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A 43 year old male with end-stage renal disease on hemodialysis, peripheral vascular disease, and MRSA bacteremia presented to dermatology as an inpatient consult for a nine-month history of a pruritic eruption on the feet. On physical examination, the patient had marked hyperkeratosis of the bilateral plantar, dorsal, and medial feet (Fig. 1a and b ), as well as erythematous, crusted papules of the finger webs, abdomen, penis, and scrotum. Skin scraping revealed the following (Fig. 1c).
What is the diagnosis?
Based on the patient's clinical and histopathological findings, the diagnosis of crusted scabies was rendered. The patient was treated with topical 5% permethrin once weekly for four weeks and oral ivermectin 0.2 mg/kg on days 1, 2, 7, 8, and 15. We then recommended immediate isolation for the patient followed by thorough room cleaning and treatment of all household contacts with topical 5% permethrin to prevent transmission.
Scabies is an infestation of the skin by the mite Sarcoptes scabiei that affects as many as 300 million people worldwide every year. In most patients, there is an initial period with an exponential increase in mites and lesions in the early weeks, but typically both decline with the help of an intact immune system. However, patients who are immunocompromised have difficulty keeping this under control, and many infestations can progress to crusted (Norwegian) scabies. Crusted scabies typically presents as poorly defined erythematous patches which quickly develop prominent scaling and verrucous hyperkeratosis. Moreover, fissures can develop in conjunction with the hyperkeratotic changes and provide a portal of entry for bacteria. This significantly increases the risk of sepsis in the already immunocompromised patient [