Ivermectin for crusted Norwegian scabies induced by use of topical steroids.

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An 11-year-old girl from a rural area was referred to our institution for a generalized dermatologic condition diagnosed as seborrheic dermatitis or psoriasis. The disease began 3 years earlier as pruritic lesions on her abdomen and buttocks. The patient had received multiple topical treatments for 3 years; the treatments had consisted of mainly fluorinated corticosteroids prescribed by general practitioners and pharmacy attendants. The intense pruritus caused by her lesions was mitigated transiently by the use of corticosteroids, but the lesions progressively worsened to the point that, at consultation, the patient walked with pain and difficulty and was not able to feed, dress, or clean herself. All family members with whom the patient lived had developed pruritic skin lesions in the previous few months. On examination, the patient was in acceptable general condition but with widespread lesions. There were erythematous and desquamative plaques on her scalp, auricular regions, axillae, and umbilicus; hyperkeratotic and fissured plaques on her palms, soles, elbows, and sacral region; and hyperkeratotic nodules on the dorsa of her hands and feet (Figure 1). Her nails were markedly dystrophic with hyperkeratosis of the hyponychia. There was also a myriad of excoriated papules on her trunk and extremities. The patient experienced severe pain when walking and standing, as well as with flexion and extension of her hands. A diagnosis of crusted Norwegian scabies (CS) was confirmed by scrapings from several skin sites that yielded a huge number of mites, eggs, and fecal pellets (Figure2). Human immunodeficiency virus antibody test results were negative, and except for a slight peripheral eosinophilic leukocytosis (8%), routine laboratory values were within normal limits. Initial treatment consisted of lindane lotion for the patient and her relatives. The symptoms of the family members rapidly resolved, but despite additional therapy with several regimens of topical permethrin and keratolytics, the patient’s lesions failed to achieve any significant improvement. THERAPEUTIC CHALLENGE