Tropical Medicine and
Infectious Disease
Article
Facilitations in the Clinical Diagnosis of Human Scabies
through the Use of Ultraviolet Light (UV-Scab Scanning):
A Case-Series Study
Gaetano Scanni 1,2
Citation: Scanni, G. Facilitations in
the Clinical Diagnosis of Human
Scabies through the Use of
Ultraviolet Light (UV-Scab Scanning):
A Case-Series Study. Trop. Med. Infect.
Dis. 2022, 7, 422. https://doi.org/
10.3390/tropicalmed7120422
Academic Editor: Roderick J. Hay
Received: 6 October 2022
Accepted: 19 November 2022
Published: 8 December 2022
Publisher’s Note: MDPI stays neutral
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Copyright: © 2022 by the author.
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This article is an open access article
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Attribution (CC BY) license (https://
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4.0/).
Trop. Med. Infect. Dis. 2022, 7, 422. https://doi.org/10.3390/tropicalmed7120422
1 Dermatology Unit, Department of Prevention ASL, 70123 Bari, Italy; g.scanni@entodermoscopy.net
2 Osservatorio Per lo Studio e la Prevenzione Delle Parassitosi ed Infezioni Nelle Collettività (OPIC),
Via Lungomare Starita n.6, 70132 Bari, Italy
Abstract: Background: To confirm the suspicion of scabies, dermatologists have one pathognomonic
sign, “the tunnel” through which Sarcoptes scabiei digs into the epidermis. Light microscopy is
considered the most reliable procedure, but it is time-consuming and operator-dependent. Recently,
dermoscopy has greatly improved the chances of recognizing mite in situ, but it is still linked to
the examiner’s experience and to the magnification capability of the device used. Methods: This
article, based on a case-series study, describes a novel diagnostic path, which uses an ultraviolet
LED source at 365 nm and a digital camera for the evaluation of lesions that raise the suspicion of
scabies. Results: The gallery emits a naked-eye-visible wavy bluish-white linear luminescence, better
than that of any standard lighting. UVA light is also able to identify Sarcoptes scabiei as a white or
green point-shaped area. This sign can only be appreciated by enlarging its picture to full frame on a
common PC monitor. Conclusions: Ultraviolet light (365 nm) seems to offer help in the diagnosis of
scabies because it saves time compared with light microscopy and because it does not require contact
with the patient’s skin, as in dermoscopy. Although examiner experience remains an important factor,
it is easily compensated by procedural simplicity, the cost of the devices and, especially, by the clarity
of the results, even in non-specific lesions.
Keywords: scabies; ultraviolet-A light; Mite-Gallery Unit; full frame view; dermoscopy; diagnosis;
neglected disease
1. Introduction
In 2020, the International Alliance for the Control of Scabies (IACS) established that
the definitive diagnosis of scabies is possible only when Sarcoptes scabiei and/or its products
(ova and scybala) are demonstrable on the patient’s skin through microscopic or dermato-
scopic procedures (A 1-2-3) [1]. In all other conditions, the reliability of the diagnosis
decreases according to the symptoms and epidemiology of the patient (B 1-2-3; C 1-2;
H 1-2) (Table 1).
This scenario demonstrates the difficulty in recognizing the infestation because it is
strongly conditioned by the demonstration of the only pathognomonic sign represented
by a superficial tiny whitish curvilinear line in target sites, such as the interdigital spaces,
wrists, elbows, armpits, mammary region and genitals [2].
Recently (2019) dermatoscopy showed that a “burrow” is not a single entity but a
structure composed of three different parts for morphology and function generally known
as the Mite-Gallery Unit (MGU) [3]. The tunnel segment in which the mite lives is called
the “head”; it generates a triangular image that resembles a hang-glider named “delta wing
sign” in wet dermoscopy (liquid film + glass plate) [4].
This section is followed by the main part of the tunnel, called the “body”, whose roof
features small, scattered holes that produce the “jet-contrail” sign. Eggs and numerous tiny
whitish spheres corresponding to the scybala (fecal pellets) can be found in this location.
https://www.mdpi.com/journal/tropicalmed
Trop. Med. Infect. Dis. 2022, 7, 422 2 of 17

Finally, this is followed by the third segment, called the “tail”, which lacks a roof and is
visible only by dry dermatoscopy (no liquid and no glass plate) as two parallel keratin
edges, which progressively diverge [5] according to the lesion’s duration and the local
host’s reaction (Figure 1).

Table 1. Diagnostic criteria established in 2020 by IACS (International Alliance for the Control
of Scabies).

A. Confirmed Scabies
At least one of:
A1. Mites, eggs, faeces on light microscopy of skin samples
A2. Mites, eggs, faeces visualized on an individual using a high-powered imaging device
A3. Mites visualized on individual using dermoscopy

B. Clinical Scabies
At least one of:
B1. Scabies burrows
B2. Typical lesion affecting male genitalia
B3. Typical lesions in a typical distribution and two history features

C. Suspected Scabies
One of:
C1. Typical lesions in a typical distribution and one history feature
C2. Atypical lesions or atypical distribution and two history features

History Features
H1. Itch
H2. Positive contact history

The knowledge of the ultra-structure of the “burrow” is useful for interpreting the
images described in this study (Figures 2–4).
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Figure 1. The Mite‐Gallery Unit in non‐polarized dry dermoscopy (d‐DS). MGU can be divided into
Figure The The
three1.parts. Mite-Gallery
Head hostsUnit in non-polarized
the mite, dry dermoscopy
the Body contains (d-DS).
parasite eggs and fecesMGU can
and the be which
Tail, divided into
hasparts.
three not roof
Thebut features
Head keratinic
hosts collarettes
the mite, the Bodythatcontains
are visible only in eggs
parasite An erythema
d‐DS.and feces andisthe
present
Tail, which
hasinnot
the background around and immediately behind the mite.
roof but features keratinic collarettes that are visible only in d-DS. An erythema is present in
the background around and immediately behind the mite.
 Trop. Med. Infect. Dis. 2022, 7, x FOR PEER REVIEW 4 of 17

Trop. Med. Infect.Infect.

Trop. Med. Dis. Dis.
2022, 7, 422
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The knowledge of the ultra‐structure of the “burrow” is useful for interpreting the
images described in this study (Figures 2, 3 and 4).
The knowledge of the ultra‐structure of the “burrow” is useful for interpreting the
images described in this study (Figures 2, 3 and 4).

Figure 2. Flash light vs. UVA. A MGU was already recognizable to naked eye (left) as an apparent
Figure
single2. Flash light
structure. vs. UVA.
However, UVAAlight
MGU waswas
ablealready recognizable
to distinguish body‐MGUto naked
(white eye (left)
wave) fromashead‐
an apparent
MGUstructure.
single (green‐dot) where Sarcoptes
However, UVA bodywas
light wasable
physically
to located (right).
distinguish body-MGU The red phlogosis
(white wave) halo
from head-
Figure 2. Flash light vs. UVA. A MGU was already recognizable to naked eye (left) as an apparent
around
MGU burrow returned a darker
where Sarcoptes light than the rest of background. A yellow highlighter was used.
single(green-dot)
structure. However, body
UVA light waswas
ablephysically located
to distinguish (right).(white
body‐MGU The red phlogosis
wave) halo around
from head‐
MGU (green‐dot)
burrow returned a where
darkerSarcoptes
light thanbody
thewas
rest physically
of background.locatedA(right).
yellowThe red phlogosis
highlighter halo
was used.
around burrow returned a darker light than the rest of background. A yellow highlighter was used.

Figure 3. Post‐therapy non‐specific lesion under buttock after two 5% Permethrin applications 7
days apart (left). Under wet dermoscopy, inside erosion, there was an unexpected MGU with the
delta sign of Sarcoptes (A) and a gallery with fecal pellets (B) that faded in a fuzzy tail (C). All around,
Figure 3. Post‐therapy non‐specific lesion under buttock after two 5% Permethrin applications 7
there was a purplish area
Post-therapy corresponding to superficial hematoma caused by patientapplications
scratching
Figure 3.
days apart (left). Undernon-specific lesioninside
wet dermoscopy, under buttock
erosion, afterwas
there twoan5% Permethrin
unexpected MGU with the 7 days
(right). A yellow highlighter was used.
delta(left).
apart sign ofUnder
Sarcoptes
wet(A)dermoscopy,
and a gallery with fecal
inside pellets (B)
erosion, that was
there fadedan
inunexpected
a fuzzy tail (C).
MGUAll around,
with the delta
there
sign of was a purplish
Sarcoptes (A) andarea corresponding
a gallery to superficial
with fecal pellets (B) hematoma
that faded caused by patient
in a fuzzy tail (C).scratching
All around, there
(right). A yellow highlighter was used.
was a purplish area (D) corresponding to superficial hematoma caused by patient scratching (right).
A yellow highlighter was used.
Trop. Med. Infect. Dis. 2022, 7, 422 5 of 17
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Figure 4. The same lesion under UVA light showed a linear white luminescence (left, red box). In
Figure 4. The
full‐frame same
vision lesionitunder
(right), UVA light
was possible showed aa linear
to distinguish white Unit
Mite‐Gallery luminescence
whose head(left,
partred
wasbox). In
full-frame
occupied vision (right),
by Sarcoptes, it was
which possible
featured to distinguish
a green a Mite-Gallery
hue (green dot). Between bodyUnit
and whose head
tail MGU, part was
there
was a luminescent
occupied cloud
by Sarcoptes, caused
which by exudate
featured and hue
a green phlogosis
(greenaround
dot). burrow
Between(rocket
bodysign).
and A yellow
tail MGU, there
highlighter was used.
was a luminescent cloud caused by exudate and phlogosis around burrow (rocket sign). A yellow
highlighter was used.
Although the diagnostic key of scabies is well defined by a specific sign, it is not
always possible to locate both because of the low number of burrows [6] and because the
Although the diagnostic key of scabies is well defined by a specific sign, it is not
patient’s scratching makes them very difficult to observe with the naked eye.
alwaysThroughout
possible tothe locate both
history of because
medicine,ofmany
the low number
attempts haveofbeen
burrows
made[6] to and
solvebecause
this the
patient’s scratching makes them very difficult to observe with the naked
problem, starting from the elementary burrow ink test up to the most recent approach, eye.
Throughout
confocal the Even
microscopy. history of medicine,
today, however, the many
gold attempts
standard ishave been made to solve
the light‐microscopy ex‐ this
problem,
amination starting from
[7], which the elementary
requires many minutes burrow ink testand
of preparation upreading
to the and,
mostinrecent approach,
particular,
confocal microscopy.
a fair amount Even
of luck in ordertoday, however,
to locate a whole themitegold
ratherstandard
than singleis the
partslight-microscopy
of it or its
eggs or feces,
examination [7],which
whichare difficult
requires to recognize
many minutesifofthey are observed
preparation separately
and reading and,from the
in particular,
parasite. For this reason, any dermatologist would desire a simple and fast test,
a fair amount of luck in order to locate a whole mite rather than single parts of it or its eggs with ob‐
orjective
feces, diagnostic
which arereliability
difficult that is not dependent
to recognize if they on
areoperator
observed experience.
separately from the parasite.
This article describes a new solution for MGU
For this reason, any dermatologist would desire a simple and identification, proposed as a with
fast test, support
objective
for traditional methods, which is able to highlight both tunnel and mite better than any
diagnostic reliability that is not dependent on operator experience.
natural or artificial light by using ultraviolet light (UVA). The discovery of this UVA prop‐
This article describes a new solution for MGU identification, proposed as a support for
erty occurred by chance during the author’s investigations, which were not specifically
traditional methods,
aimed at scabies which is
diagnosis. able to
Events of highlight both
this type are tunnel of
instances and mite better than
“serendipity”, whichanyarenatural
ornot
artificial light by using ultraviolet light (UVA). The discovery of
uncommon in the history of medicine [8]. At the time of writing, no previous publica‐ this UVA property
occurred by chance
tions regarding during
in vivo andthe author’s
in situ investigations,
diagnosis of scabies bywhich
UVA were not specifically
light have been found aimed
at using
scabies
the diagnosis. Events of thisengines.
main scientific‐web‐search type are instances of “serendipity”, which are not
uncommon in the history of medicine [8]. At the time of writing, no previous publications
2. Materials
regarding and Methods
in vivo and in situ diagnosis of scabies by UVA light have been found using the
main scientific-web-search
This study was based onengines.
a sample of patients suffering from scabies in the interval
between May 2021 and May 2022 (12 months). The age range was between 1 and 92 years
2. for
Materials
a total ofand Methods
53 patients referred to the Observatory for the Prevention and Study of Par‐
asitosis
This and
studyInfections in theonCommunities
was based a sample of(OPIC) operating
patients in the
suffering fromDepartment
scabies inofthe
Pre‐interval
vention of the Local Health Authority of Bari (ASL Bari). Some of the
between May 2021 and May 2022 (12 months). The age range was between 1 and 92 patients (about 1/3)
years for
came from elderly‐long‐term‐care facilities. The “natural” fluorescence of scabies de‐
a total of 53 patients referred to the Observatory for the Prevention and Study of Parasitosis
scribed in this article should not be confused with the artificial one induced by tetracy‐
and Infections in the Communities (OPIC) operating in the Department of Prevention of
clines topically applied to highlight burrows [9], nor with that of microscope samples
the Localwith
treated Health Authority[10].
fluorochromes of Bari (ASL Bari). Some of the patients (about 1/3) came
from elderly-long-term-care facilities.positivity
In vivo and in situ ultraviolet‐light The “natural”
concernsfluorescence
both the tunnelofand
scabies described
the body
inofthis articlescabiei.
Sarcoptes shouldThenot be confused
former is already with the artificial
appreciable one induced
to the naked eye, whilebythetetracyclines
latter
topically applied to highlight burrows [9], nor with that of microscope samples treated
with fluorochromes [10].
In vivo and in situ ultraviolet-light positivity concerns both the tunnel and the body of
Sarcoptes scabiei. The former is already appreciable to the naked eye, while the latter requires
an enlargement that is obtained by observing each photograph of suspicious lesions in
Trop. Med. Infect. Dis. 2022, 7, 422 6 of 17

full frame view (FFV). For this purpose, two 12-megapixel digital cameras (Canon Ixus
110 IS/Olympus XZ-2) were employed, along with FFV managed on a 32-inch PC monitor
by ACDsee Photo Studio Ultimate-2021 editor program. Normally, the FFV mode reveals
greater detail because the image expands to all native resolutions offered by a given sensor
size. Beyond this physical limit, clarity is impaired by digital background noise.
A torch supplied with latest LED generation at 365 nm/10W output was used as
ultraviolet-light source (Alonefire) [UVA test is in Supplementary Materials section]. The
lamp was positioned a few centimeters in front of or alongside the examined area while the
photographic UVA records took place in dim light without flash with an underexposure
between -1 and -2 EV and a variable sensitivity between 100 and 800 ISO. With this setting,
it was possible to shoot freehand with a shut speed between 1/30 and 1/80s and to obtain
satisfactory results, provided that the patient and the observer remained still for a while.
By contrast, the ordinary clinical photographs were obtained with flash-on and all camera
parameters were set in automatic mode.
When 365-nanometer UVA light is directed onto intact skin, a low-intensity uniform
bluish color returns, representing the “neutral” background to which each sign has to
be compared. The positivity of any skin lesion is described by the word “luminescence”
because it is brighter and of a different color from healthy skin. The prevalent colors
observed in scabies were bluish-white (also referred to as white for simplicity) and green
in varying shades. To facilitate the comparison between ordinary light and UVA pictures,
the skin was previously marked with a yellow highlighter that produced a very intense
luminescence if inside the UVA image.
Dermatoscopy was performed by a Delta 20 (Heine Optotechnik GmbH & Co, Bavaria,
Germany) dermatoscope in wet (glass plate + liquid film) or dry (no plate, no liquid)
modality was used.
Trop. Med. Infect. Dis. 2022, 7, 422 7 of 17

3. Results
In ordinary lighting, a scabies gallery can be recognized by the naked eye (if it remains
intact) because the mite creates a very thin stratum corneum under which air can enter.
In fact, when the air is pushed out during wet contact dermoscopy, the tunnel becomes
invisible [3]. UVA skin analysis has proven to be free from this limiting event because it
identifies the luminescence of dislodged keratin in any situation.
The results obtained in this study by UVA light can be summarized in six morphologi-
cal sets:
1. The gallery corresponding to the “body” of the Mite-Gallery Unit under UVA
produced a bluish-white luminescence easily distinguishable from the background light.
This sign was called “white wave” due to the curvilinear trace (Figures 2 and 5–12).
2. In some cases, at one end of the tunnel, a point-like area was appreciable, in which
the brightness was more compact. This sign, corresponding to the place where the Sarcoptes
Trop. Med. Infect. Dis. 2022, 7, x FOR PEER REVIEW 7 of 17
resides, was called “white dot” (Figures 5 and 13).

Figure 5. Flash light vs. UVA. Two MGUs appeared as pink fuzzy streaks (left red arrows). Under
Figure Flash
UVA5.they lightclear
became vs. UVA.
linear Two MGUs
structures appeared
(white waves),asaspink
in thefuzzy streaks (left,
pathognomonic signred arrows).
of scabies. At Under
UVAone extremity,
they becamea little
clearwhite
lineardot was recognizable
structures (A). A yellow
(white waves), as in highlighter was used. sign of scabies. At
the pathognomonic
one extremity, a little white dot was recognizable (A). A yellow highlighter was used.
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Figure 6. Flash light vs. UVA. The burrow was a clue (left red arrow) that under UVA light, a very
Figure
clear 6. Flash
linear light vs.
structure UVA.
(white Theformed,
wave) burrowsuggesting
was a clue (left, red
a typical arrow) that
Mite‐Gallery under
Unit UVA
(right). light, a very
A yellow
highlighter
clear linear
Figure was
6. Flash used.
structure (white
light vs. UVA.wave) formed,
The burrow wassuggesting a typical
a clue (left red arrow)Mite-Gallery
that under UVAUnit (right).
light, A yellow
a very
clear linearwas
highlighter structure
used.(white wave) formed, suggesting a typical Mite‐Gallery Unit (right). A yellow
highlighter was used.

Figure 7. Scabies penile papules. The at‐a‐glance bright linear UVA track (left red arrow) was con‐
firmed to be a typical Mite‐Gallery Unit surrounded by a pink vascular infiltrate under wet dermos‐
copy (right).
Figure 7. Scabies penile papules. The at‐a‐glance bright linear UVA track (left red arrow) was con‐
firmed7.to Scabies
Figure penile
be a typical papules.Unit
Mite‐Gallery The at-a-glance
surrounded by abright linear infiltrate
pink vascular UVA track (left,
under wetred arrow) was
dermos‐
copy (right).
confirmed to be a typical Mite-Gallery Unit surrounded by a pink vascular infiltrate under wet
dermoscopy (right).
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Figure 8. Flash light vs. UVA. Papular scabies. A generic brown infiltrative lesion on inner side of
Figure Flash
thigh8.(left) light vs.
produced UVA.linear
a wavy Papular scabies. A
luminescence generic
under UVAbrown
(right).infiltrative
In the upwardlesion on der‐
inset, inner side
matoscopy
of thigh (left)showed that the
produced white linear
a wavy wave was a MGU housed
luminescence in the
under papule
UVA darkerInthan
(right). thethe back‐ inset,
upward
Figure 8. Flash light vs. UVA. Papular scabies. A generic brown infiltrative lesion on inner side of
ground.
dermatoscopy showed athat thelinear
white wave wasunder
a MGU housed
thigh (left) produced wavy luminescence UVA (right).inInthe
the papule
upward darker than the
inset, der‐
background.
matoscopy showed that the white wave was a MGU housed in the papule darker than the back‐
ground.

Figure 9. Flash light vs. UVA. A little erythematous area on which a fuzzy linear lesion appeared to
the naked eye (left). UVA light highlighted the undulated line that corresponded to a MGU whose
one extremity ended with a green dot where Sarcoptes was located. A yellow highlighter was used.
Figure 9. Flash light vs. UVA. A little erythematous area on which a fuzzy linear lesion appeared to
Figure 9. Flash
the naked eyelight
(left).vs.
UVAUVA. Ahighlighted
light little erythematous arealine
the undulated on which a fuzzy linear
that corresponded to a lesion appeared to
MGU whose
the one extremity
naked ended
eye (left). withlight
UVA a green dot where the
highlighted Sarcoptes was located.
undulated A yellow
line that highlightertowas
corresponded used. whose
a MGU
one extremity ended with a green dot where Sarcoptes was located. A yellow highlighter was used.
Trop. Med. Infect. Dis. 2022, 7, 422 10 of 17
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Figure 10. Flash light vs. UVA. A MGU was distinguishable to naked eye (left). UVA light drew
Figure 10. Flash
attention to the light
greenvs.dot UVA.
whereA MGU was
Sarcoptes bodydistinguishable
was located. The to naked
gallery eye (left).
behind UVA light
had a bluish hue drew
partially
attention caused
to the
Figure 10. by
green
Flash a fabric
light dot thread
vs. UVA. glued
whereASarcopteson MGU.
MGU wasbody A yellow highlighter
was located.
distinguishable was
The gallery
to naked used.
behind
eye (left). UVA had
lightadrew
bluish hue
attention
partially to theby
caused green dot where
a fabric threadSarcoptes
glued on body was A
MGU. located.
yellow The gallery behind
highlighter was had a bluish hue
used.
partially caused by a fabric thread glued on MGU. A yellow highlighter was used.

Figure 11. Flash light vs. UVA. On thenar eminence, a very suggestive linear lesion (left) that under
UVA (right) clearly became a wavy gallery (white wave) ending with a green dot where the mite
was physically
Figure 11. Flashlocated.
light vs. UVA. On thenar eminence, a very suggestive linear lesion (left) that under
Figure
UVA11. Flash
(right) lightbecame
clearly vs. UVA. On thenar
a wavy galleryeminence, a very
(white wave) suggestive
ending linear
with a green dotlesion
where(left) that under
the mite
UVAwas physically
(right) located.
clearly became a wavy gallery (white wave) ending with a green dot where the mite was
physically located.
Trop. Med. Infect. Dis. 2022, 7, 422 11 of 17
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Figure 12. Scabies of interdigital fold of hand. Interdigital MGU under UVA exhibited a green dot
Figure ScabiesAof
12. arrow).
(left red interdigital
bright fold of hand.
blue luminescent Interdigital
fabric thread MGUDry
was nearby. under UVA exhibited
dermoscopy a green dot
of same MGU
confirmed
(left, Sarcoptes
red arrow). and its
A bright gallery
blue (right, redfabric
luminescent arrows), but was
thread site anatomy madedermoscopy
nearby. Dry it difficult toof
obtain
same MGU
all‐in‐focus
confirmed image. A
Sarcoptes yellow
and highlighter
its gallery wasred
(right, used.
arrows), but site anatomy made it difficult to obtain
all-in-focus image. A yellow highlighter was used.
2. In some cases, at one end of the tunnel, a point‐like area was appreciable, in which
the brightness was more compact. This sign, corresponding to the place where the Sar‐
3. In the palm-plantar areas, the gallery appeared as a bluish-white luminescent dis-
coptes resides, was called “white dot” (Figures 5 and 13).
continuous line due to the numerous sweat-gland openings. For the wavy and segmented
pattern, this sign was metaphorically defined as “dragon sign” due to its resemblance to
the dragons performed in Chinese festivals (Figure 13).
4. In some cases, it was possible to observe a bluish-white MGU that showed a small
greenish luminescent point at one extreme slightly apart from remaining line (Figures 2
and 9–12). This sign, defined as a “green dot”, corresponded to the position of the Sarcoptes.
Sometimes, the green dot appeared as a single element, i.e., without a tunnel behind it
(Figures 14–16). This event can partly be explained by the damage caused by the host or by
the immature forms of Sarcoptes (larvae and nymphs), which do not dig tunnels but remain
still in a small hole until they become adults (moulting niches) [11].
Trop. Med. Infect. Dis. 2022, 7, 422 12 of 17
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Figure 13. Flash light vs. UVA. Two palms under flash light did not show any problems. However,
under UVA, some Mite-Gallery Units (red arrows) were immediately visible as segmented lines
(dragon sign). At one extreme, some of them exhibited a little white dot (A) where the Sarcoptes body
was located. The lines drawn were finely segmented because the gallery roof was drilled.

Trop. Med. Infect. Dis. 2022, 7, 422
the dragons performed in Chinese festivals (Figure 13).
4. In some cases, it was possible to observe a bluish‐white MGU that showed a small
greenish luminescent point at one extreme slightly apart from remaining line (Figures 2,
9–12). This sign, defined as a “green dot”, corresponded to the position of the Sarcoptes.
Sometimes, the green dot appeared as a single element, i.e., without a tunnel behind it
(Figures 14,15 and 16). This event can partly be explained by the damage caused by the 13 of 17
host or by the immature forms of Sarcoptes (larvae and nymphs), which do not dig tunnels
but remain still in a small hole until they become adults (moulting niches) [11].

Figure 14. Flash light vs. UVA. On the left, some very suggestive signs of MGUs that in full‐frame
Figure
view on Flash
14.the rightlight vs. UVA.toOn
corresponded twothe left,dots
green some verygalleries
beside suggestive signs
(A–D), of MGUs
one isolated thatdot
green in(B)
full-frame
and on
view a white line alone
the right (C). B and to
corresponded C probably
two green belonged to thegalleries
dots beside same Mite‐Gallery
(A–D), one Unit. Sharpgreen
isolated blue dot (B)
tortuous
and a white lines arealone
line fabric (C).
threads on background.
B and C probably A red highlighter
belonged to thewas
sameused.
Mite-Gallery Unit. Sharp blue
tortuous lines are fabric threads on background. A red highlighter was used.
5. Some MGUs may occur near excoriated or exuding areas. In these cases, the tunnel
is easily recognizable under UVA because around the linear luminescence, a nebulous
luminescence is added due to the exudation of liquids. In metaphorical language, this
aspect was defined as the “rocket sign” because the light of the exudate recalls the exhaust
gas of a launch vector (Figures 3 and 4). When the inflammation manifested as erythema,
the emitted luminescence was darker than the background one.
6. In recent papular lesions, the MGU was clearly recognizable as a wavy luminescent
white line inside them (Figures 7 and 8). When the inflammation manifested as a papule, it
appeared as a blurry area darker than the background light.
Trop. Med. Infect. Dis. 2022, 7, 422 14 of 17
Trop. Med. Infect. Dis. 2022, 7, x FOR PEER REVIEW 14 of 17

Trop. Med. Infect. Dis. 2022, 7, x FOR PEER REVIEW 14 of 17

Figure 15. Surrepticius scabies. A non‐specific lesion on navel in an asymptomatic patient (left). Wet
Figure 15. Surrepticius
dermoscopy scabies.
of the same A non-specific
lesion (right) showed alesion on as
Sarcoptes navel in an asymptomatic
a brownish patient
triangle (red arrow) (left).
and a Wet
dermoscopy
burrow15.was
Figure of the same lesion
no longerscabies.
Surrepticius (right)
distinguishable showed
because
A non‐specific a Sarcoptes
it was
lesion onmodified as
navel in an a brownish
byasymptomatic triangle
host phlogosis‐exuding(red arrow)
reaction
patient (left). Wet and a
(green
burrow segment).
was no
dermoscopy of longer
the samedistinguishable because
lesion (right) showed it was modified
a Sarcoptes by host
as a brownish phlogosis-exuding
triangle (red arrow) and areaction
burrow
(green was no longer distinguishable because it was modified by host phlogosis‐exuding reaction
segment).
(green segment).

Figure 16. Surreptitious scabies. The same patient under UVA. The navel lesion shows too little
signs (left) that in full‐frame view can be identified as a green dot (A) and a fuzzy white line (B),
corresponding
Figure to Sarcoptes
16. Surreptitious body and
scabies. The gallery remnants,
same patient underrespectively
UVA. The(right).
navel lesion shows too little
Figure 16. Surreptitious
signs (left) scabies.
that in full‐frame Thebesame
view can patient
identified as aunder
green UVA.
dot (A)The
and navel
a fuzzylesion
whiteshows
line (B),too little
signs 5. Some MGUs may
(left) thattoinSarcoptes
corresponding full-frame occur
bodyview near excoriated
can be remnants,
and gallery or exuding
identifiedrespectively areas.
as a green(right). In these cases, the
dot (A) and a fuzzy white tunnelline (B),
is easily recognizable under UVA because around
corresponding to Sarcoptes body and gallery remnants, respectively (right).the linear luminescence, a nebulous
5. Some MGUs
luminescence maydue
is added occur nearexudation
to the excoriatedofor exuding
liquids. In areas. In these language,
metaphorical cases, the tunnel
this as‐
4.ispect
Discussion
easily
wasrecognizable
defined as the under UVA
“rocket because
sign” because around the of
the light linear luminescence,
the exudate recalls athe
nebulous
exhaust
luminescence
gasTheof a primary
launch is vector
added
goalsdue oftothis
(Figures the exudation
3 and
study4). When
haveof liquids. toIndemonstrate
the inflammation
been metaphorical language,
manifested
that as
UVA this as‐ is able
erythema,
light
pect
the was
emitteddefined as the
luminescence “rocket
was sign”
darker because
than the the light
background of the exudate
one.
to detect pathognomonic signs of scabies better than normal light and to define the real recalls the exhaust
gas of6.aIn launch
recentvector (Figures
papular lesions,3 and 4). When
the MGU was the inflammation
clearly recognizable manifested
as a wavyasluminescent
erythema,
nature of linear and point-like luminescences. For these reasons, the skin pictures taken by
the
white emitted luminescence
line inside was darker
them (Figure 7 and than the background
8). When the inflammation one. manifested as a papule,
flash were compared side by side to UVA pictures with a mark outlined with a common
6. In recent
it appeared as apapular lesions,
blurry area the MGU
darker than the was clearly recognizable
background light. as a wavy luminescent
yellow
white highlighter
line inside them as a (Figure
reference point.
7 and Next,the
8). When a dermoscopic
inflammationanalysismanifested of aassuspicious
a papule, lesion
concluded
it4.appeared
Discussion the demonstrative logic tree.
as a blurry area darker than the background light.
It The
wasprimary
immediately
goals of evident
this studythat the naked-eye
to demonstrate recognition
that UVA of burrows
light is able was really
to detect path‐
much more efficient
4.ognomonic
Discussion signs of under
scabiesUVA
betterthan
than under
normalany
lightnatural/artificial lightnature
and to define the real commonly used for
of linear
patientTheclinical
primaryexamination. In fact,
goals of this study when galleries
to demonstrate that do
UVA not receive
light is ableordinary light with a
to detect path‐
proper inclination,
ognomonic signs of they can
scabies go unnoticed,
better than normalespecially
light and toifdefine
they are
the short, if they
real nature are masked
of linear
by concomitant lesions, or if their roofs have been destroyed by the host. With UVA
light, tunnel identification is not affected by these interferences, demonstrating a wavy
luminescent line (white wave).
 and point‐like luminescences. For these reasons, the skin pictures taken by flash were
compared side by side to UVA pictures with a mark outlined with a common yellow high‐
lighter as a reference point. Next, a dermoscopic analysis of a suspicious lesion concluded
the demonstrative logic tree.
It was immediately evident that the naked‐eye recognition of burrows was really
Trop. Med. Infect. Dis. 2022, 7, 422 much more efficient under UVA than under any natural/artificial light commonly used 15 of 17
for patient clinical examination. In fact, when galleries do not receive ordinary light with
a proper inclination, they can go unnoticed, especially if they are short, if they are masked
by concomitant lesions, or if their roofs have been destroyed by the host. With UVA light,
Using
tunnel dermoscopy,
identification in affected
is not all cases, byitthese
was possible to demonstrate
interferences, demonstrating theacorrespondence
wavy lumi‐ be-
tween
nescenttheline
structures observed in the UVA and the dermatoscopic ones described in the liter-
(white wave).
ature,Usingthatdermoscopy,
is, the wavy in all cases, it was
linear possible to demonstrate
luminescence the correspondence
corresponded to the galleries
between2,the
(Figures 5–9structures
and 11),observed
while the in point-like
the UVA and the at
areas dermatoscopic
the ends of theonestracks
described in the
corresponded to
literature,
the that is,
mite’s body the wavy
(Figures 2, linear luminescence
4, 5, 9–14 and 16). corresponded to the galleries (Figures 2,
5‐9 and
Given11),the
while the point‐like
efficiency areas atUVA
of light-skin the ends of the tracks
scanning, corresponded
examination to the mite’s Wood’s
with high-power
body (Figures 2, 4‐5, 9‐14 and 16).
lamps could become the standard procedure for all subjects complaining of unexplained
Given the efficiency of light‐skin UVA scanning, examination with high‐power
itching. Currently, new 365-nanometer LEDs are available with high outputs (10 W or
Wood’s lamps could become the standard procedure for all subjects complaining of un‐
higher). These can be used to highlight mite tunnels sufficiently to become visible to the
explained itching. Currently, new 365‐nanometer LEDs are available with high outputs
naked eye and photographable
(10 W or higher). These can be used bytoordinary
highlight digital cameras.
mite tunnels sufficiently to become visible
Another important aspect found during the
to the naked eye and photographable by ordinary digital cameras. UVA examination concerns the accidental
luminescences (false positivity)
Another important aspect found due to exogenous
during the UVA contamination or to other
examination concerns theconcomitant
acci‐
previous dermatological pathologies (Figure 17). Some local
dental luminescences (false positivity) due to exogenous contamination or to other situations thatcon‐
require a
differential diagnosis are already known. The most common is caused by textile debris
comitant previous dermatological pathologies (Figure 17). Some local situations that re‐
quire a differential
detaching diagnosis
from clothing. are already
In general, theseknown. The most
structures havecommon is caused
a very bright andbycompact
textile linear
debris detaching from clothing. In general, these structures
or punctiform bluish luminescence. They do not belong to the epidermis but have a very bright and com‐rest on it;
pact linear or punctiform bluish luminescence. They do not belong
therefore, they are easily movable. Furthermore, cosmetic residues are very common to the epidermis but and
rest on it; therefore,
distinguishable they are
because easily
they copymovable. Furthermore, cosmetic
the dermatoglyph network residues
or show are irregular
very com‐ shapes
mon and distinguishable because they copy the dermatoglyph network or show irregular
incompatible with that of a MGU.
shapes incompatible with that of a MGU.

Figure 17. False‐positive examples. A mosaic table of possible positive signs compared to Mite‐Gal‐
Figure False-positive
17. (A
lery Units examples.
+ B). Fabric threads A mosaic
captured table of
by an erosion (1).possible positive
Single thread signs
shinier thencompared
any MGU to Mite-
Gallery Unitsabove,
(2). A thread (A + B). Fabric of
a remnant threads
burrowcaptured
down (3).by an erosion
Bright luminescent(1). exogenous
Single thread shinier
substance con‐then any
MGU (2). A thread above, a remnant of burrow down (3). Bright luminescent exogenouscol‐
taminating interdigital hand folds (4). Very superficial erosion as a faint luminescent scalloped substance
larette (5). An evident white luminescence of an epidermal keratosis (6). A very bright white
contaminating interdigital hand folds (4). Very superficial erosion as a faint luminescent scalloped
collarette (5). An evident white luminescence of an epidermal keratosis (6). A very bright white
lamellar luminescence of an actinic keratosis (7). These signs can be found separately or close to
specific scabies lesions.

On the other hand, it is more challenging to distinguish hyperkeratotic structures

(Figure 17), which can be primary or secondary to the inflammation induced by Sarcoptes.
Keratoses appear intensely bright with a bluish-white color, in which overlapping polygonal
compact laminae can be recognized. When older MGUs are no longer active, the tunnel
boundaries move away, producing areas with wavy keratin borders (ghost-MGU) [3].
In order to avoid evaluation mistakes, it is always advisable to compare the UVA
results with those in natural/flash light, while to remove the background noise produced
by the textile fibers, it is sufficient to clean the area with a common antiseptic liquid before
the examination.
Trop. Med. Infect. Dis. 2022, 7, 422 16 of 17

An interesting opportunity for the use of UVA light in scabies diagnosis is to clarify the
real nature of non-specific lesions that can occur ab initio or post-therapy. In these clinical
conditions, representing a true challenge for every dermatologist, the documentation of a
white wavy luminescence (white wave) or of a fluorescent spot isolated or tunnel-associated
(green dot/white dot) erases doubt. Depending on the extent of the patient’s anamnesis, it
is possible to diagnose “surreptitious” scabies (Figures 15 and 16) in the former case [12]
and, in the latter (Figures 3 and 4), inadequate topical applications [13] or, alternatively,
drug resistance [14].
Moreover, the usefulness of MGU study via UVA light consists in supporting tradi-
tional diagnostic procedures (scraping + light microscope or digital dermatoscopy) guiding
the dermatologist to choose an area actually inhabited by the mite, avoiding the false
negatives caused by non-parasitic skin sampling.
Finally, this method is highly advantageous for the exploration of the ano-genital
regions because it does not require any contact with the patient’s skin (Figures 3, 4 and 7),
as well as for that of the interdigital folds, where the full contact of the dermatoscope’s
glass-plate is very difficult to establish and the quality of the image can be low (Figure 12).

5. Conclusions
A discovery supported by serendipity seems to offer a new source of support for the
diagnosis of the viability of scabies infestations through in vivo and in situ identification of
burrows and mite bodies when illuminated by 365 nm of UVA light (UV-scab scanning).
This procedure is able to identify a tunnel visible to the naked eye thanks to its bluish-
white luminescence much more efficiently than any other visible-light sources. The body of
Sarcoptes scabiei also emits a dot-like luminescence (white or green), although this is visible
only when magnifying a common digital photograph at full size on any monitor.
To a greater extent than in full clinical conditions, this procedure promises the best
diagnostic results in paucisymptomatic forms characterized by ab initio ambiguous mani-
festations or in monitoring unclear lesions after treatment that create significant indecision
regarding therapeutic efficacy and patient contagiousness.
If future studies confirm the convenience of this procedure, it will represent an im-
portant diagnostic development over the inexpensive instruments already present in any
dermatologist’s office and a limited time required for the full-frame view of scabies images
on PC monitors or other displays.
Based on these premises, the classic pathognomonic sign of scabies, “the burrow”, is
more easily demonstrable in vivo and in situ thanks to fluorescence of Sarcoptes scabiei and
its gallery.
The future availability of a device able to integrate all the steps of this novel procedure
in a single action would offer a quick pre-dermoscopic/microscopic diagnosis upon the
first examination of patient.
This represents a significant breakthrough in the history of scabies.

Funding: This research received no external funding.

Supplementary Materials: The following supporting information can be downloaded at: https:
//www.mdpi.com/article/10.3390/tropicalmed7120422/s1, File S1: UVA TEST+RULER.
Institutional Review Board Statement: Not Applicable.
Informed Consent Statement: Patient consent was obtained.
Data Availability Statement: Not Applicable.
Conflicts of Interest: The author declares no conflict of interest.
Trop. Med. Infect. Dis. 2022, 7, 422 17 of 17

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