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Scabies

Clinical Cases

Case 1

  • 6-year-old male
  • Attends elementary school; develops intensely pruritic rash on wrists, umbilicus, hands and feet
  • No sick contacts
  • Excoriated scaly papules clustered on the wrists/hands, umbilicus, and scattered across the trunk; genitalia, face and scalp are spared

Initial evaluation

  • A skin scraping taken from the feet reveals mites and eggs
  • The patient is prescribed:
    • Permethrin 5% cream, to be applied overnight to the whole body except face/ scalp and repeated in 1 week
    • Triamcinolone 0.1% ointment b.i.d. (started 24 hours after first anti-parasitic treatment)
    • Hydroxyzine for nocturnal pruritus
  • Simultaneous treatment of entire family and babysitter is mandatory
  • Instructions for decontamination protocol are given
  • Report to school infection control
  • Follow-up in 2 weeks

Follow-up evaluation

  • Patient’s eruption has resolved, but pruritus persists
  • Patient has several follicular-based pustules with surrounding erythema on the legs; a bacterial culture is taken, oral cephalexin is empirically started for presumed staphylococcal pyoderma, the culture reveals methicillin-sensitive Staphylococcus aureus
  • No additional sick contacts
  • Continue oral antihistamines and topical steroids for 1-2 more weeks
  • Follow-up in 1 month (lesions, pruritus resolved)

Case 2

Crusted Scabies

  • 37-year-old HIV+ male
  • Recently discharged from hospital; was hospitalized for 2 weeks
  • 9-week history of non-pruritic eruption, almost generalized; medium-potency topical steroids alleviate scale, but lesions are persistent
  • No sick contacts

Initial evaluation

  • Patient presents with almost generalized, thickly crusted papules and plaques, including on the scalp, ears, palms, and soles
  • Skin scraping from the palms reveals numerous scabetic mites
  • The patient is prescribed:
    • Ivermectin, two doses of 200 mcg/kg given 14 days apart
    • Permethrin 5% cream, 3 applications applied overnight, 7 days apart
    • Triamcinolone 0.1% ointment b.i.d. (started 24 hours after first anti-parasitic treatment)
    • Hydroxyzine 50 mg at bedtime
  • Close contacts, including sexual partners and household members, should also all be treated at the same time as the patient
  • Instructions for decontamination protocol are given
  • Reporting to hospital infection control
  • Follow-up in 3 weeks

Follow-up evaluation

  • Patient’s eruption has resolved
  • Two pruritic nodules on the scrotum persist and are treated with intralesional triamcinolone 0.1% (5 mg/cc)
  • No additional sick contacts
  • Continue oral antihistamines and topical steroids for 2-4 more weeks
  • Follow-up in 6 weeks (lesions, pruritus resolved)