Scabies in the nursing home, misdiagnosis means costs, and embarrassment: story of a centenarian smitten by scabies!

Frequent Misdiagnosis of Scabies as Eczema in China: A Descriptive Study of 23 Cases

Objective

To outline the clinical manifestations observed in patients with scabies misdiagnosed as generalized eczema, analyse the factors contributing to these misdiagnoses and explore potential reasons for the resurgence of scabies.

Patients and Methods

A retrospective analysis was performed to investigate the patients with scabies misdiagnosed as generalized eczema.

Results

We included 23 patients, with twelve (52.17%) being male and eleven (47.83%) female. The illness duration ranged from 0.5 to 7 months. Among all patients, 12 (52.17%) were residents of nursing homes, 5 (21.74%) were staff members of these facilities, 4 (17.39%) were caregivers of long-term hospitalized relatives, 1 (4.35%) was a construction worker, and 1 (4.35%) had a history of tourism. The rash predominantly affected the trunk and extremities, 12 patients (52.17%) are each involved the perineum and fingers webbings. The presentations included erythema, papules, and nodules. The main complaint of all patients was nocturnal itch. Under direct microscopy, 5 patients (21.74%) tested positive for scabies mites, and 3 (13.04%) showed histopathological features consistent with scabies. All patients were initially misdiagnosed with generalized eczema.

Conclusion

Over half of all patients diagnosed with scabies either resided or worked in long-term care facilities. The lack of awareness of scabies among medical staff in long-term care facilities readily led to frequent misdiagnosis. Comprehensive measures should be implemented urgently to strengthen disease management.

Severe Scabies: A French Multi-centre Study Involving 95 Patients with Crusted and Profuse Disease and Review of the Literature

The aim of this multi-centre French retrospective study was to identify severe, i.e. crusted and profuse, scabies patients. Records were retrieved from 22 Dermatology or Infectious Diseases departments in the Ile-de-France from January 2009 to January 2015 to characterize epidemiology, demography, diagnosis, contributing factors, treatment features, and outcomes in severe scabies. A total of 95 inpatients (57 crusted and 38 profuse) were included. A higher number of cases was observed among elderly patients (>75 years), mostly living in institutions. Thirteen patients (13.6%) reported a history of previously treated scabies. Sixty-three patients (66.3%) had been seen by a previous practitioner for the current episode (up to 8 previous visits). Initial misdiagnosis (e.g. eczema, prurigo, drug-related eruptions, psoriasis) was documented in 41 patients (43.1%). Fifty-eight patients (61%) had already received 1 or more previous treatments for their current episode. Forty percent received corticosteroids or acitretin for an initial diagnosis of eczema or psoriasis. Median time from the onset of symptoms to the diagnosis of severe scabies was 3 months (range 0.3-22). Itch was present in all patients at diagnosis. Most patients (n=84, 88.4%) had comorbidities. Diagnostic and therapeutic approaches varied. Complications occurred in 11.5% of cases. To date, there is no consensus for diagnosis and treatment, and future standardization of is required for optimal management.

Scabies in the nursing home

Scabies infection is antediluvian and ubiquitous both in developing and developed countries, yet often neglected. Scabies has a predilection to infect vulnerable subsets of population in crowding conditions, typically applicable to residents in the nursing home. The mite incites a unique immunological response from human hosts. Scabies does not manifest as a singular skin condition and may present atypically in older adults, the majority of nursing home residents, where delay has deleterious consequences. Further, pruritus or itching, the hallmark of scabies infection, is a common complaint from a variety of causes among older adults. Hence, the diagnosis is often delayed or missed. There are several pharmacological treatment options; long-term care practitioners need to understand the characteristics of each agent before selection. Even more relevant is the importance of nonpharmacological aspects of management, crucial in the success of averting spread or outbreaks in long-term care settings.