Scabies

AT-A-GLANCE

 Human infestation caused by the Sarcoptes scabiei var. hominis mite that lives its

entire life cycle within the epidermis.

 Causes a diffuse, pruritic eruption after an incubation period of 4 to 6 weeks.

 Is transmitted by close physical contact or by fomites.

 Topical therapy with permethrin 5% cream is most effective topical therapy, but
oral ivermectin, although off-label, is also effective.

 Because of the common occurrence of asymptomatic mite carriers in the

household, all family members and close contacts should be treated
simultaneously.

EPIDEMIOLOGY
Scabies is a worldwide issue that affects all ages, races, and socioeconomic levels.
Prevalence varies considerably with some underdeveloped countries having rates from 4%
to 100% of the general population.1 In the developing world the populations affected
include children, the elderly, and immunosuppressed individuals. An infested host usually
harbors between 3 and 50 oviparous female mites,2 but the number may vary considerably
among individuals. For example, patients with crusted, formerly “Norwegian,” scabies (Fig.
178-1) who have a defective immunologic or sensory response (ie, leprosy, paraplegic, or
HIV-infected patients) harbor millions of mites on their skin surface, with minimal pruritus.
Infants and the elderly may not be effective scratchers and harbor intermediate numbers
between 50 and 250 mites.

FIGURE 178-1
Crusted scabies. Hyperkeratotic plaques populated with thousands of mites.
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It is well established that close personal contact is a prime route of transmission. Although
sometimes considered a sexually transmitted disease, the equally high prevalence in
children attests that close nonsexual contact among children and other family members is
also sufficient to transmit the infestation. Transmission via inanimate objects has been best
demonstrated with crusted scabies but is much less likely to occur in normal hosts. Crusted
scabies is notoriously contagious, and anyone roaming within the general vicinity of these
patients risks acquiring the infestation. Indeed, 6000 mites/g of debris from sheets, floor,
screening curtains, and nearby chairs have been detected.3 Mites are also prevalent in the
personal environment of normal scabies patients.4,5 In one study, live mites were recovered
from dust samples taken from bedroom floors, overstuffed chairs, and couches in every
patient’s dwelling.5

ETIOLOGY AND PATHOGENESIS

Scabies is an infestation by the highly host-specific mite, Sarcoptes scabiei var. homini,
family Sarcoptidae, class Arachnida. The mite is pearl-like, translucent, white, eyeless, and
oval in shape with 4 pairs of short stubby legs. The adult female mite is 0.4 × 0.3 mm with
the male being slightly smaller—just slightly too small to be seen by the naked eye. The
scabies mite is able to live for 3 days away from the host in a sterile test tube, and for 7 days
if placed in mineral oil mounts.4,6 Mites cannot fly or jump.

The life cycle of mites is completed entirely on human skin. The female mite, by a
combination of chewing and body motions, is able to excavate a sloping burrow of 0.5 to 5
mm/day in the stratum corneum to the boundary of the stratum granulosum. 7,8 Along this
path, which can be 1 cm long, she lays anywhere from 0 to 4 eggs a day, or up to 50 eggs
during her life span of 30 days. Eggs hatch in 10 to 12 days and larvae leave the burrow to
mature on the skin surface. After the larvae molt, they become nymphs which can only
survive 2 to 5 days off host. The male mite lives on the surface of the skin and enters
burrows to procreate.
CLINICAL FINDINGS
The diagnosis of scabies is suspected by pruritus associated with a characteristic
distribution of lesions and epidemiologic history. Onset is typically insidious, with the
patient complaining of intense nocturnal pruritus. Pruritus typically appears 4 to 6 weeks
after initial infestation, although many patients may not develop symptoms for 3 months
and some patients are never sensitized. With subsequent reinfestations, symptoms develop
within 2 to 3 days.9 Similar to the human response to other insects such as fleas, yellow
jackets, and mosquitoes, there is a wide range of clinical responses to an infestation with
scabies and some individuals remain asymptomatic despite being infested. These individuals
are considered “carriers.”

On physical examination, patients display excoriations and eczematous dermatitis that

favors the interdigital webs (see Fig. 178-1), sides of fingers, volar aspects of the wrists and
lateral palms (Fig. 178-2), elbows, axillae, scrotum, penis (Fig. 178-3), labia, and areolae in
women. The head and neck are usually spared in healthy adults, but in infants, elderly, and
immunocompromised individuals, all skin surfaces are susceptible. Indurated, crusted
nodules can be seen in infants and young children on intertriginous areas as well as on the
trunk. In crusted scabies (see Fig. 178-1), hyperkeratotic plaques develop diffusely on the
palmar and plantar regions, with thickening and dystrophy of the toenails and fingernails.
Although, patients with crusted type have an enormous mite burden they have few or no
symptoms.

2 dari tanda cardinal: pruritus nokturna (aktivitas tungau tinggi), penyakit menyerang
sekelompok manusia contoh keluarga atau tetangga kena=, ada terowongan atau funiculus
di tempat predilepsi rata2 panjang 1 cm, ditemukan npapul atu vesikel,

Kalo infeksi sekunder ada pustule dengan ekskroriasi

Kadang funiculus / terowongan ga keliatan karena pasien suka garuk.

Tmpat lokasi: stratum korneum tipis (lipat ketika, sela2 tangan, bokong,kalo bayi telapak
tangan-kaki-wajah)

Ditemukan tungau nya

Selama masi ada terowongan / lubang bisa tuh dipake uji tinta (burrow)

FIGURE 178-2
Scabies. Several thread-like burrows are present in the web spaces of the fingers and on the
knuckles, a common location for these lesions in scabies. Longitudinal scraping of a burrow
will often reveal the mite or mite products under microscopic examination.
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FIGURE 178-3
Scabies. Microscopic examination of a mineral oil preparation after scraping a burrow
reveals a gravid female mite with oval, gray eggs and fecal pellets.

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The pathognomonic lesion is a burrow, which is a thin, thread-like, linear, or often J-shaped
structure (see Figs. 178-2 and 178-4) 1 to 10 mm in length. It is a tunnel caused by the
movement of the mite in the stratum corneum. When present, the burrow is best seen in
the interdigital webs and wrists; however, it can be difficult to find in early stages of the
condition, or after the patient has extensively excoriated the lesions. In infants and young
children who are less-effective scratchers, burrows can be identified on palms and soles as
well as intertriginous areas and the trunk. Identification of a burrow can be facilitated by
rubbing a black felt-tip marker across an affected area. After the excess ink is wiped away
with an alcohol pad, the burrow appears darker than the surrounding skin because of ink
accumulation in the burrow.

FIGURE 178-4
A dermoscopic image of triangle or “delta-wing jet” sign of dense scabies head parts (long
red arrow), relatively translucent scabies body (long black arrow), scabies eggs (short red
arrows), and classic S-shaped burrow. Heine Delta 20× dermatoscope with Nikon Coolpix
4500 camera. (From Fox G. Diagnosis of scabies by dermoscopy. BMJ Case Rep. 2009;2009.
Reproduced by permission from BMJ Publishing Group Ltd.)

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A definitive diagnosis is made by microscopic identification of the scabies mites, eggs, or
fecal pellets (scybala). This is accomplished by placing a drop of mineral oil over a burrow
and then scraping longitudinally with a number 15 scalpel blade along the length of the
burrow or a suspicious skin area, being careful not to cause bleeding. Scrapings are best
taken from a burrow, papule, or vesicle that is not excoriated. The scrapings are then
applied to a glass slide and examined under low power (see Fig. 178-3). Confocal microscopy
and dermoscopy also can be used to examine the mite in vivo. 10,11 The classic dermoscopic
finding is the “delta-wing jet” sign of dense scabies head parts and body, eggs, and a burrow
(see Fig. 178-4). A skin biopsy can be diagnostic, if the mite happens to be transected in the
stratum corneum (Fig. 178-5).

FIGURE 178-5
A skin biopsy can be diagnostic, if the mite happens to be transected in the stratum
corneum. Images show (A) ×4 magnification and (B) ×10 magnification of scabies mite within
the stratum corneum.
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An enzyme-linked immunosorbent assay has been developed for serologic testing of other
mite infestations in animals; however, no serologic tests for scabies exist for
humans.12Despite the possibility of confirming the presence of mites via multiple methods
of testing, the diagnosis usually is based on clinical impression, and solidified by response to
treatment.

DIFFERENTIAL DIAGNOSIS
Table 178-1 outlines the differential diagnosis of scabies.

TABLE 178-1Differential Diagnosis of Scabies

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COMPLICATIONS
Secondary impetiginization may occur and poststreptococcal glomerulonephritis has
resulted from scabies-induced pyodermas caused by Streptococcus pyogenes. Lymphangitis
and septicemia also have been reported in crusted scabies. Finally, scabies infestation can
also trigger bullous pemphigoid.13,14

TREATMENT
Scabies is treated by a combination of a scabicide and fomite control. With all insecticidal
therapies, a second application, usually a week after the initial treatment, is required to
reduce the potential for reinfestation from fomites as well as to kill any nymphs that may
have hatched after treatment as a result of a semiprotective environment within the egg. All
household and close contacts must be simultaneously treated to prevent reinfestation from
mildly symptomatic and asymptomatic carriers.

Topical scabicides are applied overnight to the entire skin surface with special attention to
finger and toe creases, cleft of the buttocks, belly button, and beneath the fingernails and
toenails. In adults, one can exclude treating the scalp and face. Most treated individuals
experience relief from symptoms within 3 days, but patients must be informed that even
after adequate scabicidal therapy, the rash and pruritus may persist for up to 4 weeks. The
itching experienced during this time period is commonly referred to as “postscabetic itch.”
Patients should be educated that excessive washing of the skin with harsh soaps will
aggravate their skin irritation. Instead, oral antihistamines and emollients can be
beneficial. Table 178-2 summarizes the treatments for scabies, but a few comments are
warranted:

TABLE 178-2Treatment of Scabies

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 Lindane has received a “black box” warning as well as restrictive labeling changes
from the U.S. Food and Drug Administration (FDA) to greatly restrict its
usage.15,16 Moreover, it is banned in California.17 A physician should write a
prescription for lindane only when cognizant of all the caveats noted by the FDA (see
the footnote to Table 178-2).18
 There are no documented cases of scabies resistance to permethrin, but tolerance is
beginning to develop.19 Pregnant females, breastfeeding mothers, and children
younger than age 2 years should limit their 2 applications (1 week apart) to 2 hours
only when using permethrin.
 Crotamiton is considerably less effective than all other options offered.
 Five percent to 10% sulfur is messy, malodorous, tends to stain, and can produce
irritant dermatitis, but is inexpensive and may be the only choice in areas of the
world in which a lack of funds dictates therapy.20 The efficacy and toxicity of sulfur
has not been critically evaluated in recent years, but many believe that it is the safest
choice for neonates and pregnant females.21
Ivermectin is an anthelmintic agent derived from a class of compounds known as
avermectins. It has been used in veterinary medicine since 1981, and has excellent
antiparasitic properties.22-24 Ivermectin has been approved since 1996 by the FDA for
treatment of 2 diseases, namely onchocerciasis and strongyloides. Clinical efficacy for
scabies has been impressive at a dosage of 200 µg/kg given twice 1 week apart. 25,26 Given
that millions of people have been treated for onchocerciasis worldwide without significant
side effects including pregnant women, it appears to be extremely safe. Nevertheless,
because the drug acts on nerve synpases that utilize glutamate or γ-aminobutyric acid, and
because the blood–brain barrier is not fully developed in young children, it is not
recommended for use in children who weigh less than 15 kg (33 lbs) or in pregnant or
lactating women. Success rates approach 100% in studies where entire households and
close contacts of infested individuals are treated while maintaining strict fomite controls. 24,27

In crusted scabies, the combination of oral ivermectin and a topical scabicide is

recommended as the oral medication will not penetrate into the thickness of the keratinous
debris under the nails.

PREVENTION
Several measures should be considered to reduce the potential of reinfestation by fomite
transmission. Because of the common occurrence of asymptomatic mite carriers in the
household, all family members and close contacts should be treated simultaneously. After
treatment, treated individuals should wear clean clothing, and all clothing, pillow cases,
towels and bedding used during the previous week should be washed in hot water and dried
at high heat. Nonwashables should be dry-cleaned, ironed, put in the clothes dryer without
washing, or stored in a sealed plastic bag in a warm area for 2 weeks. Floors, carpets,
upholstery (in both home and car) play areas, and furniture should be carefully vacuumed.
Fumigation of living spaces is not recommended. Pets also do not need to be treated
because they do not harbor the human scabies mite.

Kudis adalah kondisi yang ditandai dengan munculnya rasa sangat gatal di kulit, terutama
pada malam hari, disertai dengan timbulnya ruam bintik-bintik menyerupai jerawat atau
lepuhan kecil bersisik. Kondisi ini merupakan dampak dari adanya tungau yang hidup dan
bersarang di kulit.
Jumlah tungau yang terdapat di kulit penderita kudis berkisar 10-15 ekor, dan dapat
berkembang biak hingga berjumlah jutaan, dan menyebar ke bagian tubuh lain, jika tidak
mendapatkan penanganan tepat, tungau.
Kudis merupakan penyakit yang mudah menular, baik secara kontak langsung atau tidak.
Maka dari itu, jika telah merasakan gejala-gejala kudis, dianjurkan untuk segera menemui
dokter.
Penyebab Kudis
Kudis disebabkan oleh tungau Sarcoptes scabiei. Tungau tersebut membuat lubang
menyerupai terowongan pada kulit untuk dijadikan sarang. Mereka bertahan hidup dengan
menjadi benalu di kulit manusia, dan akan mati dalam beberapa hari tanpa manusia.
Penularan tungau Sarcoptes scabiei terjadi melalui 2 cara, yaitu:

 Kontak langsung, seperti melalui pelukan atau berhubungan seksual. Berjabat

tangan hanya memiliki potensi kecil menularkan tungau.
 Tidak langsung, misalnya berbagi peggunaan pakaian atau tempat tidur dengan
orang yang menderita kudis.

Risiko kudis menular tergolong tinggi pada:

 Anak-anak, terutama yang tinggal di asrama.

 Orang dewasa yang aktif secara seksual.
 Seseorang yang tinggal di panti jompo.
 Seseorang yang tengah dirawat di rumah sakit.
 Seseorang yang memiliki sistem kekebalan tubuh lemah, seperti penderita HIV atau
kanker.

Gejala Kudis
Kudis ditandai dengan munculnya rasa gatal hebat, terutama saat malam hari, disertai
timbulnya ruam bintik-bintik menyerupai jerawat. Ruam yang muncul juga dapat berupa
lepuhan kecil dan bersisik. Pada anak-anak dan orag dewasa, gejala tersebut dapat muncul
pada area:

 Ketiak
 Sekitar payudara
 Puting
 Siku
 Pergelangan tangan
 Sela-sela jari dan telapak tangan
 Pinggang
 Sekitar kelamin
 Bokong
 Lutut
 Telapak kaki

Sedangkan pada bayi, balita, dan lansia, gejala dapat muncul di area:

 Kepala
 Wajah
 Leher
 Tangan
 Telapak kaki
Diagnosis Kudis
Dokter akan menanyakan riwayat munculnya gejala, riwayat kesehatan, dan faktor yang
diduga menyebabkan pasien tertular tungau, serta melakukan pemeriksaan fisik.
Setelah itu, dokter dapat melanjutkan pemeriksaan dengan melakukan serangkaian tes
untuk mengesampingkan kondisi lain yang juga dapat menimbulkan gejala serupa dengan
kudis, seperti alergi obat, eksim, dan dermatitis. Beberapa tes yang digunakan dokter untuk
memastikan kondisi yang diderita pasien:

 Uji tinta. Pemeriksaan ini dilakukan dengan mengoleskan tinta khusus pada area
kulit yang bermasalah. Setelah tinta dioleskan, kulit akan dibasuh dengan kapas yang
telah diberikan alkohol. Jika terdapat sarang tungau, tinta akan tertinggal di kulit dan
membentuk garis-garis kecil. (Burrow in test)
 Pemeriksaan mikroskopis. Tungau penyebab kudis tidak selalu terlihat kasat mata.
Maka dari itu, pemeriksaan ini bertujuan untuk mendeteksi tungau di tubuh dengan
mengikis sebagian kecil area yang bermasalah untuk dijadikan sampel. Sampel
tersebut kemudian akan diperiksa lebih lanjut di laboratorium.

Pengobatan Kudis
Penanganan kudis bertujuan untuk membasmi tungau penyebabnya. Dokter akan
meresepkan obat oles permethrin untuk membunuh tungau beserta telurnya.
Penggunaan obat dilakukan saat malam hari, dengan dioleskan ke bagian tubuh yang
mengalami kudis.
Penting untuk diketahui bahwa gejala dapat terasa memburuk di awal pengobatan. Hal itu
tergolong wajar. Gejala akan mulai berkurang setelah satu minggu pengobatan, dan sembuh
sepenuhnya setelah 4 minggu pengobatan.
Pasien dapat melakukan perawatan sederhana di rumah guna mengurangi rasa gatal yang
timbul akibat kudis. Di antaranya:

 Berendam di air dingin, atau menempelkan kain basah pada area kulit yang
bermasalah.
 Menggunakan losion kalamin. Namun, konsultasikan terlebih dahulu mengenai
penggunaannya dengan dokter.

Komplikasi Kudis
Beberapa komplikasi yang dapat terjadi akibat kudis, terutama yang tidak mendapatkan
penanganan secara tepat, adalah:

 Infeksi bakteri. Infeksi bakteri merupakan dampak dari kudis yang terus menerus

digaruk, sehingga menyebabkan luka dan memudahkan bakteri berbahaya masuk
dan menyerang tubuh.
 Norwegian scabies atau kudis berkrusta. Orang yang menderita kudis hanya
memiliki 10-15 tungau di tubuhnya. Sedangkan pada kudis berkrusta, tungau yang
 ada di tubuh dapat mencapai jutaan. Kondisi ini membuat kulit menjadi keras,
bersisik, dan kudis pun menyebar ke banyak bagian tubuh lain. Seseorang yang
memiki sistem kekebalan tubuh lemah, menderita suatu penyakit parah, atau tengah
dirawat di rumah sakit memiliki risiko tinggi mengalami komplikasi ini.

Pencegahan Kudis
Cara paling ampuh untuk mencegah kudis adalah dengan menjaga diri agar tidak terpapar
tungau Sarcoptes scabiei, baik melalui kontak langsung dengan penderita atau secara tidak
langsung.
Sedangkan bagi penderita, lakukanlah hal-hal berikut ini untuk mencegah kudis menulari
orang lain:

 Bersihkan semua pakaian atau barang pribadi menggunakan sabun dan air hangat.
Lalu, keringkan di udara yang panas.
 Bungkus dengan plastik barang yang berpotensi terkontaminasi tungau, namun tidak
bisa dicuci. Lalu, letakkan di tempat yang jauh dari jangkauan. Tungau yang terdapat
di barang tersebut akan mati dalam beberapa hari.

Edukasi keluarga trus dikasi obat kapan aja dan Harus di jam yang samaa (kalo keluarga nya
juga punya keluhan)
Trus barang2 yang dipake bersama harus di cuci di air panas dan dijemur di matahari terik

Gaboleh tinggal sama si penderita

Kasur harus yang bersih (kalo engga nular lagi ke pasiennya)

Si teman pasien juga harus dibawa.