Hyperkeratotic scabies in an immunocompetent infant: An unusual case

Zineb Mouhsine, Fatima-Ezzahra El Fatoiki, Fouzia Hali, Soumiya Chiheb

Department of Dermatology and Venereology, Ibn Rochd University Hospital, Casablanca, Morocco

Corresponding author: Zineb Mouhsine, MD, E-mail: zineb.mouhsine23@gmail.com

How to cite this article: Mouhsine Z, El Fatoiki FE, Hali F, Chiheb S. Hyperkeratotic scabies in an immunocompetent infant: An unusual case. Our Dermatol Online. 2024;15(4):421-422.
Submission: 18.03.2024; Acceptance: 01.07.2024
DOI: 10.7241/ourd.20244.24

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© Our Dermatology Online 2024. No commercial re-use. See rights and permissions. Published by Our Dermatology Online.

Sir,

Crusted scabies (also known as Norwegian scabies) is a highly contagious variant of scabies, characterized by abundant mite proliferation in the skin [1]. Typically, itching is minimal or absent. This condition is rarely reported in immunocompetent infants and generally occurs in immunocompromised individuals [2,3]. Herein, we report the case of a four-month-old immunocompetent infant affected by this severe form of scabies.

A four-month-old infant was admitted to our department with extensive crusted dermatosis evolving progressively over the past three months. He had received potent topical corticosteroids (0.05% clobetasol propionate) for suspected atopic dermatitis, which according to the mother, exacerbated the infant’s symptoms. Detailed history-taking also revealed pruritus in the mother. A dermatological examination revealed widespread erythema covering over 70% of the body surface area, with hyperkeratotic lesions having a flour-like appearance, primarily on the trunk, back, and palmoplantar region, along with impetiginized papular lesions on the limbs (Figs. 1a and 1b), and ungual hyperkeratosis (Fig. 2). Additionally, he exhibited a moon face with telangiectasias (Fig. 3), truncal obesity, limb muscle atrophy, and generalized skin atrophy suggestive of adrenal insufficiency. Urgent laboratory investigations revealed an inflammatory syndrome, anemia, markedly elevated neutrophils and basophils, decreased cortisol levels, severe malnutrition (hypoalbuminemia at 16.1 g/L), severe hypokalemia, and hypernatremia (2.54 mmol/L and 157 mmol/L, respectively). HIV serology was negative, and primary immunodeficiency screening was unremarkable. The scotch test revealed numerous live Sarcoptes mites, confirming the diagnosis of hyperkeratotic scabies associated with adrenal insufficiency. Treatment included benzyl benzoate, keratolytic, hygiene measures, and hydrocortisone, along with concurrent family treatment.

Figure 1: (a and b) Generalized erythema with floury-appearance hyperkeratosis.
Figure 2: Ungual hyperkeratosis.
Figure 3: Moon face and telangiectasias.

The hyperkeratotic form of scabies is primarily described in immunocompromised children. Few cases have been reported in immunocompetent infants [4]. In our case, the infant was treated with topical steroids iteratively, with the hypothesis of possible atopic dermatitis, leading to the emergence of hyperkeratotic scabies associated with adrenal insufficiency [1]. Prolonged application of topical corticosteroids may predispose to crusted scabies, as the iatrogenic suppression of the immune response partly contributed to this unusual presentation, misleading for over three months. Additionally, the absence of scratching due to the patient’s very young age adds to diagnostic challenges [5]. A lack of pruritus leads to the inability to mechanically eliminate mites [6]. Furthermore, it may induce adrenal insufficiency due to systemic absorption of topical corticosteroids, high body surface area relative to weight, increased permeability of infant skin, and systemic drug accumulation [7]. To our knowledge, this was the first case of an immunocompetent infant developing hyperkeratotic scabies and cortico-induced adrenal insufficiency.

This case underscores the importance of always considering all differential diagnoses with atopic dermatitis and conducting a thorough skin examination, especially in cases of corticosteroid therapy failure. It also highlights the risks associated with diagnostic errors and the excessive or prolonged use of corticosteroids, which may lead to serious complications.

Consent

The examination of the patient was conducted according to the principles of the Declaration of Helsinki.

The authors certify that they have obtained all appropriate patient consent forms, in which the patients gave their consent for images and other clinical information to be included in the journal. The patients understand that their names and initials will not be published and due effort will be made to conceal their identity, but that anonymity cannot be guaranteed.

REFERENCES

1. Gualdi G, Bigi L, Galdo G, Pellacani G. Neonatal Norwegian scabies:Three cooperating causes. J Dermatol Case Rep. 2009;3:34.

2. Banerji A. Canadian Paediatric Society first Nations, Inuit, and Métis Health Committee. Scabies. Paediatr Child Health. 2015;20:395-402.

3. Budiyarto L, Mumtazah DA. Crusted scabies in an immunocompetent child:A case report. J Pak Associat Dermatol. 2023;33:1145-50.

4. Grodner C, Miquel J, Hadj-Rabia S, Mallet S, Boralevi F, Mazereeuw-Hautier J, et al. Crusted scabies in children in France:A series of 20 cases. Eur J Pediatr. 2022;181:1167 74.

5. Gach JE, Heagerty A. Crusted scabies looking like psoriasis. Lancet. 2000;356:650.

6. Dourmishev A, Miteva L, Mitev V, Pramatarov K, Schwartz RA. Cutaneous aspects of Down syndrome. Cutis. 2000;66:420-4.

7. Zenklusen C, Feldmeyer L. [The dermocorticoids, irreplaceable and feared]. Rev Med Suisse. 2014;10:821-6.

Notes

Source of Support: This article has no funding source.

Conflict of Interest: The authors have no conflict of interest to declare.

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