Running head: PEDIATRIC CASE STUDY: SCABIES 1

Pediatric Case Study: Scabies

Alyssa Matulich

University of Tennessee Chattanooga

 PEDIATRIC CASE STUDY: SCABIES 2

Scabies is a highly contagious infection caused by the mite Sarcoptes scabiei that

burrows into the epidermis ("CDC-Scabies," 2010). For the purpose of this case study a six-year-

old Hispanic male who presented to his school nurse with intense itching and a rash will be used

for reference. Scabies is a relatively common disease but remains a neglected public health

problem (Hay, Steer, Engelman, & Watson, 2012). This case study will look at the prevalence,

recent research, diagnoses, and treatments of scabies.

Epidemiology

Scabies is a common disease that can affect people of any socioeconomic status, gender,

ethnic groups, and age (Fitch & Gaylord, 2017). Globally scabies effects one hundred thirty

million people at any time (Goldstein & Goldstein, 2018). The highest prevalence has been seen

in the Pacific region and Latin America due to the hot, tropical climates (Goldstein & Goldstein,

2018). Scabies infections easily spread in crowded conditions, so institutions like prisons, long-

term care facilities, and child care facilities commonly have epidemics of scabies infestations

("World Health Organization," n.d). Regions with limited resources are also seen to have a

higher incidence of scabies as well as communities where overcrowding and poverty coexist

(Goldstein & Goldstein, 2018). Women and children are the populations most often affected

(Fitch & Gaylord, 2017). Urban communities are more likely than rural communities to see

scabies and the outbreaks are more likely to occur in winter months ("World Health

Organization," n.d). In adults, scabies is typically sexually transmitted (Goldstein & Goldstein,

2018).

Evidence-Based Research

Scabies was added to the World Health Organization list of neglected tropical diseases in

2013. In 2014 alone, there were more reported outbreaks than in the last ten years. In 2010 alone
 PEDIATRIC CASE STUDY: SCABIES 3

the are estimated to have more than 1.5 million disability-adjusted life years which are years of

life lost to premature mortality plus years lived with disability. In areas that have a high

prevalence of scabies it was found that scabies is a major contributing factor to bacterial skin

infections as well as serious complications affecting the renal and cardiovascular systems.

The United States Center for Disease Control and Prevention guidelines for treating

scabies include the recommended regimens of permethrin 5% cream followed by oral ivermectin

("CDC," 2015). The alternative regimen is lindane 1% lotion ("CDC," 2015). Permethrin is

preferred because it is safe effective and less expensive than ivermectin ("CDC," 2015). Lindane

is an alternative because it can cause toxicity ("CDC," 2015). Children less than fifteen

kilograms should not be given ivermectin and children less than 10 years of age should not be

treated with lindine ("CDC," 2015). Patients with human immunodeficiency virus, HIV, should

receive the same as HIV negative patients ("CDC," 2015).

In other countries treatment of scabies varies. In Canada the first line treatment for

scabies is permethrin 5% cream and oral ivermectin is not available (Banerji, 2015). European

guidelines state that treatment varies depending on the country and the availability of

medications, but the recommendations are similar to the United states with permethrin 5% cream

and oral ivermectin but also includes benzyl benzoate lotion which has been seen to be a cheaper

and effective option (Salavastru, Chosidow, Boffa, Janier, & Tiplica, 2017). The European

guidelines also include malathion 0.5% aqueous lotion, topical 1% ivermectin, and topical

Sulphur (Salavastru et al., 2017). The United Kingdom guidelines state that benzyl benzoate is

no longer a recommendation because it has been found to cause skin irritation and is less

effective than permethrin 5% cream (Sashidharan, Basavaraj, & Bates, 2016). Japanese

guidelines do not include permethrin cream because it is not available. The first line treatment in
 PEDIATRIC CASE STUDY: SCABIES 4

Japan is phenothrin lotions followed by topical sulfur agents and ivermectin (Ishii et al., 2017).

Benzyl benzoate is only used when other treatment options have failed (Ishii et al., 2017).

Subjective Data

Medical Spanish translator used for interview

PATIENT IDENTIFIERS:

J.P., 6-year-old Hispanic male, established patient at the clinic. Patient’s mother present

at visit.

CHIEF COMPLAINT (CC):

“My arms are really itchy and have bumps”

HISTORY OF PRESENT ILLNESS (HPI):

Mother states patient has been complaining of itching on arms for the past two days. She

states that the child has been scratching his hands, wrists, arms and neck. Rash in not present on

face or palms. tching seems to be worse at night. She has given the child some Benadryl to help

with the itching with very little relief. No one else in the family or home has a similar rash. Child

has no other associated symptoms like fever, cough, sore throat, or congestion.

Past Medical History:

Mother states that patient’s overall health is good. Denies any illness or diagnoses.

Patient has had no surgeries or hospitalizations. Pt has a history of 2 previous scabies infections.

Last infection was a year a little over a year ago in January 2017. Patient has had 3 hepatitis B

vaccines, 4 Hib vaccines, 5 Dtap vaccines, 4 polio vaccines, 2 hepatitis A vaccines, 3 rotavirus

vaccines, 4 P13 vaccines, 2 MMR vaccines, and 2 varicella vaccines. Pt is eligible for flu vaccine

today. No history of blood transfusions, no psychiatric history.

ALLERGIES & REACTIONS:

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No known drug allergies

PERSONAL HISTORY:

Patient is a kindergarten student in Bradley county. Patient is the youngest of three

children and was born in the United States. His family moved to the U.S from Guatemala a year

before he was born. Just recently, in November 2017, the family moved to Chattanooga from

Texas. Primary language is Spanish which is spoken at home. Patient speaks and understands

English. Patients biological parents are married. Mother reports that she does not work, and

father works for a construction company. Patient lives in a three-bedroom home with a total of

fifteen people. His mother, father, 2 brothers and himself live in one bedroom while two other

families live in the remaining two bedrooms.

SOCIAL HISTORY:

The patient has no tobacco use, no social alcohol use, no illicit drug use. Health insurance

is Tenn Care. He lives 20 minutes from nearest hospital. Lower class economic status. Hispanic

culture. Mother denies any history of violence, abuse, or neglect. Mother denies exposure to

toxins such as lead or air pollution. No one in the child’s home or immediate family smokes or

uses tobacco products. Access to food, clean water, electricity, shelter with 15 others. Exercises

in school 30- 45minutes three times a week. Patient has working smoke detectors in home. Pt

eats three meals a day with breakfast and lunch eaten at school during the week. Mother reports

dinner and meals at home on weekends are well rounded and consist of protein, vegetable, fruit

and dairy. No dietary restrictions.

HEALTH MAINTENANCE:
 PEDIATRIC CASE STUDY: SCABIES 6

Mother states last PE was November 2017 with all lab work performed within normal

range, no records available. Mother states PE was done at health department in Texas. Patient

wears a seat belt when riding in an automobile and uses a helmet when riding a bike.

FAMILY HISTORY:

No history of cancer, DM, heart disease, or stroke, hypertension. Mother is overweight

and had gestational diabetes with the last pregnancy in 2016. Translator described medical terms

and conditions to mother in Spanish.

CURRENT MEDICATIONS & TREATMENTS:

Denies the use of prescribed and over the counter medications, vitamins, or supplements.

REVIEW OF SYSTEMS:


General: Denies fever, chills, malaise, fatigue, night sweats. 


Diet: Denies change in appetite, restriction in diet, taking vitamins or supplements

Skin, Hair, Nails: Reports having a rash with small red bumps on hands and arms. States the

rash is extremely itchy and is worse at night. No pigment changes or changes in hair or nails.

Head and Neck: Denies headache, dizziness, head injuries, loss of consciousness

Eyes: Denies Blurring, double vision, visual changes, wears glasses, no trauma, denies eye

disease.

Ears: Denies hearing loss, pain, discharge, dizziness, ringing in ears

Nose: Denies congestion, nosebleeds, postnasal drip, allergies

Throat and mouth: Denies hoarseness, sore throat, bleeding gums, ulcers, tooth problems

Gastrointestinal: Denies indigestion, heartburn, vomiting, constipation, stool changes

Lymph: Denies tenderness and enlargement

 PEDIATRIC CASE STUDY: SCABIES 7

Endocrine: Denies intolerance to heat or cold, changes in weight, excessive thirst or urination,

hair changes, or a change in hat, glove or shoe size.

Cardiovascular: Denies chest pains, palpitations, swelling, exercise intolerance. Sleeps with one

pillow

Chest and Lungs: Denies cough, sputum, shortness of breath, dyspnea on exertion, night sweats,

and exposure to TB

Hematology: Denies anemia and easy bruising

Genitourinary: denies pain with urination, flank pain, urgency, frequency, nocturia, hematuria,

and dribbling

Male: Denies puberty onset and testicular pain

Musculoskeletal: Denies joint pain, warmth in joints, or swelling in joints

Neurologic: Denies fainting, weakness, loss of coordination

Mental status: Denies trouble concentrating, sleeping, eating, socializing, changes in mood, or

suicidal thoughts

Objective

Physical Examination

VS: HR 67, O2Sat 98%, Temp 98.4, RR 22 Weight: 50th percentile, Height 25th percentile,

BMI 50th percentile

General Appearance: 6 years old, Hispanic, male, posture and gait intact, clean and dressed

appropriately for season.

Mental Status: A&O x3, makes appropriate eye contact, able to answer questions appropriately,

No speech impediment.
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Head, Neck, Throat: Head normocephalic, oval without deformities. Hair is clean, black, evenly

distributed throughout without infestation. Temporal arteries without bruits. Trachea midline

without tugging. Cervical range of motion intact. Carotid arteries symmetrical, pulse waveform

with distinct beginning and end without bruit. Thyroid symmetrical, no enlargement, no

tenderness, no lumps. No jugular venous distension. No lymphadenopathy.

Eyes symmetrical, irises brown, pupils equal and reactive to light bilaterally. Conjunctiva pink,

Sclera white, no drainage or discharge bilaterally. No strabismus. No nystagmus. Normal eye

movement bilaterally. Visual fields intact bilaterally.

Ears rounded, even with outer eye canthus, helix firm bilaterally. Ear lobes symmetrical. No

deformities, no lesions, no drainage externally. Internal auditory canal without drainage, redness,

edema, pain, and tenderness bilaterally. Tympanic membrane visible, grey, translucent without

inflammation. PE tubes present bilaterally. Landmarks visible, cone of light at 5 o clock in right

ear and 8 o’clock in left ear.

Nose and Mouth appropriate size for face, color confluent with entire face. Nasal mucosa pink

and moist no turbinates visible. No discharge, no sinus swelling or tenderness. Septum midline.

Lips pink, moist, symmetrical. Buccal mucosa pink and moist without lesions. Teeth clean,

without braces, no dental carries. Gums pink and moist without bleeding and tenderness. Tongue

soft, pink, midline with full range of motion intact. Tonsils +1 without swelling, exudate, or

drainage. Uvula midline. Hard and soft palates intact. Palatine arch rounded.

Skin, Hair, Nails: skin uniformly warm and dry, resilient, turgor < 2, no edema. Tan in color,

olive overtones. Small pinpoint erythematous papules disseminated on the fingers, interdigital

spaces, wrists, extensor aspects of the arms, and neck. Excoriation marks noted on arms. Hair has
 PEDIATRIC CASE STUDY: SCABIES 9

male distribution pattern. Nails are nontender, medium length, clean, without deformities. Nail

bed pink, nail base 160 degrees, no redness, exudate, or swelling around folds.

Chest/Lungs: Skin pink and warm. No pallor. No cyanosis. AP/Lateral Ratio 1:2, no barrel

chest, no pectus excavatum, no pectus carinatum. Chest movement symmetrical, Respirations

equal and regular, non-labored, no accessory muscle use. Chest expansion symmetrical.

Resonance on percussion over all lung fields. Breath sounds clear in all fields. No adventitious

breath sounds.

Heart/blood vessels: PMI nondisplaced at 5th intercostal space at the midclavicular line.

Regular heart rate and rhythm. S1 and S2 equal. No splitting, no murmurs, no bruits, no lifts, no

heaves, no thrills. Carotid pulses equal bilaterally with crescendo and decrescendo, rate regular.

No JVD. Pulses 2+ bilaterally on upper and lower extremities. No edema.

Abdomen: Skin pink, no venous pattern visible. Abdomen rounded and symmetric. No

distension. Umbilicus midline, no herniations, no masses. Bowel sounds active in all four

quadrants. No hepatomegaly, no splenomegaly. Tympany predominant in all four quadrants. No

tenderness on palpation.

MS: Gait is even, equal stride and appropriate base support. Curvature of cervical, thoracic, and

lumbar spine is appropriate. No kyphosis, no lordosis. Joints appropriate size and contour with

no swelling or crepitus. All joints have full range of motion. Muscle strength 5/5 in all

extremities. No edema, spasms, masses, atrophy, hypertrophy in any muscle groups bilaterally.

Neuro: Awake, alert3. Coordination and fine motor skills intact. All reflexes 2+ bilaterally.

Diagnoses

Scabies (ICD-B86)- the most common symptoms are itching, which is typically worse

at night, and a popular rash that affect much of the body like between the fingers, wrist, elbow,
 PEDIATRIC CASE STUDY: SCABIES 10

armpit, penis, nipple, waist, buttocks, and shoulder blades ("CDC-Scabies," 2010). Tiny burrows

may be seen on the skin and appear las grayish-white likes on the skins surface ("CDC-Scabies,"

2010).

CPT: 99214 office visit for an established patient with 2 key components: detailed history and

exam.

Differential Diagnoses

Atopic dermatitis (ICD-L20.9)- the clinical presentation of eczema includes dry skin,

itching which may be severe at night, red to brownish- gray patches, small raised bumps,

thickened and cracked scaly skin ("Mayo Clinic-Eczema," 2018). Contact dermatitis (ICD-

L30.9)- Areas of the body that have come into contact with a reaction-causing substance have a

rash that develops with minutes to hours of exposure and may experience swelling, burning or

tenderness ("Mayo Clinic- contact dermatitis," 2018). The rash is typically red and itchy with

dry, cracked, scaly skin ("Mayo Clinic- contact dermatitis," 2018). The bumps and blisters may

ooze and crust ("Mayo Clinic- contact dermatitis," 2018).

Pediculosis (ICD-B85.2-) Body lice clinical presentation includes intense itch and rash

that typically affects the mid-section of the body ("CDC-lice," 2013). Impetigo (ICD-L01.00)-

Lesion begin as papules and progress to vesicles on an erythematic bed (Baddour, 2018). Honey

colored golden adherent crusts may form. Lesions can be found on face and extremities

(Baddour, 2018). Regional lymphadenitis can be an associated symptom, but other systemic

symptoms are absent (Baddour, 2018).

Treatment Plan

This patient has been diagnosed with scabies. Diagnosis was based on the history given

by the patient and physical examination. The recommended first-line treatment for this patient is
 PEDIATRIC CASE STUDY: SCABIES 11

permethrin 5% cream. Permthrin acts on the nerve cell membrane by disrupting the sodium

channel which paralyses the mite. The prescription for this patient would be for permethrin 5%

cream to applied from the neck down and washed off after 8-14 hours and can be repeated in 14

days (Epocrates, 2018). Permethrin was chosen because it was successful in treating past scabies

infections in the patient.

Along with treating the patient with permethrin 5% cream the mother was instructed to

treat the entire family, especially his siblings who sleep in the same bed. The mother was told to

decontaminate bedding, clothing in towels by washing them in hot water and putting them in the

dryer. If the patient has stuffed animals, they should be placed in the dryer or sealing in a

garbage bag for at least 72 hours. The patient does not meet the criteria for a referral at this time.

The patient in this case study is six years old and according to Erikson’s developmental

stages experiencing industry versus inferiority. It is in this stage that a school aged child becomes

capable of deductive reasoning. The child becomes interested in how things are made, how

something works, and why certain things occur. Social institutions like school come into play

during this stage and play an important role in the child’s development (Elkind, n.d.). For this

patient who is experiencing scabies it is important to get the infection under control so that

school is not missed. This six-year-old is experiencing episodes of intense itching at night which

is disrupting his sleep habits and can affect his success in school. This patient will also have to

miss school until treatment has been established for 24 hours. Unfortunately, this child has

experienced scabies infections before and if not controlled and treated properly have continue

having infections resulting in more missed school. Missing school may affect this child’s

performance in a negative way which will have a negative effect on his self-confidence that is

beginning to develop during this stage. In order to foster this child’s self-confidence, the parents
 PEDIATRIC CASE STUDY: SCABIES 12

should encourage independence, self-responsibility, and praise accordingly at home (Hagan,

Shaw, & Duncan, 2017). As far as the patient’s treatment for scabies the mother will need to

assist the patient with applying the permethrin cream, but the child should be encouraged to do

as much of it on his own as possible. Written instructions were given to the mother in Spanish

and in English. The mother was able to verbally repeat the instructions and stated she had no

questions about the patient’s treatment.

Anticipatory Guidance

When a child comes in for a physical exam it is important to discuss point of anticipatory

guidance with parents. This child is currently up to date on his vaccines, but it is important to

make his mother aware that he will need additional vaccines at age eleven before he begins

seventh grade in the state of Tennessee and an annual physical exam. According to the shot

record available during the appointment the patient did not receive the flu vaccine so discussing

the flu vaccine with the mother would also be beneficial. Discussing social determinants of

health should be a topic of discussion according to Bright Futures This child and his family are

of low economic status so discussing safety concerns, food availability, and the child exposure to

toxins and violence should be considered. Bright Futures recommends talking to the child about

bullying and contacting community resources if the family is in need. As far as safety is

concerned the child should be wearing a seatbelt, using a helmet when riding a bike, swimming

only when supervised, using sunscreen, and should be made aware signs of sexual abuse. With

all of the school shooting that have been occurring in our society firearm safety should be

discussed with both the parent and child (Hagan et al., 2017).

When discussing the child’s growth and development oral health, nutrition, and physical

activity should make up a large part. This child should be visiting the dentist twice a year,
 PEDIATRIC CASE STUDY: SCABIES 13

brushing his teeth twice a day, and flossing once a day. The parents should be helping the child

establish healthy eating habits encouraging the child to eat breakfast, drinking milk two to three

times a day, limiting sugary drink and foods, and stopping when they feel satisfied. The

importance of physical activity should also be emphasized. This child is getting exercise during

school hours, but he should be encouraged to be active for one hour every day (Hagan et al.,

2017).

Cultural Implications

Hispanics are the largest ethnic minority in the United States with one in six people being

Hispanic ("Hispanic Health CDC," 2015). Heart disease and cancer are the two leading causes of

death in Hispanics ("Hispanic Health CDC," 2015). Compared to whites Hispanics are 50%

more likely to die from diabetes or liver disease ("Hispanic Health CDC," 2015). Hispanics are

23% more likely to be obese and 24% more likely to have uncontrolled high blood pressure than

whites ("Hispanic Health CDC," 2015). With these statistics in mind this child should be

monitored for obesity and educated about healthy diet and exercise to prevent comorbidities like

cardiac disease, diabetes, and hypertension.

The patient in this case study lives in a home with other Hispanic families within a small

Hispanic community in Chattanooga, TN. His family still practices Hispanic customs and eats

Hispanic foods. As he gets older, he may struggle with his cultural identity since his he and his

family are now living in the southeastern United States. As he assimilates to the new culture, he

may have a hard time finding a balance of the Hispanic and American lifestyle.

Appropriate Screenings

Appropriate screenings for this patient were determined using the US Preventative

Services Task Force. For a six-year-old the only B recommendation is an obesity screening. Risk
 PEDIATRIC CASE STUDY: SCABIES 14

factors for childhood obesity that apply to this patient include low family income, inadequate

sleep, parental obesity and gestational diabetes ("USPSTF," 2017). Hypertension screening begin

at age three at well-child visits and should be monitored annually ("USPSTF," 2017).

Cost Implications of Treatment

The patient’s insurance will cover the cost of the office visit today. The cost of 1 tube of

5% permethrin cream is approximately $84.00. With the patient’s insurance, the cost of the

medication will be less. The patient’s mother was informed about using a coupon from GoodRx

to reduce price to $42.00. The mother stated they will stop to get the prescription on the way

home at the pharmacy five minutes from their home. In order for the treatment to be successful

the entire family needs to be treated. The mother states that she and the father do not have

insurance, but the rest of her children do. She states that she is unsure if she can afford treating

the entire family and will have to discuss it with the child’s father. She states she understands the

importance of the treatment. Mother told that if she cannot afford the treatment, we can change

the prescription to ivermectin which costs approximately $18.00. Mother states that she would

prefer to use the cream because she knows it works and it is easier to treat the children with.

Conclusion

Scabies is a common highly contagious illness found among people who live in

populated areas and in poverty. Scabies is a neglected disease that can be found around the world

especially in developing countries. Treatment of scabies is straightforward but in order for the

treatment to be successful the patient and entire family need to be treated as well as treating

bedding, towels, and clothing. Nurse practitioners should be aware of the condition as well as the

risk factors for scabies in order to accurately treat the infection and prevent further complications

like impetigo or renal and cardiac problems.

 PEDIATRIC CASE STUDY: SCABIES 15

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