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Scabies Workup

  • Author: Megan Barry, MD; Chief Editor: Dirk M Elston, MD  more...
 
Updated: Jun 30, 2016
 

Approach Considerations

The diagnosis of scabies can often be made clinically in patients with a pruritic rash and characteristic linear burrows. The diagnosis is confirmed by light microscopic identification of mites, larvae, ova, or scybala (feces) in skin scrapings.

In rare cases, mites are identified in biopsy specimens obtained to rule out other dermatoses. Characteristic histopathology in the absence of actual mites also may suggest the diagnosis of scabies.

Clinically inapparent infection can be detected by amplification of Sarcoptes DNA in epidermal scale by polymerase chain reaction (PCR) assay.[4] In addition, elevated IgE titers and eosinophilia may be demonstrated in some patients with scabies.

A simple, cheap, sensitive, and specific test for routine diagnosis of active scabies is desirable.[39] The expression and purification of S scabiei recombinant antigens have identified numerous molecules with diagnostic potential. Current studies are assessing the accuracy of these recombinant proteins in identifying antibodies in individuals with active scabies and in differentiating them from individuals with past exposure.

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Locating Mite Burrows

Burrow ink test

A burrow can be located by rubbing a washable felt-tip marker across the suspected site and removing the ink with an alcohol wipe. When a burrow is present, the ink penetrates the stratum corneum and delineates the site. This technique is particularly useful in children and in individuals with very few burrows.

Tetracycline

Topical tetracycline solution is an alternative to the burrow ink test. After application and removal of the excess tetracycline solution with alcohol, the burrow is examined under a Wood light. The remaining tetracycline within the burrow fluoresces a greenish color. This method is preferred because tetracycline is a colorless solution and large areas of skin can be examined.

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Skin Scraping

Definitive testing relies on the identification of mites or their eggs, eggshell fragments, or scybala.[19] This is best undertaken by placing a drop of mineral oil directly over the burrow on the skin and then superficially scraping longitudinally and laterally across the skin with a scalpel blade. (Avoid causing bleeding.) Scraping 15 or more burrows often produces only 1 or 2 eggs or mites, except in a case of crusted scabies, in which many mites will be present.[40]

The sample is placed on a microscope slide and examined under low and high power. Potassium hydroxide should not be used, since it can dissolve mite pellets. Failure to find mites is common and does not rule out the diagnosis of scabies.

Superficial cyanoacrylate biopsy (SCAB) combined with conventional transillumination light microscopy reveals the anatomic features of the scabies mite in detail. It can also distinguish living mites from dead ones, because living mites are mobile on the slide.[41] Scabies mites are seen in the images below.

Scabies mite scraped from a burrow (original magni Scabies mite scraped from a burrow (original magnification, 400X).
Scabies preparation demonstrating a mite and ova. Scabies preparation demonstrating a mite and ova. Courtesy of William D. James, MD.

Crusted scabies

Add 10% potassium hydroxide to the skin scraping. This dissolves excess keratin and permits adequate microscopic examination.

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Adhesive Tape Test

Strips of tape are applied to areas suspected of being burrows and then rapidly pulled off. These are then applied to microscope slides and examined. The adhesive tape test is easy to perform and had high positive and negative predictive values, making it a good screening test. The sensitivity of skin scraping was judged to be low.

Dermatoscopy-guided tape testing may be beneficial and should be evaluated.[42] Dermatoscopy was compared with the microscopic examination of a skin scraping and with the adhesive tape test, in patients with a presumptive diagnosis of scabies.[43] The sensitivity of dermatoscopy was 0.83, which was significantly higher than that of the adhesive tape test.

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Histologic Findings

The histologic features of scabies are distinctive enough to suggest the diagnosis, although they are common to a variety of arthropod reactions. If a burrow is excised, mites, larvae, ova, and feces may be identified within the stratum corneum, as in the images below.

Scabies mite in the stratum corneum. Courtesy of W Scabies mite in the stratum corneum. Courtesy of William D. James, MD.
In crusted scabies, sections show multiple mites ( In crusted scabies, sections show multiple mites (arrows) within the hyperkeratotic stratum corneum. The epidermis is spongiotic (hematoxylin and eosin; original magnification, 100X).

A superficial and deep dermal infiltrate composed of lymphocytes, histiocytes, mast cells, and eosinophils is characteristic. Spongiosis and vesicle formation with exocytosis of eosinophils and occasional neutrophils are present, as in the image below. Biopsy of older lesions is nondiagnostic, demonstrating only excoriation and scale crusts.

In routine scabies, a single mite is seen. Eosinop In routine scabies, a single mite is seen. Eosinophilic spongiosis may be present (hematoxylin and eosin; original magnification, 400X).

Crusted scabies

Crusted scabies demonstrates massive hyperkeratosis of the stratum corneum, with innumerable mites in all stages of development. Psoriasiform hyperplasia of the underlying epidermis with spongiotic foci and occasional epidermal microabscesses is present. The dermis shows a superficial and deep, chronic inflammatory infiltrate with admixed interstitial eosinophils.

Nodular scabies

Nodular scabies reveals a dense, mixed, superficial and deep dermal inflammatory cell infiltrate. Lymphoid follicles may be present, and the infiltrate occasionally extends into the subcutaneous fat. Mite parts may be seen on serial sectioning in up to 20% of cases.

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Contributor Information and Disclosures
Author

Megan Barry, MD Resident Physician, Department of Dermatology, University of Virginia School of Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Catharine Lisa Kauffman, MD, FACP Georgetown Dermatology and Georgetown Dermpath

Catharine Lisa Kauffman, MD, FACP is a member of the following medical societies: American Academy of Dermatology, Royal Society of Medicine, Women's Dermatologic Society, American Medical Association, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Barbara B Wilson, MD Edward P Cawley Associate Professor, Department of Dermatology, University of Virginia School of Medicine

Barbara B Wilson, MD is a member of the following medical societies: Alpha Omega Alpha, Medical Society of Virginia, Sigma Xi, American Academy of Dermatology

Disclosure: Nothing to disclose.

Adam J Rosh, MD Assistant Professor, Program Director, Emergency Medicine Residency, Department of Emergency Medicine, Detroit Receiving Hospital, Wayne State University School of Medicine

Adam J Rosh, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Eugene Rozen, MD Resident Physician, Department of Emergency Medicine, Detroit Receiving Hospital

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Acknowledgements

William D Binder, MD Clinical Instructor in Emergency Medicine, Brown University Medical School; Consulting Staff, Instructor, Department of Emergency Medicine, Massachusetts General Hospital

Disclosure: Nothing to disclose.

Jennifer R Casatelli, MD Consulting Staff, Department of Pediatrics, Watson Clinic of Lakeland, Lakeland Regional Medical Center

Disclosure: Nothing to disclose.

Kevin P Connelly, DO Clinical Assistant Professor, Department of Pediatrics, Division of General Pediatrics and Emergency Care, Virginia Commonwealth University School of Medicine; Medical Director, Paws for Health Pet Visitation Program of the Richmond SPCA; Pediatric Emergency Physician, Emergency Consultants Inc, Chippenham Medical Center

Kevin P Connelly, DO is a member of the following medical societies: American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association

Disclosure: Nothing to disclose.

Kelly M Cordoro, MD Assistant Professor of Clinical Dermatology and Pediatrics, Department of Dermatology, University of California, San Francisco School of Medicine

Kelly M Cordoro, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Association of Professors of Dermatology, Dermatology Foundation, Medical Society of Virginia, National Psoriasis Foundation, Society for Pediatric Dermatology, and Women's Dermatologic Society

Disclosure: Nothing to disclose.

Kenneth E Greer, MD Former Professor, Department of Dermatology, University of Virginia School of Medicine; Former Chairman, Department of Dermatology, University of Virginia Medical Center

Disclosure: Nothing to disclose.

Ulrich Hengge, MD, MBA Professor, Department of Dermatology, Heinrich-Heine-University Düsseldorf, Germany

Disclosure: Nothing to disclose.

Daniel J Hogan, MD Clinical Professor of Internal Medicine (Dermatology), Nova Southeastern University College of Osteopathic Medicine; Investigator, Hill Top Research, Florida Research Center

Daniel J Hogan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Contact Dermatitis Society, and Canadian Dermatology Association

Disclosure: Nothing to disclose.

Camila K Janniger, MD Clinical Professor of Dermatology, Clinical Associate Professor of Pediatrics, Chief of Pediatric Dermatology, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Camila K Janniger, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Paul Krusinski, MD Director of Dermatology, Fletcher Allen Health Care; Professor, Department of Internal Medicine, University of Vermont College of Medicine

Paul Krusinski, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Mudra Kumar, MD, MBBS, MRCP Associate Professor, Department of Pediatrics, University of South Florida College of Medicine

Mudra Kumar, MD, MBBS, MRCP is a member of the following medical societies: American Academy of Pediatrics and American Society of Hematology

Disclosure: Nothing to disclose.

Audra Malerba, MD Staff Physician, Department of Family Medicine, Long Beach Medical Center, New York

Disclosure: Nothing to disclose.

Amy L McCroskey, MD Resident Physician, Department of Emergency Medicine, Wayne State University Detroit Medical Center, Detroit Receiving Hospital

Amy L McCroskey, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Student Association/Foundation, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Giuseppe Micali, MD Head, Professor, Department of Dermatology, University of Catania School of Medicine, Italy

Giuseppe Micali, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Robert E O'Connor, MD, MPH Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Adam J Rosh, MD Assistant Professor, Department of Emergency Medicine, Detroit Receiving Hospital, Wayne State University School of Medicine

Adam J Rosh, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Joseph A Salomone III, MD Associate Professor and Attending Staff, Truman Medical Centers, University of Missouri-Kansas City School of Medicine; EMS Medical Director, Kansas City, Missouri

Joseph A Salomone III, MD is a member of the following medical societies: American Academy of Emergency Medicine, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Robert A Schwartz, MD, MPH Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi

Disclosure: Nothing to disclose.

Joseph Sciammarella, MD, FACP, FACEP, FAAMA Major, MC, USAR Attending Physician, Department of Emergency Medicine, Mercy Medical Center, Rockville Centre, New York

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Jeter (Jay) Pritchard Taylor III, MD Compliance Officer, Attending Physician, Emergency Medicine Residency, Department of Emergency Medicine, Palmetto Health Richland, University of South Carolina School of Medicine; Medical Director, Department of Emergency Medicine, Palmetto Health Baptist

Jeter (Jay) Pritchard Taylor III, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Richard P Vinson, MD Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

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Scabies mite scraped from a burrow (original magnification, 400X).
A typical linear burrow on the flexor forearm. Courtesy of Kenneth E. Greer, MD.
A subtle linear burrow accompanied by erythematous papules on the sole of the foot in a child with scabies. Courtesy of Kenneth E. Greer, MD.
Erythematous papules and papulovesicles on the flexor wrist. Courtesy of Kenneth E. Greer, MD.
Scabies on the penile shaft and glans. Courtesy of William D. James, MD.
Scabietic papules on the penile shaft and scrotum. Courtesy of Kenneth E. Greer, MD.
Widespread eruption on the back of an infant with scabies. Courtesy of Kenneth E. Greer, MD.
Nodular scabies in an infant. Courtesy of Kenneth E. Greer, MD.
Nodular scabies. Courtesy of Kenneth E. Greer, MD.
Crusted scabies. Courtesy of William D. James, MD.
Crusted scabies. Courtesy of Kenneth E. Greer, MD.
Scabies preparation demonstrating a mite and ova. Courtesy of William D. James, MD.
Scabies. Erythematous vesicles and papules are present on torso extremities, some with adjacent linear excoriations.
In routine scabies, a single mite is seen. Eosinophilic spongiosis may be present (hematoxylin and eosin; original magnification, 400X).
Scabies mite in the stratum corneum. Courtesy of William D. James, MD.
In crusted scabies, sections show multiple mites (arrows) within the hyperkeratotic stratum corneum. The epidermis is spongiotic (hematoxylin and eosin; original magnification, 100X).
Scabies. Courtesy of William D. James, MD.
Scabies in the interdigital web spaces. Courtesy of William D. James, MD.
Papulovesicles and nodules on the palm in a patient with scabies. Courtesy of Kenneth E. Greer, MD.
Scabies on buttocks. Courtesy of William D. James, MD.
Scabies on penis. Courtesy of Hon Pak, MD.
 
 
 
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