Presented by : Dermatology and Parasitology Departments

A previously imprisoned, 30 years old male patient has been released from jail since two weeks. He developed severe night itching, resulting in extensive scratching till bleeding specially in the inter-digital spaces, peri-umbilical and medial aspect of the thighs.

Examination revealed the following lesions: Multiple linear scratch marks Papules Pustules

Lesions were distributed in the following areas: The web space between the fingers Peri-umbilical region Anterior axillary fold Medial aspect of the thigh

What is the probable diagnosis?

Scabies

What is scabies?

 Scabies

is a transmissible ectoparasitic skin infestation caused by infestation with and sensitization to adult female of Sarcoptes scabiei. It is characterized by superficial burrows , intense pruritus (itching) and secondary bacterial infection

What is Sarcoptes scabiei ?

Sarcoptes scabiei is a small arthropode belonging to class ARACHNIDA; order ACARINA It is a small mite having an unsegmented rounded or oval body, 4 pairs of legs, and tegument covered with bristles.
ARTHROPODA

CRUSTACEA

ARACHNIDA

INSECTA

SCORPIONIDA

ACARINA

TICKS

MITES

S scabeii

What is the life cycle of Sarcoptes scabiei mite ?

 When

the impregnated female tunnels into the stratum corneum of the skin and deposits eggs in the burrow , which hatch in 3-10 days, the larvae move on the skin and then mature into adult mites. The adult mites live 3-4 weeks in the host's skin.

What is the mode of transmission of infection?

 Scabies

is transmitted readily, often throughout an entire household, by skin-to-skin contact with an infected person

In what special situations could scabies spread?

Scabies spreads among overcrowded poor population, with poor hygienic conditions

What are the usual sites of infestation with Sarcopetes scabeii mite?

The usual sites involved are the inter-digital spaces, ulnar, aspect of the arm, elbows, axilla, groin, breast, umbilicus shoulder, back and buttocks.

What is the characteristic lesion for scabies?

 Itchy

skin burrows (tunnels) are characteristic for scabies.

How are skin tunnels formed?

 Sarcopetes

scabeii penetrates the horny layer of the skin and keeps on burrowing in the epidermis, resulting in the formation of tunnels. As the mites feed on the tissues, they deposit minute faecal pellets believed to provoke the characteristic vesiculations of the skin and the severe pruritis.

Fecal pellets epidermis

When does itching occur?

 Severe

itching is intensified at night. It is enhanced by warmth and perspiration of the affected area. Warmth initiates an acidic secretion which intensifies the irritation.

Why does itching occur? (Factors reponsible for itching)

mites wandering within the skin Presence of the eggs and the mite excreta produce a massive allergic response which, in turn, produces more itching. Both type I and type IV hypersensitivity reactions occur which take about one month for sensitization after initial infestation yet upon reinfection only 24 hrs are needed to produce clinical symptoms of intense itching.

What is the most common complication?

Pustules, due to secondary bacterial infection introduced by intense skin scratching caused by itching, often complicate the lesion.

If pus was seen oozing from the previous lesion, what is the most common complication that may occur?

 I-Secondary

bacterial infections: 1-Impetigo. 2-Cellulitis. 3-Mixed bacterial infection.

II-Hypersensitivity&

allergic reactions which complicated by secondary bacterial infections

What are the most common organisms to be involved ?

1-Impetigo caused by Streptococcus group A. 2- Cellulitis caused by Streptococcus group A. 3-Mixed bacterial infection by : Gram positive cocci; Staphylococcus aureus. Streptococcus group A. Gram negative bacilli ; enterobacteriaceae eg. Escherichia coli , proteus. Gram negative bacilli eg. Pseudomonas aeruginosa . Anaerobic bacteria eg. Peptostreptococci .

Describe the main lines of laboratory diagnosis of these organisms?

1-Specimen: Pus swab( Precautions for specimen collection should be regarded) 2-Smears : Gram stained smears to detect the presence of bacteria and pus cells. 3-Culture & biochemical testing to identify the organism. 4-Antibiotic susceptibility testing to detect the appropriate antibiotic to be prescribed by the physician to treat such a condition.

How can you reach a proper diagnosis?

History: low hygienic conditions, over-crowdening, contact with infected person Complaint: Characteristic nocturnal itching, vesiculations, papules. Examination:

Site of the lesion: inter-digital spaces, ulnar aspect of the arm, elbows, axilla, groin, breast, umbilicus, shoulder, back and buttocks Character of the lesions: scratch marks, burrows, vesiculations, and sometimes pustules.

1.

2.

Diagnosis confirmation: Skin scrapping: tunnels scrapping with a sharp needle. The scraped material is cleared in 10% potassium hydroxide and examined microscopically to detect the mite. Skin biopsy

How can this case be managed?

MANAGEMENT

CAUSATIVE TREATMENT

SYMPTOMATIC TREATMENT

COMPLICATION TREATMENT

PREVENT REINFESTATION

EURAX CREAM

SOOTHING CREAM MEDICATED SOAP

ANTIBIOTICS

Topical treatment Eurax (crotamiton)

Cream or lotion. Acaricidal & inhibits the growth of bacteria. It has also antipruritic proparty. Apply on the skin, paying particular attention to skin folds and webs in between the fingers and toes for 5 consecutive days.

Oral treatment Ivermectin

The drug is given orally. It targets the parasite's CNS resulting in its paralysis.

Soothing cream for itching Topical corticosteroides and antihistamines.

 Medicated

Soap Scrub the whole body using lifa and soap containing sulfur for 5 consecutive days. Antibiotics In severe cases of scabies where pustules, antibiotic therapy may be considered (after performing culture and sensitivity) Prevent re-infestation

How could we prevent re-infection or cross contamination?

Maintenance of good personal hygiene Patients' clothes and bed sheets should be sterilized by boiling during the course of treatment. Avoidance of contact with infested persons. All family and close contacts should be treated at the same time . Treatment must be thorough and simultaneous .