A 25-year-old man comes to the physician with intense itching of his hands and wrists that prevents him from sleeping. The itching started about 1 week after he returned from a month-long stay in Europe. He had sexual contact with 2 paid sex workers while there. His itching involves predominantly the webs of his fingers and the flexor surfaces of his wrists. He has no other medical problems and takes no medications.
Vital signs are within normal limits. Examination of the skin shows the following:

Rapid HIV and syphilis testing return negative.
What would be the most effective treatment for his current condition?

Question

A 25-year-old man comes to the physician with intense itching of his hands and wrists that prevents him from sleeping.  The itching started about 1 week after he returned from a month-long stay in Europe.  He had sexual contact with 2 paid sex workers while there.  His itching involves predominantly the webs of his fingers and the flexor surfaces of his wrists.  He has no other medical problems and takes no medications.
Vital signs are within normal limits.  Examination of the skin shows the following:

Rapid HIV and syphilis testing return negative.
What would be the most effective treatment for his current condition?

Quizplus · Accepted Answer

This patient's presentation is most consistent with scabies. Scabies is due to a burrowing mite that produces an intensely pruritic rash that is often worse at night. It is transmitted by person-to-person contact and rarely through clothing or bedding. Classic distribution is the flexor surfaces of the wrist, lateral surfaces of the fingers, and the finger webs. Except for the back and head, any other body part can be involved. However, the head can be involved in children. Examination shows excoriations with small, crusted, red papules scattered around the region. Rarely, a burrow from the mite can be visualized. Scabies can also present as crusted scabies. This is a distinct form with poorly defined erythematous patches that develop into prominent scales. Crust and fissures also tend to appear and are often malodorous. Nails surrounding the region are often thickened and dystrophic. Itching can be minimal or not present. Crusted scabies is common in patients with AIDS, leprosy, lymphoma, and Down syndrome and in the elderly. Any area can be affected. crusted scabies The diagnosis of scabies is established by clinical history, but confirmation can be made by skin scraping, tape test (tape applied to affected area, removed, and adhered to slide), or dermatoscopy showing the mites and eggs. Topical permethrin 5% cream or oral ivermectin is usually the treatment of choice for scabies. Topical 5% permethrin or topical 5% benzoyl benzoate plus oral ivermectin should be used for crusted scabies due to the high failure rate with use of topical creams alone. Antihistamines can be given as an additive measure to control the itching (Choice C). Intralesional injection of corticosteroids (eg, triamcinolone) can be applied to residual nodules after eradication of the mites (Choice A). (Choices B and D) Oral acyclovir and topical ketoconazole are not helpful for treatment of scabies. Educational objective: Scabies is due to a burrowing mite that produces an intensely pruritic rash that is often worse at night. Physical examination findings show excoriations with small, crusted, red papules scattered around the affected regions. Topical permethrin 5% cream or oral ivermectin is usually the treatment of choice. __________ References: Scabies: a review of diagnosis and management based on mite biology. (http://www.ncbi.nlm.nih.gov/pubmed/22210934)

A 25-Year-Old Man Comes to the Physician with Intense Itching