Scabies changes its behavior during epidemics and becomes a mimicking skin disease: Sulfur ointment is still the standard therapy

Abstract

Background: Scabies is an old skin disease which has classical and characteristic cutaneous manifestations like nocturnal itching, papulo-nodular rash of genitalia especially among males, around pelvis and axillae but in late undiagnosed cases generalized rash could be seen. Scabies is running as endemic disease in Iraqi population with periods of outbreaks and epidemics during the period from 1982 till now as a consequences of repeated wars. Hence its clinical presentations are changing over time. Patients and Methods: This is a case series descriptive study that was conducted during the period from 2014-2024, where thousands of cases with scabies were screened for unusual strange presentations with delayed diagnosis. Their ages ranged from 3 months to 60 years with a mean of 35 years while males were affected in 69(59.4%) and females in 47(40.5%).In this study, all cases with scabies were screened for unusual strange presentations with delayed diagnosis. Full demographic information was evaluated and extensive examination was carried out looking for the features of rash, sites of burrows and sometimes mite extraction was carried out. All patients including infants, children and adults were treated by 7% sulfur ointment for three successive nights (12 hours) by applying from chin to soles for adults while from scalp to soles in infants and young children. In addition to oral antihistamine and topical and oral antibiotic. Results: A total of 116 patients with scabies with unusual and mimicking skin lesions were selected among thousands cases with scabies. These patients presented with one or more of the following features: unusual sites and mostly rash was predominant in one region like scalps, hands, soles and umbilicus. Also with atypical clinical pictures of scabies like dermatitis, pyoderma like impetigo, bullous rash, papular urticaria and other presentations. While no rash was detected although there was an associated sever itching as seen in 4 cases with so called clean scabies. All patients responded very well to 7% sulfur ointment for three successive nights. Conclusions: Scabies should be remembered when there is itching but with unusual sites like scalp or with odd presentations like dermatitis, pyoderma, bullous lesions, papular urticarial rash and not responding to standard therapies. Scabies change its behaviors and manifestations during outbreaks and epidemics as a result of change in the epigenetics of infested patient. Sulfur ointment remains one of the standard effective therapy and for all ages.