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Original Article

Dermoscopic Study of Scabies in Children

Abstract Shilpitha Srinivas,

Background: Dermoscopy is a technique involving the rapid and magnified observation of the Kallappa C Herakal,
skin. Infection with Sarcoptes scabiei in children usually presents with pruritus. Primary scabetic Srinivasa
lesions consist of small, erythematous papules, and burrows. The definitive diagnosis of scabies is
by visualizing the mites, eggs, or feces under the microscope. Aims and Objectives: The aim of Krishnamurthy
the study was to compare the diagnosis of scabies in children with naked eye examination and a Murthy1,
dermoscope. The objective was to find out if there was a significant difference between the two Shwetha
methods of diagnosis of scabies. Subjects and Methods: A cross‑sectional study was done. Fifty Suryanarayan2
children aged between 1–15  years with symptoms clinically suspicious of scabies from May 15, Department of Dermatology
2016 to May 14, 2017 were taken. Thirty were male and 20 were female. After taking history, the Venereology and Leprosy,
lesions were examined clinically and with Dermalite DL4 and photographs were taken. A triangular Navodaya Medical College
structure with a furrowing burrow was considered to indicate the presence of a mite. Results: Among Hospital and Research Centre,
50 children, 37 children had clinical features of scabies: the presence of burrows and scabetic Raichur, 1Dr. Srinivasa Murthy’s
nodules. Among 50, 45 children had dermoscopic features of scabies: the presence of the delta Skin and Cosmetology Centre,
glider sign. The data were analyzed using Z‑test using MS Excel 2010. There was a significant Bangalore, 2Sambharam
Institute of Medical Sciences,
difference (P < 0.03) on comparing the number of children diagnosed with scabies with naked eye
Kolar, Karnataka, India
and dermoscopic examination. Conclusion: A handheld dermoscope can be a useful tool to rapidly
and non invasively diagnose scabies with high sensitivity compared to Clinical Examination.

Keywords: Delta glider sig, dermoscopy, scabies

Introduction symptoms clinically suspicious of scabies

Scabies is a contagious skin disease
caused by the infestation of sarcoptei
scabei var.hominis. Overcrowding is an
important factor in the transmission of
scabies. In developing countries, scabies is
commonly seen in the preschool children
and adolescents and it decreases in
mid‑adulthood and increases in the elderly.[1]
For many years, ex vivo skin scrapings were
used for the diagnosis of scabies. Recently,
dermoscopy has been used for the in vivo
diagnosis of scabies. As scraping the skin
can cause trauma and anxiety to the child,
dermoscopy is an effective and noninvasive
method to diagnose scabies.
Subjects and Methods
A cross‑sectional study was done.
The study was approved by the Ethics
Committee and Institutional Review
Board. Informed consent was obtained
from all participants at study entry. Fifty
coming to the OPD from May 15, 2016,
to May 14, 2017, were taken. Thirty males
and 20 females were taken. The aim of
the study was to compare the number of
children diagnosed with scabies on naked
eye examination alone and on dermoscopic
examination after selecting children with
history suggestive of scabies. The objective
of the study was to find out if there was
a significant difference between the two
methods of diagnosis of scabies.
History and clinical examination were Address for correspondence:
done, and the data were recorded. Informed Dr. Shilpitha Srinivas,
Room No. 39, Department of
consent was taken from the parents. Out of
Dermatology Venereology and
50 children, 40 had been given treatment Leprosy, Navodaya Medical
for pruritus. Children had symptoms of College Hospital and Research
nocturnal itching from 1 week to 3 months. Centre, Mantralayam Road,
Raichur - 584 103, Karnataka,
Inclusion criteria India.
E‑mail: shilpitha90@gmail.com
• Children aged between 1 and 15  years
irrespective of whether treatment was
given to them or not Access this article online

children aged between 1 and 15 years with
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For reprints contact: reprints@medknow.com
• The classical sites of involvement Website: www.ijpd.in
of scabies, visible burrows, scabetic
DOI: 10.4103/ijpd.IJPD_25_18
nodules, or family history of scabies
Quick Response Code:
were included in the study.
How to cite this article: Srinivas S, Herakal KC,
Murthy SK, Suryanarayan S. Dermoscopic study
of scabies in children. Indian J Paediatr Dermatol
2019;20:46-51.

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Srinivas, et al.: Dermoscopic study of scabies in children

Exclusion criteria and out of 20  females, 15  (30%) could be diagnosed as
having scabies [Table 5]. On dermoscopic examination,
• Children who were not cooperative for dermoscopic
out of 30 males 28 (56%) and out of 20 females, 17 (34%)
examination.
were diagnosed definitely as having scabies  [Table 6].
Clinical examination Dermoscopy of the web spaces of a 13‑year‑old boy in
polarized light showing burrow [Figure 2].
Children were examined at seven common sites of
involvement of scabies: Web spaces, flexural aspect Using the Z‑test, the one‑tailed probability value of
of wrists and elbows, axillae, umbilicus, buttocks, and P was obtained. The P value calculated for the diagnosis
genitalia for the presence of burrows. Burrows are seen as of scabies using only clinical history and examination
a wavy, scaly gray line on the skin surface.[2] Apart from was 0.0001. The P value calculated using clinical history
burrows, infestation with scabies also presents with papules,
vesicles, pustules, and nodules in the affected sites. If the Table 1: Age and sex distribution of cases
above clinical features were seen in the children, they were Sex Age (years)
diagnosed as having scabies. 1‑5 5‑10 10‑15
Dermoscopy Male 7 15 8
Female 4 11 5
The lesions were examined a dermoscope at seven
topographic areas where the mite was suspected. If the
parents noticed less than seven sites, all the sites were Table 2: Age and sex distribution chart
examined with the help of a dermoscope. If more than
seven sites were reported by the parent, seven sites
were chosen and were examined using a dermoscope.
The dermoscopic examination was done with Dermalite
DL4  ×10 magnification  [Figure 1]. Application of a liquid
interface was not done in all cases as it was not required
in every case. Photographs were taken with Canon
IXUS 133. A triangular structure with a furrowing burrow
was considered to indicate the presence of a mite. This
is also called as a contrail, jetliner with its trail, or delta
glider sign.[3] Even the burrow filled with eggs is another
diagnostic feature. This is only seen with the use of a Table 3: Family history of contagiousness
videodermoscopy which uses a higher power magnification Sex Age (years)
and was not seen in our study. 1‑5 5‑10 10‑15
Male 5 8 3
Statistical analysis used
Female 2 5 3
The data were numerical data and were analyzed using
Z test using MS Excel 2010.
Table 4: History of pruritus with nocturnal exacerbation
Results Sex Age (years)
1‑5 5‑10 10‑15
Fifty children aged between 1 and 15 years with
Male 5 11 6
symptoms clinically suspicious of scabies coming to
Female 2 6 3
the OPD from May 15, 2016, to May 14, 2017, were
taken. Thirty males and 20 females were taken. In
30  male children, 14%  (7) were aged between 1 and Table 5: Clinical history and naked eye examination
5  years, 30%  (15) were between 5 and 10  years, and Sex Age (years) P
16%  (8) were between 10 and 15  years  [Tables 1 and 1‑5 5‑10 10‑15
2]. Among 20  female children, 8%  (4) aged between Male 4 12 6 0.0001
1 and 5  years, 22%  (11) between 5 and 10  years, and Female 2 10 3
1%  (five) who were aged between 10 and 15  years.
After taking history, it was seen that among 50 children,
16 males (32%) and ten females (20%) had family history Table 6: Clinical history and dermoscopic examination
of contagiousness [Table  3]. Twenty‑two males  (44%) Sex Age (years) P
and 11  females  (22%) had H/O pruritus with nocturnal 1‑5 5‑10 10‑15
exacerbation [Table 4]. On naked eye examination after Males 6 15 7 0.02
taking of history, out of the 30  males, 22  males  (44%) Females 3 10 4

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Srinivas, et al.: Dermoscopic study of scabies in children

Figure 1: Dermalite DL4

Figure 2: Dermoscopy of the web spaces of a 13-year-old boy, magnified

image. Polarized light mode used. Arrow showing mite

Figure 3: Dermoscopy of the web spaces of a 2-year-old boy in polarized

light. Arrow showing burrow

Figure 4: Dermoscopy of web spaces of a 2-year-old boy in polarized light

under magnification. Arrow showing burrow

Figure 5: Hands of a 2-year-old boy suspected of scabies

and dermoscopy was 0.02. On comparison of the total

number of patients diagnosed with scabies using clinical
examination (37) and dermoscopic examination (45) using
Z‑test, a P = 0.03 was obtained [Table 7]. This indicates that
Figure 6: Erythematous papules on the dorsum and the web spaces of the
a significant difference exists between the two results. On hands of a 2-year-old boy
comparison of the number of male children diagnosed with
scabies using clinical examination (22) and dermoscopic of the number of female children diagnosed with
Examination (28), P = 0.03 [Table 7]. On comparison scabies using clinical examination (15) and dermoscopic
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Srinivas, et al.: Dermoscopic study of scabies in children

Figure 7: Dermoscopy of the flexural aspect of wrist of a 10-year-old girl. Figure 8: Dermoscopy of the Flexural aspect of wrist of a 10yr- yr- old girl.
Polarized light mode used. 40x magnification. Arrow showing burrow Polarised light mode was used. 10x magnification. Arrow showing burrow

Figure 9: Dermoscopy showing a burrow in the web spaces of a 10-year-old Figure 10: Dermoscopy showing a burrow in the web spaces of a 10-year-old boy,
boy. Polarized light mode used. Arrow showing burrow with mite magnified image. Polarized light mode used. Arrow showing burrow with mite

examination (17), P = 0.42 was obtained [Table 7]. Thus, Table 7: Comparison of clinical examination and
this P =  0.03 was significant, and the P = 0.42 was not dermoscopic findings
statistically significant. Clinical Dermoscopic P
Among the seven sites dermoscopically examined, the examination examination
web spaces and axillae were the most common sites Total 37 45 0.03
Males 22 28 0.03
in which the mite could be visualized. Dermoscopy of
the web spaces of a 2‑year‑old boy [Figures 3 and 4]. Females 15 17 0.42
Clinical examination of the 2‑year‑old boy showing
erythematous papules on the dorsum and web spaces of the Table 8: Most common sites of positive dermoscopic
hands [Figures 5 and 6]. In the 45 children diagnosed with findings: Web spaces
scabies using a dermoscope, 38 children had web space Sex Age (years) Total
involvement, 32 had axillae involvement. Twenty‑seven 1‑5 5‑10 10‑15
and 25 children had flexural aspect of wrists and elbows Males 3 14 4 21
involvement, respectively. Twenty three, 25 and 13 Females 3 10 4 17
children had umbilicus, genitalia and buttocks involvement, Total 38
respectively [Tables  8‑14]. Dermoscopy of the flexural
aspects of the wrists of a 10‑year‑old girl in polarized light
showing burrow [Figures 7 and 8]. Dermoscopy of the web
Discussion
spaces of a 10‑year‑old boy in polarized light showing The female mite is around 0.2–0.4  mm long and burrows
burrow [Figures 9 and 10]. into the stratum corneum to lay its eggs. Burrows are often
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Srinivas, et al.: Dermoscopic study of scabies in children

Table 9: Axillae as the circle of Hebra. Identification of the burrow can

Sex Age (years) Total be done with the help of a black felt tip marker applied
1‑5 5‑10 10‑15 to the burrow.[4] Diagnosis of scabies invasively is by skin
Males 2 13 3 18 scrapings. After scraping the skin, the sample is suspended
Females 2 9 3 14 in mineral oil or saline. The presence of the mite or egg
Total 32 casings under microscopy is considered to be the diagnostic
criteria. As the specimen debris can look like the scybala,
it alone is not considered diagnostic. Often while handling
Table 10: Flexural aspect of the wrists and processing, the skin scrapings errors can occur. Scabies
Sex Age (years) Total affects all socioeconomic classes with women and children
1‑5 5‑10 10‑15 being disproportionately affected. Among adults, sexual
Males 2 10 2 14 transmission is probably the most important route of
Females 2 8 3 13 transmission. Crusted scabies is a severe variant of scabies
Total 27 and is characterized by the presence of severe hyperkeratotic
lesions seen in the immunocompromised host.[6] It is
characterized by the absence or presence of only minimal
Table 11: Flexura l aspect of the elbows
itching.[7] Scabies is caused by prolonged close personal
Sex Age (years) Total
contact and transmission through fomites is more common
1‑5 5‑10 10‑15
in crusted scabies.[7] Pruritus with nocturnal exacerbation is
Males 2 8 5 15
the main symptom. Diagnosing scabies in infants, elderly or
Females 1 7 3 11
in patients on prolonged immunosuppressive therapy could
Total 26
be a challenge as they lack the typical clinical features.[8]
Scabies in infants affects the face, palms, soles, head, neck,
Table 12: Umbilicus and scalp. Neonatal scabies is a different subset of scabies
Sex Age (years) Total with atypical presentations.[9] Lesions can be in the form of
1‑5 5‑10 10‑15 papules, pustules, and vesicles.[10] Crusting and secondary
Males 2 8 4 14 bacterial infection of involved skin are commonly seen.
Females 2 3 4 9 Nocturnal Pruritus is absent. As burrows are rarely seen,
Total 23 neonates were not included in this study. In developing
countries, scabies is associated with considerable morbidity
including secondary infection, abscess, lymphadenopathy,
Table 13: Genitalia and poststreptococcal glomerulonephritis.[11] Scabies is a
Sex Age (years) Total common infestation seen in preschool children.[12] Scabies
1‑5 5‑10 10‑15 in children can mimic other itchy skin disorders such
Males 4 8 4 16 as papular urticaria and atopic dermatitis and accurate
Females 3 4 2 9
diagnosis is needed to give effective treatment.
Total 25
Dermoscopy was initially used for the diagnosis of skin
tumors. Nowadays, it has gained popularity in the use
Table 14: Buttocks of infectious and inflammatory skin disorders. Thus, it
Sex Age (years) Total has been found to be of good use in the daily practice
1‑5 5‑10 10‑15 of the dermatologist.[13] A dermoscope can be considered
Males 4 3 1 8 as the dermatologist’s stethoscope.[14] A pocket handheld
Females 3 2 0 5 dermoscope is portable, painless and is easy to use.
Total 13 Dermoscope is useful in a tertiary care center. It is also
useful for diagnosing scabies in the field, in the endemic
in an s shape or z shape. The life cycle of the scabies mite or epidemic context. It is less time‑consuming and is more
is for around 30 days. Infection is spread by close skin to acceptable to patients than skin scrapings. It can be used
skin contact. It makes a 0.5–5  mm burrow every day, and to replace skin scrapings as it allows a quick screening
it survives on dissolved skin and does not feed on blood. It of a large number of sites. Apart from that, it can also be
is estimated only 10% of the eggs mature into adults. There used in therapeutic trials to select the site in patients where
are estimates that over 300 million people worldwide are skin scrapings can be done. In a study done by Dupuy
affected with scabies.[4] Classical scabies affects the anterior et  al., sensitivity for the diagnosis of scabies  (91%) using
axillary folds, nipple area, periumbilical skin, elbows, dermoscopy was higher than the microscopic examination
volar surface of the wrists, interdigital webspaces, thighs, for the diagnosis of scabies  (90%).[15] A handheld
buttocks, penis, scrotum, and ankles.[5] This is referred to dermoscope has been shown to have high sensitivity

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Srinivas, et al.: Dermoscopic study of scabies in children
even in unexperienced hands.[15] It can also help to make
treatment decisions. High cost of the dermoscope is a
disadvantage. Dermoscopy has been found to be useful for
the diagnosis of Incognito scabies.[16] To avoid an invasive
test‑like skin scrapings, even adhesive tape test to diagnose
scabies has been done in resource poor settings.[17]
Jetliner sign is seen as a triangular structure which
corresponds to the anterior section of the mite including
the mouth part and the two pairs of the front legs.[6] It has
also been called as spermatozoid. Sometimes, traditional
methods of diagnosis of scabies can be missed due to the
absence of skin signs as the reaction to the mite can be
less pronounced. This is when dermoscopy has been found
to be useful. Apart from dermoscopy, videodermoscopy,
reflectance confocal microscopy, and optical coherence
tomography are other newer, noninvasive methods that can
be used for the diagnosis of scabies.[18]
This study was done as not many studies have been done to
study the dermoscopic features of scabies in children. In this
study, it was seen that on history and clinical examination
alone, the number of children diagnosed as scabies was
less compared to history and dermoscopic examination.
This is useful in a resource‑poor setting where microscopic
examination of the skin scrapings may not be possible due
to the unavailability of microscopes. In such a clinical
setting, the pocket handheld dermoscope is portable, and the
dermoscopic examination of the patients can be rapidly done.
The success rates are higher than clinical examination with
the naked eye. A statistical significant difference was seen in
the number of children diagnosed with scabies on comparing
the clinical examination versus dermoscopic examination (P
0.03). Also as more number of males were included in the
study compared to females, the number of males diagnosed
with scabies was more in both clinical examination (22)
and dermoscopic examination (28) compared to the number
of females in clinical examination (15) and dermoscopic
examination (17). Thus, on comparing the two noninvasive
techniques, dermoscopic examination was more sensitive
than only clinical examination of children in the diagnosis
of scabies.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form, the patients have given
their consent for their images and other clinical information
to be reported in the journal. The patients understand that
their names and initials will not be published and due
efforts will be made to conceal their identity, but anonymity
cannot be guaranteed.
Acknowledgments
We would like to express our sincere gratitude to
Dr. Girianna Gowda for help with the statistics and
Dr. Sweta Prabu for her inputs and suggestions.
Indian Journal of Paediatric Dermatology | Volume 20 | Issue 1 | January-March 2019
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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