SCHOOL AGE

Ursula Comla P. Filio, R.N.

SCABIES
SCABIES

• An infestation of the skin with the mite Sarcoptes scabiei

• Causes intensely pruritic lesions with erythematous papules and
burrows in web spaces, wrists, waistline, and genitals
ETIOLOGY

• Caused by the mite Sarcoptes scabiei var. hominis, an obligate human

parasite that lives in burrowed tunnels in the stratum corneum
• Easily transmitted from person to person through physical contact
• Animal and fomite transmission probably also occurs
• Primary risk factor is crowded conditions (as in schools, shelters,
barracks, and some households)
• There is no clear association with poor hygiene.
ETIOLOGY

• For unknown reasons, crusted scabies is more common among

immunosuppressed patients (eg, those with HIV infection,
hematologic cancer, chronic corticosteroid or other
immunosuppressant use)
• Infestations occur worldwide
• Patients in warm climates develop small erythematous papules with
few burrows
• Severity is related to the patient’s immune status, not geography
SIGNS AND SYMPTOMS

• Primary symptom of scabies is intense pruritus

• Classically worse at night
SIGNS AND SYMPTOMS

CLASSIC SCABIES
• Initially appear in finger web spaces, flexor surfaces of the wrist and
elbow, axillary folds, along the belt line, or on the lower buttocks
• Papules can affect any area of the body, including the breasts and
penis
• Face remains uninvolved in adults
SIGNS AND SYMPTOMS

INFANTILE SCABIES
• The palms, soles, face, and scalp may be involved, especially in the
posterior auricular folds
SIGNS AND SYMPTOMS

OTHER FORMS
• Crusted scabies (Norwegian scabies) is dueto an
impaired host immune response, allowing mites to
proliferate and number in the millions
• Scaling erythematous patches often involve the
hands, feet, and scalp and can become widespread
SIGNS AND SYMPTOMS

• Nodular scabies is more common among infants

and young children and may be due to
hypersensitivity to retained organism
• Nodules are usually erythematous, 5 to 6 mm, and
involve the groin, genitals, axillary folds, and
buttocks
• Nodules are hypersensitivity reactions and may
persist for months after eradication of mites
SIGNS AND SYMPTOMS

• Bullous scabies occurs more commonly among

children
• When it occurs in older people, it can mimic 
bullous pemphigoid, resulting in a delay in
diagnosis
SIGNS AND SYMPTOMS

• Scalp scabies occurs in infants and

immunocompromised people and can mimic
dermatitis, particularly atopic dermatitis or 
seborrheic dermatitis
SIGNS AND SYMPTOMS

• Scabies incognito is a widespread atypical form in patients who use

topical corticosteroids
DIAGNOSIS

• Clinical evaluation
• Burrow scrapings
DIAGNOSIS

• Confirmation is by finding mites, ova, or fecal pellets on microscopic

examination of burrow scrapings; failure to find mites is common and
does not exclude scabies
• Scrapings should be obtained by placing glycerol, mineral oil, or
immersion oil over a burrow or papule (to prevent dispersion of mites and
material during scraping), which is then unroofed with the edge of a
scalpel. The material is then placed on a slide and covered with a
coverslip
• Imaging and magnification of the skin using a hand-held instrument
(dermoscopy) can be done to help identify scabies
TREATMENT

Topical permethrin, lindane, or spinosad
• Permethrin is the first-line topical drug
• Older children and adults should apply permethrin or lindane to the entire
body from the neck down and wash it off after 8 to 14 hours
• Treatments should be repeated in 7 days
• For infants and young children, it should be applied to the head and neck,
avoiding periorbital and perioral regions
TREATMENT

• Special attention should be given to intertriginous areas, fingernails,

toenails, and the umbilicus
• Mittens on infants can keep permethrin out of the mouth
• Lindane is not recommended in children < 2 years of age or in patients
with a seizure disorder because of potential neurotoxicity
TREATMENT

• Precipitated sulfur 6 to 10% in petrolatum, applied for 24 hours for 3

consecutive days, is safe and effective and usually used in infants < 2
months of age
TREATMENT

• For adults and children 4 years of age and

older, spinosad 0.9% topical suspension should be
applied to the entire cutaneous surface from the neck
down, including the soles and feet
• In bald patients, the suspension should be applied to
the scalp, forehead, hairline, and temples
TREATMENT

• The suspension should be allowed to dry for 10 minutes before getting

dressed and then left on the skin for 6 hours before showering or
bathing
• Treatment should be repeated in 1 week (1)
TREATMENT

• Precipitated sulfur 6 to 10% in petrolatum,

applied for 24 hours for 3 consecutive days, is
safe and effective and usually used in infants <
2 months of age
TREATMENT

Sometimes oral ivermectin
• Indicated for patients who do not respond to topical treatment, are unable
to adhere to topical regimens, or are immunocompromised with
Norwegian scabies
• Has been used with success in epidemics involving close contacts, such as
nursing homes
TREATMENT

• Close contacts should also be treated simultaneously, and personal items

(eg, towels, clothing, bedding) should be washed in hot water and dried in
a hot dryer or isolated (eg, in a closed plastic bag) for at least 3 days
• Pruritus can be treated with corticosteroid ointments and/or oral
antihistamines (eg, hydroxyzine 25 mg orally 4 times a day)
TREATMENT

• Secondary infection should be considered in patients with weeping,

yellow-crusted lesions and treated with the appropriate systemic or topical
antistaphylococcal or antistreptococcal antibiotic
• Symptoms and lesions take up to 3 weeks to resolve despite killing of the
mites, making failed treatment due to resistance, poor penetration,
incompletely applied therapy, reinfection, or nodular scabies difficult to
recognize.
• Skin scrapings can be done periodically to check for persistent scabies
PEDICULOSIS
LICE

• Can infect the scalp, body, pubis, and eyelashes

• Head lice are transmitted by close contact
• Body lice are transmitted in cramped, crowded conditions
• Pubic lice are transmitted by sexual contact
• Symptoms, signs, diagnosis, and treatment differ by location of
infestation
LICE

• Wingless, blood-sucking insects that infest the

head (Pediculus humanus var. capitis), body (P.
humanus var. corporis), or pubis (Phthirus
pubis)
• The 3 kinds of lice differ substantially in
morphology and clinical features
• Head lice and pubic lice live directly on the
host; body lice live in garments
HEAD LICE

• Most common among girls aged 5 to 11 but can affect almost anyone
• Easily transmitted from person to person with close contact (as occurs
within households and classrooms) and may be ejected from hair by
static electricity or wind
• Transmission by these routes (or by sharing of combs, brushes, and
hats) is likely but unproved
• There is no association between head lice and poor hygiene or low
socioeconomic status
HEAD LICE

• Lice are detected by a thorough combing-through of wet hair from the

scalp with a fine-tooth comb (teeth of comb about 0.2 mm apart)
• Lice are usually found at the back of the head or behind the ears
• Nits are more commonly seen and are ovoid, grayish white eggs fixed
to the base of hair shafts
• Each adult female louse lays 3 to 5 eggs/day, so nits typically vastly
outnumber lice and are not a measure of severity of infestation
HEAD LICE

• Drug resistance is common and should be managed with use of

oral ivermectin and by attempting to rotate pediculicides
• After applying a topical pediculicide, nits are removed by using a
fine-tooth comb on wet hair (wet combing)
• Hot air has been shown to kill > 88% of nits but has been variably
effective in killing hatched lice
• Thirty minutes of hot air, slightly cooler than a blow dryer, may be an
effective adjunctive measure to treat head lice
BODY LICE

• Primarily live on bedding and clothing, not people, and are most
frequently found in cramped, crowded conditions (eg, military
barracks) and in people of low socioeconomic status
• Transmission is by sharing of contaminated clothing and bedding.
Body lice are main vectors of epidemic typhus, trench fever, and 
relapsing fever
BODY LICE

• Cause pruritus; signs are small red puncta caused by bites, usually
associated with linear scratch marks, urticaria, or superficial bacterial
infection
• These findings are especially common on the shoulders, buttocks, and
abdomen
• Nits may be present on body hairs
BODY LICE

• Diagnosis of body lice is by demonstration of lice and nits in clothing,

especially at the seams
• Primary treatment of body lice is thorough cleaning (eg, cleaning,
followed by drying at 65° C [149° F]) or replacement of clothing and
bedding, which is often difficult because affected people often have
few resources and little control over their environment
PUBIC LICE

• (“crabs”) are sexually transmitted in adolescents and adults and may

be transmitted to children by close parental contact
• They may also be transmitted by fomites (eg, towels, bedding,
clothing)
• They most commonly infest pubic and perianal hairs but may spread
to thighs, trunk, and facial hair (beard, mustache, and eyelashes)
PUBIC LICE

• Cause pruritus
• Physical signs are few, but some patients have excoriations and
regional lymphadenopathy and/or lymphadenitis
• Pale, bluish gray skin macules (maculae ceruleae) on the trunk,
buttocks, and thighs are caused by anticoagulant activity of louse
saliva while feeding; they are unusual but characteristic of infestation
• Eyelash infestation manifests as eye itching, burning, and irritation
PUBIC LICE

• Diagnosis of pubic lice is by demonstration of nits, lice, or both by

close inspection (Wood lamp) or microscopic analysis
• A supporting sign of infestation is scattering of dark brown specks
(louse excreta) on skin or undergarments
• Treatment of eyelid and eyelash infestation is often difficult and
involves use of petrolatum, physostigmine ointment, oral ivermectin,
or physical removal of lice with forceps
• Sex partners should also be treated
IMPETIGO AND ECTHYMA
IMPETIGO AND ECTHYMA

• Impetigo is a superficial skin infection with crusting or bullae caused

by streptococci, staphylococci, or both
• Ecthyma is an ulcerative form of impetigo
• Diagnosis is clinical
• Treatment is with topical and sometimes oral antibiotics
IMPETIGO AND ECTHYMA

• Impetigo is a superficial skin infection with crusting or bullae caused

by streptococci, staphylococci, or both
• Ecthyma is an ulcerative form of impetigo
• Diagnosis is clinical
• Treatment is with topical and sometimes oral antibiotics
IMPETIGO AND ECTHYMA

• General risk factors seem to be a moist environment, poor hygiene, or

chronic nasopharyngeal carriage of staphylococci or streptococci
• Impetigo may be bullous or nonbullous
• Staphylococcus aureus is the predominant cause of nonbullous
impetigo and the cause of all bullous impetigo
• Bullae are caused by exfoliative toxin produced by staphylococci
NONBULLOUS IMPETIGO

Nonbullous impetigo
• Typically manifests as clusters of vesicles or
pustules that rupture and develop a honey-
colored crust (exudate from the lesion base)
over the lesions
• Smaller lesions may coalesce into larger
crusted plaques
BULLOUS IMPETIGO

Bullous impetigo
• Similar except that vesicles typically
enlarge rapidly to form bullae
• The bullae burst and expose larger bases,
which become covered with honey-
colored varnish or crust
ECTHYMA

• Characterized by small, purulent,

shallow, punched-out ulcers with thick,
brown-black crusts and surrounding
erythema
ECTHYMA

• Impetigo and ecthyma cause mild pain or discomfort

• Pruritus is common
• Scratching may spread infection, inoculating adjacent and
nonadjacent skin
DIAGNOSIS

Clinical evaluation
• Diagnosis of impetigo and ecthyma is by characteristic appearance
• Cultures of lesions are indicated only when the patient does not
respond to empiric therapy
• Patients with recurrent impetigo should have nasal culture
• Persistent infections should be cultured to identify MRSA
TREATMENT

• Topical mupirocin, retapamulin, fusidic acid, or ozenoxacin

• The affected area should be washed gently with soap and water
several times a day to remove any crusts.
• Treatment for localized impetigo is topical mupirocin antibiotic
ointment 3 times a day for 7 days, retapamulin ointment 2 times a day
for 5 days, or ozenoxacin 1% cream applied every 12 hours for 5 days
• Fusidic acid 2% cream 3 to 4 times a day until lesions resolve
TREATMENT

• The affected area should be washed gently with soap and water
several times a day to remove any crusts.
• Oral antibiotics (eg, dicloxacillin or cephalexin 250 to 500 mg 4 times
a day [12.5 mg/kg 4 times a day for children] for 10 days) may be
needed in immunocompromised patients, those with extensive or
resistant impetigo lesions, or for ecthyma; clindamycin 300 mg every
6 hours or erythromycin 250 mg every 6 hours may be used in
penicillin-allergic patients
TREATMENT

• Treatment of MRSA should be directed by culture and sensitivity test

results; typically, clindamycin, trimethoprim/sulfamethoxazole,
and doxycycline are effective against most strains of community-
associated MRSA
• Other therapy includes restoring a normal cutaneous barrier in
patients with underlying atopic dermatitis or extensive xerosis using
topical emollients and corticosteroids if warranted
TREATMENT

• Chronic staphylococcal nasal carriers are given topical antibiotics

(mupirocin) for 1 week each for 3 consecutive months
PROGNOSIS

• Prompt recovery usually follows timely treatment

• Delay can cause cellulitis, lymphangitis, furunculosis, and
hyperpigmentation or hypopigmentation with or without scarring
• Children aged 2 to 4 years are at risk of acute glomerulonephritis if
nephritogenic strains of group A streptococci are involved (types 49,
55, 57, and 59)