Retrospective Evaluation of Misdiagnosed Scabies Cases: Clinical and Epidemiological Features and Resemblance to Other Dermatological Conditions

Objective : The purpose of this study is to investigate the skin disease in Sanghanron"傷寒論" and Geumgweyoryak"金匱要略". Methods : We conducted a study on the original text paragraphs of Sanghanron and Geumgweyoryak containing the skin disease and analysis of Woo, Oh, Sung, Zhang, etc. We drew a parallel between skin disease from Sanghanron and Geumgweyoryak and matching diagnoses from western medicine. Results : The results were as follows. 1. In Sanghanron and Geumgweyoryak pruritus was related to psychogenic pruritus and similar to skin disease caused by decrease of sweating, dry skin in cholinergic urticaria, atopic dermatitis and eczema, etc. in western medicine. 2. In Geumgweyoryak ichthyosis was caused by woman's disease, after menopause, chronic disease and malnutrition and related to winter itch and xerotic eczema in western medicine. 3. In Sanghanron Goose bumps, keratosis follicularis, acute and chronic urticaria and cold urticaria were occurred because of poorly managed fever care and side effect of antibiotic. 4. In Geumgweyoryak red face was similar to face flushing and side effects, which is after drug and laser treatment on face, in western medicine. 5. In Geumgweyoryak urticaria was, in a broad sense, skin disease with pruritus and secondary infection resulted from scratch. Skin diseases with pruritus are similar to urticaria, dermatitis herpetiformis, lichen planus, atopic dermatitis, contact dermatitis, psoriasis, nummular eczema, lichen simplex chronicus, prurigo nodularis, neurodermatitis and internal disease with pruritus in western medicine. 6. In Geumgweyoryak spots in the skin were caused by fever and similar to allergic purpura and SLE symptom in western medicine. 7. In Geumgweyoryak bullous disease with yellowish discharge was similar to eczema, pustule, atopic eczema, etc. in western medicine. 8. In Geumgweyoryak repeated inflammation of oral cavity, genitals, eyes and skin was similar to Behcet's disease in western medicine. 9. In Sanghanron and Geumgweyoryak boil was similar to abscess and acute lymphadenitis in western medicine caused by oily foods and infections. 10. In Geumgweyoryak swelling and boil were occurred in a poor health. Damage from metalic material could cause a convulsion and was similar to tetanus in western medicine. Conclusion : We analyzed the original text paragraphs of Sanghanron and Geumgweyoryak and explanations about skin disease. As a results, we found out etiology, pathogenesis, treatments of the skin disease in Sanghanron and Geumgweyoryak. Further we compared with western medicine to develop better understanding of the skin disease.

Bullous scabies is an uncommon subtype of scabies that frequently mimics other blistering skin diseases. Nocturnal pruritus is a hallmark symptom of bullous scabies. We report an unusual case of bullous scabies presenting in the absence of pruritus in an immunosuppressed pediatric patient. It is critical that clinicians consider the diagnosis of bullous scabies in any patient with bullae, irrespective of pruritus symptoms.

BackgroundScabies is a common parasitic infection caused by the mite Sarcoptes Scabiei. About 300 million cases of scabies are reported annually. Scabies usually presents clinically with an erythematous excoriated papulovesicular rash, burrows, nodules and hyperkeratotic lesions in specific body areas.A rare presentation of scabies is the bullous pemphigoid-like bullous scabies. So far, to the best of our knowledge, only 32 cases of bullous scabies have been reported in medical literature, of which only 11 were under 60 years of age at the time of initial presentation. This is the first case of bullous scabies being reported from Pakistan.Case presentationHerein we discuss, with reference to the existing literature, the case of a 23-year-old Punjabi male who presented with a 3 day history of a tense, non-erythematous, non-tender bulla measuring approximately 0.5 cm x 0.8 cm on the right foot near the interdigital cleft. He was diagnosed to have bullous scabies.ConclusionThe diagnosis of scabies should be considered in all patients who present with tense bullous lesions accompanied by pruritus and a maculopapular rash. This is particularly relevant if these lesions do not resolve with steroid treatment. In such patients, in order to prevent a misdiagnosis of bullous pemphigoid, scrapings for Sarcoptes Scabiei mites and eggs should be taken.

Scabies is a contagious parasitic dermatitis that is a significant cause of morbidity, especially outside of the United States. Scabies is diagnosed most often by correlating clinical suspicion with the identification of a burrow. Although scabies should be on the differential for any patient who presents with a pruritic dermatosis, clinicians must consider a wide range of diagnostic possibilities. This approach will help make scabies simultaneously less over- and underdiagnosed by clinicians in the community. Atypical or otherwise complex presentations may necessitate the use of more definitive diagnostic modalities, such as microscopic examination of KOH prepared skin scrapings, high-resolution digital photography, dermoscopy, or biopsy. Scabies therapy involves making the correct diagnosis, recognizing the correct clinical context to guide treatment of contacts and fomites, choosing the most effective medication, understanding how to use the agent properly, and following a rational basis for when to use and reuse that agent. Although the development of new therapeutic agents is always welcome, tried and true treatments are still effective today. Permethrin is the gold standard therapy, with malathion being an excellent topical alternative. Ivermectin is an effective oral alternative that is especially useful in crusted scabies, patients who are bed ridden, and in institutional outbreaks. Despite the availability of effective therapeutics, treatment failures still occur, mostly secondary to application error (ie, failure to treat the face and scalp or close contacts, failure to reapply medication) or failure to decontaminate fomites. Because increasing resistance to scabies treatments may be on the horizon, we propose that standard of care for scabies treatment should involve routine treatment of the scalp and face and re-treating patients at day 4 on the basis of the scabies life cycle to ensure more efficient mite eradication. Practitioners should attempt to treat all close contacts simultaneously with the source patient. To eradicate mites, all fomites should be placed in a dryer for 10 minutes on a high setting, furniture and carpets vacuumed, and nonlaunderables isolated for a minimum of 2 days, or, for those who wish to be rigorous, 3 weeks.

The Pattern of Skin Diseases in Hail Region, Saudi Arabia

There has been an increase in scabies cases in Türkiye, and is considered to be an epidemic. The aim of this study was to assess scabies cases and the current status of scabies treatment by comparing patients who received scabies diagnosis and treatment before the COVID-19 pandemic, during the pandemic, and the normalization process. In this study, data of patients who applied to Van İpekyolu 1st Family Health Center and received a scabies diagnosis were evaluated retrospectively. Demographic data such as age, sex, application dates, and treatment methods were received from the electronic registration database of Van İpekyolu 1st Family Health Center. Categorical variables were presented as numbers (n) and percentages (%). The "two proportions Z-test and Fisher's exact" test of the ratios were used for categorical variables. Before the pandemic, among 4009 patients with dermatology complaints, 56 (1.4%) received a scabies diagnosis. An increase in scabies cases has been observed since 2018, and the annual case count has further increased during the pandemic. Before the pandemic, 10 (17.9%) out of 56 patients diagnosed with scabies and 70 (31.1%) out of 225 patients diagnosed with scabies during and after the pandemic experienced recurrence after permethrin treatment. Patients who did not respond to permethrin treatment were successfully treated with ivermectin. An increase in scabies cases has been identified in conjunction with the COVID-19 pandemic and the recurrence of scabies in patients treated with permethrin after the pandemic has raised concerns about the potential development of resistance to permethrin.

The morphology of scabies, a mite infestation of worldwide proportion, is characterized by a variety of cutaneous lesions. Patients with classic scabies present with characteristic burrows often located on the web spaces of the fingers and toes. Scabies surrepticius refers to the non-classic atypical presentation of scabies; establishing the diagnosis of scabies in these individuals can be difficult. To facilitate the diagnosis of scabies, criteria have been proposed by the International Alliance for the Control of Scabies (IACS). These criteria are intended for scabies research; however, they can be utilized by clinicians to establish either a confirmed diagnosis, a clinical diagnosis or a suspected diagnosis of scabies. Visualization of mites, eggs or feces is necessary for a confirmed diagnosis of scabies. A clinical diagnosis can be established by observation of either genital lesions in men or burrows or classically distributed classical lesions in individuals with two historic features: pruritus and close contact with an individual who itches and has classically distributed classical scabetic lesions. The clinical features and management of a woman residing in an assisted living environment with a confirmed diagnosis of scabies and a man with a clinical diagnosis of scabies are described. The criteria for the suspected diagnosis of scabies require either one historic feature and typical lesions in a typical distribution or both historic features and the presence of atypical lesions or an atypical distribution of the skin lesions. Once the diagnosis of scabies is established, not only the patient but also close contacts should receive treatment with either a topical medication (such as permethrin 5% cream) or a systemic drug (ivermectin) or both. The number and frequency of treatments are variable; classic scabies typically is managed with a total of two treatments performed weekly to biweekly. Patients with crusted scabies usually require multiple topical and oral antiscabetic treatments in addition to topical keratolytic therapy. Bacterial impetiginization or infection (most commonly by Staphylococcus aureus or Streptococcus pyogenes) can complicate scabies infestation and potentially result in cellulitis, abscess, sepsis, rheumatic fever, rheumatic heart disease and post-streptococcal glomerulonephritis; therefore, in some patients, systemic antimicrobial therapy may be necessary in addition to scabies-directed treatment. In addition to systemic antihistamines, oral and/or topical corticosteroids may be used to provide symptomatic pruritus relief once the diagnosis of scabies has been established and mite-directed treatment has been initiated. The clinician should consider several potential causes (such as inadequate treatment, reinfection, mite resistance, delusions of parasitosis and the development of a new non-scabetic dermatosis) in scabies patients who fail to respond to treatment with a topical or oral scabicide therapy.

[This corrects the article DOI: 10.7759/cureus.7419.].

BackgroundScabies disproportionately affects people in resource-poor areas. Clinical diagnosis risks misdiagnosis due to resemblance to other skin diseases, but laboratory confirmation improves accuracy. Scabies allow for secondary bacterial infections. Associated bacteria exacerbate scabies and antibiotic resistance. Ethiopian scabies diagnosis relies solely on clinical exams without confirming parasites or investigating secondary bacterial infections. This study aims to identify parasites via scraping, isolate secondary bacteria, and evaluate their antibiotic susceptibility profiles.MethodsA hospital based cross-sectional study was conducted from September 2022 to July 2023 among scabies suspected patients who visited the dermatology clinic at Borumeda General Hospital in Northeast Ethiopia. A systematic random sampling technique was used to select 422 study participants. Socio-demographic, hygiene, and clinical characteristics data were collected via face-to-face interviews and observation. Skin scrapings for parasitological investigations and swab samples for microbiological investigations were collected and transported for analysis and drug susceptibility testing. Descriptive statistics and logistic regression analysis were employed to assess risk factors.ResultAmong 422 skin scraping samples, 156 (37.0%) cases of scabies were microscopically confirmed. Bed-sharing and having contact history were independent predictors of microscopically confirmed scabies. The prevalence of secondary bacterial infections among scabies-confirmed patients was 35.9% (56/156). The most prevalent bacterial species were Staphylococcus aureus, coagulase-negative staphylococci, and Streptococcus pyogenes. Tetracycline for Gram-positive bacteria and ampicillin for Gram-negative bacteria showed the highest rate of resistance. In both Gram-positive and Gram-negative strains, multidrug resistance was also observed.ConclusionThis study found that over one-third of skin scrapings tested positive for scabies. Additionally, more than one-third of scabies cases were complicated by secondary bacterial infections. Improved scabies diagnosis and consideration of secondary bacterial infections are important for better controlling this neglected tropical disease.

Scabies is a skin infestation that has been known for hundreds of years and is caused by the ectoparasitis of Sarcoptes scabiei. Scabies is a public health problem that can be seen in all age groups, races, genders, socioeconomic groups, and all societies. The aim of this study was to identify the prominent histopathological findings in scabies cases and to guide the clinical approach. Scabies cases, which were clinically diagnosed between January 2016 and December 2020 in our hospital, were retrospectively screened, and 3,027 cases were detected. As a result of the screening, a skin punch biopsy-histopathological examination was performed in only 62 cases that were included in the study. Cases without punch biopsy were excluded from the study. After a histopathological evaluation, the cases were divided into two groups: those diagnosed with scabies (n=9) and those diagnosed with nonscabies (n=53). Pathological findings of the groups were statistically compared using Fisher's exact Chi-square test. After microscopic examination, superficial and deep inflammatory reactions and the presence of lymphocytes were detected in 100% of cases. Furthermore, eosinophils and spongiosis were detected in 55% of cases. Histomorphological findings of the two groups were statistically examined and significant differences were found in spongiosis and eosinophil findings (p=0.019, p=0.025). There were no statistically significant differences in the other histopathological findings (parakeratosis, vesicle, bullae, intraepidermal pustule, vasculitis, dermal edema, superficial and deep inflammatory reaction, neutrophils, and plasma cells - p=0.259, p=0.266, p=0.083, p=0.683, p=0.557, p=0.066, p=0.980, p=0.290, and p=0.083, respectively). In histopathological examination of scabies biopsies, spongiosis and eosinophil findings may be useful in differential diagnosis. Pathological diagnosis can be a decisive stage for controlling scabies, which has epidemic potential, especially in crowded environments such as schools, dormitories, and refugee camps. For pathology science to play an active role in the diagnosis of scabies, more punch biopsies are needed from cases. Large-sample prospective clinical studies comparing histopathological findings and the severity of the disease may contribute to the literature.

Allergic skin diseases

A 54-year-old Taiwanese lady presented with intermittent fever for 1 week. Examination revealed hepatosplenomegaly. Laboratory studies revealed marked leukocytosis (leukocyte count of 316,000 /μL) and an elevated lactate dehydrogenase of 2,929 IU/L. Examination of her peripheral blood morphology disclosed abnormal lymphoid cells with flower-shaped nuclei (Figure 1A), and a subsequent serology testing for human T-cell lymphotropic virus 1 (HTLV-1) antibody showed a positive result. A bone-marrow biopsy specimen demonstrated marrow infiltration of atypical lymphoid cells (Figure 1B), around 20%–30%, which were immunoreactive for UCHL-1, CD3, and CD7, but non-immunoreactive for CD20, CD34, TdT, and myeloperoxidase. In addition, multiple intra-abdominal lymphadenopathies were discovered by a computed tomography scan. She was diagnosed with acute type adult T-cell lymphotropic/leukemia (ATL) and was treated with a combination of chemotherapy regimen (cyclophosphamide, vincristine, doxorubicin, and prednisolone (CHOP)), isotretinoin (Roaccutane), and subcutaneous recombinant interferon alfa-2a (Roferon-A). A response of partial remission was achieved after the treatments, and her following blood routines were in stable status. About 14 months later, she came to our emergency room because of general malaise and abdominal fullness for several days. She had a leukocyte count of 19,400/μL and hypercalcemia (free calcium of 2.57 mmol/L) on laboratory investigation. Moreover, she presented with scaly crusted skin lesions over the scalp (Figure 1C) and external ears (Figure 1D), which were initially considered as skin involvement of ATL. No burrows were identified between fingers or over wrists or other skin parts. However, microscopic examination of the scraping scales with potassium hydroxide staining disclosed many scabies mites and hatched eggs (Figure 1E). Norwegian scabies was settled and she was treated with topical anti-scabies ointment, gamma benzene hexachloride. Unfortunately, her condition deteriorated rapidly with development of sepsis and subsequent acute respiratory distress syndrome. She died of rapid progression of ATL 1 week later. Figure 1. A: A flower-like nucleated T cell in the peripheral blood smear from the patient. B: Pathology of marrow biopsy revealed lymphomatous involvement in marrow space. C, D: Crusted scaly lesions at the scalp and posterior auricular skin fold (arrow). E: Microscopic ... HTLV-1 infection is not endemic in Taiwan (1); the prevalence of ATL in Taiwan has been reported to be 6% in 317 patients with non-Hodgkin's lymphoma (NHL) during 1983–1988 in northern Taiwan (2), and 2.8% in 72 patients with T-cell NHL during 1989–2002 in southern Taiwan (3). In HTLV-1 non-endemic regions, the diagnosis of ATL can be challenging and difficult to establish. Crusted scabies has been reported in HTLV-1-seropositive patients, some of whom had ATL (4,5). The scabies skin lesions usually involve limbs and trunk, either localized or diffuse, and only rarely involve the face or scalp area (6,7). The dermatological presentation of scabies seen in our patient was unusual in that only the scalp and ears were predominately involved, and there were no classical ‘burrows’ that were commonly seen on hands and wrists in patients with scabies infections. HTLV-1-induced immunosuppression has been linked to the occurrence of crusted scabies in HTLV-1 carriers and in ATL patients (8). The atypical dermatological presentation of scabies in patients with ATL may cause diagnostic confusion with the more commonly seen skin involvement of ATL. Moreover, the presence of scabies in ATL patients may represent a sign of marked immunosuppression and thus indicate a poorer prognosis. The rapid deterioration after the diagnosis of scabies seen in our patient supports this correlation. Although ATL-associated skin lesions are common in ATL patients, crusted scabies should also be considered in the differential diagnosis of either localized or generalized cutaneous eruptions in patients with ATL.

A Case of Hypercalcemia and Scabies

Introduction: Scabies is one of the common public health problems but neglected parasitic diseases caused by Sarcoptes scabies var hominies. Global scabies prevalence was about a 204million cases with 0.21% of total disability-adjusted life years lost. In Ethiopia, scabies is common, especially during natural or man-made disasters. This study was aimed to investigate scabies suspected outbreak and risk factors in Gumbichu District, Central Ethiopia, 2021. Methods: A community-based unmatched case-control study among 96 participants (32 cases and 64 controls) was conducted in the Gumbichu district from July 1-20/2021. Data were collected using a structured questionnaire. Line-listed data were entered into Microsoft Excel for descriptive analyses. Multivariable logistic regression analysis was computed using SPSS version 25 to identify factors associated with scabies. The odds ratio of 95% CI and a p-value less than 0.05 were used to describe the strength of the association and statistical significance. Results: A total of 1231 scabies cases line listed with overall attack rate of 16/1,000 population. The mean age was 14 years, and most affected age group was 5–14 years. Frequency of shower per month [AOR (95% CI) = 6.51(1.26-33.54)], sleeping with scabies patient [AOR (95% CI) = 10.52(3.75-29.53)], contact history [AOR (95%) = 11.44(1.72-76.22)], family size ≥5 [AOR (95% CI) = 8.63(2.42-30.84)], and sharing clothes with scabies cases [AOR (95% CI) = 14.31(3.04-67.35)] were found to be determinant factors of scabies outbreak. Conclusion: Frequency of shower per month, contact history, sleeping with scabies case, family size ≥5, and sharing clothes with scabies case were associated with a high frequency of scabies. Therefore, it is recommended to raise awareness about the transmission, prevention, and control of scabies disease.

In the WHO-EORTC classification (6) lymphomatoid papulosis (LP) is included among the primary cutaneous lymphomas; this term refers to non-Hodgkin’s lymphomas which at the time of diagnosis do not present extracutaneous manifestations; after the gastro-enteric system, the skin is the most frequent site of extranodal lymphomas (5). Primary cutaneous lymphomas (PCL), despite being made up of a cell population comparable to that of lymph node lymphomas, have a clinical behavior significantly different from lymph node lymphomas localized secondarily in the skin, because they remain confined to the skin for a long time or always and often regress spontaneously; therefore PCLs require a different therapy. PCLs are distinguished in T-cell PCLs, which make up 80%, and B-cell PCLs. Among the T-cell PCLs, after mycosis fungoides, CD30+ lymphoproliferative disorders (6) are most common: the latter include LP and anaplastic large cell lymphoma, that represent parts of the same disease spectrum, are not histologically distinguishable and differ essentially because skin lesions do not heal spontaneously in lymphoma unlike those in lymphomatoid papulosis. The primary lesion of LP is a papule that can enlarge to become a nodule; this usually does not exceed 2 cm in diameter; papules and nodules can become exuding and ulcerate; they usually come in subintrant crops of 1-10 elements and spontaneously regress in 3-6 weeks (1). LP can last from a few months up to 40 years (5). In contrast to the rather monomorphic and repetitive clinical features, histology shows highly variable patterns that recall different types of primitive cutaneous T lymphomas; in the same patient different histological types can be observed at the same time or at a later time (3). The medium-term prognosis of LP is good with a 10-year survival close to 100% (5). The risk of developing another lymphoma in adults with lymphomatoid papulosis is 10-20% (2) and mycosis fungoides is the most frequently associated lymphoma. In children, the risk is lower: in a recent meta-analysis of 251 children with lymphomatoid papulosis (4), the incidence of lymphomas is 5.6%, but the most frequent lymphoma is anaplastic large cell primary cutaneous lymphoma. In most cases, symptomatic therapy is sufficient; topical corticosteroids may be useful in lesions of exposed areas to limit the duration of cosmetic damage.