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Norwegian scabies mimicking rupioid psoriasis.
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MedLine Citation:
PMID:  23197214     Owner:  NLM     Status:  In-Data-Review    
Abstract/OtherAbstract:
Norwegian scabies is a highly contagious skin infestation caused by an ectoparasite, Scarcoptes scabiei var. Hominis, which mainly affects immunosuppressed individuals. Clinically, it may simulate various dermatoses such as psoriasis, Darier's disease, seborrheic dermatitis, among others. This is a case report of a 33-year-old woman, immunocompetent, diagnosed with generalized anxiety disorder (cancer phobia), who had erythematous, well-defined plaques, covered with rupioid crusts, on her neck, axillary folds, breast, periumbilical region, groin area, besides upper back and elbows, mimicking an extremely rare variant of psoriasis, denominated rupioid psoriasis.
Authors:
Juliana Bastos Costa; Virna Lygia Lobo Rocha de Sousa; Pedro Bezerra da Trindade Neto; Thomás de Aquino Paulo Filho; Virgínia Célia Dias Florêncio Cabral; Patrícia Moura Rossiter Pinheiro
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Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  Anais brasileiros de dermatologia     Volume:  87     ISSN:  1806-4841     ISO Abbreviation:  An Bras Dermatol     Publication Date:  2012 Dec 
Date Detail:
Created Date:  2012-11-30     Completed Date:  -     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  0067662     Medline TA:  An Bras Dermatol     Country:  Brazil    
Other Details:
Languages:  eng     Pagination:  910-3     Citation Subset:  IM    
Affiliation:
Hospital Onofre Lopes, Federal University of Rio Grande do Norte, Natal, RN, Brazil.
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Journal Information
Journal ID (nlm-ta): An Bras Dermatol
Journal ID (iso-abbrev): An Bras Dermatol
Journal ID (publisher-id): An. bras. dermatol.
ISSN: 0365-0596
ISSN: 1806-4841
Publisher: Sociedade Brasileira de Dermatologia
Article Information
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http://www.anaisdedermatologia.org.brhttp://www.scielo.br/abd©2012 by Anais Brasileiros de Dermatologia
open-access:
Received Day: 12 Month: 9 Year: 2011
Accepted Day: 17 Month: 11 Year: 2011
Print publication date: Season: Nov-Dec Year: 2012
Volume: 87 Issue: 6
First Page: 910 Last Page: 913
PubMed Id: 23197214
ID: 3699911
DOI: 10.1590/S0365-05962012000600016

Norwegian scabies mimicking rupioid psoriasis*
Juliana Bastos Costa1
Virna Lygia Lobo Rocha de Sousa1
Pedro Bezerra da Trindade Neto2
Thomás de Aquino Paulo Filho3
Virgínia Célia Dias Florêncio Cabral4
Patrícia Moura Rossiter Pinheiro1
1MD - Resident in Dermatology at the Teaching Hospital Onofre Lopes - Federal University of Rio Grande do Norte (Hospital Universitário Onofre Lopes - Universidade Federal do Rio Grande do Norte - HUOL-UFRN) - Natal (RN), Brazil
2PhD - Associate Professor of Dermatology at the Federal University of Rio Grande do Norte (Universidade Federal do Rio Grande do Norte - UFRN) - Natal (RN), Brazil
3Assistant Professor of Dermatology at the Federal University of Rio Grande do Norte (Universidade Federal do Rio Grande do Norte - UFRN) - Natal (RN), Brazil
4MD, Dermatologist at the Teaching Hospital Onofre Lopes - Federal University of Rio Grande do Norte (Hospital Universitário Onofre Lopes - Universidade Federal do Rio Grande do Norte - HUOL-UFRN) - Natal (RN), Brazil
Correspondence: Mailing address: Juliana Bastos Costa, Rua Paula Ney, 827 Apto 1002 - Aldeota, 60140-200 Fortaleza, CE, E-mail: ju_bastos@yahoo.com.br

INTRODUCTION

Crusted or Norwegian scabies is an uncommon, highly contagious, ectoparasitic infection transmitted by Sarcoptes scabiei, mainly affecting immunosuppressed patients. 1 Immunocompetent individuals rarely develop crusted scabies. 2 As a reaction to the massive infestation, the horny layer thickens, mimicking other dermatoses such as psoriasis, seborrheic dermatitis, Darier's disease, dermatitis herpetiformis and drug- induced eruptions. 3,4 Rupioid or ostraceous psoriasis is an extremely rare variety of psoriasis with few publications in the literature. This form of psoriasis is characterized by sharply demarcated, erythematous, well-defined plaques, covered with scales and crusts, sometimes in a cone-shaped appearance. 5 We describe the case of a 33-year-old woman, immunocompetent, with improper hygiene habits, diagnosed with generalized anxiety disorder (cancer phobia), who had erythematous, well-defined plaques, covered with rupioid crusts, on her neck, axillary folds, breasts, periumbilical region, groin area, upper back and elbows, mimicking rupioid psoriasis.


CASE REPORT

A 33-year-old woman presented with a 9-month history of a painful erythematous scaly eruption on her trunk and extremitites, associated with slight pruritus. Despite these symptoms, she did not seek medical help due to an extreme fear of being diagnosed with a malignant disease.

Besides the anxiety disorder, the patient had no other medical problems, such as underlying immunosuppression. She also denied systemic complaints and similar cases among family members.

Physical examination revealed sharply demarcated, erythematous, well-defined plaques covered with crusts, producing a wart-like appearance, on her neck, chest, periumbilical region, axillary folds, elbows, upper back and groin area (Figures 1 and 2).

At first, the eruption was misdiagnosed as generalized ostraceous psoriasis and the patient was initially treated with methotrexate 7.5mg/week and the application of 6% liquor carbonis detergens, 3% salicylic acid and 0.05% clobetasol cream. A couple of weeks later, unexpected histopathological findings were revealed: epidermal hyperparakeratosis and acanthosis; numerous adult mites transected in the stratum corneum; the dermis showed superficial perivascular infiltrate, predominantly by lymphocytes (Figure 3). These findings supported the diagnosis of crusted Norwegian scabies.

As a result, a microscopic examination was made. Scrapings of the lesions showed an abundance of adult mites, eggs and faecal pellets of Sarcoptes scabiei by KOH mount (Figure 4).

Laboratory tests were requested in order to exclude severe systemic diseases and immunosuppressive disorders. A white blood cell count showed 20110/mm3, with 56% neutrophils, 11% eosinophils, 30% lymphocytes. HIV, antinuclear antibodies and rheumatoid factor were negative.

The previous treatment was discontinued. Aggressive therapy was performed with three doses of 200mcg/kg oral ivermectin 1 week apart in combination with topical permethrin 5% lotion applied once daily for three days in a row, one week apart for three weeks. This extensive treatment cleared the crusted skin lesions (Figure 5).


DISCUSSION

Crusted or Norwegian scabies is a highly contagious, ectoparasitic infection transmitted by Sarcoptes scabiei, mainly affecting immunosuppressed patients, such as individuals with human T-cell lymphotropic virus 1, human immunodeficiency virus, leukemia, lymphoma, organ transplant recipients, and during the use of immunosuppressive therapy. 1,6,7,8,9,10 Among this group, the weak immune response fails to contain the disease and there is no impulse to scratch, resulting in fulminant hyper-infestation. 2,4,6

Additional non-immunosuppressive conditions like neuropathy, severe arthropathies, mental retardation and psychiatric disorders are also risk factors because of the inability to scratch in response to itch. 1,7 Scratching is important to remove scabies mites and to destroy its burrows. 4,7

As a reaction to the massive infestation, the horny layer thickens, forming crusted and warty hyperkeratotic lesions, mimicking other dermatoses such as psoriasis, seborrheic dermatitis, Darier's disease, dermatitis herpetiformis, and drug- induced eruptions. 3,4

Given the large number of mites in the epidermis and the hyperkeratotic skin, the Norwegian scabies can be very difficult to treat, especially if the patient is immunosuppressed. Therefore, this condition generally requires repeated application of topical and systemic scabicidal agents. 2,4

Rupioid or ostraceous psoriasis is an extremely rare variety of psoriasis, with few publications in the literature. This form of psoriasis is characterized by sharply demarcated, erythematous, well-defined plaques, covered with scales and crust, sometimes in a cone-shaped appearance. 5

In our case, although immunocompetent, the patient had generalized anxiety disorder and skin cancer phobia. Therefore, since she started to present the first lesions, nine months ago, she ended up not being well-cleaned and not manipulating the injuries, which caused the exuberant and unusual presentation. Due to the presence of rupioid crusts and lesion distribution in a few areas traditionally affected in psoriasis, the eruption was misdiagnosed as ostraceous psoriasis.

Our case highlights the importance of keeping an open mind about Norwegian scabies in the differential diagnosis of skin diseases coursing with hyperkeratotic and verrucous plaques, even in immunocompetent individuals with no obvious risk factor for the disease.

A high index of suspicion and early diagnosis help in successfully curing and containing the spread of this highly contagious and deceptive form of scabies. 2


Notes

Conflict of interest: None

Financial funding: None

fn01* Study carried out at the Teaching Hospital Onofre Lopes - Federal University of Rio Grande do Norte (Hospital Universitário Onofre Lopes - Universidade Federal do Rio Grande do Norte - HUOL-UFRN) - Natal (RN), Brazil.

REFERENCES
1. Green MS. Epidemiology of scabiesEpidemiol RevYear: 1989111261502509232
2. Subramaniam G,Kaliaperumal K,Duraipandian J,Rengasamy G. Norwegian scabies in a malnourished young adult: a case reportJ Infect Dev CtriesYear: 2010434935120539068
3. Gach JE,Heagerty A. Crusted scabies looking like psoriasisLancetYear: 200035665010968439
4. Monari P,Sala R,Calzavara-Pinton P. Norwegian scabies in a healthy woman during oral cyclosporine therapyEur J DermatolYear: 20071717317337413
5. Arias-Santiago SA,Naranjo-Sintes R. Images in clinical medicine. Generalized ostraceous psoriasisN Engl J MedYear: 201036215520071705
6. Kartono F,Lee EW,Lanum D,Pham L,Maibach HI. Crusted Norwegian scabies in an adult with Langerhans cell histiocytosis: mishaps leading to systemic chemotherapyArch DermatolYear: 200714362662817515513
7. Webber NK,Choudary R,du Peloux Menage HG. Human T-cell lymphotrophic virus tropical paraparesis, hyperhidrosis and Norwegian scabiesClin Exp DermatolYear: 200934e510119747336
8. Towersey L,Cunha MX,Feldman CA,Castro CGC,Berger TG. Dermoscopia da sarna crostosa associada à síndrome da imunodeficiência adquiridaAn Bras DermatolYear: 20108522122320520938
9. Suzumiya J,Sumiyoshi A,Kuroki Y,Inoue S. Crusted (Norwegian) scabies with adult T-cell leukemiaArch DermatolYear: 19851219039043874601
10. Magee KL,Hebert AA,Rapini RP. Crusted scabies in a patient with chronic graftversus-host diseaseJ Am Acad DermatolYear: 1991258898911722227

Figures

[Figure ID: f01]
FIGURE 1 

Erythematous, well-defined zplaques, covered with rupioid crusts, on the neck, chest and periumbilical region



[Figure ID: f02]
FIGURE 2 

errucous plaque on the elbow



[Figure ID: f03]
FIGURE 3 

Numerous scabies mites transected in the stratum corneum



[Figure ID: f04]
FIGURE 4 

Adult mites of Sarcoptes scabiei by KOH mount



[Figure ID: f05]
FIGURE 5 

Clinical results four weeks after treatment



Article Categories:
  • Case Report

Keywords: Anxiety, Mite infestations, Psoriasis, Sarcoptes scabiei.

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