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Clinical presentation of scabies in a nursing home population
396
Journal of the American Academy of Dermatology
Correspondence
REFERENCE i. Friedman SJ. Leukopenia and neutropenia associated with isotretinoin therapy. Arch Dermatol 1987;123:293-4.
Clinical presentation of scabies in a nursing home population To the Editor: Human scabies is a c o m m o n derrnatosis whose areas of predilection are classically described as involving the interdigital web spaces, flexor areas of the wrists, extensor surfaces of the elbows, anterior axillary folds, breasts, umbilical area, genitalia, and buttocks. Recently I encountered a scabies epidemic in a nursing home for the elderly. The patients had lesions involving the trunk and extremities in a haphazard array. I believe the clinical presentation of scabies in the elderly represents a distinct subset caused by a multitude of host-parasite interactions. Case report. Thirty-two patients were involved in an epidemic that occurred in a high level care nursing home. All patients were white, and all were suffering from multiple systemic disorders. Twenty-nine of the thirty-two patients had been treated previously with topical steroids without significant change in symptoms or presentation. All thirty-two patients had involvement of the trunk; five patients had lesions scattered on the extremities. In addition, eight patients had papulopustules at the time of presentation, and one had a l-era hyperkeratotic plaque on the outer aspect of the arm. A clear linear burrow was seen in only one very debilitated patient. No site preference was noted in regard to involvement of the breasts, genitalia, elbows, or buttocks. The papulopustule was found to harbor the mite in three of four epidermal shave biopsies performed. Some of the patients had involvement of the volar aspects of the wrists, web spaces of the hands, or genitalia. Lindane was elected as the mitocide. Lindane 1% lotion was applied from the neck down, left on for 8 hours, and repeated in 1 week. All signs and symptoms of the eruption abated within approximately 2 weeks, except in two patients who required a third treatment. Among the support staff, several members were infected. The clinical presentation in these patients was more classic in distribution, with a positive scraping for Sarcoptes scabiei noted on the web space of one individual. However, the most common diagnosis was acrophobia. In these cases, if the individual had no close contact with direct patient care, reassurance and bland emollients were prescribed. Four months after treatment no recurrence of the epidemic had been noted.
Discussion. Treatment o f a scabies epidemic in a nursing home requires intense dermatologic intervention. Partial treatment of the high-risk and moderaterisk groups is d o o m e d to failure. Close coopera-
Fig. 1, Excoriated patches noted on anterior aspect of chest.
tion of the entire support staff is critical for complete success. In the elderly patients studied, several interesting features emerged. A higher incidence of infection was noted in the patients as opposed to the support staff. This probably reflects an altered inflammatory response in the elderly, as well as racial differences; many of the support staff are Negro. z'3 Of particular interest was the distribution of the lesions, as shown in Fig. 1. A similar epidemic has been reported with these unusual and atypical f e a t u r e s . 4 It is my position that this presentation is not "atypical" but represents the true presentation of scabies in the elderly. The adult female S. scabiei walks a brisk 2.5 cm per minute looking for an ideal site to burrow. 5 As the ultrastructure of the stratum corneum changes with aging, it is of little surprise that the adult organism and its immature larvae and nymph respond to the changing topography. Some of these changes include an alteration in comeocyte shedding and an increase in stratum corneum renewal time. 6 Surface lipid changes are also known to O c c u r . 7 Other epidermal changes are a progressive uniformity of the epidermal undersurface, with a subsequent loss of epidermal undulations. These observations have been noted in the lower abdomen, areolae of the breasts, and genitalia of women. In the extreme elderly, frank uniformity is found, with the undersurface o f the epidermis completely flattened, s This uniformity of skin topography, along with changes in the stratum corneum associated with aging, may reflect in the site specificity acceptable to the mite. Scabies presents differently in the extreme elderly
Volume 18 Number 2, Part 1 February 1988
Correspondence 397
b e c a u s e the skin harboring the m i t e is different. The d i a g n o s i s of scabies is difficult u n d e r any circumstances. Scabies in the elderly is a distinct dermatosis as o p p o s e d to scabies in the young and middle-aged; c o m b i n i n g two very distinct disorders o n l y confounds the diagnosis more.
Lawrence Nijaki Meyers, M.D. East Orange General Hospital East Orange, NJ 07019 REFERENCES
3. 4.
5.
6. 7.
1. Juranek D, Currier R. Scabies control in institutions. In: Orkin M, Maiback H, eds. Cutaneous infestations and insect bites. New York: Marcel Dekker, 1985. 2. Roberts-Thomson IC, Wittingham S, Youngehiyud V,
8.
Mackay IR, Aging, immune response and mortality. Lancet 1974;2:368-70. Alexander AM. Role of race in scabies infestation. Arch Dermatol t981;114:627. Moberg SAW, Lrwhagen G-BE, Hersle KS. An epidemic of scabies with unusual features and treatment resistance in a nursing home. J AM AcAo DERMATOL 1984;11: 242-4. Mellenberg K. Biology of the parasite. In: Orkin M, Maibach H, Parish L, Schwartzman R, eds. Scabies and pediculosis. Philadelphia: Lippincott, 1977. Baker H, Blair C. Cell replacement in the human stratum comeum in old age. Br J Dermatol 1968;80:367. Plewig G, Kligman A. Proliferative activity of the sebaceous glands of the aged. J Invest Dermatol 1978;80: 314-7. Montagna W, Carlisle K. Structural changes in aging human skin. J Invest Dermatol 1979;73:47-53.
ABSTRACTS
Dermatologic complications of addiction to drugs administered by parenteral route Bosca AR, Liglorit EA, Garcia JG, Rodellas AC. Actas Dermo-Sif 1987;78:101-3 (Spanish) The first things to look for when examining the skin of a suspected drug addict are signs of multiple venipuncture on the forearms in the form of multiple pigmented scars, tortuous venous tracks, sclerosis and hyperpigmentation, above all in the anteeubital fossae. The hyperpigmentation is due to chronic venous inflammation as well as to the presence of foreign body type subcutaneous particles. Scars, ulcers, and abscesses in the drug addict's skin are related to the subcutaneous injection of "skin poppers" accompanied by adulterated substances, leading to necrosis and fibrosis. Chronic edema of the hands ("puffy hands") resulting from thrombophlebltis, as well as from sclerosis of the lymph vessels draining the area, is a major long-term complication of drug addiction, especially in patients who use "skin poppers," causing the vein to become obliterated by repeated injections and infection. "Puffy hands" are more often unilateral than bilateral and are often the first sign of drug addiction in a patient trying to avoid using the antecubital fossac for injections because they know this is the first place at which doctors look for signs of drug addiction. Urticaria occasionally occurs after dmg injection, lasting hours and sometimes days. It can be localized to the area around the injection site or it can be generalized. It is thought to be due to repeated exposure to the same sensitizing substances, either the addicting agent or adulterating substances mixed with it. Frequent cutaneous and soft tissue spreading infections are the most common dermatologic manifestations of drug addiction, especially by the subcutaneous route. The lack of sterility of the syringes, needles, and the contamination of the drag itself, as well as the substances used to dissolve it, favors frequent infection that easily spreads from user to user (Editorial note: Of these, hepatitis B and now acquired immunodeficiency syndrome (AIDS) are of the greatest consequence, but Staphylococcus aureus, streptococcal infection,
gram-negative organisms, and Candida are even more common and sometimes progress to cause osteomyelitis, thrombophlebitis, and endocarditis.) Local irritation from contaminated injected substances can also lead to superimposed infection, even with tetanus. Sexually transmitted diseases am much more common in the drag addict population because prostitution is often the only way to finance drag addiction. Syphilis, gonorrhea, condylomata acuminata, and trichomoniasis are particularly common. (Editorial note: Plus AIDS and hepatitis B.) Mucocutaneous eandidiasis in unusual forms is seen in drag addiction--multiple cutaneous pustules of long duration, sometimes with ocular involvement, as well as chronic disseminated mucocutaneous candidiasis, with nodules, pustules, chorioretinitis, endophthalmitis, and osteoarticular involvement. It is believed that the use of lemon in preparing the drag mixture favors candidal growth. This complication can lead to permanent eye damage and blindness. Direct microscopic examination for Candida sp., as well as culture, confirms the diagnosis. Yehudi M. Felman, M.D.
Dermatophytoses in Kashmir, India Bhardwaj G, Hajini GH, Khan IA, Masood Q, Khosa RK. Mykosen 1987;30:135-8 (German) Three hundred nineteen clinically suspected cases of tinea capifia were studied. It was found that about 89% of patients belonged to the age group between 0 and 15 years and 74.6% were male. Trichophyton violaceum was the commonest isolate. Only 19 suspected cases of favus were encountered. Isolation of Trichophyton verrucosum from tinea capitis is being reported for the first time from India; 181 patients clinically suspected of tinea eorporis and tinea cmris were investigated. T. violaceum was the commonest isolate in both clinical types, Compared to tinea capitis, an older age group was involved. Yehudi M. Felman, M.D.
Journal of the American Academy of Dermatology
Correspondence
REFERENCE i. Friedman SJ. Leukopenia and neutropenia associated with isotretinoin therapy. Arch Dermatol 1987;123:293-4.
Clinical presentation of scabies in a nursing home population To the Editor: Human scabies is a c o m m o n derrnatosis whose areas of predilection are classically described as involving the interdigital web spaces, flexor areas of the wrists, extensor surfaces of the elbows, anterior axillary folds, breasts, umbilical area, genitalia, and buttocks. Recently I encountered a scabies epidemic in a nursing home for the elderly. The patients had lesions involving the trunk and extremities in a haphazard array. I believe the clinical presentation of scabies in the elderly represents a distinct subset caused by a multitude of host-parasite interactions. Case report. Thirty-two patients were involved in an epidemic that occurred in a high level care nursing home. All patients were white, and all were suffering from multiple systemic disorders. Twenty-nine of the thirty-two patients had been treated previously with topical steroids without significant change in symptoms or presentation. All thirty-two patients had involvement of the trunk; five patients had lesions scattered on the extremities. In addition, eight patients had papulopustules at the time of presentation, and one had a l-era hyperkeratotic plaque on the outer aspect of the arm. A clear linear burrow was seen in only one very debilitated patient. No site preference was noted in regard to involvement of the breasts, genitalia, elbows, or buttocks. The papulopustule was found to harbor the mite in three of four epidermal shave biopsies performed. Some of the patients had involvement of the volar aspects of the wrists, web spaces of the hands, or genitalia. Lindane was elected as the mitocide. Lindane 1% lotion was applied from the neck down, left on for 8 hours, and repeated in 1 week. All signs and symptoms of the eruption abated within approximately 2 weeks, except in two patients who required a third treatment. Among the support staff, several members were infected. The clinical presentation in these patients was more classic in distribution, with a positive scraping for Sarcoptes scabiei noted on the web space of one individual. However, the most common diagnosis was acrophobia. In these cases, if the individual had no close contact with direct patient care, reassurance and bland emollients were prescribed. Four months after treatment no recurrence of the epidemic had been noted.
Discussion. Treatment o f a scabies epidemic in a nursing home requires intense dermatologic intervention. Partial treatment of the high-risk and moderaterisk groups is d o o m e d to failure. Close coopera-
Fig. 1, Excoriated patches noted on anterior aspect of chest.
tion of the entire support staff is critical for complete success. In the elderly patients studied, several interesting features emerged. A higher incidence of infection was noted in the patients as opposed to the support staff. This probably reflects an altered inflammatory response in the elderly, as well as racial differences; many of the support staff are Negro. z'3 Of particular interest was the distribution of the lesions, as shown in Fig. 1. A similar epidemic has been reported with these unusual and atypical f e a t u r e s . 4 It is my position that this presentation is not "atypical" but represents the true presentation of scabies in the elderly. The adult female S. scabiei walks a brisk 2.5 cm per minute looking for an ideal site to burrow. 5 As the ultrastructure of the stratum corneum changes with aging, it is of little surprise that the adult organism and its immature larvae and nymph respond to the changing topography. Some of these changes include an alteration in comeocyte shedding and an increase in stratum corneum renewal time. 6 Surface lipid changes are also known to O c c u r . 7 Other epidermal changes are a progressive uniformity of the epidermal undersurface, with a subsequent loss of epidermal undulations. These observations have been noted in the lower abdomen, areolae of the breasts, and genitalia of women. In the extreme elderly, frank uniformity is found, with the undersurface o f the epidermis completely flattened, s This uniformity of skin topography, along with changes in the stratum corneum associated with aging, may reflect in the site specificity acceptable to the mite. Scabies presents differently in the extreme elderly
Volume 18 Number 2, Part 1 February 1988
Correspondence 397
b e c a u s e the skin harboring the m i t e is different. The d i a g n o s i s of scabies is difficult u n d e r any circumstances. Scabies in the elderly is a distinct dermatosis as o p p o s e d to scabies in the young and middle-aged; c o m b i n i n g two very distinct disorders o n l y confounds the diagnosis more.
Lawrence Nijaki Meyers, M.D. East Orange General Hospital East Orange, NJ 07019 REFERENCES
3. 4.
5.
6. 7.
1. Juranek D, Currier R. Scabies control in institutions. In: Orkin M, Maiback H, eds. Cutaneous infestations and insect bites. New York: Marcel Dekker, 1985. 2. Roberts-Thomson IC, Wittingham S, Youngehiyud V,
8.
Mackay IR, Aging, immune response and mortality. Lancet 1974;2:368-70. Alexander AM. Role of race in scabies infestation. Arch Dermatol t981;114:627. Moberg SAW, Lrwhagen G-BE, Hersle KS. An epidemic of scabies with unusual features and treatment resistance in a nursing home. J AM AcAo DERMATOL 1984;11: 242-4. Mellenberg K. Biology of the parasite. In: Orkin M, Maibach H, Parish L, Schwartzman R, eds. Scabies and pediculosis. Philadelphia: Lippincott, 1977. Baker H, Blair C. Cell replacement in the human stratum comeum in old age. Br J Dermatol 1968;80:367. Plewig G, Kligman A. Proliferative activity of the sebaceous glands of the aged. J Invest Dermatol 1978;80: 314-7. Montagna W, Carlisle K. Structural changes in aging human skin. J Invest Dermatol 1979;73:47-53.
ABSTRACTS
Dermatologic complications of addiction to drugs administered by parenteral route Bosca AR, Liglorit EA, Garcia JG, Rodellas AC. Actas Dermo-Sif 1987;78:101-3 (Spanish) The first things to look for when examining the skin of a suspected drug addict are signs of multiple venipuncture on the forearms in the form of multiple pigmented scars, tortuous venous tracks, sclerosis and hyperpigmentation, above all in the anteeubital fossae. The hyperpigmentation is due to chronic venous inflammation as well as to the presence of foreign body type subcutaneous particles. Scars, ulcers, and abscesses in the drug addict's skin are related to the subcutaneous injection of "skin poppers" accompanied by adulterated substances, leading to necrosis and fibrosis. Chronic edema of the hands ("puffy hands") resulting from thrombophlebltis, as well as from sclerosis of the lymph vessels draining the area, is a major long-term complication of drug addiction, especially in patients who use "skin poppers," causing the vein to become obliterated by repeated injections and infection. "Puffy hands" are more often unilateral than bilateral and are often the first sign of drug addiction in a patient trying to avoid using the antecubital fossac for injections because they know this is the first place at which doctors look for signs of drug addiction. Urticaria occasionally occurs after dmg injection, lasting hours and sometimes days. It can be localized to the area around the injection site or it can be generalized. It is thought to be due to repeated exposure to the same sensitizing substances, either the addicting agent or adulterating substances mixed with it. Frequent cutaneous and soft tissue spreading infections are the most common dermatologic manifestations of drug addiction, especially by the subcutaneous route. The lack of sterility of the syringes, needles, and the contamination of the drag itself, as well as the substances used to dissolve it, favors frequent infection that easily spreads from user to user (Editorial note: Of these, hepatitis B and now acquired immunodeficiency syndrome (AIDS) are of the greatest consequence, but Staphylococcus aureus, streptococcal infection,
gram-negative organisms, and Candida are even more common and sometimes progress to cause osteomyelitis, thrombophlebitis, and endocarditis.) Local irritation from contaminated injected substances can also lead to superimposed infection, even with tetanus. Sexually transmitted diseases am much more common in the drag addict population because prostitution is often the only way to finance drag addiction. Syphilis, gonorrhea, condylomata acuminata, and trichomoniasis are particularly common. (Editorial note: Plus AIDS and hepatitis B.) Mucocutaneous eandidiasis in unusual forms is seen in drag addiction--multiple cutaneous pustules of long duration, sometimes with ocular involvement, as well as chronic disseminated mucocutaneous candidiasis, with nodules, pustules, chorioretinitis, endophthalmitis, and osteoarticular involvement. It is believed that the use of lemon in preparing the drag mixture favors candidal growth. This complication can lead to permanent eye damage and blindness. Direct microscopic examination for Candida sp., as well as culture, confirms the diagnosis. Yehudi M. Felman, M.D.
Dermatophytoses in Kashmir, India Bhardwaj G, Hajini GH, Khan IA, Masood Q, Khosa RK. Mykosen 1987;30:135-8 (German) Three hundred nineteen clinically suspected cases of tinea capifia were studied. It was found that about 89% of patients belonged to the age group between 0 and 15 years and 74.6% were male. Trichophyton violaceum was the commonest isolate. Only 19 suspected cases of favus were encountered. Isolation of Trichophyton verrucosum from tinea capitis is being reported for the first time from India; 181 patients clinically suspected of tinea eorporis and tinea cmris were investigated. T. violaceum was the commonest isolate in both clinical types, Compared to tinea capitis, an older age group was involved. Yehudi M. Felman, M.D.