Five-year-old John is brought in to see you by his father, Mar, with complaints of intense itching in between his fingers and toes which is worse at night. John’s family moved to Australia two months ago as refugees from Sudan; they are living in a public housing unit. John attends the local school and goes to after school care as his parents work long hours.
Communication and consultation skills
How would you communicate with the father if he has difficulty communicating in English?
How would you sensitively find out if anyone else in the family has similar symptoms?
How could you communicate the diagnosis to John’s school and after school care?
1. Communicating with the Father:
- Use simple and clear language.
- Utilize visual aids or pictures to explain symptoms and treatment.
- Employ a professional interpreter if available, especially for complex discussions.
- Show empathy and patience, allowing extra time for the conversation.
2. Finding Out About Family Symptoms:
- Ask gently if anyone else at home has similar itching.
- Frame the question around concern for the health of the entire family.
- Offer reassurance that you are asking to help prevent the spread and ensure everyone’s well-being.
3. Communicating with School and After School Care:
- Obtain consent from the father to share the diagnosis.
- Explain the importance of informing the school to prevent further spread.
- Provide a written note explaining the diagnosis, treatment, and any necessary precautions for the school and after school care.
Clinical information gathering and interpretation
What other information would you like to know about John’s skin?
What would your approach be if John had obvious patches of flexural eczema?
1. Additional Information About John’s Skin:
- Duration of symptoms.
- Any other affected areas besides fingers and toes.
- Presence of any rash, lesions, or secondary infections.
- Family history of skin conditions.
2. Approach to Flexural Eczema:
- Assess for signs of eczema, such as dry, red, inflamed skin.
- Ask about any history of allergies, asthma, or other atopic conditions.
- Consider the possibility of concurrent eczema and scabies.
Making a diagnosis, decision making and reasoning
From the clinical history, how would you make a diagnosis of scabies?
What differential diagnoses would you consider for John?
What if John was 50 years old and not an immigrant?
What if the patient was a female and pregnant?
Clinical Presentation:
Pruritus:
- Intense, generalized pruritus, worse at night.
- Due to delayed type-IV hypersensitivity reaction to mite and mite products.
- Symptoms appear 3-6 weeks after initial infestation or within 24 hours after reinfestation.
Lesions:
- Erythematous papules, often excoriated.
- Distribution: interdigital web spaces, sides of fingers, under fingernails, flexor aspects of wrists, extensor aspects of elbows, anterior and posterior axillary folds, nipples in women, penis and scrotum in men, umbilicus, upper medial thighs, buttocks, sides and back of feet.
- Back is usually not involved, and head is spared except in children.
- Palms and soles affected in the elderly and in infants/young children.
- Atypical presentations in immunocompromised patients (e.g., crusted scabies, secondary infections).
Diagnosis:
- Based on typical appearance and distribution of lesions/rash, and presence of burrows.
- Classic burrow: linear intra-epidermal tunnel (short wavy greyish/white threadlike elevations, 2-10 mm).
- Confirm diagnosis by identifying mite, eggs, or faecal matter through:
- Removing mite with needle tip from burrow.
- Skin scraping and microscopic examination with KOH.
- Dermatoscope identification.
Differential Diagnoses:
- Contact dermatitis
- Atopic dermatitis (eczema)
- Insect bites
- Fungal infections (tinea)
- Psoriasis
If John Was 50 Years Old:
- Consider occupational exposures, sexual contacts, and immune status.
- Differential diagnoses might include conditions more common in adults like dermatitis herpetiformis or other pruritic dermatoses.
If the Patient Was Female and Pregnant:
- Common Causes:
- Cholestasis of Pregnancy (Intrahepatic Cholestasis of Pregnancy – ICP):
- Description: Liver condition causing bile acid accumulation in the blood.
- Symptoms: Intense itching, especially on palms and soles, without rash. May be worse at night.
- Risks: Preterm birth, fetal distress, stillbirth.
- Diagnosis: Elevated serum bile acids, liver function tests (LFTs).
- Treatment: Ursodeoxycholic acid, early delivery consideration.
- Atopic Eruption of Pregnancy:
- Description: Eczema-like condition, common in women with a history of atopy.
- Symptoms: Erythematous, itchy papules or eczematous plaques.
- Treatment: Emollients, topical corticosteroids, antihistamines.
- Polymorphic Eruption of Pregnancy (PEP or PUPPP – Pruritic Urticarial Papules and Plaques of Pregnancy):
- Description: Common skin condition in late pregnancy.
- Symptoms: Itchy, red, raised lesions, typically starting in the stretch marks on the abdomen and spreading to thighs, buttocks, and arms.
- Treatment: Topical corticosteroids, antihistamines, oral steroids in severe cases.
- Pemphigoid Gestationis:
- Description: Rare autoimmune blistering disorder.
- Symptoms: Intense itching followed by red, raised patches that form blisters.
- Risks: Preterm delivery, small for gestational age infants.
- Diagnosis: Skin biopsy, direct immunofluorescence.
- Treatment: Systemic corticosteroids, immunosuppressive agents.
- Prurigo of Pregnancy:
- Description: Condition with itchy, excoriated papules and nodules.
- Symptoms: Lesions typically on extensor surfaces of limbs.
- Treatment: Topical corticosteroids, antihistamines.
- Pruritic Folliculitis of Pregnancy:
- Description: Rare condition with follicular pustules.
- Symptoms: Itchy pustules, mainly on the trunk.
- Treatment: Topical antibiotics, corticosteroids.
- if its in fact scabies
- Ivermectin: Generally contraindicated in pregnancy, especially in the first trimester.
- Permethrin: Safe in pregnancy and for children over 2 months old.
Clinical management and therapeutic reasoning
What would be your general management plan for John?
What medication options would you consider and why?
If John came from a remote Aboriginal or Torres Strait Islander community, what would be your management approach?
Management
General Scabies:
- Permethrin 5% cream: First-line treatment,, Apply topically from neck down, leave on for 8-14 hours, then wash off. May repeat in 1-2 weeks if symptomatic.
- Post-treatment rash/itch: Can persist for up to 2 weeks; relieved with anti-itch lotions (crotamiton 10% cream or lotion) or 1% hydrocortisone cream.
- Pustular lesions: May require antibiotics.
- Treatment failure: Due to resistance or faulty application; consider alternative regimen.
Crusted Scabies/Severe Cases:
- Ivermectin (200 mcg/kg) PO, days 1 and 14:
- Alternative for those intolerant to topical therapy.
- Useful in cases of widespread infestation or when topical treatment is impractical.
- Contraindicated in children, pregnant, or breastfeeding women.
- Gamma benzene hexachloride (Lindane®): Not recommended due to neurotoxicity and aplastic anemia risk.
Application Tips:
- Apply with sponge or brush, especially on elbows, breasts, groin, genitals, natal cleft, hands, soles (under nails), avoiding eyes, nose, mouth.
- Better absorption post-shower; leave on for at least 8 hours.
- Reapply if hands are washed during the treatment period.
- Repeat application after a week; not infectious 24 hours post-treatment.
Environmental Management:
- Decontaminate bedding, clothing, and towels used in the previous 4 days:
- Wash at 60°C and dry in a hot dryer, dry-clean, or seal in a plastic bag for 72 hours.
- Shoes/non-washable items: Seal in plastic bag for at least 3 days.
- Mites do not survive more than 72 hours away from human skin.
Contact Tracing & Partner Management:
- All household and close physical contacts should be treated simultaneously, even if asymptomatic.
- Repeat treatment in 7-10 days.
- Decontaminate bedding, clothing, and towels used by contacts in the previous 4 days.
Management for Remote Aboriginal or Torres Strait Islander Community:
- Ensure accessibility to medications and follow-up.
- Involve community health workers for education and adherence.
- Consider mass treatment if the prevalence of scabies is high.
Preventive and population health
What treatment and prevention strategies would you recommend to the family?
Considering John attends school and after school care, how would you manage this situation?
What might you need to consider if John was 90 years old and living in an aged care facility?
If John was living in the same house with his extended family and a newborn cousin, how would you approach this situation?
1. Treatment and Prevention Strategies for the Family:
- Treat all household members simultaneously.
- Wash all bedding, clothing, and towels in hot water and dry on high heat.
- Advise vacuuming furniture and carpets.
2. Managing School and After School Care:
- Inform school of the diagnosis with parental consent.
- Recommend John stays home until treatment is complete.
- Encourage the school to educate staff and parents about scabies.
3. Considerations for a 90-Year-Old in Aged Care Facility:
- Assess for frailty and comorbidities.
- Collaborate with facility staff for treatment and prevention measures.
- Consider potential for an outbreak and need for facility-wide intervention.
4. Living with Extended Family and Newborn:
- Emphasize the importance of treating all close contacts.
- Provide specific instructions for treating a newborn safely.
- Permethrin 5% Cream: Safe for use in infants over 2 months.
- Sulfur 5-10% Ointment: An alternative treatment, considered safe for newborns.
- Decontamination:
- Wash bedding, clothing, and towels used by the infant in hot water (60°C) and dry on a hot setting.
- Items that cannot be washed should be sealed in a plastic bag for at least 72 hours.
- Contact Management:
- All household members and close contacts should be treated simultaneously to prevent reinfestation.
Professionalism
If John’s father does not want to tell other family members about the diagnosis so that they can be treated, what would be your approach?
If John’s father is not willing to tell the school and after school care of the diagnosis, how would you manage this?
1. If Father Refuses to Inform Family:
- Emphasize the importance of treating all contacts to prevent reinfection.
- Offer to assist with communication if needed.
2. If Father Refuses to Inform School:
- Discuss the public health implications and importance of preventing further spread.
- Respect confidentiality but encourage transparency for the well-being of others.
General practice systems and regulatory requirement
How would you follow up to ensure John’s symptoms resolve and he is no longer infectious?
What practice policies would you review for following up with John?
Follow-Up:
- Schedule a follow-up visit to ensure treatment efficacy.
- Monitor for resolution of symptoms and potential secondary infections.
Practice Policies:
- Review protocols for managing contagious conditions.
- Ensure proper documentation and communication with public health authorities if required.
Procedural skills
If you are not sure about the reason for John’s itching, how would you do skin scraping to confirm the diagnosis?
Skin Scraping:
- Use a sterile scalpel blade to scrape the affected area gently.
- Place the scrapings on a slide and examine under a microscope for mites, eggs, or fecal pellets.
Managing uncertainty
If the symptoms were less clear-cut and you were uncertain of the diagnosis, how would you manage this situation?
- Conduct a thorough examination and consider a trial of scabicidal treatment.
- Monitor response to treatment and re-evaluate if symptoms persist.
Identifying and managing the significantly ill patient
What would your management approach be if a patient presents with crusted scabies?
What if the patient lived in an aged care facility?
Crusted (Norwegian) Scabies vs. Scabies
Differences:
| Aspect | Scabies | Crusted (Norwegian) Scabies |
|---|---|---|
| Cause | Infestation by Sarcoptes scabiei | Infestation by Sarcoptes scabiei |
| Infestation Level | Few mites (10-15 mites) | Thousands to millions of mites |
| Population | Generally healthy individuals | Immunocompromised, elderly, disabled individuals |
| Symptoms | Intense itching, rash, burrows | Severe thick crusts of skin, mild itching |
| Lesion Appearance | Erythematous papules, burrows, vesicles | Thick, crusted plaques, extensive scaling |
| Areas Affected | Interdigital web spaces, wrists, elbows, etc. | Hands, feet, scalp, ears, entire body |
| Transmission | Close skin-to-skin contact | Brief skin-to-skin contact, contaminated items high mite load potential for widespread contamination |
| Diagnosis | Clinical exam, skin scrapings, dermatoscope | Clinical exam, skin scrapings, dermatoscope |
| Treatment Aspect | Scabies | Crusted (Norwegian) Scabies |
|---|---|---|
| Primary Topical Treatment | Permethrin 5% cream: Apply neck down, leave for 8-14 hours, repeat in 1 week | Permethrin 5% cream: Apply daily for 7 days, then twice weekly until cure |
| Alternative Topical Treatments | Benzyl benzoate 25% lotion | Benzyl benzoate 25% lotion: Use with keratolytic agent if needed |
| Oral Treatment | Ivermectin (200 mcg/kg) if topical fails or impractical | Ivermectin (200 mcg/kg): Days 1, 2, 8, 9, and 15; may require additional doses |
| Keratolytic Agents | Not typically needed | Required to reduce crusts, facilitates topical treatment absorption |
| Environmental Measures | Machine wash clothes, bedding; dry clean non-washables; seal items in plastic bag for 72 hours | Intensive environmental cleaning, same as scabies but more thorough due to heavy contamination |
| Contact Precautions | Treat household and close contacts simultaneously | Strict isolation in single room, staff and visitors use gloves and gowns |
| Duration of Treatment | 1-2 weeks, depending on response | Prolonged, multiple courses often necessary |
| Follow-up | Monitor for resolution, treat secondary infections | Close follow-up, may need multiple treatments, monitor for complications |
Aged care facility
Isolation:
- Isolate suspected or confirmed cases in a single room until all treatments are successfully completed.
- Treatment may be prolonged for crusted scabies.
Treatment:
- Identify and treat all suspected or confirmed cases, including staff and relatives with brief skin-to-skin contact and contact with contaminated items (e.g., bedding, clothing, furniture).
- Offer treatment to household members of staff receiving scabies treatment.
- Treat patients, staff, and household members simultaneously to prevent transmission.
- Use a keratolytic agent to soften and shed the outer skin layer.
- Treat crusted scabies on more than one occasion, at least 1 week apart.
- Oral antiparasitic agents (e.g., ivermectin) may be necessary.
Contact Precautions:
- All staff and visitors should wear gloves and gowns when entering the room or having direct contact with patients.
- Use single-use gowns and gloves.
- Change gowns and gloves between each patient.
- Wash hands thoroughly after removing gloves.
Staff Exclusion:
- Staff can return to work 24 hours after the first treatment is completed.
- Monitor staff to ensure treatment effectiveness.
Environmental Disinfection:
- Mites do not survive more than 2-3 days away from human skin.
- Machine wash and dry bedding, clothing, and towels used by infested people during the 3 days before treatment using hot water and hot dryer cycles, or dry-clean them.
- Items that cannot be dry-cleaned or laundered can be stored in a closed plastic bag for at least 72 hours.
- Collect and transport bedding and clothing used by a person with crusted scabies in a plastic bag, empty directly into a washer.
- Laundry personnel should use gowns and gloves when handling contaminated items.
- Routine cleaning and careful vacuuming of furniture and carpets in rooms used by people with suspected or confirmed scabies.
- Regularly clean the room of patients with crusted scabies to remove contaminating skin crusts and scales containing mites.