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THROUGH THE LENS
Year : 2015  |  Volume : 6  |  Issue : 2  |  Page : 140-141  

Crusted scabies presenting as palmoplantar psoriasis in Down's syndrome


Department of Dermatology and Venereology, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India

Date of Web Publication11-Mar-2015

Correspondence Address:
Kaliaperumal Karthikeyan
Department of Dermatology and Venereology, Sri Manakula Vinayagar Medical College and Hospital, Kalitheerthalkuppam, Puducherry - 605 107
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5178.153025

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How to cite this article:
Murugaiyan R, Sengottian K, Karthikeyan K. Crusted scabies presenting as palmoplantar psoriasis in Down's syndrome. Indian Dermatol Online J 2015;6:140-1

How to cite this URL:
Murugaiyan R, Sengottian K, Karthikeyan K. Crusted scabies presenting as palmoplantar psoriasis in Down's syndrome. Indian Dermatol Online J [serial online] 2015 [cited 2019 Jun 25];6:140-1. Available from: http://www.idoj.in/text.asp?2015/6/2/140/153025

Address for correspondence: Dr. Kaliaperumal Karthikeyan, Department of Dermatology and Venereology, Sri Manakula Vinayagar Medical College and Hospital, Kalitheerthalkuppam, Puducherry - 605 107, India.   E-mail: karthikderm@yahoo.co.in

Crusted or Norwegian Scabies is characterized by hyperkeratosis and crusting with presence of innumerable mites in the skin. [1] It is rare variant of scabies and can easily mimic other dermatologic disorders. [1],[2] Our patient was a child with Down's syndrome and crusted scabies that had lesions mimicking palmoplantar psoriasis causing diagnostic difficulty.

A 11-year-old male child, a known case of Down's syndrome residing in a hostel presented with the complaints of itchy scaly lesions predominantly over his hands and feet for the past 1΍ years. His family members also had a similar complaint but with less severity.

General examination showed poor hygiene status of the child with clinical features of Down's syndrome.

Cutaneous examination revealed hyperkeratotic crusted scaly plaques over bilateral hands and feet [Figure 1]. Finger nails showed dystrophic changes and subungual hyperkeratosis. Though his clinical presentation was that of palmoplantar psoriasis, presence of papular eruptions over the trunk raised the suspicion of scabies. The diagnosis was confirmed by scraping the lesion and demonstrating innumerable mites on potassium hydroxide mount [Figure 2]. A diagnosis of crusted scabies was made. The other routine investigations were within the normal limits. The patient was treated with oral ivermectin and topical permethrin. He is on follow-up and is lesion free. His family members were also treated for scabies.
Figure 1: Crusted lesion mimicking psoriasis in the palms

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Figure 2: Scabies mite on potassium hydroxide mounts (×10)

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   Discussion Top


Crusted scabies is rare and cases are reported sporadically since the description by Boeck and Danielssen in 1848. It occurs due to altered host immune response to the infestation by the mite. [1]

The crusted scabies usually presents as plaque composed of a parakeratotic crust that varies in thickness from about 3 to 15 mm. On removal of the crust, the under surface is smooth, red, moist and velvety in appearance. Such crusts are seen over the palms, on the extensor aspect of the elbows, on the scalp and ears and on the soles of the feet and the toes. The nails are dystrophic with abundant psoriasis like subungual hyperkeratosis and debris. The nails are the frequent source of relapse.

Crusted scabies can also mimic various diseases such as psoriasis, eczema, seborrheic dermatitis, Darier's disease, pityriasis rubra pilaris, lichen planus, cutaneous lymphoma etc. [1],[3]

Diagnosis is primarily based on clinical findings and the demonstration of the mites, eggs and mite feces (scybala). The patient should be isolated and the household contacts or hospital staff should be instructed to take adequate precautions to avoid getting infested.

Treating crusted scabies can be very challenging due to various factors such as host's compromised immunity, widespread nature of the eruption, the high mite burden and the limited penetration of the topical agents into the hyperkeratotic lesion. Thus, the treatment of crusted scabies not only includes scabicidals but also keratolytic agents to remove the thick crusts, which are a nidus for the mite. [1] These crusts can be removed by employing a keratolytic agent such as 5-10% salicylic acid in petrolatum, 40% urea or by soaking in a hot bath. [4]

In spite of widespread reporting of crusted scabies, its occurrence in children is rare. The predisposing causes of crusted scabies in children reported in literature are given in [Table 1]. Though most of crusted scabies in children has been reported in Down's syndrome, the exact reason for Down's syndrome predisposing to crusted scabies is unclear. [5] Probably the mental retardation predisposes them to develop crusted scabies in a suitable environment such as residential homes as in our case.
Table 1: Predisposing factors for crusted scabies in children[1]


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In spite of its varied presentation, its manifestation like palmoplantar psoriasis is unknown. Further it drives home the message that any crusted lesions in Down's syndrome should be investigated for scabies.

 
   References Top

1.
Karthikeyan K. Crusted scabies. Indian J Dermatol Venereol Leprol 2009;75:340-7.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.
Orkin M. Special forms of scabies. In: Orkin M, Maibach HI, Parisch LC, Schwartzman RM, editors. Scabies and Pediculosis. Philadelphia: Lippincott; 1977. p. 23-30.  Back to cited text no. 2
    
3.
Gladstone HB, Darmstadt GL. Crusted scabies in an immunocompetent child: Treatment with ivermectin. Pediatr Dermatol 2000;17:144-8.  Back to cited text no. 3
    
4.
Bitman LM, Rabinowitz AD. Hyperkeratotic plantar plaques in an HIV-positive patient. Crusted scabies, localized to the soles. Arch Dermatol 1998;134:1019, 1022-3.  Back to cited text no. 4
    
5.
Dourmishev A, Miteva L, Mitev V, Pramatarov K, Schwartz RA. Cutaneous aspects of Down syndrome. Cutis 2000;66:420-4.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1]


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