SCABIES

y The human itch mite, Sarcoptes scabiei, is a common cause of itching dermatosis y Epidemiology: o Infesting ~300 million persons worldwide. o In the United States, scabies may account for up to 5% of visits to dermatologists. o Outbreaks occur in nursing homes, mental institutions, and hospitals. y Characteristic: o Gravid female mites,  measuring ~0.3 mm in length,  burrow super cially beneath the stratum corneum,  depositing three or fewer eggs per day. o Nymphs  mature in ~2 weeks and  then emerge as adults to the surface of the skin,  where they mate and (re)invade the skin of the same or another host. o Transfer of newly fertilized female mites from person to person occurs mainly by:  intimate contact and is facilitated by crowding,  poor hygiene, and  multiple sexual partners  infrequent: transmission via sharing of contaminated bedding or clothing o Generally, these mites die within a day or so in the absence of host contact.

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Clinical pictures:
y The itching and rash associated with scabies derive from a sensitization reaction directed against the excreta that the mite deposits in its burrow. o An initial infestation remains asymptomatic for up to 6 weeks, and a reinfestation produces a hypersensitivity reaction without delay. o Burrows become surrounded by in ltrates of eosinophils,lymphocytes, and histiocytes, and a generalized hypersensitivity rash later develops in remote sites. o Immunity and associated scratching limit most infestations to <15 mites per person. o Hyperinfestation with thousands of mites, a condition known as crusted scabies or Norwegian scabies, may result from glucocorticoid use,

immunode ciency, and neurologic and psychiatric illnesses that limit itching and scratching. Intense itching worsens at night and after a hot shower. Typical burrows may be dif cult to nd because they are few in number and may be obscured by excoriations. Burrows appear as dark wavy lines in the epidermis and measure up to 15 mm. Lesions occur most frequently on: o the volar wrists, o between the ngers, o on the elbows, and o on the penis. Lesion characteristics: o Small papules and vesicles, often accompanied by eczematous plaques, pustules, or nodules, are o Symmetrically distributed:  in these sites (mentioned before) and  in skin folds: y under the breasts and y around the navel, y axillae, y belt line, y buttocks, y upper thighs, and y scrotum. o Except in infants, the face, scalp, neck, palms, and soles are spared. o Crusted scabies resembles psoriasis in its typical widespread erythema, thick keratotic crusts, scaling, and dystrophic nails. o Characteristic burrows are not seen in crusted scabies, and patients usually do not itch, although their infestations are highly contagious and have been responsible for outbreaks of classic scabies in hospitals. The hallmark of scabies is: o intractable pruritus,  characteristically more severe at night  disproportionately severe, o Lesions may be eczematous and often are excoriated, but the pathognomonic lesion is the burrow, a short, wavy, dark line.  The classical features are often obscured by excoriations, impetiginization or eczematization.

Diagnosis:
y Scabies should be considered in patients with pruritus and symmetric polymorphic skin lesions in characteristic locations, particularly if there is a history of household contact with a case. y Burrows should be sought and unroofed with a sterile needle or scalpel blade, and the scrapings should be examined microscopically for the mite, its eggs, and its fecal pellets. y Biopsies, scrapings of papulovesicular lesions, and microscopic inspection of clear adhesive tape lifted from lesions may also be diagnostic. y In the absence of identi able mites or mite products, the diagnosis is based on clinical presentation and history. y Diverse kinds of dermatitis due to other causes are frequently misdiagnosed as scabies. DIRECT EXAMINATION y One or two drops of mineral oil are applied to the lesion, which is scraped or shaved with a scalpel blade to remove the tops of the burrows or papules. y The scrapings, along with the oil, covered with a coverslip, are examined microscopically under low power. y Potassium hydroxide should not be used, because it can dissolve the fecal pellets ( scyballa). y Alternatively, the papule or burrow can be curetted with a small dermal curette. o A toothpick or applicator stick may be used to clear the tissue/oil mixture from the curette, and o the specimen is then examined microscopically. o This technique is not frightening to children and uncooperative or anxious patients, and may be a preferred method in patients suspected of having HIV/AIDS. DERMOSCOPY o epiluminescence microscopy, or dermoscopy, to be an effective in vivo means of diagnosing scabies. o The magnified view shows small, dark, triangular structures corresponding to the pigmented anterior section of the mite, and a subtle linear segment behind the triangle containing small air bubbles; together resembling a jet with contrail and thought to be the burrow along with the eggs and fecal pellets.

POLYMERASE CHAIN REACTION y To prove scabies in a patient presenting with clinically atypical eczema. y Epidermal scales were PCR positive for S. scabiei DNA before, and negative 2 weeks after, therapy. 8

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.

Scabetic nodule. A scabies mite is present in the stratum corneum. Intense lymphocytic and eosinophilic dermatitis is induced as a hypersensitivity reaction to the mite and its eggs and feces.