A 42 year old, HIV positive man (not on HAART therapy) is brought in by his brother because “the skin on his head is turning into smelly frosting”. The patient’s brother tells you that he too has had “the itch” for a week…
You look at the brother’s hands and see linear burrows between his fingers and on the dorsum of his hand. The patient, however, looks like this:
You find extensive, malodorous crusting over his scalp and hands with bloody fissures, and a forlorn expression on his face.
When you ask his social history he tells you that he thinks he had accidentally sold his soul to the bodega down the block and that he is bound for eternal decrepitude (he had just finished reading The Picture of Dorian Gray).
You pause, think, and reassure him that it’s just his disgusting brother.
What severe manifestation of a common infestation does this man have?
Crusted scabies (AKA Norwegian scabies, Scabies crustosa, keratotic scabies). Severe manifestation of Scabies (Sarcoptes scabiei) that occurs in immunocompromised individuals (HIV, elderly, lymphoma, etc.). In a typical infestation, due to cellular immunity the mite burden tends to be <100, while in crusted scabies, the crusts and scales contain >100,000 mites.
NB: In simple scabies, the itching tends to be worse at night and is due to a type IV hypersensitivity.
What are the two treatments options for this infestation and how do you administer them?
Simple scabies:
Permethrin 5% thoroughly applied to skin of entire body, including face and scalp if necessary (excluding eyes and mucosa) and removing in shower after 8-14 hours. One time application is recommended, but an additional dose may be given one week later for recurrence.
OR
Ivermectin 200 mcg/kg – single dose (especially if you have a coinfection with another parasite like Strongyloides).
Crusted Scabies:
Permethrin 5% daily for 7 days
AND
Ivermectin on days 1, 2, 8, 9, and 15
* Treat coinhabitants or other people in close contact.
** Don’t forget contact isolation. It is a highly contagious disease, in particular crusted due to the immense parasite burden.
*** Wash all fabric that came in close contact with the patient.
References (including image):
Goldstein, Beth G., MD, and Adam O. Goldstein, MD. “Scabies.” Uptodate.com. N.p., 21 May 2015. Web. 07 June 2015.
Written by Itamar
Special thanks to Dr. Willis
Itamar
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