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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 17  |  Issue : 1  |  Page : 62-64

An unusual guest in the panel of differentials!


1 Department of Dermatology, Cutis Academy of Cutaneous Sciences, Bengaluru, Karnataka, India
2 Department of Dermatology, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India

Date of Web Publication4-Jan-2016

Correspondence Address:
Samipa Samir Mukherjee
Bangalore Medical College and Research Institute, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2319-7250.172462

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  Abstract 

Scabies is a common infestation in children with the varied presentation. Unusual types of clinical presentation of scabies are encountered generally in patients with immunosuppression either due to disease conditions or external medications in the form of immunosuppressant. This poses a diagnostic dilemma and a therapeutic challenge to the treating physician. Reporting of atypical presentation of scabies manifestations widens the horizon and increases the chances of rapid diagnosis and appropriate treatment. We hereby report a case of 6-month-old child of scabies presenting with a cluster of jewel appearances of the lesions masquerading a chronic bullous dermatosis of childhood like picture.

Keywords: Chronic bullous disease of childhood, cluster of jewel appearance, scabies


How to cite this article:
Chandrashekar B S, Mukherjee SS. An unusual guest in the panel of differentials!. Indian J Paediatr Dermatol 2016;17:62-4

How to cite this URL:
Chandrashekar B S, Mukherjee SS. An unusual guest in the panel of differentials!. Indian J Paediatr Dermatol [serial online] 2016 [cited 2019 Feb 19];17:62-4. Available from: http://www.ijpd.in/text.asp?2016/17/1/62/172462


  Introduction Top


Human scabies is a mite infestation characterized by pruritus exacerbating in the night and is caused by an obligate human parasite of the phylum Arthropoda, Sarcoptes scabiei var. Hominis, that is directly transmitted between individuals by skin to skin contact or seldom through an indirect transmission.[1] In some countries, the prevalence in the general population ranges between 4% and 27%.[2] Globally the annual incidence of scabies reported is approximately 300 million.[3] Although scabies is easy to identify, the atypical presentations may pose a diagnostic challenge. Such manifestations are common in infants and children. This may be hypothesized on the basis of the immature immune system in this age group leading to the atypical manifestations as we know that clinical features in scabies occur due to the hypersensitivity reaction of the host to the mite. We herein report a case of 6-month-old child presenting with atypical features of scabies thereby posing a diagnostic challenge.


  Case Report Top


A 6-month-old male child born of nonconsanguineous marriage was referred with complaints of pruritic vesicular eruptions on the body since last 3 months. There was no family history of itching or any diurnal variation noted by the parents in the severity of pruritus. History of atopy was noted in the child. Lesions first developed over the trunk as single vesicle which rapidly progressed to form annular plaques surrounded by vesicles at the margin that gradually spread to involve the body including face palms and soles in the next 1-month [Figure 1] and [Figure 2]. The child was treated with multiple topical steroids, emollients along with antihistamines with minimal response.
Figure 1: Annular dusky erythematous scaly plaques and papulovesicles scattered over the entire body

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Figure 2: Close up view of lesions on trunk

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Cutaneous examination revealed annular plaques with very little scaling and studded vesicles at the margin giving rise to the cluster of jewel appearance over the trunk, upper and lower limbs with scattered vesicular lesions over the face, palms, soles, and genitalia. Mucosa was not involved. There were few erosions and excoriations noted over the abdomen and upper limbs. Hair and nail examination was within normal limits.

All routine hematological and biochemical investigations were within normal limits. A tzanck smear from the vesicles revealed occasional neutrophils. A KOH mount from the scales was negative for fungal elements. A biopsy was considered at this stage. However, it was deferred as the parents did not consent.

As the child had received multiple topical medications elsewhere in the form of topical steroids and antibiotics it was decided worthwhile to consider a therapeutic trial of antiscabetic medications empirically and the child was treated with permethrin 5% application for 6 h followed by thorough cleansing. The child was put on topical emollients and antihistaminics and was anti scabetic therapy with permethrin 5% cream was repeated after a week. The child was followed up on the 15th day with complete resolution of lesions. Examination revealed only post inflammatory hyperpigmentation over the pre-existing lesions [Figure 3]. Based on clinical findings and response to therapy with permethrin 5% cream a clinical diagnosis of atypical presentation of scabies was made.
Figure 3: Clearance of lesions posttreatment with permethrin 5% cream

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  Discussion Top


Classic scabies is characterized with small erythematous papulovesicular rash, papules, erosion due to scratching, burrows, and nodules. These findings have a predilection for anterior axillary folds, nipple area, periumbilical skin, elbows, volar surface of the wrists, interdigital webspaces, belt line, thighs, buttocks, penis, scrotum, and ankles.[4] This distribution is commonly referred as the circle of Hebra. Scabies often affects the face, head, neck, scalp, palms, and soles in infants and young children,[5] whereas involvement of the dorsum of the fingers is rare both in adults and children. Nodular scabies, scabies incognito, and bullous scabies are known as uncommon presentations.[6] Atypical features of scabies frequently occur in infants and children and patients with the prolonged use of corticosteroids or immunosuppression.

Unusual presentations of scabies are important not only for therapy but because it has a potential to spread in the community if not adequately treated. These manifestations which are more commonly seen in infants, children and immunocompromised patients, which could be attributed to the altered immune response in this group.

Yoshinaga et al. reported a case of adolescent scabies with clinical features mimicking Gottron's papules.[7]

Gualdi et al. reported three cases of neonatal Norwegian scabies which they attributed to be due to the underlying skin conditions of the patient, since skin atopy is characterized by a preponderant Th2 lymphocyte response and increased interleukin-4 production, which it was reported to contribute to the mite proliferation in the epidermis. They concluded that the atopic dermatitis immunological pattern seemed to be the predisposing substrate on which the physiological inability to scratch and the iatrogenic immunodeficiency promoted the uncontrolled mite proliferation. Although our case showed a clinical pattern of chronic bullous dermatoses of childhood the background of atopy could have been an underlying factor in the altered immunological response thereby leading to an atypical presentation of scabies.


  Conclusion Top


This case is being reported to emphasize the fact that a background of atopy can lead to alterations in the classical manifestation of scabies in an infant and children, and also we suggest that this presentation should be included in the panel of atypical manifestation of scabies.

Declaration of Patient Consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

 
  References Top

1.
Burkhart CG, Burkhart CN, Burkhart KM. An epidemiologic and therapeutic reassessment of scabies. Cutis 2000;65:233-40.  Back to cited text no. 1
[PUBMED]    
2.
Mahé A, Prual A, Konaté M, Bobin P. Skin diseases of children in Mali: A public health problem. Trans R Soc Trop Med Hyg 1995;89:467-70.  Back to cited text no. 2
    
3.
McCarthy JS, Kemp DJ, Walton SF, Currie BJ. Scabies: More than just an irritation. Postgrad Med J 2004;80:382-7.  Back to cited text no. 3
    
4.
Hicks MI, Elston DM. Scabies. Dermatol Ther 2009;22:279-92.  Back to cited text no. 4
    
5.
Johnston G, Sladden M. Scabies: Diagnosis and treatment. BMJ 2005;331:619-22.  Back to cited text no. 5
    
6.
Cestari TF, Martignago BF. Scabies, pediculosis, bedbugs, and stinkbugs: Uncommon presentations. Clin Dermatol 2005;23:545-54.  Back to cited text no. 6
    
7.
Yoshinaga E, Oiso N, Kawara S, Kawada A. An adolescent patient with scabies mimicking gottron papules. Case Rep Dermatol 2010;2:8-12.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]


This article has been cited by
1 Dermoscopic study of scabies in children
Shilpitha Srinivas,KallappaC Herakal,SrinivasaKrishnamurthy Murthy,Shwetha Suryanarayan
Indian Journal of Paediatric Dermatology. 2019; 20(1): 46
[Pubmed] | [DOI]



 

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Abstract
Introduction
Case Report
Discussion
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