CASE REPORT

ATYPICAL SCABIES IN INFANT

Endang Tri Wahyuni, Khairuddin Djawad, Nurelly Waspodo

Departement of Dermatovenereology Medical Faculty of Hasanuddin University / Wahidin

Sudirohusodo Hospital Makassar

ABSTRACT
Scabies is a human skin infestation caused by the penetration of the obligate
human parasitic mite Sarcoptes scabiei var.hominis into the epidermis. The
classic manifestation of scabies is generalized itching that is more intense at
night. The skin findings include papules, nodules, burrows, and
vesiculopustules and the most common location are the interdigital space,
wrist, and abdomen. Atypical presentation in infants often involve the face,
scalp, palm, and soles.
It was reported a case of scabies in infant six months old with clinical findings
include erythematous macules, erythematous papules, nodule, erosion and
excoriated. The distributin of the lesion involved the whole body area including
scalp, face, neck, trunk, extremities, palms and soles. Treatment with
permethrin 5% gave good result.

Key word : Atypical scabies, permethrin 5%, infant

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IJDV
INTRODUCTION
Scabies is a skin eruption caused by
flea infestation and sensitization of
Sarcoptes scabiei variety hominis and
manifest as a popular lesions, pustules,
vesicles, and sometimes crusting and
erosion as well as tunnels that gray is
accompanied with symptoms of itching
was found in the cracks and folds.1,2
Infections caused by direct skin contact,
mite transmission via clothing, bedding
and towels but it rare.3, 4, 5It is estimated
that more than 300 million people world
wide infected with scabies mites. Scabies
can affect all social groups and econo-
mics.5
Scabies has spread throughout the
world particularly in tropical and
subtropical area.6 Disease progression is
influenced by several factors: the econo-
mic level, density and hygiene in a
community is very complex. Very dense
housing as a factor believed to contribute
the most to the spread of scabies. Low
economic level also raises the problem of
poor nutritional status and therefore
contributes to the individual's immune
system.7
The most common symptoms of a
more intense form of pruritus is felt in the
evening accompanied papular.7,8 Spots
and pruritus caused by slow type
hypersensitivity reaction to the mites, eggs
and faecal material. Predilection site in
men are generally on fingers, wrist flexors,
elbows, buttocks, ankles, periareolar area,
antekubiti fossa, anterior fold of axilla,
waist, genitalia and low abdomen.7, 8
Sometimes scabies provide
atypical clinical picture, where it can cause
difficulty diagnose than the form classic.9
Scabies in infants and young children can
be a picture of skin lesions vesicles,
pustules, or nodul.10 Location of lesions in
infants may occur on the head, face , alms
and soles of the feet, where the location is
very rare in adult people.5, 11
Here is reported a case of scabies in
an infant aged six months and given
treatment with permethrin 5% and after
64
Vol.1 No.1 2012
one week to the patient got clinical
improvement.
CASE REPORT
A male infant aged six months to
come to the clinic of dermatovenereology
RSWS with his mother, from the
alloanamnesis (from mother) is known to
have a complaint that the baby have patch
and reddish rash on the head, face and
entire body are accompanied by intense
itching that is marked with the child
frequent scratching and crying. This has
been experienced since three months ago.
Itching is felt at any time. The same
complaint is also found in the child's
mother. It have treated with powder and
ointment (name unknown drugs) but gave
no improvement.
Either patient's general condition,
skin lesions found on the scalp, face,
torso, extremities superior et inferior right
and left, palms, and soles. Skin lesions
showed erythematous macules, papules,
erythematous papules, nodules, erosions
and excoriation.
(Figure 1)Investigations conducted in
this case the skin scrapings. Before the
skin specimens scraped, it spilled with
emersi oil, then scraped with a scalpel.
Results scrapings placed over the object
glass, then covered with glass cover, and
examined under a microscope. Exami-
nation results in skin lesions found
Sarcoptes scabiei mites, eggs and skibala.
(Figure 2). The patient subsequently
diagnosed as scabies and given treatment
in the form of permethrin 5% and cetirizine
syrup. After one week the patient showed
clinical improvement, and the lesions
appear as macular hyperpigmentation.
(figure 3)
Picture of patient
Endang Tri Wahyuni
Figure 1 skin lesion on head, face, chest, abdomen,
genitalia, trunk, palm, and soles with erythematous
macule, erythematous papules, nodule, erotion, and
excoriation.
Microscopic examination
a b
c exposure to scabies mites, it may take six
Figure 2 Microscopic result from skin scraping, a.
Egg, b. Mite sarcoptes scabiei, c. Scibala
Picture post treatment
Figure 3 Control picture after one week
65
Atypical Scabies In Infant
DISCUSSION
Scabies is an infestation of human
skin caused by the mite Sarcoptes scabiei
hominis variants. These mites are obligate
parasites in humans and occupy the
tunnels in the epidermis of human skin.11
Scabies can affect men and women,
at all ages, all ethnicities and all socio
economic levels.8,12 Scabies can be
spread through direct contact with an
infested individual, but may also occur
through the transmission of bedding and
clothing, where the mites can survive
outside the human skin up to three days.5,
11
Transmission of scabies that lasted
through the close and direct contact long
enough can occur when live and sleep
together, especially the kids who got a
mite infestation of his mother.1This is
consistent with the case where the patient
is a transmission from the mother who is
also infested with the mite Sarcoptes
scabiei.
The incubation period of classical scabies
is about three weeks.Initial symptom of
scabies is usually only include itching
before clinical symptom.7,11After early
to eight weeks to then clinic
manifestation.5Pruritus due to scabies low
type hypersensitivity reaction to the mites,
eggs, and mite feces (skibala) .10The skin
lesions of an erythematous papules and
nodules, there scale, and sometimes it
seems that there is excoriation on the
sidelines of the volar wrist finger, the
lateral part of the palm of the hand, elbow,
axilla, scrotum, penis, labia, and areola
mammae in women. Diffuse erythematous
eruption on the body is the result of a
hypersensitivity reaction to mite antigen.
Pathognomonic lesions in the form of a
thin tunnel, such as yarn, with a length of
1-10 mm, and the tunnel is caused by
movement of the mite in the stratum
corneum.5 Complaints of itching and red
spots on the case has been experienced
over the past three months.
IJDV
Occasionally scabies picture gives
an unusual shape making it difficult to
diagnose than classic.9 Clinical
manifestation of scabies in infants are
different from scabies in adult.13 The
atypical clinical picture in infants, indicated
bythe involvement ofthe head, palms,
soles, and axilla, where the location is very
rare in adult people.9, 11Skin lesions in
infants who are exposed to scabies may
include vesicles, pustules or nodul.10,
13
Lesions in children are usually more
inflammatory than in adult.14This is
consistent with cases where there are skin
lesions throughout the body, from head,
face, body, superior and inferior
extremities, palms and feet, in the form of
erythematous macules, papules, ery-
thematous papules and nodules with
erosion and excoriatio.
Diagnosis of scabies in children can
be suspected if there are clinical
symptoms of pruritus, papules or papulo
vesicular eruption of the tunnel and the
distribution spesific pattern.11Definite
diagnosis of scabiesis made by
identification of mites, oreggs, ormite feces
(skibala) on microscopic examination.
5.11
This examination is performed by
dripping mineral oil above the tunnel and
then made scraping longitudinally using
as calpel number 15 along the tunnel, and
arranged so as not to cause bleeding, skin
scrapings and then placed over the object
glass and examined under microscop.5,
11
Skin lesions are ideal for scraping is a
papule lesions that are new and the
tunnel.11Results of skin scrapings in this
case found the eggs, mites, and skibala,
therefore the diagnosis is established as
scabies.
Sarcoptes scabiei is an obligate
ectoparasite that belongs to a group
arthropoda.7 Mite life cycle begins when
adult mites dig tunnels in human skin and
reproduction.12 Females will dig a tunnel
under the skin surface and left the two to
three eggs per day of grains in the stratum
corneum during six weeks, it is this that
causes papules on skin.7 Eggs will then
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Vol.1 No.1 2012
hatch after four days and the larvae will
move to the surface of the skin and
develop into adult form. After two weeks of
females and males will copulated, and
after she was pregnant female will dig a
tunnel back in the stratum corneum.5 Male
mites will then die after copulation.7
Permethrin has been used as a first
choice treatment of scabies in patients
older than two months.16, 17 Permethrin is a
synthetic pyrethroid which is a neurotoxin
and is a good.11 skabisidal agent is highly
effective, minimally absorbed and minimal
toxicity.16 Permethrin cream 5% was
applied to the entire body, starting from
the neck to down.10 Permethrin application
in infants and in children younger than five
years, basting should also cover the head,
neck and entire body.5, 10,11 Cream rinse
after 8-14 hours. Providing one-time
permethrin 5% on the entire body can
usually heal, but if it is still necessary or if
new lesions appear giving the
recommended one to two weeks after. 10,
16
Several studies have shown that
permethrin gave greater cure rate,
reducing the pruritus and adverse effects
were smaller when compared with
lindane.15 Study by Strong and Johstone
states that permethrin is more effective
than krotamiton, lindane and oral
ivermectin.18 Patients should be informed
that itching may persist for up to four
weeks after therapy. The itching can be
treated with antihistamin.8, 15 patients in
this case given permethrin 5% is applied
starting from the head, face and entire
body and are also given an antihistamine
to relieve the itch.
Jin SP, et al from Korea report the
case of scabies in a two-month-old infant
with symptoms of itching and skin lesions
are erythematous macules, papules,
nodules, vesicles and pustules over the
body. The patient was treated with lindane
and there are no side effects. The reason
is because in korea is not available
permetrin.19
Endang Tri Wahyuni Atypical Scabies In Infant

Therapy alone without regard to the 9. Chosidow O. Scabies. N Engl J Med

environment is a cause of treatment 2006; 354: 1718-27
failure, because the mites can survive and 10. Flinders DC, Schweinitz P. Pediculosis
re-infest the patient, therefore all clothing, and scabies. Am Fam Physician 2004; 69:
341-8
towels and bed linens that have been used
11. Paller AS, Mancini AJ. Bites and
four days earlier were washed with hot infestation. In Hurwitz Clinical paediatric
water (60 C) and dried in bed under the rd
Dermatology. 3 ed. Chicago: Elsevier
sun. Materials that can not be washed in Saunders; 2006. p. 479-483
hot water should dry cleaning or oclusing 12. Currie BJ, Mccarthy J. Permetrin and
plastic for five day.10 ivermectin for scabies. N Engl J Med
2010; 362; 717-25
13. Quarterman MJ, Lesher JL Jr. Neonatal
REFERENCES scabies treated with permethrin 5%
cream. Pediatr Dermatol 1994: 11: 264-
1. Meinking T, Taplin D. Scabies Infes- 266
tations. In: schacner LA, Hansen RC, 14. Hurwitz S. Scabies in babies. Am J Dis
nd
editor. Paediatric Dermatology. 2 ed. Child 1973; 126: 226-228.
New York: Churchill livingstone; 1995. p. 15. Sunderkotter C, mayser P, Folster-Holst
1347-89. R, Maier WA, Kampen H, Hamm H.
2. McKoy KC, Moschella SL. Parasites. Scabies. JDDG 2007; 5: 424-30
Arthropods, hazardous animal and 16. Albakri L, Goldman R. Permetrin for
tropical dermatology. In: Moschella SL, scabies in children. Can Fam Physician
Hurley HJ, editor. Dermatology. Phila- 2010: 56: 1005-6
delphia: WB Saunders Co; 1985. p. 1731- 17. Executive Committee of Guideline for the
820. Diagnosis and Treatment of Scabies.
3. Wendel K, Rompalo A. Scabies and Guideline for the diagnosis and treatment
pediculosis pubis: An update of treatment of scabies in Japan (second edition). J
regimens and general review. CID 2002; Dermatol 2008; 35: 378-393.
35 (suppl 2): 146-151. 18. Strong M, Johnstone PW. Interventions
4. Executive Committee of guideline for for treating scabies. Cochrane Database
diagnosis and treatment of scabies. syst Rev 2007; 3: CD000320.
Guideline for the diagnosis and treatment
19. Jin SP, Choi JE, Won CH, Cho S. Scabies
of scabies in Japan (second edition). J
in a 2-month-old Infant successfully
Dermatol 2008; 35: 378-93.
treated with lindane. Ann Dermatol 2009;
5. Stone SP, Goldfard JN, Bacelieri RE.
21(2): 200-2.
Scabies, other mites, and pediculosis. In:
Wolff K, Goldsmith LA, Katz SI, Gilchrest
BA, Paller AS, Leffel DJ, editors.
Fitzpatricks Dermatology in General
th
Medicine. 7 ed. USA: McGraw-Hill; 2008.
p. 2029-31.
6. Burns DA. Disease caused by arthropods
and other noxious animals. In: Champion
RH, Burton JL, Burns DA, Breatnach SM,
editors. Rook/Wilkinson/Ebling Textbook
th
of Dermatology. 6 ed. London: Blackwell
Sciense; 1998. p. 1458-63.
7. Walton SF, Currie BJ. Problems in
diagnosing scabies, a global disease in
human and animal populations. Clin
Microbiol Rev 2007; 20(2): 268-79
8. Johnston G, Sladden M. Scabies:
Diagnosis and treatment.BMJ 2005; 331:
61922

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