Tropical Medicine and International Health doi:10.1111/j.1365-3156.2006.01809.

volume 12 no 4 pp 493–502 april 2007

Clinical features and associated morbidity of scabies in a rural

community in Alagoas, Brazil
Anne Jackson1, Jörg Heukelbach2, Arthur Ferreira da Silva Filho3, Evônio de Barros Campelo Júnior3 and
Hermann Feldmeier1

1 Institute of Microbiology and Hygiene, Charité–University Medicine Berlin, Berlin, Germany

2 Department of Community Health, School of Medicine, Federal University of Ceará and Mandacaru Foundation, Fortaleza, Brazil
3 Department of Pathology, School of Health Sciences of Alagoas, Maceió, Brazil

Summary objective To describe the clinical characteristics of scabies and the associated morbidity in an
impoverished rural community in northeast Brazil.
method A door-to-door survey was made to examine twice the population of an endemic area; first at
the end of the rainy season, and a second time in the dry season 4 months later.
results In total, 2005 individuals were examined. The overall prevalence of scabies was 9.8%
(95% CI 8.5–11.2). Predilection sites with similar relative frequencies in all age groups were the
abdomen (83.7%) and the inguinal area/inner part of the thighs (66.3%). Hands, feet, genitals and the
scalp/neck/face were significantly more often affected in children <7 years (all P < 0.03). Fifty-five per
cent of the patients showed scabies lesions simultaneously at ‡12 distinct topographic areas. Papular
lesions were most commonly found, followed by papular-crusted lesions. Vesicles were significantly
more often observed in children (P ¼ 0.04). Sixty-four per cent of the patients had three or more types of
lesions. Local lymphadenopathy was present in 53.6% and superinfection in 36.7% of the cases. The
number of topographic areas affected, as well as the proportion of superinfected lesions, was inversely
correlated with age (rho ¼ )0.22, P ¼ 0.002 and rho ¼ )0.358, P < 0.05, respectively). The quantity
of skin surface infested, the proportion of superinfected lesions and the presence of a superinfected lesion
distal to an enlarged lymphnode were predictors of lymphadenopathy. Seventy-two per cent of the
patients suffered from sleep disorders, mainly because of itching.
conclusion Scabies is associated with considerable morbidity in this endemic community. Predilection
sites, clinical presentation, quantity of skin surface affected and proportion of secondary infected lesions
show a dichotomy between children and adults.

keywords scabies, clinical features, morbidity, community-based study, Brazil

literature (Estes 1982; Gerbase et al. 1984; Kenawi et al.

Introduction
Scabies is a common parasitic skin disease caused by the
infestation with the mite Sarcoptes scabiei var. hominis.
Clinical appearances are differentiated into primary
(macules, papules, vesicles, burrows, nodules) and secon-
dary lesions (crusts, excoriation, eczematisation, secondary
bacterial infection) (Estes 1982; Gerbase et al. 1984;
Sarwat et al. 1993; Kenawi et al. 1993; Chosidow 2006).
At least in the tropics, burrows are only inconsistently
present, and the development of nodules seems to be
restricted to certain topographic areas (Orkin & Maibach
1978; Tonkin & Wynne-Jones 1979; Gerbase et al. 1984;
Chouela et al. 2002; McCarthy et al. 2004). Numerous
topographic areas are considered to be predilection sites,
but a clear ranking cannot be inferred from the existing
1993; Flinders & De 2004; McCarthy et al. 2004; Sarwat
1 et al. 1993; Chosidow 2006). There are hints that
predilection sites may vary between children and adults,
although the existing evidence is not convincing (Hurwitz
1973; Orkin & Maibach 1978; McCarthy et al. 2004;
Heukelbach et al. 2005; Chosidow 2006).
Intense itching is invariably present and affects also areas
other than the site of the lesion (Estes 1982; Flinders & De
2004; McCarthy et al. 2004; Sarwat et al. 2004). The most
frequent complication is secondary bacterial infection
caused by scratching and the subsequent development of
lymphadenopathy (Tonkin & Wynne-Jones 1979; Burgess
1994; McCarthy et al. 2004). In the developing world, post-
streptococcal glomerulonephritis is common and scabies is
considered as an important cause of group A streptococci

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A. Jackson et al. Scabies in Brazil
2 (GAS)-induced renal disease (Mahe 2001; McCarthy et al.
2004; Feldmeier et al. 2005; Lawrence et al. 2005).
In contrast to the industrialized countries, where
scabies occurs mainly sporadically or in form of epidemics
in institutions, in the developing world ectoparasitosis is
endemic, and prevalence may be up to 29% in the general
population (Gulati et al. 1977a; Sharma et al. 1984;
Carapetis et al. 1997; Downs et al. 1999; Hegazy et al.
1999; Andersen et al. 2000; Larrosa et al. 2003; Heu-
kelbach et al. 2005; Heukelbach & Feldmeier 2006).
Surprisingly, the clinical features of scabies and the
associated morbidity in these settings have only rarely
been described (Sharma et al. 1984; Heukelbach et al.
2005). Clinical characteristics are almost exclusively
derived from observations made in patients seen by
general practitioners, or from patients in hospitals and
institutions (Gerbase et al. 1984; Kenawi et al. 1993;
Pasternak et al. 1994; Sarwat et al. 2004). It is ques-
tionable whether these findings reflect the clinical features
and the associated morbidity of scabies present in an
endemic community. Here, we report the results of a
systematic study on patients with scabies in an impover-
ished rural population in northeast Brazil, based on two
subsequent door-to-door surveys.
Materials and methods
Study area and design
The study area and the design have been described
previously (Jackson et al. 2006). In brief, the study was
conducted in three districts of Feliz Deserto, a traditional
fishing village in Alagoas state, northeast Brazil. These
areas were chosen because they had shown the highest
prevalences of scabies in a pilot study performed in May
2003. Atopic diseases were rare. Houses are constructed of
brick, clay tiles or palm stems covered with a mixture of
clay and straw. Eighty-eight per cent of the houses are
connected to electricity, and all have piped water. People
mainly dress in shorts, summer skirts and tee-shirts or
sleeveless tops; boys usually wear only shorts. The climate
is tropical with most rainfall occurring from April to
August. The average 24-h temperature is 26.6 C in the dry
and 25.1 C in the rainy season.
Each individual who had spent in average at least four
nights per week during the last three months in a
household situated in the study area was eligible for the
study. Individuals moving into the study area after the first
survey were registered and examined in the second survey
only. One door-to-door survey was carried out in June/July
2003 (rainy season), the other in October/November 2003
(dry season). At both surveys, households were revisited
494
volume 12 no 4 pp 493–502 april 2007
three times if a household member was absent. Each survey
was carried out within a period of 10 weeks.
Clinical examination and case definition
The household leaders were asked for a room with good
light and in which privacy was guaranteed. In this room,
the whole body including the breasts and the genital area
was thoroughly examined for the presence of skin lesions
typical for scabies. Children <10 years were only examined
in the presence of a caretaker, usually the mother.
The diagnosis of scabies was made clinically using a case
definition. The diagnosis of scabies by means of defined
clinical parameters is a well-established and approved
method in the developing world (Gulati et al. 1977a,b;
Hassan et al. 1979; Gerbase et al. 1984; Sharma et al.
1984; Landwehr et al. 1998; Heukelbach et al. 2005).
Skin scraping cannot be considered to be of help in this
setting, as its sensitivity is low and as its application is not
suitable for surveys in resource-poor settings (Parish &
Witkowski 1999; Flinders & De 2004; Sarwat et al. 2004;
Chosidow 2006). Scabies was suspected, if an itchy
papular, papular-crusted or vesicular rash was present at
the interdigital spaces, flexion sites of the wrists, extension
sites of the elbows, the axillae, mamillae, perimammilar
area, periumbicular area, penis, scrotum or the buttocks.
These areas are usually considered as predilection sites
(Gerbase et al. 1984; Orkin & Maibach 1985; Kenawi
et al. 1993; McCarthy et al. 2004; Sarwat et al. 2004). An
individual was considered to have scabies, if two of the
following requirements were fulfilled: pruritus which
intensified at night, presence of the lesions for >2 weeks, at
least one more family member with similar lesions.
Immediately after the diagnosis, the patient was treated
with 0.2% deltamethrin lotion (Deltacid; Solvay Farma,
São Paulo, Brazil). Superinfected lesions were treated with
oral roxithromycin (Floxid, 150 mg b.i.d. over 5 days;
Solvay Farma).
To determine the topographic distribution of the lesions
and the surface of the skin affected, the body surface was
divided vertically into right and left. Each side was
subdivided into 16 areas as follows: interdigital spaces,
hand, wrist, arm, elbow, axilla, leg (except the medial
area of the thigh), foot, abdomen, thorax, mamilla/
perimammilar area, back, buttock, genitals, inguinal area/
medial area of the thigh and scalp/neck/face.
Primary lesions were differentiated into macular, papu-
lar, papular-crusted (appearing as papules with a tiny
haemorrhagic crust) and vesicular. As in scabies pruritus is
not limited to infested sites, excoriations on uninfested skin
areas were also documented (Mellanby 1977; McCarthy
et al. 2004; Sarwat et al. 2004; Chosidow 2006). Bacterial
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Tropical Medicine and International Health
A. Jackson et al. Scabies in Brazil
superinfection was diagnosed when pustules, abscesses or
suppuration were present. Lymphadenopathy was diag-
nosed, if swollen lymph nodes were palpated during
clinical examination along the lymph vessels draining the
affected topographic area.
Patients were asked about their complaints. Itching was
subjectively classified into weak, moderate and severe;
sleep disturbances into sleep initiation disorders and sleep
maintenance disorders. To reduce inter-observer bias, the
clinical examinations were carried out by the same
investigator (Anne Jackson) on all occasions.
Data storage and analysis
Data were entered twice into a database using the Epi Info
software package (version 6.04d; Centers for Disease
Control, Atlanta, GA, USA) and checked for errors which
may have occurred during their entry. Ninety-five per cent
confidence intervals were calculated using the respective
Epi Info module. The chi-square test, the Fisher’s exact test
and the Spearman rank correlation coefficient test were
applied where appropriate, using the SigmaStat software
package (version 3.1; Systat software Incorporation,
Richmond, CA, USA). Odds ratios were calculated to
measure the association between the presence of lympha-
denopathy as the dependent and demographic and clinical
characteristics as independent variables.
Ethical considerations
The study was approved by the Ethical Committee of the
Escola de Ciências Médicas de Alagoas, the responsible
ethical body in Alagoas state, as well as from an ad hoc
committee of the health department of the municipality of
Feliz Deserto. Prior to the study, meetings were held in the
community with healthcare workers to explain the objec-
tives. All participants were informed about the study and
asked for written consent. In the case of minors, the
guardian was asked for written consent. Any inhabitant of
the study area was free to refrain from participating
without any disadvantage for himself/herself or other
persons.
Results
In June 2003, the study area was inhabited by a total of
1255 inhabitants living in 265 households. Household size
varied from 1 to 13 persons, the median being 4.5. Fifty-six
individuals were excluded because they spent less than four
nights a week in Feliz Deserto; 53 persons refused to take
part in the study. The mean age of non-participants was
28.5 years; 74.3% of non-participants were males, and
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25.7% were females. During the second survey, 261
households with a total of 1169 individuals existed in the
study area. Seventeen families (159 individuals) had moved
away, whereas 13 families (73 individuals) had moved
into the study area. In total, 55 persons refused to take part
in the second survey, and 27 were excluded as they spent
less than four nights a week in the study area. Non-
participants in the second survey had a mean age of
31.0 years; 74.4% were males, and 25.6% were females.
This resulted in a target population of 1146 individuals for
the first and 1087 for the second survey. All households
were visited in June/July 2003 (rainy season) and a second
time in October/November 2003 (dry season). In the rainy
season 88.6% (n ¼ 1015) of the target population was
examined, in the dry reason 91.1% (n ¼ 990). Males aged
15–59 years were underrepresented in both the surveys.
Eighty-six per cent of the households had a monthly family
income of more than or equal to one official minimum
wage (equivalent to US$ 86 in 2003). Of the individuals
>14 years, 34% were illiterate and 96% had not completed
secondary school. Sixty-nine per cent of the population
shared a bed or mattress, 15% shared their clothing and
48% their towels with other household members.
In the rainy season, 102 of the 1015 persons examined
were infested with scabies [10.0%; 95% confidence inter-
val (CI) 8.3–12.1%], in the dry season 94 out of 990
persons (9.5%; 95% CI 7.8–11.5%), thus giving an overall
prevalence of 9.8%. The median age of the patients was
8 years (range 0–79 years).
The types of lesions observed are summarized in
Table 1. Simultaneous presence of different types of lesions
was very common. Of the patients, 51.5% had signs of
scratching on uninfested skin. Vesicles were significantly
more often found in children £7 years than in the other age
groups (35.5% vs. 17.5%; P ¼ 0.04). Children also
presented a greater diversity of lesions than adults. Types
of lesions were similar in males and females, except for
excoriated lesions (28.6% vs. 50.0%; P ¼ 0.06) and did
not vary between the rainy and the dry seasons.
The topographic distribution of scabies lesions is shown
in Table 2. Predilection sites with similar frequencies in all
age groups were the abdomen (83.7% of the patients) and
the inguinal area/inner side of the thighs (66.3%). The
hands, feet, genitals and scalp/neck/face were significantly
more often infested in children £7 years (all P < 0.03).
Other areas with a clear preponderance in children were
the wrists, interdigital spaces, axillae, legs and buttocks.
However, the differences between the age groups were not
significant. The scalp, neck and face were exclusively
infested in patients £11 years (median 3 years, interquar-
tile ranges 1–7 years). Sixty per cent of the patients with
infestation of the mamillae and the perimammilar area
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A. Jackson et al. Scabies in Brazil

Table 1 Types of lesions found in 196 patients with scabies neously found at ‡30 topographic areas; these were all
children £1 year. There was an inverse correlation between
Number of
the number of topographic areas affected and the age of the
Type of lesion* patients (%) 
patients (rho ¼ )0.221; P ¼ 0.002).
Papules 132 (67.3) In total, 36.7% of the patients presented signs of
Crusted papules 131 (66.8) superinfection; 10.4% of the topographic areas affected
Macules 84 (42.9) were superinfected (Table 3). The proportion of superin-
Vesicles 51 (26.0)
fection ranged between 0% (mamillae and perimammilar
Excoriated lesions 80 (40.8)
Excoriations at uninfested skin 101 (51.5) area) and 64% (scalp/neck/face). The proportion of
Simultaneous presence of at least 165 (84.2) superinfected lesions inversely correlated with the age of
two different types of lesions the patients (rho ¼ )0.358; P < 0.05) and positively with
Simultaneous presence of three 100 (51.0) the number of topographic areas affected (rho ¼ 0.408;
to four different types of lesions P < 0.05) (Figure 1a,b).
Simultaneous presence of more than 26 (13.3) Superinfection was further classified into suppuration,
four different types of lesions
pustules and abscesses (Table 3). Suppuration was more
Simultaneous presence of primary 80 (40.8)
lesions and excoriationsà common than pustules (52% vs. 44%), and abscesses were
rare. Abscesses were only located at the upper extremity
*Burrows, nodules and eczematization were not found in a single (two at the elbows, two at the arms and one at the hands).
case. Areas where lesions predominantly were suppurated were
 Multiple observations possible.
the buttocks and the scalp/neck/face.
àFor definition, see Materials and methods.
Fifty-four per cent of the patients presented with
lymphadenopathy proximal to the lesion (Table 4). Ingu-
were >9 years (median 11 years, interquartile ranges inal lymphadenopathy (44.4%) was more common than
4–31 years). This manifestation was seen significantly axillar (26.5%) and cervical lymphadenopathy (16.8%).
more often in females than in males (40.2% vs. 15.5%, The results of the bivariate analysis are depicted in Table 5.
P ¼ 0.008). Young age, the number of topographic areas infested, the
Fifty-five per cent of the patients showed simultaneous presence of superinfection distal to the swollen lymph
lesions at ‡12 of the 32 topographic areas assessed, and nodes and the proportion of superinfected areas were all
6.6% at ‡24 areas. In four patients, lesions were simulta- significant predictors for the presence of lymphadenopathy.

Table 2 Topographic distribution of le-

Individuals Individuals sions according to age group
infested infested
Localization of lesions* All (%) £7 years (%) >7 years (%) P-value

Abdomen 164 (83.7) 77 (82.8) 87 (84.5) 1.0

Inguinal area/medial parts of thighs 130 (66.3) 62 (66.7) 68 (66.0) 1.0
Axillas 122 (62.2) 67 (72.0) 55 (53.4) 0.25
Wrists 110 (56.1) 65 (69.9) 45 (43.7) 0.07
Interdigital spaces 105 (53.6) 60 (64.5) 45 (43.7) 0.14
Legs 100 (51.0) 56 (60.2) 44 (42.7) 0.22
Thorax 100 (51.0) 47 (50.5) 53 (51.5) 0.96
Back 99 (50.5) 51 (54.8) 48 (46.6) 0.59
Elbows 98 (50.0) 52 (55.9) 46 (44.7) 0.43
Buttocks 93 (47.4) 54 (58.1) 39 (37.7) 0.12
Arms 93 (47.4) 47 (50.5) 46 (44.7) 0.72
Hands  66 (33.7) 42 (45.2) 24 (23.3) 0.03
Mamillae/perimamillar area 58 (29.6) 21 (22.6) 37 (35.9) 0.17
Feet 45 (23.0) 34 (36.6) 11 (10.7) 0.001
Genitals 33 (16.8) 26 (28.0) 7 (6.8) 0.002
Scalp/neck/face 6 (3.1) 9 (9.7) 1 (1.0) 0.02
Total 196 93 103

*Multiple observations possible.

 Other parts than the interdigital spaces and the wrists.

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A. Jackson et al. Scabies in Brazil

Table 3 Localization of lesions, superinfection and type of superinfection in 196 patients with scabies

Type of superinfection (n)

Number of topographic Number of topographic areas
Localization of lesions areas affected with superinfected lesions (%) Pustule Suppuration Abscess

Abdomen 316 10 (3.2) 4 6 0

Inguinal area/inner side of thighs 244 6 (2.5) 4 2 0
Axillas 208 6 (2.9) 2 4 0
Thorax 183 1 (0.5) 1 0 0
Interdigital spaces 181 61 (33.7) 30 31 0
Back 179 3 (1.7) 1 2 0
Buttocks 175 33 (18.9) 3 30 0
Wrists 167 38 (22.8) 24 14 0
Legs 166 22 (13.3) 9 13 0
Elbows 157 13 (8.3) 6 5 2
Arms 148 7 (4.7) 2 3 2
Hands 102 23 (22.5) 13 9 1
Mamillae/perimamillar area 86 0 (0.0) 0 0 0
Feet 71 22 (31.0) 11 11 0
Genitals 65 4 (6.2) 2 2 0
Scalp/neck/face 18 7 (63.6) 1 6 0
Total 2466 256 (10.4) 113 138 5

1.2
(a)
1

0.8

0.6

0.4
Proportion of superinfected lesions

0.2

0
0 10 20 30 40 50 60 70 80 90
Age of patients
-0.2

1.2
(b)
1

0.8

0.6

0.4

Figure 1 (a) Correlation between age of 0.2

patients and proportion of superinfected
lesions; (b) Correlation between number of 0
topografic areas affected and proportion of 0 5 10 15 20 25 30 35
superinfection. Number of topografic areas affected

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A. Jackson et al. Scabies in Brazil

Table 4 Lymphadenopathy in 196 patients with scabies Table 6 Complaints of 196 patients with scabies

Localization of lymphadenopathy* N (%) Type of complaint n (%)

Inguinal area 87 (44.4)  Itching 183 (93.4)à

Axillar area 52 (26.5) Light 57 (31.1)
Cervical area 33 (16.8)à Moderate 54 (29.5)
Total 105 (53.6%) Severe 72 (39.3)
Sleep disturbance (total) 142 (72.4)à
*Multiple observations possible. Sleep initiation disorder* 32 (16.3)à
 Thirty-five individuals had another parasitic skin disease at their Due to itching 29 (90.6)§
feet (33 tungiasis, 2 cutaneous larva migrans). Due to pain 3 (9.4)§
àEight individuals were concomitantly infested with pediculus Sleep maintenance disorder  139 (70.9)à
capitis. Due to itching 133 (95.7)–
Due to pain 6 (4.3)–
No complaints 7 (3.6)à
Table 5 Predictors of lymphadenopathy*
*Fifteen individuals were concomitantly affected by one or more
Independent 95% confidence other parasitic skin disease (nine tungiasis, six pediculosis capitis,
variable Odds ratio interval P-value two cutaneous larva migrans).
 Seventy individuals were concomitantly affected by one or more
Sex other parasitic skin disease (52 tungiasis, 29 pediculosis capitis, 8
Male Reference cutaneous larva migrans).
Female 0.66 0.4–1.2 P ¼ 0.15 àOf those with scabies.
Age §Of those with sleep initiation disorders.
>15 years Reference –Of those with sleep maintenance disorders.
6–15 years 4.4 1.9–10.2 P < 0.001
< ¼ 5 years 7.5 3.1–18.4 P < 0.001
Number of topographic areas affected
in the developing world (Gulati et al. 1977a; Sharma et al.
< ¼ 12 Reference
13–24 5.2 2.7–9.9 P < 0.001
1984; Carapetis et al. 1997; Hegazy et al. 1999; Heukel-
>24 >1000 >1000-n.d.  P < 0.0001 bach et al. 2005). Although the disease is highly prevalent
Presence of superinfected lesions distal to lymphadenopathy in these settings, the clinical features and the associated
No Reference morbidity have rarely been assessed systematically (Stanton
Yes 2.3 1.4–3.8 P ¼ 0.001 et al. 1987; Heukelbach et al. 2005). For example, it is still
Proportion of superinfected lesions a matter of debate whether the clinical appearances depend
0% Reference
on the age of the patient. There is also controversy
1–25% 2.2 1.1–4.5 P ¼ 0.04
>25% 12.9 3.7–44.8 P < 0.001 concerning the topographic localization of the lesions, and
a broad spectrum of different predilection sites is reported
*Cervical, axillar and inguinal lymphadenopathy combined. in the literature (Orkin & Maibach 1978; Estes 1982;
 Not defined. Kenawi et al. 1993; Flinders & De 2004; McCarthy et al.
2004; Orion et al. 2004; Sarwat et al. 2004; Chosidow
Only seven patients (3.6%) were without any complaints 2006). In order to obtain reliable population-based data on
(Table 6). Of the 196 patients, 183 (93.4%) complained clinical features and associated morbidity of scabies, we
about itching at the site of infestation or adjacent skin. In performed two subsequent door-to-door surveys in an
39.3% of the cases, itching was classified as severe. Sleep endemic community in rural northeast Brazil.
disturbances were common: 139 patients (70.9%) woke up Eighty per cent of the patients presented simultaneously
during the night, either because of itching (133 patients) with two ore more different types of lesions, and primary
or pain (6 patients). Thirty-two patients (16.3%) com- and secondary lesions frequently co-existed. This confirms
plained about impaired sleep initiation, and 29 (15.0%) the notion that in most patients the clinical presentation is
stated that sleep initiation and sleep maintenance was a mixture of primary lesions, intermingled with or oblit-
disturbed. erated by excoriation, crusting and secondary infection
(Orkin & Maibach 1978, 1984; Estes 1982; Hurkin 1985;
Flinders & De 2004; Orion et al. 2004; Chosidow 2006).
Discussion
The only pathognomonic sign, the presence of a burrow,
Scabies is a common, though relatively neglected, parasitic is inconsistently present, and particularly in tropical
skin disease of resource-poor rural and urban communities environments seems to be very rare (Orkin & Maibach

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A. Jackson et al. Scabies in Brazil
1978; Taplin et al. 1983; Burgess et al. 1986; Orion et al.
2002; Heukelbach & Feldmeier 2006).
In our study papules, crusted papules and excoriations
on uninfested skin were the most common types of lesions
irrespective of the age of the patients. The latter sign
occurred in 52% of the patients. Hitherto, the frequency of
excoriations on otherwise healthy skin has not been
reported. Although it is known for long that scabies causes
pruritus on healthy skin, previous studies did not differ-
entiate between excoriations on infested and uninfested
sites (Mellanby 1977; Gerbase et al. 1984; Kenawi et al.
1993; McCarthy et al. 2004; Sarwat et al. 2004). How-
ever, in our opinion this sign is an important criterion for
the diagnosis of scabies, if microscopy or videodermatos-
copy are not at hand.
The simultaneous presence of various lesion types was
more frequent in young children. Supposedly, in an
endemic community young children experience repeated
infestations within a short period of time. As treatment is
usually delayed, and reinfestation is common, this explains
the simultaneous presence of primary and secondary
lesions in the majority of the cases in this age group. The
number of topographic areas, and in consequence the
quantity of body surface affected, was inversely correlated
with age. This indicates that young children are prone to
multiple infestations. Whether the higher attack rate of
children is related to a lack of protective immune respon-
siveness against scabies mites developing later in life
remains to be determined.
Our data show that only the abdomen and the inguinal
area/inner side of thighs are true predilection sites, irres-
pective of the age of the patient. Areas with a clear
preponderance in children were the interdigital spaces,
hands, wrists, axillae, legs, feet, buttocks and genitals. The
scalp, neck and face were predominantly infested in
children <6 years, although elder children also showed
lesions at these topographic sites. This is in contrast to
historical data from Hurwitz (1973), who categorically
stated that these areas are only affected in infants and small
children (Hurwitz 1973). Conversely, the mamillae and the
perimammilar area were mainly infested in females
experiencing puberty or who have reached sexual maturity.
This confirms suggestions from other authors who claim
that scabies affects the breasts only of adults and older
children, and especially of female patients (Green 1989;
McCarthy et al. 2004; Orion et al. 2004; Sarwat et al.
2004). In general, our data clearly indicate that the
topographic distribution of scabies lesions is age-depend-
ent.
The dichotomy in the topographic distribution of scabies
lesions according to the patient’s age may be because of
different factors. First, the bodies of babies and toddlers
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are short. In consequence, a mite can more easily reach
distant sites like the scalp, neck and face or the feet
irrespective where body contact with a contagious indi-
vidual had occurred. Second, infants and small children
have a soft and thin skin free of callus at the hands and feet
which facilitates the penetration of mites at these locations
(Green 1989). Third, in the study area mothers and elder
sisters often carry small children and babies on their arms,
hips or in front of their belly and by doing so press the faces
of the children to their breasts or the naked abdomen
where scabies infestations are frequent in adults. Fourth,
frequent and prolonged contact of children’s faces may
occur when playing together or sleeping in the same bed.
We attempted to quantify the intensity of infestation by
dividing the body surface into 32 topographic areas and
by assessing the number of areas infested in each
individual. This approach showed that in the majority of
patients ‡12 areas simultaneously presented scabies
lesions. It can be assumed that in these patients a
considerable part of the body surface was affected by
scabies. It gives also credit to the notion that, at least in
children, the whole body including the neck and the
scalp has to be covered with scabicides, if topical therapy
is the preferred treatment option (Chouela et al. 2002;
Mengesha & Bennett 2002; McCarthy et al. 2004;
Heukelbach & Feldmeier 2006).
The high intensity of infestation in our study population
presumably is related to behavioural factors. In Feliz
Deserto, people mainly wear shorts, summer skirts,
sleeveless T-shirts and tops and young children frequently
carry only underpants or slips. Thus, the greater part of the
body surface is not covered with clothing. Socially
determined behaviour such as sharing bedsteads or
carrying around babies and toddlers implicates extensive
and prolonged close physical contact which is considered
to be the most important way of transmission (Mellanby
1944; Estes 1982; Chouela et al. 2002; Orion et al. 2004;
Chosidow 2006).
The proportion of patients with superinfected lesions
was 37% with 10% of all affected topographic areas
showing signs of superinfection. Again there was a clear
dichotomy between age groups: young children had
significantly more often their lesions superinfected than
elder age groups, and the highest proportions of super-
infection were found at sites predominantly infested in
children £7 years. Children can probably not refrain
from scratching when pruritus is present, whereas adults
may do so, e.g. when scratching in public offends
societal concepts. Similar high frequencies of superinfec-
tion have been observed in previous studies in resource-
poor settings (Sharma et al. 1984; Kristensen 1991;
Heukelbach et al. 2005).
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A. Jackson et al. Scabies in Brazil
All but seven patients complained of itching, and 40%
graded itching as severe. Without doubt, scratching is caused
by the itchiness of scabies lesions. Scratching results in
denudation of deeper layers of the epidermis and facilitates
the infection with pathogenic micro-organisms from adja-
cent parts of the skin or the soil. A similar frequency of
superinfection is known from other parasitic skin diseases
such as tungiasis or cutaneous larva migrans (Lima et al.
1984; Feldmeier et al. 2002; Heukelbach et al. 2003).
More than half of the patients had enlarged cervical,
axillar or inguinal lymph nodes. Enlarged lymph nodes
may have many reasons, particularly in the tropics, and
difficultly can be associated with a single cause. However,
in our patients there is evidence that lymphadenopathy was
related to the presence of scabies lesions. The number of
topographic areas affected, the proportion of lesions
superinfected and the presence of a superinfection distal to
enlarged lymph nodes were all significantly associated with
the presence of lymphadenopathy.
Unexpectedly, 72% of the patients complained about
sleep disturbances. Although the cause of sleep disorders is
difficult to disentangle, in this setting altered sleep may be a
consequence of severe pruritus caused by the lesions. Half
of the patients showed signs of scratching on apparently
healthy, uninfested skin, indicating that the pruritic skin
surface was considerably greater than the surface affected
by specific lesions. This should intensify the severity of
pruritus. The assumption that scabies was responsible for
sleep disturbances is further supported by the observation
that sleep maintenance was more often disturbed than
sleep initiation. Presumably, intense itching awaked
patients during the night when mite activity is higher
(Orkin & Maibach 1978; Estes 1982; Green 1989;
Chouela et al. 2002). However, as in our study several
patients were simultaneously infected with other ectopar-
asites that may cause pruritus, and because there was no
appropriate control group living under similar conditions,
we cannot infer on the true proportion of sleep distur-
bances induced by scabies.
As the diagnosis of scabies was made clinically, false-
positive and false-negative diagnoses may have occurred.
We used a case definition that should have minimized false-
positive diagnoses. The use of a case definition seems to be
warranted, as other studies in similar settings are also
based on case definitions (Gulati et al. 1977a; Stanton
et al. 1987; Heukelbach et al. 2005). False-negative results
might have occured, but skin scraping is no alternative
because its sensitivity is low in such settings (Parish &
Witkowski 1999; Sarwat et al. 2004; Flinders & De 2004;
Chosidow 2006). Moreover, it is not practicable in
resource-poor settings. Finally, the clinical diagnosis of
scabies is a well-established and approved method in the
500
volume 12 no 4 pp 493–502 april 2007
developing world (Gulati et al. 1977a,b; Hassan et al.
1979; Gerbase et al. 1984; Sharma et al. 1984; Landwehr
et al. 1998; Heukelbach et al. 2005).
In conclusion, we convincingly demonstrated that the
clinical presentation of scabies, the quantity of body
surface affected, the topographic distribution of lesions and
the degree of superinfection depend on the age of the
patient and that there is a clear dichotomy between young
children and elder age groups.
Conflicts of interest
Anne Jackson, Jörg Heukelbach, Arthur Ferreira da Silva
Filho, Evônio de Barros Campelo Júnior and Hermann
Feldmeier have no conflicts of interest to declare.
Acknowledgement
This study was supported in part by a grant from the
Deutsche Akademie für Flug- und Reisemedizin. We thank
Solvay Farma, São Paulo, Brazil for providing Roxythr-
omicin (Floxid) free of charge. We are obliged to the
community healthcare workers of Feliz Deserto and to
Cláudia Maria Lins Calheiros and Valquı́ria de Lima
Soares for their assistance. Anne Jackson received a travel
grant from the DAAD-CAPES PROBRAL exchange pro-
gramme. The data are part of a medical thesis by Anne
Jackson.
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Corresponding Author Prof. Hermann Feldmeier, Institute of Microbiology and Hygiene, Charité–University Medicine, Campus
Benjamin Franklin, Hindenburgdamm 27, 12203 Berlin, Germany. Tel.: +49 4181 281628; Fax: +49 4181 36943;
E-mail: hermann.feldmeier@charite.de

Présentations cliniques et morbidité associée à la gale dans une communauté rurale à Alagoas au Brésil

objectif Décrire les caractéristiques cliniques de la gale et la morbidité associée dans une communauté rurale appauvrie dans le nord-est du Brésil.
méthode Une surveillance de porte-à-porte a été utilisée pour examiner deux fois de suite la population d’une zone endémique; d’abord à la fin de la
saison des pluies et durant la saison sèche 4 mois plus tard.
résultats Au total, 2005 individus ont été examinés. La prévalence totale de la gale était de 9,8% (IC95%: 8,5–11,2). Les zones corporelles de
prédilection, avec des fréquences relatives semblables, dans tous les groupes d’âge étaient l’abdomen (83,7%) et la région inguinale (partie intérieure des
cuisses) (66,3%). Les mains, les pieds, les parties génitales et le cuir chevelu/cou/visage étaient significativement plus souvent affectés chez les enfants < 7
ans (p < 0,03 pour toutes ces zones). 55% des patients présentaient des lésions de gale simultanément dans ‡ 12 zones topographiques distinctes. Des
lésions papuleuses étaient plus communément observées, suivi par des lésions papuleuses en croûte. Des vésicules étaient significativement plus souvent
d’observées chez les enfants (p ¼ 0,04). 64% des patients avaient trois types de lésions ou plus. Des lymphadénopathies locales étaient présentes chez
53,6% et des lésions surinfectées chez 36,7% des cas. Le nombre de zones topographiques affectées ainsi que la proportion de lésions surinfectées étaient
inversement associés avec l’âge (rho ¼ )0,2; p ¼ 0,002 et rho ¼ )0,358; p < 0,05 respectivement). L’étendue de surface de peau infestée, la proportion
de lésions surinfectées et la présence d’une lésion surinfectée distale à un ganglion élargie étaient des facteurs prédictifs de lymphadénopathie. 72% des
patients souffraient de troubles de sommeil, principalement dus aux démangeaisons.
conclusion La gale est associée à une morbidité considérable dans cette communauté endémique. Les zones corporelles de prédilection, la présen-
tation clinique, l’étendue de surface de peau affectée et la proportion de lésions secondaires infectées montrent une dichotomie entre les enfants et les
adultes.

mots clés la gale, présentions cliniques, morbidité, étude basée sur la communauté, Brésil

Caracterı́sticas clı́nicas y asociadas con la morbilidad de la sarna, en una comunidad rural en Alagoas, Brasil.

objetivo Describir las caracterı́sticas clı́nicas de la sarna y la morbilidad asociada, en una comunidad rural empobrecida al noreste del Brasil.
método Se realizó un estudio puerta a puerta con el fin de examinar dos veces a la población de un área endémica; la primera vez al final de la estación
de lluvias, y la segunda durante la estación seca, cuatro meses después.
resultados Se examinaron 2005 individuos en total. La prevalencia total de sarna fue de 9.8% (95% IC 8.5–11.2). Los lugares de predilección, con
frecuencias relativas similares en todos los grupos de edad, fueron el abdomen (83.7%) y el área inguinal/parte interna de los muslos (66.3%). Las
manos, pies, genitales y el cuero cabelludo/cuello/cara estaban significativamente más afectados en niños <7 años (todos p < 0.03). Un 55% de los
pacientes tenı́an lesiones de sarna simultáneas en ‡12 áreas topográficas distintivas. Las lesiones papulares eran las más comúnmente encontradas,
seguidas por las lesiones papulares crostosas. Las vesı́culas eran significativamente más observadas en niños (p ¼ 0.04). Un 64% de los pacientes tenı́an
tres o más tipos de lesiones. La linfoadenopatı́a local estaba presente en un 53.6% y la sobreinfección en un 36.7% de los casos. El número de áreas
topográficas afectadas, ası́ como la proporción de lesiones sobreinfectadas, estaban inversamente correlacionadas con la edad (rho ¼ )0.22, p ¼
0.002 y rho ¼ )0.358, p < 0.05, respectivamente). El área de superficie de piel infestada, la proporción de lesiones sobreinfectadas y la presencia de una
lesión sobre infectada, distal a un nodo linfático engrandecido, eran predictores de una linfoadenopatı́a. Un 72% de los pacientes sufrı́an de desórdenes
de sueño, principalmente debido a los picores.
conclusión La sarna está asociada con una morbilidad considerable en esta comunidad endémica. Los lugares predilectos, la presentación clı́nica y la
cantidad de superficie de piel afectada ası́ como la proporción de lesiones secundarias infectadas muestran una dicotomı́a entre niños y adultos.

palabras clave sarna, caracterı́sticas clı́nicas, morbilidad, estudio basado en la comunidad, Brasil

502 ª 2007 Blackwell Publishing Ltd