CASE REPORT

Insight into scabies

Faye Mariz Razon; Emily Weidman-Evans, PharmD, BC-ADM

ABSTRACT
Scabies, an infectious disease caused by the scabies mite,
manifests as an intensely pruritic skin rash. Children, the
underprivileged, and patients with immunocompromise are
at a higher risk of acquiring this contagious disease. Infectiv-
ity occurs worldwide in patients of all races, ages, and sex.
The classical appearance of papular burrows between the
webbed spaces of digits or along the wrists can help distin-
guish scabies from other dermatologic diseases. Practitioners
need to be familiar with how scabies may present so that
patients can be treated and taught how to prevent spread of
the disease.
Keywords: scabies, mite infestation, permethrin, ivermectin,
immunocompromised, rash

FIGURE 1. Scabies lesions on a different patient

CASE
A 2-year-old boy with a rash of unknown duration was
brought to the ED by his mother. The mother discovered
small pink bumps between the child’s fingers as he was
grasping his bottle of milk. She reported that he recently
had become irritable throughout the night, despite no fever,
cough, or a runny nose. On physical examination, the child
was observed intensely scratching an area of linear papules
over the flexor surface of his left wrist. According to the
child’s daycare provider, other children at his facility seem
to be experiencing similar symptoms. What is causing this
contagious rash?
This child suffers from a classic infestation of the scabies
mite. Young children are at a greater risk of contracting
this disease. This article describes how to recognize scabies
early and provide an accurate diagnosis to help protect
patients from the complications and spread of this disease.
EPIDEMIOLOGY AND CAUSE
Sarcoptes scabiei var. hominis is a tiny mite that can invade
human skin. According to the CDC, this microscopic
arthropod lives within the skin’s outermost layer, creating
At the time this article was written, Faye Mariz Razon was a
student in the PA program at LSUHSC School of Allied Health.
Emily Weidman-Evans is a clinical associate professor in the PA
program at LSUHSC. The authors have disclosed no potential
conflicts of interest, financial or otherwise.
DOI:10.1097/01.JAA.0000511790.29560.a2
Copyright © 2017 American Academy of Physician Assistants
pruritic burrows on the host (Figure 1).1 Disease transmis-
sion occurs through prolonged and direct skin contact with
an infected person. High-risk populations include young
children and persons of lower socioeconomic status who
occupy close quarters.1 Older adults and patients who are
immunosuppressed are at high risk for crusted scabies,
which is characterized by crusted skin lesions caused by
the high quantity of mites and the eggs they lay.1
Scabies have been a worldwide problem for humans over
many years. Infestations of scabies were previously believed
to be cyclic in nature; however, researchers are now con-
sidering that environmental and social factors such as war,
overcrowding, and climate change are the primary influ-
ences on the survival of scabies.2 Transmission is thought
to occur after 15 to 20 minutes of direct skin contact, which
allows time for an adult female mite to lay eggs within the
burrows that she produces beneath the skin. Within a
2-week span, the eggs will develop into adult mites. An
estimated 300 million people worldwide are infected, with
neither race nor gender being predictive of infectivity. In
2013, a review by Fuller reported about 2.81 women and
2.27 men per 1,000 have scabies.3 The ability of scabies
to infect humans was found not to discriminate between
any type of community and the signs and symptoms can
be found in all levels of society.
CLINICAL PRESENTATION
The mites, larvae, or eggs in the burrows cause type I and
IV hypersensitivity reactions, which result in tissue

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CASE REPORT
Key points
Scabies, an infectious disease caused by the scabies mite,
manifests as an intensely pruritic skin rash characterized
by papular burrows.
Children, the underprivileged, and patients with immuno-
compromise are at higher risk.
Patient education is key to preventing spread of this conta-
gious disease.
Oral ivermectin and permethrin 5% cream are both effec-
tive treatments; however, permethrin 5% cream had a
faster activation time.
hyperplasia.4 The allergic reaction may take an incubation
period of 4 to 6 weeks with a possible mite count of 50;
however, if recontamination occurs, a diminished mite count
can trigger a swifter allergic response due to the accumula-
tion of acquired immunity. Patients classically experience
the insatiable need to scratch, causing an excoriated rash
with vesicles or pustules (Figure 1). This itch is character-
istically worse at night with the severity intensifying 2 to 3
weeks before clinical presentation. Often, several members
of a household will simultaneously present with pruritus,
indicating that cross-contamination has occurred.5
Scabies also causes mental and emotional adverse reac-
tions. Research conducted by Worth and colleagues in
Brazil found that the increased pruritus at night deprived
patients of sleep.6 Patients had feelings of shame, stigma-
tization, and social exclusion, which were felt more severely
by females compared with males in all age groups.
DIAGNOSTIC STUDIES
Diagnosing scabies involves a thorough patient history
and physical examination and a clear visualization of the
mites, feces, or larvae.
• Skin scrapings, one method of diagnosis, involves placing
a drop of mineral oil on a nonexcoriated burrow and using
a scalpel blade to laterally scrape a superficial layer of skin
onto a glass slide for microscopic visualization of mites or
eggs.7
• A dermatoscope, used by dermatologists, can help iden-
tify the “delta glider” sign, a triangular figure that denotes
the location of a mite; however, this finding is difficult to
determine in patients with dense body hair.8
• The adhesive tape test can be performed by tightly seal-
ing a lesion with transparent tape and then quickly remov-
ing it. That tape is then placed onto a glass slide and
thoroughly examined underneath the lens of a microscope
for evidence of mite feces or larvae.
A study by Walter and colleagues found that patients
who had access to resource-poor clinics benefited most
from dermatoscopy as long as the practitioner was profi-
cient at making these observations.9 The study also noted
that the second most helpful method was the adhesive tape
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test, which is cheap, highly accessible, and can be easily
learned by untrained personnel.
ASSESSMENT
Perform a full skin examination, paying close attention to
regions where scabies classically reside—the webbed spaces
between digits, the wrists, and the elbows. Also consider
the patient’s age: Boralevi and colleagues recently conducted
research in France and compared how the clinical presen-
tation of scabies affected certain age groups.10 Their study
found that scabies had more nodular appearances and face
and scalp involvement in infants under age 2 years com-
pared with children ages 2 to 15 years and adults over age
15 years. Also, the researchers noted that infants and
children were more likely to relapse, have a history of
eczema, or form scabies lesions that most often appeared
over the head, neck, ankles, and feet. In contrast, the study
indicated that adults more often exhibited scabies in areas
involving the upper extremities, nipples, and genitals.
DIFFERENTIAL DIAGNOSIS
Clinicians must consider a multitude of dermatologic
diseases that can explain the clinical picture of erythema-
tous and pruritic excoriations. Other insects can cause
similar findings including lice, bedbugs, or fleas. Folliculi-
tis, bullous pemphigoid, and erythroderma can be consid-
ered as differential diagnoses for classic scabies, although
psoriasis, eczema, and ichthyosis can be candidates for
crusted scabies.5 Therefore, with a large list of differential
diagnoses for scabies, clinicians must use the methods of
skin scraping, dermatoscopy, or adhesive tape test to clearly
visualize these mites, reach an accurate diagnosis, and start
appropriate pharmacologic intervention.
TREATMENT AND FOLLOW-UP
The treatments for scabies involve treating the patient and
his or her surroundings. The first-line treatment is perme-
thrin 5% cream, which should be applied to the entire
body from the neck down, let sit for 8 to 14 hours, and
then rinsed off and repeated 1 week later.7 If permethrin
5% cream fails to cure scabies, 200 mcg/kg of oral iver-
mectin can be given on the day of the follow-up appoint-
ment and again in 14 days. Patients with crusted scabies
should receive a combination of permethrin 5% cream
and oral ivermectin.
A study to determine the more successful treatment for
scabies—permethrin 5% cream or oral ivermectin—tested
three regimens:11
• a single dose of permethrin 5% cream on day 1 of the
infestation
• a single dose of oral ivermectin on the first day of infestation
• two doses of oral ivermectin: one given on the 1st day
of infestation and the second on the 15th day.
These authors found that oral ivermectin and permethrin
5% cream were both successful treatments; however,
Volume 30 • Number 2 • February 2017

permethrin 5% cream had a faster activation time, and
patients who used permethrin 5% cream from day 1 of
infestation experienced the most significant decrease in the
amount of lesions and pruritus after 1 week.11
The patient’s environment also must be addressed. All
members of the household need to be treated prophylacti-
cally to prevent recontamination. Bed sheets and clothes
should be washed in hot water (60° C [140° F]) or sealed
in plastic bags for at least 14 days.12
PROGNOSIS AND COMPLICATIONS
The intense scratching caused by scabies puts patients at
risk for secondary bacterial skin infections from Staphy-
lococcus aureus or Streptococcus pyogenes. Patients with
classic scabies may develop furunculosis, cellulitis, or
impetigo; immunocompromised patients with crusted
scabies can experience severe complications including
eczema, sepsis, or death. Worldwide, out of the 660,000
patients with scabies who develop secondary Streptococcus
pyogenes infections, 160,000 will die.13 Other potentially
severe complications of these secondary infections include
acute rheumatic fever, poststreptococcal glomerulonephri-
tis, rheumatic heart disease, and chronic kidney disease
(CKD). A study in Taiwan compared patients diagnosed
with scabies versus an unaffected group to investigate who
would subsequently be diagnosed with CKD after 5 years.14
The study found higher rates of CKD in patients with
scabies compared with the unaffected group. Also, the study
specifically showed that compared with patients in the unaf-
fected group, men with scabies were 1.4 times more likely
and women 1.27 times more likely to have CKD.14 Over-
all, the short-term and long-term complications of scabies
validate the need for quick diagnosis and treatment by
healthcare providers in order to avoid serious complications.
PREVENTION AND PATIENT EDUCATION
Several approaches are recommended to prevent the spread
of scabies. According to the CDC, patients should be advised
against prolonged physical contact with the skin, clothing,
or bed sheets of infected patients, and articles of clothing
should be laundered and dried on high heat.1 The CDC also
advises that all close contacts be treated prophylactically,
and patients with crusted scabies be given intensive treatment
regimens, as described above. If symptoms have not resolved
by the date of the follow-up appointment, suspect nonadher-
ence or inappropriate application of the medicine, and repeat
the treatment and application instructions.12 Vacuuming
and maintaining sterile surfaces are recommended for resi-
dential facilities such as long-term-care and assisted living
facilities. However, spraying pesticides is not encouraged.7
A study of 500 patients with scabies who were living or
working in a long-term-care facility for persons with dis-
abilities found that an effective method for terminating an
outbreak involved planning, examining and treating patients
in a time-sensitive manner, performing decontamination
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Copyright © 2017 American Academy of Physician Assistants
Insight into scabies
and quarantine, and following up with patients.15 Preven-
tion methods such as these can minimize the transmission
of scabies.
CONCLUSION
After reassuring the child’s mother, the clinician performed
a tape test and diagnosed scabies. The mother was told to
buy over-the-counter permethrin 5% cream for the entire
family, and was instructed in its use. Ensure that the fam-
ily has adequate laundry facilities to wash clothing and
bedding in hot water. Tell the mother to bring her son in
for follow-up if the lesions have not begun to clear after
the second treatment in 1 week.
Scabies infestation affects the superficial skin layers,
causing severe pruritus. Young children and immunocom-
promised patients are especially susceptible, and complica-
tions can be severe and life-threatening. Healthcare
providers should focus on quick and accurate diagnosis,
appropriate treatment, and effective education and preven-
tion methods to avoid large outbreaks. JAAPA
REFERENCES
1. Centers for Disease Control and Prevention. Scabies—epidemiology
& risk factors. www.cdc.gov/parasites/scabies/epi.html. Accessed
November 8, 2016.
2. Hay RJ, Steer AC, Engelman D, Walton S. Scabies in the devel-
oping world—its prevalence, complications, and management.
Clin Microbiol Infect. 2012;18(4):313-323.
3. Fuller LC. Epidemiology of scabies. Curr Opin Infect Dis. 2013;
26(2):123-126.
4. Walton SF, Oprescu FI. Immunology of scabies and translational
outcomes: identifying the missing links. Curr Opin Infect Dis.
2013;26(2):116-122.
5. Barry M. Scabies. http://emedicine.medscape.com/article/1109204-
overview. Accessed November 8, 2016.
6. Worth C, Heukelbach J, Fengler G, et al. Impaired quality of life
in adults and children with scabies from an impoverished com-
munity in Brazil. Int J Dermatol. 2012;51(3):275-282.
7. Gunning K, Pippitt K, Kiraly B, Sayler M. Pediculosis and sca-
bies: treatment update. Am Fam Physician. 2012;86(6):535-541.
8. Dupuy A, Dehen L, Bourrat E, et al. Accuracy of standard dermos-
copy for diagnosing scabies. J Am Acad Dermatol. 2007;56(1):53-62.
9. Walter B, Heukelbach J, Fengler G, et al. Comparison of dermoscopy,
skin scraping, and the adhesive tape test for the diagnosis of scabies
in a resource-poor setting. Arch Dermatol. 2011;147(4):468-473.
10. Boralevi F, Diallo A, Miquel J, et al. Clinical phenotype of sca-
bies by age. Pediatrics. 2014;133(4):e910-e916.
11. Sharma R, Singal A. Topical permethrin and oral ivermectin in the
management of scabies: a prospective, randomized, double blind,
controlled study. Indian J Dermatol Venereol Leprol. 2011;77(5):
581-586.
12. Berger T. Dermatologic disorders. In: Papadakis M, McPhee S,
eds. Current Medical Diagnosis and Treatment. New York, NY:
McGraw-Hill; 2014:143-144.
13. Engelman D, Kiang K, Chosidow O, et al. Toward the global
control of human scabies: introducing the International Alliance
for the Control of Scabies. PLoS Negl Trop Dis. 2013;7(8):e2167.
14. Chung SD, Wang KH, Huang CC, Lin HC. Scabies increased the
risk of chronic kidney disease: a 5-year follow-up study. J Eur
Acad Dermatol Venereol. 2014;28(3):286-292.
15. Stoevesandt J, Carlé L, Leverkus M, Hamm H. Control of
large institutional scabies outbreaks. J Dtsch Dermatol Ges.
2012;10(9):637-647.
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