Mites

Mites are small, eight-legged arthropods characterized by

a saclike body and no antennae. A large number of mite
species are free-living or are normally associated with
other vertebrates (e.g., birds, rodents) and may cause
dermatitis in humans on rare occasions. The number of
mites that are considered true human parasites or present
real medical problems is quite small and include the
human itch mite (Sarcoptes scabiei), the human follicle
mite (Demodex folliculorum), and the chigger mite.
Mites affect humans in three ways: by causing dermatitis,
by serving as vectors of infectious diseases, and by
acting as a source of allergens.
Itch Mites
Physiology and Structure
The itch mite (S. scabiei) causes an infectious skin
disease variably known as scabies, mange, or the itch.
The adult mites average 300 to 400╯μm in length with
an oval, saclike body in which the first and second pairs
of legs are widely separated from the third and fourth
pairs (Figure 86-5). The body has dorsal transverse parallel
ridges, spines, and hairs. The ova measure 100 to
150╯μm.
Adult mites enter the skin, creating serpiginous
burrows in the upper layers of the epidermis. The female
mite lays her eggs in the skin burrows, and the larval and
nymph stages that develop also burrow in the skin. The
female mites live and deposit eggs and feces in epidermal
burrows for up to 2 months. Characteristically, the preferred sites of infestation are the
interdigital and popliteal
folds, the wrist and inguinal regions, and the inframammary
folds. The presence of the mites and their
secretions cause intense itching of the involved areas.
The mite is an obligate parasite and can perpetuate itself
in a single host indefinitely.

Epidemiology
Scabies is cosmopolitan in distribution, with an estimated
global prevalence of about 300 million cases. The
mite is an obligate parasite of domestic animals and
humans; however, it may survive for hours to days away
from the host, thus facilitating its spread. Transmission
is accomplished by direct contact or by contact with
contaminated objects such as clothing. Sexual transmission
has been well documented. Spread of the infection
to other areas of the body is accomplished by scratching
and manual transfer of the mite by the affected person.
Scabies may occur in epidemic fashion among people in
crowded conditions, such as day-care centers, nursing
homes, military camps, and prisons.

Clinical Syndromes
The outstanding clinical diagnostic symptom is intense
itching, usually in the interdigital folds and sides of the
fingers, buttocks, external genitalia, wrists, and elbows.
The uncomplicated lesions appear as short, slightly raised
cutaneous burrows. At the end of the burrow, there is
frequently a vesicle containing the female mite. The
intense pruritus usually leads to excoriation of the skin
secondary to scratching, which in turn produces crusts
and secondary bacterial infection. Patients experience
their first symptoms within weeks to months after exposure;
however, the incubation period may be as little as
1 to 4 days in persons sensitized by prior exposure. Host
hypersensitivity (delayed or type IV) probably plays an
important role in determining the variable clinical manifestations
of scabies.
Some immunodeficient people may develop a variant
of scabies, so-called Norwegian scabies, characterized
by generalized dermatitis with extensive scaling and
crusting and the presence of thousands of mites in the
epidermis. This disease is highly contagious and suggests

that host immunity also plays a role in suppressing S.

scabiei.
Diagnosis
The clinical diagnosis of scabies is based on the characteristic
lesions and their distribution. The definitive diagnosis
of scabies depends on the demonstration of the
mite in skin scrapings. Because the adult mite is most
frequently found in the terminal portions of a fresh
burrow, it is best to make scrapings in these areas. The
scrapings are placed on a clean microscope slide, cleared
by the addition of 1 or 2 drops of a 20% solution of
potassium hydroxide, covered with a coverslip, and
examined under a low-power microscope. With experience,
the mite and ova may be recognized. Skin biopsy
may also reveal the mites and ova in tissue sections.
Treatment, Prevention, and Control
The standard, and very effective, treatment for scabies
is 1% gamma benzene hexachloride (lindane) in a lotion
base. One or two applications (head to toe) at weekly
intervals is effective against scabies. Lindane is absorbed
through the skin, and repeated applications may be toxic.
For this reason its use is not advisable in treating infants,
small children, or pregnant or lactating women.
Recently, a 5% permethrin cream (Elimite) has
replaced lindane lotions as the treatment of choice for
scabies. Clinical trials have shown permethrin to be more
effective and less toxic than lindane. Other preparations
used to treat scabies include crotamiton sulfur (6%)
preparations, benzyl benzoate, and tetraethylthiuram
monosulfide. The last two preparations are not available
in the United States.
Primary prevention of scabies is best achieved with
good hygiene habits, personal cleanliness, and routine
washing of clothing and bed linens. Secondary prevention
includes the identification and treatment of infected
people and possibly their household and sexual contacts.
In an epidemic situation, simultaneous treatment of all
affected people and their contacts may be necessary. This
is followed by thorough cleansing of the environment
(e.g., boiling clothing and linens) and ongoing surveillance
to prevent recurrence.