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Vol. 12. Issue 2.
Pages 107-108 (March - April 2016)
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Vol. 12. Issue 2.
Pages 107-108 (March - April 2016)
Images in Clinical Rheumatology
DOI: 10.1016/j.reumae.2015.05.004
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Hyperkeratotic Lesions and Pruritus in an Immunosuppressed Patient
Lesiones hiperqueratósicas y prurito en paciente inmunodeprimida
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Ana Varela-Veiga
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ana.varela.veiga@sergas.es

Corresponding author.
, Alejandro Vilas-Sueiro, Benigno Monteagudo, Beatriz Fernández-Jorge
Servicio de Dermatología, Complejo Hospitalario Universitario de Ferrol, Área Sanitaria de Ferrol, SERGAS, Ferrol, A Coruña, Spain
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Scabies is a parasitosis caused by Sarcoptes scabiei var. hominis; Norwegian scabies is a rare, highly contagious subtype that is common in immunosuppressed patients.

Case Report

The patient was an 82-year-old woman with a history of hypertension, insulin-dependent diabetes mellitus and polymyalgia rheumatica, being treated with oral corticosteroids. She was referred to the dermatology department with a 9-month history of generalized pruritus, accompanied by hyperkeratotic plaques and numerous lesions in the form of linear burrows, predominantly on her scalp and breasts and in the interdigital spaces of both hands.1 She had applied topical corticosteroids, which had had a negative effect on her clinical status.2 It was also interesting to know that individuals with whom she lived were also affected (Figs. 1 and 2).

Figs. 1 and 2.

(1) Hyperkeratotic plaques and numerous linear burrow tracks distributed on the patient's trunk, predominantly in the facial area and on her breasts. (2) Hyperkeratotic plaques and linear burrows on the back of the hands, predominantly in the interdigital spaces.

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The suspected diagnosis was reached on the basis of the clinical signs and the results of dermatoscopic examination. The microscopic study of skin scales disclosed the presence of mites and their feces and eggs, and the diagnosis was confirmed. It important to include diseases such as ichthyosis and psoriasis in the differential diagnosis (Figs. 3–5).

Fig. 3.

Dermatoscopic image showing brownish structures, in the form of a “hang glider” at the end of the burrows (arrows).

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Figs. 4 and 5.

(4) Image from the histological study under direct vision (at 400×) showing a mite (arrows) and feces. (5) Histological study under direct vision (at 400×) showing eggs (arrows) and feces.

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Treatment is based on oral ivermectin, 5% salicylate vaseline in hyperkeratotic lesions and, in certain lesions, surgical debridement to facilitate the penetration of the topical treatment.

As a result of her comorbidities, the patient died of a respiratory tract infection before treatment for scabies could be initiated.

Discussion

When a patient receiving immunosuppressive therapy has generalized pruritus—predominantly at night—with crusted lesions,3 and the individuals with whom the patient lives are affected, it is essential to perform a differential diagnosis that includes Norwegian scabies, which occurs relatively frequently in these individuals. Moreover, the incidence is rising as a consequence of the increasingly widespread use of immunosuppressive agents.

Ethical DisclosuresProtection of human and animal subjects

The authors declare that no experiments were performed on humans or animals for this study.

Confidentiality of data

The authors declare that they have followed the protocols of their work center on the publication of patient data.

Right to privacy and informed consent

The authors declare that no patient data appear in this article.

Conflicts of Interest

The authors declare they have no conflicts of interest.

Acknowledgments

The authors thank Juan Carlos Álvarez of the Pathology Department of Complejo Hospitalario Universitario de Ferrol. Ferrol Health Area, SERGAS, Ferrol, A Coruña, Spain.

References
[1]
L.Y. Chan, W.Y. Tang, H.H. Ho, K.K. Lo.
Crusted scabies in two old-age home residents.
Hong Kong Med J, 6 (2000), pp. 428-430
[2]
I. Binic, A. Jankovic, D. Jovanovic, M. Liubenovic.
Crusted (Norwegian) scabies following systemic and topical corticosteroid therapy.
J Korean Med Sci, 25 (2010), pp. 188-191
[3]
M.M. Maghrabi, S. Lum, A.T. Joba, M.J. Meier, R.J. Holmbeck, K. Kennedy.
Norwegian crusted scabies: an unusual case presentation.
J Foot Ankle Surg, 53 (2014), pp. 62-66

Please cite this article as: Varela-Veiga A, Vilas-Sueiro A, Monteagudo B, Fernández-Jorge B. Lesiones hiperqueratósicas y prurito en paciente inmunodeprimida. Reumatol Clin. 2016;12:107–108.

Copyright © 2015. Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología
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