Scabies is an ectoparasitic skin infection with the mite Sarcoptes scabei var. humanus. First described in 1687, with the organism responsible being identified in the 18th century, this intensely pruritic disease was named from the Latin word for: scratch “Scabere“.
Scabies affect people of all races and age groups and the geographic distribution is worldwide. It is spread by skin to skin, via both sexual and nonsexual contact, and in some cases as fomites.
Sign and Symptoms of Scabies
Patients with scabies complain of an intensely itching rash. The itching may be more severe at night and may affect any part of the body, but the most commonly affected areas are the inter-digital web spaces, axillae, genital area, buttocks, and breasts.
In the first attack of scabies, the symptoms do not occur for three to four weeks, till the patient is sensitized to the products of the mite. In subsequent attacks the symptoms may develop within few hours of infestation.
The patient presents with nocturnal itching, most marked when the person is warm in bed. It is associated with burrows, papules, papulo-vesicles, vesicles or pustules. Burrows, though considered pathognomic of scabies, are not frequently encountered in Indian patients. This is because they present late for treatment and by this time the burrows have been excoriated and the secondary bacterial infection has often supervened, resulting in impetiginization.
The distribution of lesions is characteristic and the sites of predilection are the inter-digital spaces of the fingers, palms, wrists, elbows, anterior axillary folds, lower abdomen, buttocks, nipple area in females, and external genitalia in the males. In infants and small children the scalp, face, palms, and the soles may also be involved. Very often, more than one member of the family may affected.
Pathophysiology of scabies
Scabies, a common cause of itching, is produced by infection with the mite Sarcoptes scabies varhominis. Poor hygienic conditions and overcrowding, permitting close body contact, favor the transmission of the disease.
Sarcoptes scabiei var. hominis is a mite, approximately 0.5 mm in length, that cause human scabies.
The female mite burrows under the skin and produces eggs and scybala. Acarus scabiei has four pairs of legs. The male is appreciably smaller. Acarus scabiei undergoes its life cycle on the skin surface. The male mite fertilizes the female and dies.
The adult female, after impregnation, burrows into the skin and forms and a tunnel in the horny layer (stratum corneum). It burrows at the rate of 1 to 5 mm per day. Two days after fertilization, it starts laying eggs along her course in the burrow. Two to the three eggs are laid each day.
A female Acarus lays a total of 10 to 25 eggs during her life span of 30 days and then dies at the end of the burrow. The egg hatches in 3 to 4 days producing a larva that moves to the skin surface. It then moults through various stages of octopod nymph into an adult mite in 10 to 14 days.
A type 4 delayed hypersensitivity reaction occurs after approximately 1 month in unsensitized patients or within hours in sensitized patients. This leads to the severe itching that is characteristic of scabies infection.
Diagnosis of scabies
It may take up to 6 weeks following exposure before symptoms of scabies infestation develop. In those who have been previously infected, symptoms can develop much sooner, sometimes within several days.
Infested person can transmit scabies to other prior to the development of symptoms. In those who are infected, pruritus eventually develops secondary to a hypersensitivity reaction to the mites and their secretion, eggs, and feces.
Lesions are most commonly found on the inter-digital web spaces, wrists, elbows, axillae, female breasts, and male genital areas. In typical scabies, patients usually develop red, raised papules.
Scabies is commonly misdiagnosed as other common skin conditions, such as eczema, drug reaction, impetigo, Folliculitis, atopic dermatitis, insect bites, and contact dermatitis. During scratching, skin lesions can become colonized and then infected with bacteria, such as staphylococcus or streptococci.
Burrows are often difficult to visualize because of excoriation. Skin scrapings should be done in all suspected cases, although the sensitivity of this test depends greatly on the experience of the examiner. Mineral oil should be placed upon a popular lesion or a burrow.
The involved skin is the scalpel blade and placed and placed on a glass slide. Under low power on the microscope, the examiner should search for mites, eggs, and fecal matter.
If scabies is suspected, the diagnosis can be confirmed by opening of a burrow or other skin lesion with a scalpel blade. The contents are placed on a slide, and a drop of oil is applied. Diagnosis is confirmed with identification of mites, eggs, or scybala (feces) on microscopic examination.
How it spreads?
Scabies is spread by personal contact, e.g., by shaking hands or sleeping together or by close contact with infected articles such as clothing, bedding or towels. It is usually found where people are crowded together or have frequent contact, and is most common among school children, families, roommates, and sexual partners. It is now accepted that mites can spread when a non-infected person stands too close to an infected person.
DIFFERENTIAL DIAGNOSIS of Scabies
• Papular urticaria.
• Atopic skin lesions in children with maximal lesions on extremeties.
• Generalised pruritus.
• Dermatitis herpetiformis.
GENERAL MANAGEMENT of SCABIES
• Maintain personal hygiene.
• Change clothes, bed linens daily.
• Regular daily bath.
• Clothes & bed linens to be boiled in hot water, dried in sun & ironed.
• Thorough scrubbing with soap & water.
• Through drying of skin after bathing.
• Treat all close contacts.
Complications of scabies
If untreated for several weeks or months, various complications can occur.
- Scratch dermatitis frequently of frank eczematous type.
- Bacterial infection
- Urticaria-occasional complication.
- Nummular dermatitis
- Glomerulonephritis in infants and children.
Treatment of Scabies
Because of resistance and neurotoxicity, lindane is no longer routinely recommended for the treatment of scabies. The currently recommended treatment for scabies is 5 % permethrin cream.
Permethrin is well tolerated but may cause burning stinging, or itching following application. Because of a lack of safety data, permethrin should not be used on those who are pregnant unless the diagnosis has been confirmed. The following plan should be followed when treating scabies:
- Immediately prior to treatment, all washable sheets, blankets, and personal clothes worn during the preceding week should be placed into a plastic bag, sealed, and sent to the laundry. These clothes should be washed in hot dryer. All non-washable personal clothes, such as shoes and jackets worn during the preceding week, should be placed in a plastic bag. These items should be dry cleaned or placed into a hot dryer for 20 minutes. If this is not possible, the bag should be scaled and set aside for 5 to 7 days.
- The person being treated should shower prior to applying permethrin. Hair should be washed, and fingernails and toe nails should be cut short. Permethrin should be massaged into the skin covering the entire body from the hairline to the soles of the feet. Medication should not contact the mucous membrane of the eyes, nose, or mouth. Scabicide should be applied under the fingernails and toenails.
- After applying permethrin, all towels and washcloths used by the inmate should be placed in a plastic bag and sent to the laundry for processing. Laundry staff should be advised to not sort these items and to wash and dry them separately from other laundry.
- Permethrin should be left on the body overnight and showered of the next morning. After permethrin has been washed off, bed lines, towels, and clothing should be changed again. The mattress, pillows, bedside equipment, and floors should be disinfected. Because they may be contaminated, all creams, ointments, and lotions used by symptomatic cases should be discarded.
Isolation of Patients with Typical Scabies
For a typical case of scabies, the infected inmate should be placed on contact isolation precautions in his or her assigned cell for the duration of the first treatment period (8 to 12 hours).
Isolation precautions can be discontinued after permethrin has been washed off. Patients who are being treated prophylactically need not be isolated.
Treatment of Crusted or Keratotic Scabies
Those with crusted scabies should be placed in contact isolation precautions in a private room until at least three negative skin scrapings have been documented and symptoms have resolved.
This may take weeks, depending upon the severity of the infestation. If permethrin is used, multiple treatments may be required for successful treatment of crusted or keratotic scabies. Crusts may need to be debrided to hasten eradication of infestation.
Homeopathic treatment of Scabies
Homeopathy is one of the most popular holistic systems of medicine. The selection of remedy is based upon the theory of individualization and symptoms similarity by using holistic approach.
This is the only way through which a state of complete health can be regained by removing all the sign and symptoms from which the patient is suffering.
The aim of homeopathy is not only to treat Scabies but to address its underlying cause and individual susceptibility. As far as therapeutic medication is concerned, several remedies are available to treat scabies that can be selected on the basis of cause, sensations and modalities of the complaints.
For individualized remedy selection and treatment, the patient should consult a qualified homeopathic doctor in person. There are following homeopathic remedies which are helpful in the treatment of scabies:
Mercurius Solubilis Hahnemanni
Silicea, Silica Terra
Squilla Maritima, Scilla
KENT- SKIN- ERUPTIONS- SCABIES.
BOENNIG HAUSEN- SKIN & EXTREMETIES- ITCH- SCABIES.
BOERICKE- SKIN- SCABIES.
KNERR- SKIN- ERUPTIONS- SCABIES.
The eruption appears on the bends of knees. The eruptions could be dry as well as full of small pustules. There is presence of burning and itching which is worse at night, application of cold water > by local application of warmth. The scabies has tendency to alternate with bronchial asthma.
Great Prostration, with rapid sinking of the vital forces; fainting. The disposition is:
a. Depression, melancholy, despairing, indifferent.
b. Anxious, fearful, restless, full of anguish.
c. Irritable, sensitive, peevish, easily vexed.
The greater the suffering the greater the anguish, restlessness and fear of death. Mentally restless, but physically too weak to move. Indicated by its periodicity and time aggravation: after mid-night, and from 1-2 a.m. And by its intense restlessness, mental and physical: its anxiety and prostration.
The eruptions are dry almost over the whole body, especially worse on extremities. There is presence of itching which is worse after undressing at night. Scabies can occur after abuse of mercurial salts. Concomitant symptoms like dyspepsia, belching, passing flatus should help the physician to select drug. Once infection takes place, there is presence of acrid, bloody, foul discharge. The pus smells like asafoetida. There is presence of excessive burning in lesion which is worse by local application of heat as well as cold.
Cachectic persons whose vitality has become weakened or exhausted. Persons who
have never fully recovered from the exhausting effects of some previous illness. Weakness of memory and slowness of thought.
It is an extremely important drug when scabies are suppressed by local application of mercury and sulphur. There is excessive itching of whole body at night, also when secondarily infected there is presence of humid vesicles oozing corroding pus. The other concomitant symptoms are yellowish looking skin, warts, involuntary urination when coughing, sneezing or walking. The patient on the whole is extremely sensitive to cold air.
Adapted to persons with dark hair and rigid fibre; weakly, psoric, with excessively yellow, sallow complexion; subject to affections of respiratory and urinary tracts.
The eruptions that resemble scabies are present on folds of skin, hands and feet. The eruptions are pustular and crusty, oozing a foul, old cheese like discharge. The skin is extremely sensitive to cold air. The itching is worse at night and better by warm application. Presence of scabies in an individual where eruptions are suppressed by mercury.
For torpid lymphatic constitutions; persons with light hair and complexion, slow to act, muscles soft and flabby. The slightest injury causes suppuration. Diseases where the system has been injured by the abuse of Mercury. In diseases where suppuration seems inevitable, Hepar may open the abscess and hasten the cure. Oversensitive, physically and mentally; the slightest cause irritates him; quick, hasty speech and hasty drinking. Patient is peevish, angry at the least trifle; hypochondriacal; unreasonably anxious. Extremely sensitive to cold air, imagines he can feel the air if a door is opened in the next room; must be wrapped up to the face even in hot weather; cannot bear to be uncovered; takes cold from slightest exposure to fresh air.
Eruptions on the scalp, extremities, genitals and abdomen. The eruptions are yellowish brown, moist, purulent. Itching and burning sensation is worse by warmth and better by cold application, especially itching while burning is better by local application of heat. GIT concomitants like weak digestion, craving for sweets, flatulence should help one to prescribe the drug.
For persons intellectually keen, but physically weak; upper part of body emaciated, lower part semi-dropsical; predisposed to lung and hepatic affections; especially the extremes of life, children and old people. Deep-seated, progressive, chronic diseases. Pains: aching-pressure, drawing; chiefly right-sided, <. four to eight p.m. affects right side, or pain goes from right to left.
This nosode should be used in those cases of scabies where one has a repeated history of scabies in the past or scabies are suppressed with the help of conventional medicine resulting into internal affection e.g. asthma, migraine, heart trouble, etc. the eruptions are present on bends of elbow. The scabies appear in every winter and disappear in summer. There is presence of violent itching, worse by warmth of bed or by scratching.
Especially adapted to the psoric constitution. In chronic cases when well selected remedies fail to relieve or permanently improve; when Sulphur seems indicated but fails to act. Lack of reaction after severe acute diseases. Appetite will not return.
The eruptions is predisposed to crack and ulcerate as soon as it appears. There is presence of itching & burning sensation which is worse in the evening, open air. Better in warm room. Scabies comes periodically every spring. It is also useful in those cases of scabies after previous used of sulphur.
Adapted to persons of dark hair, rigid fibre, but mild and easy decomposition.
It is one of the supreme remedy for recurrent maltreated, obstinate, suppressed cases of scabies. There is presence of voluptuous tingling & itching in the bends of joint in between fingers, as soon as he gets warm in bed, also it is worse when undressing. Itching is accompanied by burning & soreness, especially after scratching. The skin appears rough & scaly with formation of little vesicles & pustules.
Adapted to persons of a scrofulous diathesis, subject to venous congestion; especially of portal system. Persons of nervous temperament, quick motioned, quick tempered, plethoric, skin excessively sensitive to atmospheric changes. For lean, stoop-shouldered persons who walk and sit stooping like old men. Standing is the worst position for sulphur patients; they cannot stand; every standing position is uncomfortable. Dirty, filthy people, prone to skin affections. Aversion to being washed; always <. after a bath.