Scabies in Emergency Medicine Clinical Presentation

  • Author: Amy L McCroskey, MD; Chief Editor: Robert E O'Connor, MD, MPH   more...
 
Updated: Oct 6, 2010
 

History

Suspect scabies in any patient, regardless of age or socioeconomic status, who presents with severe persistent pruritus. The patient with scabies has generally been itching for a short time. On the other hand, the infestation can persist indefinitely, thus the appellation "the seven year itch."

Signs and symptoms tend to crescendo progressively over 2-3 weeks before compelling the patient to seek medical attention.

In developed nations, scabies occurs more commonly in fall and winter months.

Scabies appears to occur in clusters. If there is an outbreak in the community, consider scabies in an individual presenting with itching and a rash.

Consider a diagnosis of scabies if multiple family members are involved.

Nocturnal pruritus is a highly characteristic complaint associated with scabies infestation.

Although unusual in the neonate, scabies has been reported in this age group.

Debilitated or immunocompromised patients may not have the urge to scratch.[14]

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Physical

Primary lesions of scabies

These include burrows, papules, pustules, nodules, occasionally urticarial papules and plaques[14] located between web space of fingers, flexor aspects of the wrists, axilla, antecubital area, abdomen, umbilicus, genital and gluteal areas, and feet[15] (See the image below.)

Scabies on the buttocks. Courtesy of William D. JaScabies on the buttocks. Courtesy of William D. James, MD.

A short elevated pink or gray, straight or tortuous line, serpiginous (S-shaped) track in the superficial epidermis, with a small vesicle at the tip is known as a burrow; this is pathognomonic of scabies infestation.[14] A burrow appears as a thin (approximately the width of a human hair), short (perhaps 2-3 mm in length), gray brown, wavy channel on the skin.

In women, the nipples and areola of the breasts often are affected. In men, red papules or nodules on the penile glans, shaft, and scrotum are typical of scabies. See the image below.

Scabies on the penis. Courtesy of William D. JamesScabies on the penis. Courtesy of William D. James, MD.

Compared with adults, scabies in infants and young children tend to be more disseminated and, while the head and face usually are spared in adults, they may be affected in the very young.

Geriatric scabies demonstrates a propensity for the back, often appearing as excoriations.

Occasionally, the mite is visible to the naked eye as a small white dot.

A small vesicle or papule may appear at the end of the burrow, where the mite enters the skin.

Nodular scabies may erupt on covered parts of the body as either few or many lesions. They are characterized by firm, red nodules approximately 0.5 cm or larger. These can form during or after the infestation has been treated. Usually no organisms are found in the lesions. The nodules are suspected to represent an immune reaction to the scabetic antigens.[6]

Norwegian scabies presents with extensive crusting of the skin with thick, hyperkeratotic scales overlying the elbows, knees, palms, and soles.

Bullous lesions may be observed in immunocompromised patients.

Canine scabies does not exhibit the classic burrow. Instead, papules and vesicles are the most prominent lesions surfacing on the arms, chest, abdomen, and thighs.

Secondary lesions

These include urticaria, impetigo, and eczematous plaques.[16]

One study found aerobic and anaerobic bacteria were grown from specimens obtained from children with secondary infections. Aerobes were present in 47% of children: Staphylococcus aureus, group A streptococci, and Pseudomonas aeruginosa. Anaerobes were found to be present in 20% of children: Peptostreptococcus, Prevotella, and Porphyromonas species. Mixed anaerobic-aerobic flora were present in 33% of patients.[13]

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Causes

Scabies is caused by the mite S scabiei var hominis, an arthropod of the order Acarina.

Patients who are immunocompromised (eg, HIV, systemic corticosteroid therapy) may develop a severe form called Norwegian scabies.[7]

Animal forms of scabies exist and are generally referred to as mange. S scabiei causes mange in many companion and livestock animals and is responsible for epizootic diseases in wild populations of cats, ungulates, boars, wombats, ferrets, koalas, and great apes. It is considered to be a major cause of mortality among red foxes, coyotes, and wombat.

Animal scabies causes a transient pruritic papular or vesicular erythremic lesion that occurs 24 hours after an exposure to an infested animal. This differs from the rapid sensitivity that occurs with primary infections in humans. This may be due to previous sensitization in the human host. The immediate itching may lead to a protective mechanism in the human host—scratching—which can prevent the mite from burrowing.

Animal mites do not multiply on the human host.[1]

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Contributor Information and Disclosures
Author

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.

Coauthor(s)

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

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.

Specialty Editor Board

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.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine 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.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

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.

References

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Scabies mite. Courtesy of William D. James, MD.
Scabies mite scraped from a burrow (original magnification, 400X). Courtesy of Audra Malerba, DO.
Scabies. Courtesy of William D. James, MD.
In crusted scabies, sections show multiple mites (arrows) within the hyperkeratotic stratum corneum (H&E, original magnification 100X). The epidermis is spongiotic. Courtesy of Audra Malerba, DO.
In routine scabies, a single mite is seen. Eosinophilic spongiosis may be present (H&E, original magnification 400X). Courtesy of Audra Malerba, DO.
Norwegian scabies. Courtesy of William D. James, MD.
Scabies on the leg. Courtesy of William D. James, MD.
Erythematous vesicles and papules are present on torso extremities, some with adjacent linear excoriations. Courtesy of Audra Malerba, DO.
Scabies on the buttocks. Courtesy of William D. James, MD.
Scabies on the hand. Courtesy of William D. James, MD.
Scabies on the penis. Courtesy of William D. James, MD.
Scabies on the penis. Courtesy of Hon Pak, MD.
 
 
 
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