28- Scabies

(History of cataclysmic scabies: fallow photos...  "pxx304...")

Diagnosis

Often scabies is a diagnosis of exclusion: if the patient has severe itching, especially at night, without any clear origin, you should initially consider a diagnosis of scabies.

Pruritus is the main symptom, all over the body.  It is due to a secondary eczema, especially on the abdominal area pxx029// pxx098//.  But often eczema is not visible if the infection is recent. 
Typical primary lesions can be visible between finger pxx026// pxx051// pxx099// pxx123// and/or on scrotum/penis.  ghx009//
"Confused" lesions (+ itching!) Are often visible in genital area.  gx012// ghx013// ghx032// ghx054//

Scabies with AIDS can give spectacular characteristic crusts.  Often, the specific locations (fingers/hands, penis, fingers/feet, nipples, armpits…) help diagnosis... axx007// axx022- axx023// axx029// ghx007// ghx009// ghx027// ghx029// pxx001//pxx027- pxx028// pxx030// pxx044// pxx064- pxx065// pxx133- pxx134- pxx135//pxx188- pxx189- pxx192- pxx193//pxx248- pxx249- pxx250//ghx062//

In some rare cases, infection is so severe that we observe lesions on the ears and scalp as well (this exception to the rule that scabies only occurs below the neck.  Involvement of the head is sometimes observed in immunocompromised patients)!!!  // ptx006// ptx029- ptx030// Confusion with psoriasis or tinea is possible, especially if you look only at the lesions on the head!  Lesions on the palm area also occur...pxx065// pxx253

Treatment

Lindane applied nightly for 3 or 4 days (mild cases) or benzyl benzoate 25% for 3-5 days consecutively.  Apply on ALL the body except head, after a shower (if possible have hot shower to make skin softer for better drug penetration), before sleep.  Don't wash any part of body before morning!  If patient forgets to do the treatment one night then the treatment must be started again for 3 consecutive nights.  Change clothes and bedclothes after first night.  If the symptoms are very severe, itching can continue for a few days after treatment.

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Antipruritus (Chlorpheniramine 1-2tabs 4x/day or chlorpromazine 1-2tabs 3x/day if severe)

Caution!

1- Application of benzyl benzoate, for 25% of the patients, causes serious local pain (+/- 10 minutes).  If skin is in very bad condition (especially on scrotum/labia), consider injecting short-action analgesic before treating...

2- High doses of benzyl benzoate for patients with severe generalized scabies (pxx028...)  (pxx044...)  (ptx066.)  (pxx134...)  (pxx249...)  (pxx285...)  Can give serious neurological (reversible) side effects (confusion...).  Since the time when we first observed this, we no longer treat the whole body of such patients on one day, but rather go region by region with less lindane each time...  (Takes around 10 days to have normal skin on the whole body)