30 years), size of institution (>120
beds), ratio of beds to health care workers (>10:1).
Pathogenesis
Hypersensitivity of both immediate and delayed types occurs in the development of lesions other
than burrows. For pruritus to occur, sensitization to S. scabiei must take place. Among persons
with their first infection, sensitization takes several weeks to develop; after reinfestation, pruritus
may occur within 24 h. Various immunocompromised states or individuals with neurologic
disease predisposed to crusted Norwegian scabies. Infestation is usually by only approximately
10 mites. In contrast, the number of infesting mites in crusted scabies may exceed a million.
History
Patients are often aware of similar symptoms in family members or sexual partners. Patients with
crusted scabies are usually immunocompromised (HIV disease, organ transplant recipient) or
have neurologic disorders (Down's syndrome, dementia, strokes, spinal cord injury, neuropathy,
leprosy).
Incubation Period
Onset of pruritus varies with immunity to the mite: first infestation, about 21 days; reinfestation,
immediate, i.e., 1 to 3 days.
Duration of Lesions
Weeks to months unless treated. Crusted scabies may be present for years.
Skin Symptoms
Pruritus
Intense, widespread, usually sparing head and neck. Itching often interferes with or prevents
sleep. Often present in family members. One-half of patients with crusted scabies do not itch.
Rash

Ranges from no rash to generalized erythroderma. Patients with atopic diathesis scratch,
producing eczematous dermatitis. Other individuals experience pruritus for many months with no
rash. Tenderness of lesions suggests secondary bacterial infection.
Physical Examination
Skin Findings
Common cutaneous findings can be classified: lesions occurring at the sites of mite infestation,
cutaneous manifestations of hypersensitivity to mite, lesions secondary to chronic rubbing and
scratching, secondary infection. Variants of scabies in special hosts including those with an
atopic diathesis, nodular scabies, scabies in infants/small children, scabies in the elderly, crusted
(Norwegian) scabies, scabies in HIV disease, animal-transmitted scabies (zoonosis), scabies of
the scalp, dyshidrosiform scabies, urticarial/vasculitis scabies, and bullous scabies.
Lesions at Site of Infestation
Intraepidermal Burrows
Gray or skin-colored ridges, 0.5 to 1 cm in length (Figs. 26-16, 26-17, and 26-18), either linear
or wavy (serpiginous), with minute vesicle or papule at end of tunnel. Each infesting female mite
produces one burrow. Mites are about 0.5 mm in length. Burrows average 5 mm in length but
may be up to 10 cm. In light-skinned individuals, burrows have a whitish color with occasional
dark specks (due to fecal scybala). Fountain-pen ink applied to infested skin concentrates in
tunnels, highlighting and marking the burrow. Blind end of burrow where mite resides appears as
a minute elevation with tiny halo of erythema or as a vesicle.

Figure 26-16

Scabies: webspace Papules and burrows in typical location on the finger web. Burrows are tan
or skin-colored ridges with linear configuration with a minute vesicle or papule at the end of the
burrow; they are often difficult to define.

Figure 26-17

Scabies Multiple, crusted, and excoriated papules and burrows on the penile shaft.

Figure 26-18

Scabies Papules and burrows on the lateral foot; in young children, the feet and neck are often
infested, sites usually spared in older individuals. In this adult case, there was massive
infestation of the foot.

Distribution
Areas with few or no hair follicles, usually where stratum corneum is thin and soft, i.e.,
interdigital webs of hands > wrists > shaft of penis > elbows > feet > genitalia > buttocks >
axillae > elsewhere (Image 26-1). In infants, infestation may occur on head and neck.

Image 26-1

Scabies: Predilection sites Burrows are most easy to identify on the webspace of the hands,
wrists, lateral aspects of the palms. Scabietic nodules occur uncommonly, arising on the
genitalia, especially the penis and scrotum, waist, axillae, and areolae.

Scabietic (Scabious) Nodule

Inflammatory papule or nodule (Fig. 26-19); burrow sometimes seen on the surface of a very
early lesion.

Figure 26-19

Scabietic nodules: penis, scrotum Red-brown papules and nodules on the penis and scrotum;
these lesions are pathognomonic for scabies, occurring at sites of infestation in some
individuals.

Hyperkeratosis/Crusting Psoriasiform
In areas of heavily infested crusted scabies, well-demarcated plaques covered by a very thick
crust or scale (Figs. 26-20, 26-21, and 26-22). Warty dermatosis of hands/feet with nail bed
hyperkeratosis. Erythematous scaling eruption on face, neck, scalp, trunk.

Figure 26-20

Crusted scabies: buttocks An eczematous dermatitis on the buttock in a chronic care facility
patient. Pruritus, may be mild, and the diagnosis of scabies missed for months, during which
time staff and other patients become infested.

Figure 26-21

Crusted scabies: chest, axilla, arm An eczematous dermatitis with lichen simplex chronicus in
an HIV-infected male with chronic pruritus.

Figure 26-22

Crusted scabies Crusted erythematous papules becoming confluent over the elbow; numerous
pustules are seen associated with secondary S. aureus infection.

Cutaneous Manifestations of Hypersensitivity to Mite

Pruritus
Some individuals experience only pruritus without any cutaneous findings.
"Id" or Autosensitization-Type Reactions
Characterized by widespread small urticarial edematous papules mainly on anterior trunk, thighs,
buttocks, and forearms.
Urticaria
Usually generalized.
Eczematous Dermatitis
At sites of heaviest infestation: hands, axillae (Figs. 26-20 and 26-21).
Lesions Secondary to Chronic Rubbing and Scratching
Excoriation, lichen simplex chronicus, prurigo nodules. Generalized eczematous dermatitis.
Psoriasiform lesions. Erythroderma.
Atopy
In individuals with atopic diathesis, atopic dermatitis occurs at sites of excoriation, most
commonly on the hands, webspaces of hands, wrists, axillae, areolae, waist, buttocks, penis,
scrotum. In adults, the scalp, face, and upper back are usually spared; but in infants, the scalp,
face, palms, and soles are involved.
Postinflammatory Hyper- and Hypopigmentation
Especially in more deeply pigmented individuals.
Secondary Infection
S. aureus or Group A Streptococcus Infection
(Fig. 26-22) Impetiginized excoriations (crusted, tender, surrounding erythema), ecthyma,
folliculitis, abscess formation; lymphangitis, lymphadenitis; cellulitis; bacteremia, septicemia.
Acute poststreptococcal glomerulonephritis reported associated with streptococcal
impetiginization.
Variants of Scabies in Special Hosts

Infants/Young Children
Atypical lesions: vesicles, pustules, nodules; generalized; lesions concentrated on
hands/feet/body folds. Head, palms, soles are not spared. Difficult to differentiate from infantile
acropustulosis, which may be a postscabietic nonspecific reaction.
Elderly
Altered inflammatory response may delay diagnosis. In bedridden patients, lesions may be
concentrated on the back. Bullous scabies can mimic bullous pemphigoid.
Nodular Scabies
Nodular lesions develop in 7 to 10% of patients with scabies. Nodules are 5 to 20 mm in
diameter, red, pink, tan, or brown in color, smooth (Fig. 26-19). A burrow may be seen on the
surface of early nodule.
Distribution
Penis, scrotum, axillae, waist, buttocks, areolae (Image 26-1). Resolve with postinflammatory
hyperpigmentation. May be more apparent after treatment, as eczematous eruption resolves.
Upper back, lateral edge of foot (infants). Nodules are usually countable.
Crusted or Norwegian Scabies
Predisposing factors: glucocorticoid therapy, Down's syndrome, HIV disease, HTLV-I infection,
organ transplant recipients, elderly. May begin as ordinary scabies. In others, clinical appearance
is of chronic eczema, psoriasiform dermatitis (Figs. 26-21 and 26-22), seborrheic dermatitis, or
erythroderma. Lesions often markedly hyperkeratotic and/or crusted.
Distribution
Generalized (even involving head and neck in adults) or localized. Scale/crusts found on dorsal
surface of hands, wrists, fingers, metacarpophalangeal joints, palms, extensor aspect of elbows,
scalp, ears, soles, and toes. In patients with neurologic deficit, crusted scabies may occur only in
affected limb. May be localized only to scalp, face, finger, toenail bed, or sole.
General Findings
Lymphadenopathy in some cases.
Differential Diagnosis
Pruritus, Localized or Generalized, Rash

Adverse cutaneous drug reaction, atopic dermatitis, contact dermatitis, fiberglass dermatitis,
dyshidrotic eczema, dermatographism, physical urticaria, pityriasis rosea, dermatitis
herpetiformis, animal scabies, pediculosis corporis, pediculosis pubis, lichen planus, delusions of
parasitosis, metabolic pruritus.
Pyoderma
Impetigo, ecthyma, furunculosis.
Nodular Scabies
Urticaria pigmentosa (in young child), papular urticaria (insect bites), Darier's disease, prurigo
nodularis, secondary syphilis, pseudolymphoma, lymphomatoid papulosis, vasculitis.
Crusted Scabies
Psoriasis, eczematous dermatitis, seborrheic dermatitis, erythroderma, Langerhans cell
histiocytosis.
Laboratory Examinations
Microscopy
Finding the Mite
A healthy adult with scabies has an average of 6 to 12 adult mites infesting the body. Highest
yield in identifying a mite is in typical burrows on the finger webs, flexor aspects of wrists, and
penis. A drop of mineral oil is placed over a burrow, and the burrow is scraped off with a no. 15
scalpel blade and placed on a microscope slide.
Conventional Microscopy
A drop immersion of mineral oil is placed on the scraping, which is then covered by a coverslip.
Three findings are diagnostic of scabies: S. scabiei mites, their eggs, and their fecal pellets
(scybala) (Fig. 26-23).

Figure 26-23

Burrow with Sarcoptes scabiei (female), eggs, and feces Under a microscope, a mite at the
end of a burrow with seven eggs and smaller fecal particles obtained from a papule on the

webspace of the hand.

Dermoscopy
Characteristic image of scabies, "jet-with-contrail" image.
Dermatopathology
Scabietic burrow: located within stratum corneum; female mite situated in blind end of burrow.
Body round, 400 m in length. Spongiosis near mite with vesicle formation common. Eggs also
seen. Dermis shows infiltrate with eosinophils. Scabietic nodules: dense chronic inflammatory
infiltrate with eosinophils. In some cases, persistent arthropod reaction resembling lymphoma
with atypical mononuclear cells. Crusted scabies: thickened stratum corneum riddled with
innumerable mites.
Hematology
Eosinophilia in crusted scabies.
Cultures
S. aureus and GAS cause secondary infection.
Diagnosis
Clinical findings, confirmed, if possible, by microscopy (identification of mites, eggs, or mite
feces). Assiduous search for burrows or papules should be made in every patient with severe
generalized pruritus. Sometimes when the mite cannot be demonstrated, a "therapeutic test" will
clinch the diagnosis.
Course and Prognosis
Pruritus
Often persists up to several weeks after successful eradication of mite infestation, understandable
in that the pruritus is a hypersensitivity phenomenon to mite antigen(s). If reinfestation occurs,
pruritus becomes symptomatic within a few days. Most cases resolve after recommended
regimen of therapy. Glomerulonephritis has followed GAS secondary infection. Bacteremia and
death have followed secondary S. aureus infection of crusted scabies in an HIV-infected patient.
Delusions of parasitosis can occur in individuals who have been successfully treated for scabies
or have never had scabies.
Crusted Scabies

May be impossible to eradicate in HIV-infected individuals. Recurrence more likely to be relapse

than reinfestation.
Nodular Scabies
In treated patients, 80% resolve in 3 months but may persist up to 1 year.
Management
Principles of Treatment
Infested individuals and close physical contacts should be treated at the same time, whether or
not symptoms are present. Topical agents are more effective after hydration of the skin, i.e., after
bathing. Application should be to all skin sites, especially the groin, around nails, behind ears,
including face and scalp. Sexual partners and close personal or household contacts within last
month should be examined and treated prophylactically.
Scabicides
Choice of scabicide based on effectiveness, potential toxicity, cost, extent of secondary
eczematization, and age of patient. Permethrin is effective and safe but costs more than lindane.
Lindane is effective in most areas of the world, but resistance has been reported. Seizures have
occurred when lindane was applied after a bath or used by patients with extensive dermatitis.
Aplastic anemia after lindane use was also reported. No controlled studies have confirmed that
two applications are better than one. Clean clothing should be put on afterwards. Clothing and
bedding are decontaminated by machine-washing at 60C. Pruritus can persist for up to 1 to 2
weeks after the end of effective therapy. After that time, cause of persistent itching should be
investigated.
Recommended Regimens
Permethrin 5% Cream Applied to all areas of the body from the neck down. Wash off 8
to 12 h after application. Adverse events very low.
Lindane (-Benzene Hexachloride) 1% Lotion or Cream Applied thinly to all areas of the
body from the neck down; wash off thoroughly after 8 h. Note: Lindane should not be
used after a bath or shower, and it should not be used by persons with extensive
dermatitis, pregnant or lactating women, and children younger than 2 years. Mite
resistance to lindane has developed in North, Central, and South America and Asia. Low
cost makes lindane a key alternative in many countries.
Alternative Regimens
Crotamiton 10% Cream Applied thinly to the entire body from the neck down, nightly for
2 consecutive nights; wash off 24 h after second application.
Sulfur 2 to 10% in Petrolatum Applied to skin for 2 to 3 days.

Benzyl Benzoate 10% and 25% Lotions Several regimens are recommended: swabbing
only once; two applications separated by 10 min, or two applications with a 24-h or 1week interval. 24 h after application, preparation should be washed off and clothes and
bedding changed. The compound is an irritant and can induce pruritic irritant dermatitis,
especially on face and genitalia.
Benzyl Benzoate with Sulfiram Several regimens are recommended: swabbing only once:
Esdepallethrine 0.63%
Malathion 0.5% Lotion
Sulfiram 25% Lotion Can mimic effect of disulfiram; no alcoholic drinks should be
consumed for at least 48 h.
Ivermectin 0.8% Lotion
Systemic Ivermectin
Ivermectin, 200 g/kg PO; single dose reported to be very effective for common as well as crusted
scabies to be repeated in 15 to 30 days. Average adult dose is 15 mg. Two to three doses,
separated by 1 to 2 weeks, usually required for heavy infestation or in immunocompromised
individuals. May effectively eradicate epidemic or endemic scabies in institutions such as
nursing homes, hospitals, and refugee camps. Not approved by U.S. Food and Drug
Administration or European Drug Agency.
Infants, Young Children, Pregnant/Lactating Women
Permethrin or crotamiton regimens or precipitated sulfur ointment should be used with
application to all body areas. Lindane and ivermectin should not be used.
Crusted Scabies
Scabicides
Lindane should be avoided because of risk of CNS toxicity. Multiple scabicide applications are
required to all the skin. Treatment should also be directed at removing scale/crusts that protect
mites from scabicide; nails should be trimmed. Oral ivermectin combined with topical therapy is
most effective. Control of dissemination is essential and includes isolation of patient, avoidance
of skin-to-skin contact, use of gloves/gowns by staff, prophylactic treatment of contacts (entire
institution and visitors or family members).
Decontamination of Environment
Bedding, clothing, and towels should be decontaminated (machine washed or machine dried
using heat cycle or dry-cleaned) or removed from body contact for at least 72 h. Thorough
cleaning of patient's room or residence.
Treatment of Eczematous Dermatitis
Antihistamines

Systemic sedating antihistamine such as hydroxyzine hydrochloride, doxepin, or

diphenhydramine at bedtime.
Topical Glucocorticoid Ointment
Applied to areas of extensive dermatitis associated with scabies.
Systemic Glucocorticoids
Prednisone 70 mg, tapered over 1 to 2 weeks, gives symptomatic relief of severe hypersensitivity
reaction.
Postscabietic Itching
Generalized itching that persists a week or more is probably caused by hypersensitivity to
remaining dead mites and mite products. Nevertheless, a second treatment 7 days after the first is
recommended by some physicians. For severe, persistent pruritus, especially in individuals with
history of atopic disorders, a 14-day tapered course of prednisone (70 mg on day 1) is indicated.
Secondary Bacterial Infection
Treat with mupirocin ointment or systemic antimicrobial agent.
Scabietic Nodules
May persist in association with pruritus for up to a year after eradication of infestation.
Intralesional triamcinolone, 5 to 10 mg/mL into each lesion, is effective; repeat every 2 weeks if
necessary.
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Fitzpatrick Dermatology Atlas The Color Atlas and Synopsis of Clinical
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