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Chapter 368

Scabies is a common condition in children caused by an infestation of the Sarcoptes scabiei mite. Scabies is primarily contracted by direct contact with an infested person; therefore, the acquisition and spread of scabies, particularly from parents to children, or mother to infant, occurs with relative ease. The highest prevalence is in children younger than 2 years. The disease affects all age groups, races, and social classes; however, poor socioeconomic conditions, in particular, crowding, lack of proper hygiene, and immunosuppression, are risk factors for the disease. The female mite burrows through the skin, leaving behind a trail of debris, eggs, and feces. Clinical findings result from hypersensitivity and irritation to the mite and mite products. Scabies infestation is extremely pruritic and notoriously worse at night. Frequently, other family members also complain of itching.

The distribution of scabies lesions is helpful in making the diagnosis. In infants, the insteps of the feet are commonly affected, often with vesicles or pustules. An important diagnostic clue is an infant who is vigorously rubbing his or her feet together in an attempt to relieve itching. Unlike older children, infants commonly have involvement of the palms and soles, axillae, and scalp. The characteristic distribution of scabies lesions at any age is wrists, finger web spaces, and waistline. Pruritic, nodular lesions of the area around the nipples, umbilicus, axillae, or genitalia are also suspicious for scabies. Lesions in children are generally more inflammatory than in adults and are often vesicular or bullous. A unique clinical feature is the finding of the scabies burrow, which, although difficult to find in children, can be seen as a gray threadlike trail of scale on the skin.

Clinical variants of scabies may present diagnostic difficulties. For example, scabies incognito occurs when treatment with topical or oral glucocorticoids masks the characteristic symptoms and signs of scabies. Lesions may be atypical in both appearance and distribution and are generally more widespread. Crusted (Norwegian) scabies is a highly contagious form of scabies often seen in immunocompromised or debilitated, often institutionalized, patients. Widespread scale and crust formation is present, which may be remarkably thick over the palms, soles, and nails. Nodular scabies presents with discreet, orange-red nodules affecting the axillae and groin. Similar to the tick granuloma, nodules most likely represent a hypersensitivity reaction to retained mite parts or antigens. Lesions may persist for weeks to months and are often resistant to therapy.1

The scabies preparation is a simple and rapid means of establishing the diagnosis of scabies. Using a mineral oil–coated Joseph knife or sterile scalpel blade, multiple lesions are scraped. It is ideal to perform this procedure on the child’s caregiver if he or she has skin findings suspicious for scabies. The best lesions for diagnosis are burrows, vesicles, and unexcoriated papules, and the best scrapings obtain the material underneath the tops and crusts of lesions. The material obtained is then transferred onto a glass slide and examined microscopically ...

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