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Hello, hello and welcome to another episode.  Today I want to talk about a patient that came in with scabies.  I don’t know what it is, but we have a lot of scabies in our clinic.  We deal heavily with a hispanic population, and a lot of these patients actually live with a lot of other people.  So, that might be the reason as to why that contributes to that.  So, lets just get started with scabies.  So, the initial presentation was a three year old that actually came in for a routine physical.  As I’m doing the physical, I start to notice these lesions and I start to notice a rash pretty diffusely throughout the body.  So, I ask the mother how long has this rash been going on?  And she says that its been their for about a month.  Now, this poor kid, three years old, has been having a rash for about a month.  So, I ask if there are any symptoms? Is there itchiness? Does it hurt? Does it burn?  She says its very very itchy and she notices that the itchiness is worse at night.  So, I ask if anyone else in the family has the same thing, and she says yes. So she shows me her arm.  She shows me her legs and the exact same rash is noted on her.  She says that she has another little girl which that has the exact same thing.  So, all of these people have been having this rash for about one month and never decided to get checked up.  This is scabies.

Scabies is a mite, and as you can see there, this is what the mite actually looks like.  This is very easily transmitted through direct contact.  Whats going to happen is that the male and female are going to be on the surface of the skin, but only the females is going to burrow its way into the skin and leave whats called burrows.  Burrows are actually seen on clinical exam.  The female is going to lay its eggs, the eggs are going to hatch a few days later, the female will stay stuck underneath the skin and eventually die.  The mites that hatch from these eggs will go up to the surface and repeat this life cycle over and over again.

Some clinical manifestations.  Usually your going to have a three week incubation period before you start to get symptoms and this is going to be a delayed hypersensitivity reaction which is what causes this intense pruritus.  The majority of the time the pruritus is going to be worse at night.  So, thats something very important to ask your patient.  On clinical exam, your going to notice erythematous papules.  The papules are going to be mostly evident, but you still need to look for them.  So, a lot of times they are not going to be blatantly in your face, but its going to be something your going to have to look for.  Sometimes you can see burrows and this is where the female mite goes into the skin.  Now, your going to have a very typical distribution and the distribution is going to be the wrists, the webs of the fingers and toes, axilla, genitals, and waist.  If you notice the picture here, these are the papules that are noted.  Sometimes, your going to have little burrows that go along here like this, and they are going to be connected. They are still going to be red brownish in color, but they are going to be linear.  This is a typical exam finding that you’ll see with scabies.

Alright so how do we treat somebody with scabies?  Well its going to be permethrin cream and its going to be a 5 % cream.  They have a 1% cream, but thats usually going to be for lice.  You need the 5% for scabies.  As we stated earlier, the typical distribution spares the face and it spares the scalp.  Sometimes in younger children, you can see the scalp being affected, but for the most part its going to be neck down.  So, your going to apply this cream from the neck all the way to the soles of the feet and your going to get every little nook and cranny of their body, even areas that don’t have the rash.  What your going to do is, your going to leave this cream on for about 10-12 hours, so your going to have them apply the cream at night, leave it on throughout the night while they sleep, and in the morning, after 10-12 hours, they can go ahead and shower.  Now, whats also recommended is after 7-10 days after the first treatment you go ahead and repeat.  So, your going to do this twice, and your going to wait a week in between intervals.  For the itching, your going to give these patients antihistamines and antihistamines will relieve the itching.  Sometimes this just doesn’t do it, and I’v had plenty of patients that no matter how many antihistamines they take like hydroxyzine or benadryl, the itchiness doesn’t go away.  So, we need to give them oral steroids, and I give them prednisone. I usually do about 40mg a day and slowly start tapering them after a week.  The itchiness can last for a couple of weeks even after the infection has cleared.  So, these patients are going to have a week of treatment but still continue to be itching for another two or three weeks.  So, thats a long time to be very itchy, and some of these patients are extremely itchy, to the point where they start cutting their skin which can lead to secondary bacterial infections.  So, its very important that you need to address this.  Alright guys, this has been a quick case of scabies, hope you guys learned something and I will see you guys on the next video!

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