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reatment of crusted scabies with albendazole: A case report

Thaer Douri MD, A Z Shawaf MD


Dermatology Online Journal 15 (10): 17

Ministry of Health, Syria-Hama. s-dori@scs-net.org


Abstract

Crusted scabies is a severe variant of scabies caused by the ectoparasite Sarcoptes


scabiei. It is characterized by high mite burden, extensive hyperkeratotic scaling,
crusted lesions, variable pruritus, generalized lymphadenopathy, erythroderma, and
eosinophilia, in some cases. There is an increased incidence of crusted scabies,
particularly among patients with HIV infection. We describe a 22-year-old Syrian
immunocompetent female who had hyperkeratotic psoriasiform plaques and
hyperkeratosis without itching. She was treated with oral albendazol and topical
crotamiton with salicylic acid 5 percent.

Case report

Figure 1

Figure 2

A 22-year-old Syrian female had hyperkeratotic psoriasiform lesions of her axillae,


anterior flexors, and the dorsum of her hands without itching (Figs. 1-4); the lesions
had started two years previously and they were treated as psoriasis plaques without
benefit.

Figure 3

Figure 4

Her skin examination revealed large erythematous, hyperkeratotic, scaly plaques on


the trunk, abdomen, and extremities, as well as numerous small erythematous
papules with scattered excoriations around the umbilicus. Her head, as well as her
palmoplantar surfaces and nails were free of any lesions.

Itching was absent. The patient had no history of significant medical problems and
her general physical examination was normal. Laboratory exams were normal and
HIV negative.

The presence of itching in the patient's family members made us concerned about a
possible diagnosis of scabies.

Figure 5

Figure 6

Figure 7
A biopsy was made: The epidermis shows marked hyperkeratosis, acanthosis, and
burrows in the subcorneal layer containing female mites and feces (Figs. 5-7); the
diagnosis of crusted scabies was made.

She was successfully treated with 800 mg of albendazole with fatty meals for 3
consecutive days and an application of a 5 percent salicylic acid in crotamiton twice
daily for 1 week (Figs. 8 & 9). Her family was treated with benzyl benzoate 25
percent.

Figure 8

Figure 9

Discussion

Crusted scabies is a severe variant of scabies caused by the ectoparasite Sarcoptes


scabiei. The condition is characterized by high mite burden, extensive
hyperkeratotic scales, crusted lesions, variable pruritus, generalized
lymphadenopathy, erythroderma, and eosinophilia, in some cases. Crusted scabies
may masquerade as hyperkeratotic eczema, psoriasis, Darier disease, and contact
dermatitis [1].

In common scabies, there are few mites, probably because scratching destroys the
burrows [1]. However, in crusted scabies there may be thousands or even millions
of mites. The diagnosis is confirmed by examination of scrapings and biopsies that
are teeming with mites and eggs [1].

Our patient, who apparently had not any underlying significant disease, lacked
several features that are usually seen in crusted scabies. She also did not have any
palmoplantar or subungual lesions.

Itching, which is the hallmark of scabies, was minimal or absent in this patient. It is
generally believed that patients with crusted scabies do not itch. But, at least 50
percent of the patients have some degree of itching [2]. The itch, if present,
diminishes with time. In our patient the itching was absent.

Treatment of crusted scabies can be very challenging because of various factors


including the host's compromised immunity, the widespread nature of the eruption,
the high mite burden, and the limited penetration of the topical agents into the
hyperkeratotic lesions. Thus, the treatment of crusted scabies doesn't only include
scabicidals, but also keratolytic agents to remove the thick crusts, which are a nidus
for the mite. Removal of these crusts can be performed by employing a keratolytic
agent such as 5-10 percent salicylic acid in petrolatumor 40 percent urea; soaking
in a hot bath may also help. This may reduce the mite load and also enhances the
efficacy of topical scabicidals [3]. Various topical agents and oral drugs used in the
treatment of classical scabies are also used in treating crusted scabies [4] including
topical sulfur compounds, benzyl benzoate, crotamiton, lindane, malathion,
permethrin, and ivermectin [5].

Oral ivermectin has been proven to be very effective and is now considered as the
treatment of choice for crusted scabies [4] and other resistant cases, but it is not
available in Syria. Hence, we treat these patients with a daily dose of 800 mg of
albendazole with fatty meals for 3 consecutive days and an application of 5 percent
salicylic acid in crotamiton twice daily for 1 week.

Benzimidazoles (albendazole, fenbendazole, oxfenbendazole, mebendazole, and


thiabendazole) are broad-spectrum antiparasitic agents used against a wide range
of nematodes and cestodes. By binding to free B-tubulin, benzimidazoles inhibit the
polymerization of tubulin and microtubule-dependant glucose uptake, leading to
parasite death. These agents may additionally interfere with the synaptic
transmission of parasites through a probable cholinergic effect [6]. Effectiveness of
oral and topical thiabendazole against scabies has been pointed out in only a few
reports since the 1960s [6, 7]; thiabendazole and the newer agent albendazole have
been successfully used against pediculosis capitis [8, 9]. Drs. N. Ayoub, M. Merhy,
and R. Tomb treated 2 cases of scabies successfully with a daily dose of 1000 mg of
albendazole with fatty meals for 3 consecutive days and an application of a 5
percent salicylic acid ointment once daily for 1 week [10].

In conclusion, crusted scabies without involvement of palms, soles, and head is


unusual. Our patient was also without subungual crusting, but exhibited the usual
lack of pruritus. Crusted scabies can occur in apparently healthy persons. This
possibility should be kept in mind in order to prevent misdiagnosis of this
uncommon condition. Oral albendazol is safe and effective for treating scabies.

Acknowledgement: We thank reviewer Dr. Rasha Nabhan

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