Introduction
Crusted scabies is a rare, severe form of scabies characterized by generalized thick, scaly, and erythematous plaques with or without itching and it is common in immunosuppressed, chronically debilitated individuals belonging to extremes of ages.[1] However unlike the classical forms, the crusted scabies resembles other dermatological conditions such as psoriasis, and delay in the diagnosis may lead to a scabies epidemic.[23] The WHO review collated data from 18 prevalence studies between 1971 and 2001, have reported a scabies prevalence ranging between 0.2% and 24%.[4] However, the prevalence of crusted scabies is comparatively very low and usually spare face and eyelid involvement. Only few cases of crusted scabies with eyelids and conjunctiva have been reported in the past.[56]
This case report was approved by the institutional ethics committee. The study and picture collection were compliant with the principles of the Declaration of Helsinki.
Case Report
A 10-year-old boy who presented with complaint of inability to open his left eye and right eye irritation for the past 4 days. Mother had a history of similar eruptions over forearms for the past 7 days but less severe. No other family member was affected. Ocular examination showed multiple large yellowish-white crusting lesions completely covering LE upper and lower lids causing disfigurement of the lids and adnexa [Figures 1 and 2]. RE showed a small patchy yellowish lesion (3 mm × 4 mm) in nasal bulbar conjunctiva [Figure 3]. The rest of the anterior segment was normal in both eyes. The systemic evaluation showed the presence of multiple large crusted scaly skin eruptions involving the face, neck, palm, shoulder, extensor aspect of elbows, and both lids [Figure 4]. Conjunctival scraping was obtained using a wet swab and sent for histopathological examination along with the scraped lids lesions. KOH mount under high magnification (×40) demonstrated sarcoptid mites confirming the diagnosis [Figure 5]. Routine investigations showed anemia, hypoproteinemia, low serum electrolytes levels. Based on the clinical findings and laboratory confirmation of conjunctival scrapping diagnosis of crusted scabies with conjunctival and lids involvement was made. The patient was admitted and oral ivermectin 6 mg was given as a stat dose and then repeated on day 3 and day 7, along with topical 5% permethrin and emollient for local application from dermatology. Injection ceftriaxone 750 mg was also started as prophylaxis. The patient on third-week follow-up showed complete resolution of conjunctival and skin lesions with scarring over the affected areas of the skin [Figure 6].
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Figure 1: Ocular involvement of crusted scabies
Figure 2: Excoriated area over eyelids following scrapping off the crusted material
Figure 3: Black arrow showing the conjunctival area of involvement from which biopsy was taken
Figure 4: Showing involvement of extremities, trunk and scalp
Figure 5: KOH mount of conjunctival scrapping showing sarcoptes scabiei under high (×40) magnification
Figure 6: At third-week follow-up showed complete resolution of conjunctival and skin lesions with residual skin scar
Discussion
Crusted scabies is a rare variant of scabies presenting as hyperinfestation of Sarcoptes scabiei and commonly acts as a source for the epidemic outbreak of classic scabies in overcrowded population. Unlike classical scabies, Norwegain Scabies usually presents as acute onset of hyperkeratotic lesions, especially involving the palm, sole, head, and scalp area, which are usually spared in classical form of scabies. In spite of the involvement of the head and scalp area in crusted Scabies, the face is spared in these cases.[7] Involvement of the eye and adnexal structures in crusted scabies is very rare. As per auhor knowledge, only two cases of crusted scabies with conjunctival involvement were reported in the past.[56] Furthermore, very few cases of Norwegian scabies involving children have been reported in the past [Table 1].[4891011]
Table 1: Illustrating cases of crusted scabies in children with immune status and various body parts affected
Our case had a severe form of crusted scabies with involvement both lids and right bulbar conjunctiva and responded drastically with scabicidal drugs and topical medications for systemic and ocular manifestation, respectively.
Conclusion
Crusted scabies although is a very rare form of scabies but because of its resemblance to other skin lesions and its role as a source of scabies outbreak, prompt diagnosis, and intervention is required. Based on the earlier published reports and the findings of the present case, it is important for ophthalmologists to have a knowledge about the condition and should also look for any intraocular involvements in severe cases.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form of the patient being a minor, his father has given the consent for his images and other clinical information to be reported in the journal. The patients and his parents understands that their names and initials will not be published and due efforts will be made to conceal their identity but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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