Scabies

Superficial epidermal infestation by the mite

S. scabiei var. hominis. Transmission: Usually
spread by skin-to-skin contact and fomites.
Clinical Manifestation. Pruritus often with
minimal cutaneous findings. Burrows under
stratum corneum.
Etiology and Epidemiology
Etiologic Agent. S. scabiei var. hominis. Obligate
human parasite. Mites of all developmental
stages burrow into epidermis shortly after
contact, no deeper than stratum granulosum;
deposit feces in tunnels (Fig. 28-16).

Female
life span 46 weeks; lays 4050 eggs. Lays
3 eggs per day in burrows; eggs hatch in 4 days.
Burrow 23 mm daily, usually at night, and lay
eggs during the day. Hatched larvae migrate
to skin surface and mature into adults. Males
and females copulate. Gravid female burrows
back under stratum corneum; male falls off.
Demography. Major public health problem in
many less-developed countries. Transmission by skin-to-skin contact
and fomites. Mites can remain alive for >2
days on clothing or in bedding. Persons with

hyperinfestation shed many mites into their

environment daily and pose a high risk of infecting
those around them.
Pathogenesis
Hypersensitivity of both immediate and
delayed types occurs in the development of
lesions other than burrows. During first infestation,
pruritus occurs after sensitization to
S. scabiei has occurred, usually within 46
weeks. After reinfestation, pruritus may occur
within 24 h. With hyperinfestation, persons are
often immunocompromised or have neurologic
disorders.
Clinical Manifestation
Symptoms
Patients are often aware of similar symptoms
in family members or sexual partners. Pruritus is
intense, widespread, usually sparing head and
neck. Itching often interferes with or prevents
sleep. Pruritus may be absent with hyperinfestation.
Rash ranges from no rash to generalized
erythroderma. Patients with atopic diathesis
scratch, producing eczematous dermatitis.
Some individuals experience pruritus for many
months with no rash. Tenderness of lesions
suggests secondary bacterial infection.
Cutaneous Findings
(1) Lesions occurring at the sites of mite infestation,
(2) cutaneous manifestations of hypersensitivity
to mites, (3) lesions secondary to
chronic rubbing and scratching, (4) secondary
infection, (5) hyperinfestation, and (6) variants
of scabies in special hosts: those with an atopic
diathesis, nodular scabies, scabies in infants/
small children, scabies in the elderly.
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. 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, buttocks, axillae > (Fig. 28-18). In infants,

infestation may occur on head and neck.

Scabies with nodules 520 mm in diameter,

red, pink, tan, or brown in color, smooth
(Fig. 28-19); burrow sometimes seen on the
surface of a very early lesion. Distribution:
Scrotum, penis, axillae, waist, buttocks, areolae
(Fig. 28-20). Resolve with postinflammatory
hyperpigmentation. May be more apparent
after treatment, as eczematous eruption
resolves.
Course

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. Delusions of parasitosis
can occur in individuals who have been

successfully treated for scabies or have never

had scabies. Hyperinfestation: May be impossible
to eradicate; recurrence more likely to
relapse than reinfestation. Nodules: In treated
patients, 80% resolve in 3 months but may persist
up to 1 year.
Management
Principles of Treatment. Treat infested individuals
and close physical contacts (including
sexual partners) at the same time, whether or
not symptoms are present. Application should
be to all skin sites.
Recommended Regimens. Permethrin 5%
Cream applied to all areas of the body.
Lindane
(g-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, or by patients with
extensive dermatitis, pregnant or lactating
women, or children younger than 2 years.
Low cost
makes lindane a key alternative in many
countries.
Alternative Regimens. Topical. Crotamiton
10%, sulfur 210% in petrolatum, benzyl benzoate
10% and 25%, benzyl benzoate with
sulfiram, malathion 0.5%, sulfram 25%, ivermectin
0.8%.
Systemic. Oral ivermectin, 200 g/kg; single
dose reported very effective in 1530 days.
Two to three doses, separated by 12 weeks,
usually required for heavy infestation or in
immunocompromised individuals. Do not use in infants, young children
or pregnant/lactating women.
Crusted Scabies. Oral ivermectin combined

with topical scalicides (not ivermectin). Decontamination

of environment.
Postscabietic Itching. Generalized itching that
persists a week or more is probably caused by
hypersensitivity to remaining dead mites and
mite products. For severe, persistent pruritus,
especially in indivuduals 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. Intralesional triamcinolone,
510 mg/ml into each lesion, is effective; repeat
every 2 weeks if necessary.