PADJADJARAN UNIVERSITY

MEDICAL SCHOOL

TROPICAL MEDICINE BLOCK

CASE 9 : SCABIES

TUTOR GUIDE

Block title: Tropical Medicine

Case title: Scabies
Case theme: The purpose of this week is to review the sign and symptoms, aetiology,
epidemiology, pathophysiology, laboratory findings, diagnosis,
complication, management prevention and control, and medicoethico-legal aspect of scabies.
Case objective for the student:
By the end of the week the students will be able to describe the:
1. Sign and symptoms of scabies.
2. Etiology.
3. Epidemilogy.
4. Pathogenesis.
5. Laboratory findings.
6. Diagnosis.
7. Complication
8. Management.
9. Prevention and control of scabies.
10. Ethico-medico-legal aspect of scabies.

CASE TITLE: SCABIES

CASE SYNOPSIS
Budi 15 year-old boy , present to the Dermato-Venereogical out patient clinic with
pruritic lesions affecting the whole body surface. He feels very itchy especially at
night.. Skin lesions distribute generally mainly on the finger webs, wrist, axillary
folds and his scrotum. The lesions consist of many pruritic papular lesions with mild
erytematous papules and crusts. On direct microscopic examination from skin
scrapings revealed mite. His mother and his younger brother also have the same skin
disease. The patient was diagnosed as scabies based on history, physical
examination and laboratory findings. After the patient treated with permethrin 5%
cream once a week for two weeks, the patient was free from symptomps.
TUTORIAL CASE : SCABIES

Reference for the students and tutors.

1. Odom R.B, James W.D, Berger T.G. Andrews Diseases of the Skin.
Clinical Dermatology, W.B Saunders Company; Philadelphia, 2000: 563567.
2. PARASIT
Tutorial 1 Page 1
You are a medical student at the fourth year in Dermato-venereological out patient
clinic. You meet a 15 year-old patient, name Budi who complain about itching
especially at night for about one month.. His brother and mother have the same
symptomps . He stayed with another 8 persons in a small house (6x6 m). On
physical examination revealed pruritic papular lesions located on his finger webs,
wrist, axillary folds and scrotum.

Identify the problems

- Pruritic papular lesion especially at night
- Distribution of the lesion
- The member of the family have the same diseases
- Overcrowded
Problem 1: Pruritic papular lesions.
Guiding question for tutor to focus on skin lesions

What is the definition of pruritic papular lesions? (please refer to

neurobehaviour system) :
-

Pruritic means itch, especially at night because the mite more active in
low humidity and warm.

Papule : are circumscribed, solid elevations with no visible fluid,

varying in size from a pinhead to 1 cm, they maybe acuminate,
rounded conical, flat topped, or umbilicated and may appear white, red,
yellow etc.

What are the possible causing of pruritic papular lesions ?

-

Itching begins with sensitization of the host. In reinfections, itching

begin immediately and the reaction maybe clinically more intense.

Problem 2: Distribution of the lesion

Guiding question for tutor:

What kind of diseases which have the same lesions and its distributions?
-

Scabies with the distribution of

lesions are finger webs, wrist,

antecubital fosae, axillae, areolae, and areas around the umbilicus, the
lower abdomen, genitals and buttocks. And this distributions called the
circle of Hebra.
-

The lesions of pediculosis corporis and pediculosis pubis can mimics

scabies however the distribution of pediculosis corporis mainly on the
inter scapular area and for pediculosis pubis on the genitals area.

Whats your Hypothesis? - Scabies, Pediculosis corporis , pediculosis pubis

Tutorial 1 Page 2
Dermatological examination: Beside pruritic papular lesions and erythematouspapules lesions, you find many canaliculies on Budi's interdigital areas of his hands.
Skin scraping from this area you find an oval and ventrally flattened mite with 0,4
mm long and some eggs.
-

What is the diagnosis of this patient ?

Explain the pathogenesis of the disease !

What is the complication ?

What is the diagnosis of this patient?

-

The cardinal signs for scabies: 1.the presence of fierce itching at night (what
is?). 2. The distributions of the diseases are: finger webs, wrist, axillary folds
and scrotum. 3. Another member of friend or family is also affected. The
eruption is characteristic in boy; itchy papules on the scrotum and penis are
typically. 4. Microscopic examination under lower magnification demonstrate
mite, egg, larva, nympha and or scibala of the mite

Explain the pathogenesis of the disease!

-

Sarcoptes scabiei

is the causative organism, usually contracted by close

personal contact, such as nursing an infested patience, over crowding or

sleeping together, and in frequently by the common use of contaminated

towels, bed linen and clothing. The female mite is 0,3 to 0,5 mm long the
fertilized female burrows into the stratum corneum and there deposits her
eggs. A view after start of the burrows, egg laying begins. The male dies after
copulation, the female dies after laying the eggs. The eggs hatch into larvae in
3 to 4 days. The larvae are transformed into nymphs and these in turn into
adults. During this time the parasites maybe on the skin and ay burrow into it
without causing pruritus or discomfort. Sensitization begins about 2 to 4
weeks after onset of infection. Severe itching begins sensitization of the host.
In reinfection itching begins immediately and the reaction maybe clinically
more intense.
Whats the canaliculi ?
The characteristic lesions barely discernible to the naked eye. These are slightly
elevated, grayish, straight or tortuous lines in the skin. A vesicle or pustule maybe
produced at the end of the burrow, especially in infants and children. The burrow or
canaliculi which are produces female mites, occur mainly on the palms, the palmar
and lateral aspects of the finger. The mite is situated at the vesicle near the blind end
of the burrow. In addition, a papular pruritic eruption is present, ussualy without
recognizable burrow. In histologic examination of the specimen containing a burrow
refills that the burrow in almost its entire length is located within the horney layer.
Only the extreme, blind and of the burrow, when the female mite is situated, extends
in to the stratum malphigi.
What are the complications ?
-

The complications are: secondary infection and eczematization.

Tutorial 2 Page 1
Budi is treated by cream permethrin 5% for 10 hours once in a week, repeated one
Guiding
question:
week later.
The patient advised to control next 2 weeks.
Is the treatment appropriate?
-

Permethrin 5% is the safest as well as the most effective medication for

scabies. Permethrin is a synthetic piretroid that is lethal to mites and has
extremely low toxicity for humans.

Permethrin is thoroughly rubbed to the skin from the neck to the feet with
particular attention given to the creases perianal areas and the free nail edge
and folds. It is washed off 8 to 10 hours later.
-

The other treatment for scabies are lindane, 6% to 10% precipitated sulphur in
petrolatum.

Tutorial 2 Page 2
After 3 weeks Budi visited Dermato-Venereological clinic and feels the itching
subside. No new lesions were found. No more medication was given.

Guiding question:
1. Why is the itching still present?
2. How is to prevent this disease?
Tutor guide
1. Why is the itching still present?
- The itching is still present because of the hypersensitization reaction.
2. How to prevent this disease?
- Everybody who contact with the patient should be treated.
- Health education especially personal hygiene.

EPILOGUE
After 2 weeks Budi comes and completely cured.

Tutorial 1 Page 1
You are a medical student at the fourth year in Dermato-venereological out patient
clinic. You meet a 15 year-old patient, name Budi who complain about itching
especially at night for about one month.. His brother and mother have the same
symptomps . He stayed with another 8 persons in a small house (6x6 m). On
physical examination revealed pruritic papular lesions located on his finger webs,
wrist, axillary folds and scrotum.

Tutorial 1 Page 2
Dermatological examination: Beside pruritic papular lesions and erythematouspapules lesions, you find many canaliculies on Budi's interdigital areas of his hands.
Skin scraping from this area you find an oval and ventrally flattened mite with 0,4
mm long and some eggs.

Tutorial 2 Page 1
Budi is treated by cream permethrin 5% for 10 hours once in a week, repeated one
Guiding
question:
week later.
The patient advised to control next 2 weeks.

Tutorial 2 Page 2
After 3 weeks Budi visited Dermato-Venereological clinic and feels the itching
subside. No new lesions were found. No more medication was given.

EPILOGUE
After 2 weeks Budi comes and completely cured.