What is your diagnosis for this 6-months-old baby? 

Diagnosis: Scabies

  Omid Zargari;

 I think this is a very typical case of scabies in infants. Scabies is a common skin disease in many parts of the world, including Iran and unfortunately still is a commonly missed disease !

I selected this case as a quiz to stress the importance of early diagnosis of a common disease.

Thanks to your participations, we had invaluable comments  which below you may read some of them ;

Furthermore to read more about scabies you can click on www.iranderma.com/scabies.htm

  M. Mehravaran, MD.   Szeged/ hungary;

Scabies is a transmissible ectoparasite skin infection characterized by superficial burrows, intense pruritus (itching) and secondary infection.

The word scabies comes from the Latin word for "scratch" (scabere).

Scabies is caused by the mite Sarcoptes scabiei, variety hominis, as shown by the Italian biologists Diacinto Cestoni in the 18th century. It produces intense, itchy skin rashes when the impregnated female tunnels into the stratum corneum of the skin and deposits eggs in the burrow. The larvae, which hatch in 3-10 days, move about on the skin, molt into a "nymphal" stage, and then mature into adult mites. The adult mites live 3-4 weeks in the host's skin.

The action of the mites moving within the skin and on the skin itself produces an intense itch which may resemble an allergic reaction in appearance. The presence of the eggs produces a massive allergic response which, in turn, produces more itching.

Scabies is transmitted readily, often throughout an entire household, by skin-to-skin contact with an infected person (e.g. bed partners, schoolmates, daycare), and thus is sometimes, although inaccurately, classed as a sexually transmitted disease. Spread by clothing, bedding, or towels is a less significant risk, though possible.

Onset

It takes approximately 4-6 weeks to develop symptoms after initial infestation. Therefore, a person may have been contagious for at least a month before being diagnosed. This means that person might have passed scabies to anyone at that time with whom they had close contact. Someone who sleeps in the same room with a person with scabies has a high possibility of having scabies as well, although they may not show symptoms.

The symptoms are caused by an allergic reaction that the body develops over time to the mites and their by-products under the skin, thus the 4-6 week "incubation" period.

A delayed hypersensitivity (allergic) response resulting in a papular eruption (red, elevated area on skin) often occurs 30-40 days after infestation. While there may be hundreds of papules, fewer than 10 burrows are typically found. The burrow appears as a fine, wavy and slightly scaly line a few millimeters to one centimeter long. A tiny mite (0.3 to 0.4 mm) may sometimes be seen at the end of the burrow. Most burrows occur in the webs of fingers, flexing surfaces of the wrists, around elbows and armpits, the areolae of the breasts in females and on genitals of males, along the belt line, and on the lower buttocks. The face usually does not become involved in adults. But in children the most frequent localization are in palmo-plantar and face (as in the Quiz case)

1. Permethrin: Another pesticide, meanwhile use as first therapeutic weapon, lacks carcinogenic and teratogenic testing in humans although animal tests showed no signs of carcinogenic or teratogenic effects. Toxicity may resemble allergic reactions.
2. Crotamiton (Eurax®): Less toxic, but less effective. Must use for roughly 3 days.
3. Benzyl benzoate: Less toxic, but can cause asthmatic and allergic reactions. Must use for a week on 1st, 4th, and 7th day.
4. Ivermectin (Stromectol®): Broad spectrum anti-parasite medication. Newest scabies treatment. Safer than other alternatives and is the easiest and quickest to use.
5. 10% sulfur ointment: Safest treatment. Non-toxic. Used in pregnant women and infants under two months of age but effective in everyone if used for 7 days. It is available over-the-counter, and is also the cheapest treatment. May be used as often with no risk of toxicity. Drawbacks include: messy, stained clothes, therefore, one should not wear white sheets and T-shirts after application.

Important to Notice:

·        Without a host, scabies mites can on average survive up to 3 days away from human skin. As in cases of Crusted Scabies, they can survive much longer, usually 7 days. Therefore it is recommended, after treatment, to wash all material (such as clothes and bedding) that has been in prolonged contact with the infested person or persons in the last four days.

·        A person can be reinfected with scabies: all household contacts must be treated simultaneously, even if asymptomatic.

References

1.        Heukelbach J, Feldmeier H. Scabies: Lancet 2006;367:1767-74.

2.      Hengge UR, Currie BJ, Jager G, Lupi O, Schwartz RA. Scabies: a ubiquitous neglected skin disease. Lancet Infect Dis. 2006 Dec;6(12):769-79. Review.

On first sight I would think of an infantile akropustulosis, skabies, dyshidrotic ekzema or impetigo.
I would think of an "Scabid" (scabies causing an dyshidrotic reaction with secondary impetiginisation)

Dr. med. Martin Hüttemann
Dermatologist Bergisch Gladbach Germany.