BMJ 2017;357:j2912 doi: 10.1136/bmj.

j2912 (Published 2017 June 29) Page 1 of 3

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CASE REVIEW

A case of generalised papules

Valencia Long medical officer, Henry Foong consultant
National Skin Centre, Singapore

A 75 year old man who lived in a nursing home complained of

itching and a rash that had lasted for four months. The man had
experienced a traumatic cervical cord injury six months earlier
and had sensory impairment but no other substantial medical
history. On examination, he had markedly thickened crusts and
hyperkeratosis on his hands and feet bilaterally, with
involvement of his finger and toe web spaces (fig 1, fig 2). There
were excoriated erythematous papules over his trunk and axillae
(fig 3) and erythematous papules or nodules on his glans penis.
A fungal scrape was performed and this was negative for fungal
elements.

Correspondence to V Long valencialong@gmail.com

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BMJ 2017;357:j2912 doi: 10.1136/bmj.j2912 (Published 2017 June 29) Page 2 of 3

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Fig 1 Thickened crusts in the digits and palm Fig 4 Sarcoptes scabiei mite (arrow)

Discussion
Scabies is a common ectoparasitic infestation that occurs in
residents of nursing homes, day care centres, and hospitals.
Uncomplicated scabies is generally associated with a smaller
mite load. Crusted scabies tends to affect immunocompromised,
debilitated patients, who present with a high scabiei mite load
of tens of thousands of mites, and is extremely infectious.
Clinically, crusted scabies produces less itching than scabies,
and is more insidious in onset. This might be due to paralysis,
decreased cutaneous sensation, an altered immune system, or
altered perception of itch. Areas of the body commonly affected
in crusted scabies include the neck, face, scalp, and the
periorbital and subugunal regions. The genitalia are another
Fig 2 Crusts in the toe web spaces important site to examine. The early diagnosis of crusted scabies
is crucial for infection control. The presence of burrows, a “delta
sign” on dermoscopy, and characteristic appearances on
potassium hydroxide mount enable the final diagnosis of crusted
scabies.

2.
What are the differential diagnoses?
Short answer
Psoriasis, eczema, tinea and seborrheic dermatitis.

Discussion
Psoriasis presents as hyperkeratotic scaly plaques that affect
similar regions to crusted scabies. Other differentials include
tinea corporis, lichen planus, severe eczema, seborrheic
dermatitis, Darier’s disease, and even Langerhans’ cell
Fig 3 Excoriated erythematous papules over the trunk
histiocytosis where the history and clinical features are
appropriate. Tinea corporis and seborrheic dermatitis are readily
treatable disorders without substantial clinical sequelae, but in
Questions some debilitated individuals can become extensive.
1. What is the diagnosis?
2. What are the differential diagnoses? 3.
What are the management options for this
3. What are the management options for this patient? patient?
Short answer
Answers Topical permethrin and malathione are options, or oral
1. ivermectin. Close contacts should also be treated. The patient’s
What is the diagnosis? local environment should be decontaminated.
Short answer
Discussion
Crusted scabies (Norwegian scabies) (fig 4).
Treatment of crusted scabies can be challenging because of the
high mite burden and limited penetration of topical agents
through the hyperkeratotic lesions. Co-treatment with keratolytic

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BMJ 2017;357:j2912 doi: 10.1136/bmj.j2912 (Published 2017 June 29)
agents can decrease mite burden and allow for scabicidals to
penetrate more effectively.1 Topical permethrin is the preferred
agent for eradication of mites but might require repeated
applications. Oral ivermectin is commonly used but is
contraindicated in people with central nervous system disorders
and in pregnant or lactating women and children under 5 because
of possible neurotoxicity. Gloves and gowns should be used
while changing the bedding of patients with crusted scabies.
Clothes and bed linen can be decontaminated by washing at
60°C. Prophylactic treatment of patient contacts often include
an entire institution or individuals visiting the patient.
Patient outcome
This patient was treated with permethrin 5% solution to his
entire body, including his web spaces, for 12 hours on 2-3
consecutive nights. The treatment was repeated one week after
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Page 3 of 3
ENDGAMES
the first application. Close contacts living in the patient’s nursing
home were also appropriately treated. The patient was
completely eradicated of disease after two cycles of treatment.
Ivermectin was not required as he had good response with
topicals.
We have read and understood the BMJ policy on declaration of interests
and declare no competing interests.
Patient consent obtained.
Provenance and peer review: not commissioned; externally peer
reviewed.
1 Bitman LM, Rabinowitz AD. Hyperkeratotic plantar plaques in an HIV-positive patient.
Crusted scabies, localized to the soles. Arch Dermatol 1998;357:1019, 1022-3. doi:10.
1001/archderm.134.8.1019 pmid:9722734.
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