CASE SERIES
Crusted scabies at a tertiary care center: Case
series and cautionary tale
Michael Lause, MD, MBA,a Karissa Libson, BA,b Abraham M. Korman, MD,a Nora Colburn, MD,c
Shandra Day, MD,c Marek Greer, MD, MPH,d Michele Hardgrow, BSN, RN,d Kimberly Malcolm, RN,e
Marcy Mcginnis, RN,e Elizabeth Seely, MHA,e Justin Smyer, MBA, MPH,e and John Trinidad, MD, MPHf
Key words: crusted scabies; epidemiology; infectious diseases; medical dermatology; occupational health;
prevention; public health; scabies.
INTRODUCTION
Scabies is a cutaneous infection characterized by
rash and pruritus that is caused by the burrowing of
Sarcoptes scabiei mites in the epidermis. Crusted
scabies is the most severe form of this infestation
and typically occurs in patients with risk factors
including immunosuppression, cognitive impair-
ment, advanced age, and immobility. Crusted scabies
is highly contagious and has the potential to cause
significant outbreaks in patients in close living
quarters; in the hospital setting, it has the potential
to cause significant morbidity to other patients and
hospital staff.1 In addition, management of nosoco-
mial scabies outbreaks may require substantial
administrative and financial resources. Herein, we
describe the presentation, diagnosis, and treatment
of 3 patients with crusted scabies in a tertiary care
hospital; further, we highlight the broad sweeping
clinical and economic impacts these infections had
on the medical center.
CASE SERIES
Case 1
An elderly woman with a history of advanced
Alzheimer disease was transferred from an extended
care facility to our institution with a longstanding rash
previously treated with topical corticosteroids and
From the Department of Dermatology, The Ohio State University
Wexner Medical Center, Columbus, Ohioa; Ohio State University
College of Medicine, Columbus, Ohiob; Department of Infec-
tious Disease, Internal Medicine, The Ohio State University
Wexner Medical Center, Columbus, Ohioc; Occupational Health
and Wellness, The Ohio State University Wexner Medical
Center, Columbus, Ohiod; Department of Clinical Epidemiology,
The Ohio State University Wexner Medical Center, Columbus,
Ohioe; and Department of Dermatology, Massachusetts General
Hospital, Harvard Medical School, Boston, Massachusetts.f
Dr Lause and Author Libson contributed equally to this article.
Funding sources: None.
Patient consent: Patients gave consent for their photographs and
medical information to be published in print and online with
oral antihistamines. Dermatology was consulted, and
examination revealed hyperkeratotic and excoriated
papules and plaques on the face, trunk, and extrem-
ities with extensive hyperkeratosis of the palms and
interdigital web spaces (Fig 1). Crusted scabies was
suspected and contact precautions were immediately
implemented. Dermatoscopy revealed ‘‘delta wing’’
and ‘‘contrail’’ signs, and mineral oil skin scrapings
showed numerous live scabies mites on light micro-
scopy (Figs 2 and 3). Epidemiology was notified for
contact tracing purposes. Per Ohio Department of
Public Health guidelines, the patient completed a
course of combined topical permethrin (5% cream
with full-body application repeated daily for 7 days,
then twice weekly for an additional 3 weeks) and oral
ivermectin (200 g/kg/dose on days 1, 2, 8, 9, and
15).2 Following resolution with treatment at our
institution, the patient was discharged to an extended
care facility.
Case 2
An elderly man with history of heart failure,
chronic kidney disease, and vascular dementia was
brought to the emergency department for sepsis and
acute encephalopathy. On examination, the primary
team noted a diffuse rash that had been diagnosed as
a morbilliform eruption secondary to hydralazine
the understanding that this information may be publicly
available.
IRB approval status: Reviewed and approved by The Ohio State
University IRB (2021H0307).
Correspondence to: John Trinidad, MD, MPH, Department of
Dermatology, Massachusetts General Hospital, Harvard
Medical School, 50 Staniford St. Boston, MA 02114. E-mail:
jtrinidad@partners.org.
JAAD Case Reports 2023;41:17-21.
2352-5126
Ó 2023 by the American Academy of Dermatology, Inc. Published
by Elsevier Inc. This is an open access article under the CC BY
license (http://creativecommons.org/licenses/by/4.0/).
https://doi.org/10.1016/j.jdcr.2023.08.030
17
18 Lause et al
Fig 1. Case 1: Extensive hyperkeratosis of the palm and
interdigital web spaces.
4 months prior. At the time of that diagnosis, hydral-
azine was stopped and the patient started a 2-week
course of topical steroids; however, the rash per-
sisted for months until hospitalization at our
institution.
Upon inpatient dermatology evaluation, the pa-
tient was noted to have diffuse erythematous, exco-
riated, and hyperkeratotic papules and erosions,
which were accentuated at the umbilicus, waist,
interdigital spaces, and eyebrows (Figs 4 and 5).
Extensive cutaneous burrows were noted on gross
examination of acral surfaces, and dermatoscopy
revealed positive ‘‘delta wing’’ and ‘‘contrail’’ signs,
confirming a diagnosis of crusted scabies. Bedside
staff and epidemiology were notified, contact pre-
cautions were instituted, and the patient completed
topical permethrin and oral ivermectin per Ohio
Department of Public Health guidelines. The
patient’s hospital course was complicated by septic
shock with methicillin-resistant Staphylococcus
epidermidis, attributed in part to crusted scabies
infection. Following stabilization of the patient’s
complex medical diseases and treatment of crusted
scabies, the patient was discharged with home health
services.
Case 3
A middle-aged man with history of kidney trans-
plant, on oral mycophenolate mofetil and tacrolimus
was brought to the emergency department for septic
shock and acute hypoxic respiratory failure. On
primary team examination, the patient was noted to
have coarse abdominal skin and was treated with
emollients for xerosis cutis. Later in the hospital
admission, dermatology was consulted for persistent
JAAD CASE REPORTS
NOVEMBER 2023
Fig 2. Case 1: Positive ‘‘delta wing’’ and ‘‘contrail’’ signs
confirmed a diagnosis of crusted scabies. Blue arrows:
scabies mite; red arrow: scabies burrow; black arrow:
scybala or feces.
rash, and examination demonstrated extensive xero-
sis and lichenification, with the skin having the
appearance of ‘‘wet sand’’ (Fig 6). A diagnosis of
crusted scabies was confirmed with positive ‘‘delta
wing’’ and ‘‘contrail’’ signs on dermatoscopy and
microscopic visualization of live scabies mites with
mineral oil skin scraping. Scabies mites were also
seen on histology from biopsy of a suspicious nodule,
which was performed to rule out infection (Fig 7).
Contact precautions were instituted, and the patient
completed treatment with topical permethrin and oral
ivermectin per Ohio Department of Public Health
guidelines. His hospital course was complicated by
polymicrobial sepsis without a clear source and
multisystem organ failure. Following resolution of
these conditions, the patient was discharged to
inpatient rehabilitation services.
DISCUSSION
Crusted scabies is a rare and severe presentation of
scabies characterized by the presence of millions of Sa
scabiei mites. The increased mite burden in crusted
scabies compared with noncrusted scabies predis-
poses to increased disease transmission through not
only skin contact but also environmental infestation.1
In health care settings, scabies outbreaks typically
stem from patients with undiagnosed crusted scabies
who exemplify well-known risk factors, such as
cognitive impairment, immunosuppression, advanced
age, and immobility (Table I). Prompt suspicion and
diagnosis of crusted scabies are critical to preventing
outbreaks in nosocomial settings. In 2 of the described
cases, patients demonstrated multiple risk factors and
had a history of persistent rash for months before
admission. Misdiagnosis is common in crusted scabies,
as it is often mistaken for psoriasis, drug reactions, and
acral eczema.3-5 Additionally, patients are often
JAAD CASE REPORTS
VOLUME 41
Fig 3. Case 1: Sarcoptes scabiei mite visualized with
mineral oil preparation under light microscopy.
Fig 4. Case 2: Excoriated and erythematous papules and
erosions on the dorsal foot with hyperkeratosis of the
interdigital web spaces.
misdiagnosed and prescribed topical corticosteroids,
which can lead to and worsen crusted scabies
infections.5
Morphologic findings in crusted scabies can be
diverse but often include some combination of
crusted or psoriasiform plaques, hyperkeratosis,
excoriations, and/or burrows.6 The distribution of
mites is often multifocal and has a tendency toward
body surfaces containing a thin epidermis; the most
common locations are periumbilical skin, areolae,
axillary folds, waist, genitals in men, and interdigital
web spaces.7,8
Lause et al 19
Fig 5. Case 2: Mildly erythematous and hyperkeratotic
papules accentuated at the eyebrows.
The diagnosis of crusted scabies can be confirmed
by direct visualization of scabies mites, eggs, or feces
using any one of the following modalities: light
microscopy with mineral oil preparation, histology,
or dermatoscopy. On histology, scabies mites are
typically seen within the epidermis, as the mites are
unable to penetrate the dermoepidermal junction.6
On dermatoscopy, imagery of an airplane and its
contrails is used to depict the appearance of scabies
mites and burrows, respectively. More precisely, the
‘‘delta wing’’ sign describes the triangular head of the
scabies mite, which is likened to an airplane; the
‘‘contrail sign’’ represents the trailing burrow, which is
compared with an airplane’s trailing vapor streams
often observed in the sky (Fig 2). As the infection
clears, so too does the presence of the delta wing sign
as the mites decompose.9,10
Unrecognized and untreated crusted scabies
frequently leads to outbreaks in family homes,
hospitals, and places of communal living such as
extended care facilities.3,4 Scabies outbreaks in health
care facilities can lead to significant morbidity for
other patients and staff, in addition to administrative
burden.11 In all 3 cases, the patients arrived at the
hospital without a diagnosis of scabies and did not
have contact precautions, leading to numerous ex-
posures for frontline health care workers. Once
scabies was suspected, patients were placed on
contact precautions and hospital epidemiology was
notified. Once notified, an exposure investigation
was initiated in collaboration with Occupational
Health and pharmacy. An exposure was defined as
providing direct patient care without wearing a gown
and gloves. Contact tracing utilized medical and
staffing records for each case and identified 373 total
employee exposures. At the hospital outpatient
pharmacy, exposure was confirmed via a standard
questionnaire assessing the temporal relationship and
20 Lause et al
Fig 6. Case 3: Diffuse and extensive hyperkeratosis and
lichenification of the groin, inner thighs, and lower
abdomen.
Fig 7. Case 3: Sarcoptes scabiei mites observed within the
epidermis. (hematoxylin and eosin stain; original magni-
fication : 3100.)
degree of exposure. Prophylactic oral ivermectin or
topical permethrin were provided to all individuals
with confirmed exposure in accordance with Ohio
Department of Public Health guidelines. The hospi-
tal’s outpatient pharmacy then provided a list of all
exposed and treated individuals to Occupational
Health for follow-up. An associated direct cost for
the medications was estimated to be over $10,000.
Additionally, there were numerous indirect costs,
including the implementation of a large-scale contact
tracing protocol, frequent room sanitization and linen
changes, and pharmacist and administrative time, all
of which contributed to the organizational costs and
challenges to the medical center. Following imple-
mentation of epidemiology protocols, including con-
tact tracing and prophylactic treatment for exposed
health care workers, no additional patients or staff
became infected in any of the cases.
Patients with crusted scabies are at risk for life-
threatening and long-term sequelae of scabies,
namely secondary bacterial infections.6 Two of the
patients in this series experienced infections that
JAAD CASE REPORTS
NOVEMBER 2023
Table I. Risk factors of crusted scabies seen in each
case
Cognitive Elderly
Case impairment Immunosuppression (age [65 y) Immobile
case 1 x x x
case 2 x x x
case 3 x
likely had contributions from the underlying crusted
scabies infestation: patient 2 with methicillin-
resistant St epidermidis septic shock and patient 3
with polymicrobial sepsis and multisystem organ
failure.
CONCLUSION
In this case series, we describe the risk factors,
presentation, diagnostic features, and clinical course
of 3 patients diagnosed with crusted scabies at a
tertiary care medical center. We demonstrate the
magnitude of morbidity and administrative burden
that undiagnosed crusted scabies infections had on
our hospital; in particular, these cases led to 373 total
employee exposures, with the cost of prophylactic
ivermectin and permethrin exceeding $10,000.
Ultimately, scabies should be kept on the differential
diagnosis list for pruritic rashes in patients who
exemplify well-known risk factors, and contact pre-
cautions should be instituted while diagnostic
workup is pursued.11
Conflicts of interest
Dr Trinidad is on the editorial board of JAAD. Drs Lause,
Korman, Colburn, Day, and Greer and authors Libson,
Hardgrow, Malcolm, Mcginnis, Seely, and Smyer have no
conflicts of interest to declare.
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