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Year : 2020  |  Volume : 65  |  Issue : 4  |  Page : 304-306
Crusted scabies complicated with herpes simplex and sepsis

1 Department of Dermatology, Tehran University of Medical Sciences (TUMS), Tehran, Iran
2 Dermopathology, Razi Hospital; Department of Pathology, Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences (TUMS), Tehran, Iran
3 Department of Dermatology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences (TUMS), Tehran, Iran

Date of Web Publication11-Jun-2020

Correspondence Address:
Safoura Shakoei
Department of Dermatology, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran - 1419733141
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijd.IJD_463_18

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Crusted scabies is a rare and extremely contagious infestation by Sarcoptes scabiei. Kaposi's varicelliform eruption (KVE) refers to herpes simplex virus infection superimposed on pre-existing dermatosis such as atopic dermatitis, Darier's disease, and pemphigus. We report a case of KVE superimposed on crusted scabies in a middle-aged woman. Her condition was complicated with sepsis. She was treated with IV meropenem, vancomycin, and acyclovir and was released 2 weeks later in good condition. To our knowledge, only rare cases of crusted scabies complicated by KVE have been reported.

Keywords: Crusted scabies, kaposi varicelliform eruption, scabies

How to cite this article:
Azizpour A, Nasimi M, Ghanadan A, Mohammadi F, Shakoei S. Crusted scabies complicated with herpes simplex and sepsis. Indian J Dermatol 2020;65:304-6

How to cite this URL:
Azizpour A, Nasimi M, Ghanadan A, Mohammadi F, Shakoei S. Crusted scabies complicated with herpes simplex and sepsis. Indian J Dermatol [serial online] 2020 [cited 2023 Sep 24];65:304-6. Available from:

   Introduction Top

Crusted scabies is an uncommon and severe form of infestation induced by the mite Sarcoptes scabiei var. hominis

, which was first described in a leprosy patient. This is characterized by diffuse hyperkeratotic plaques, commonly involving the scalp, face, and intertriginous areas.[1] Crusted scabies is associated with conditions, such as old age, institutionalized hosts, human immunodeficiency virus, human T-cell lymphotropic virus type 1 (HTLV-I), and other immunosuppressive conditions.[2],[3] In contrast to conventional scabies, severe pruritus or burrows are rare in these patients.[4],[5]

Kaposi varicelliform eruption (KVE) is an extensive herpes simplex virus infection superimposed on pre-existing dermatosis. KVE has been found in several skin diseases including atopic dermatitis, Darier's disease, and pemphigus diseases.[6],[7]

To the best of our knowledge, only one case of crusted scabies in association with KVE without underling disease has been reported till date.[3]

Herein, we report another case of KVE superimposed upon crusted scabies that was complicated with sepsis in a 43-year-old woman.

   Case Report Top

A 43-year-old woman with a 4-year history of moderate plaque-type psoriasis presented to our hospital with diffuse erythema and scaling. She reported exacerbation of cutaneous lesions 20 days before admission.

She had been treated with the diagnosis of psoriasis exacerbation by topical corticosteroid, oral methotrexate (MTX) 10 mg/week, and prednisolone 5 mg/d in another clinic. However, as the patient had shown no significant improvement after 2 weeks of treatment, she had been referred to our department. She did not complain of significant itching. Family history was non-contributory.

Physical examination revealed large, yellow-erythematous hyperkeratotic plaques on the trunk, extremities, face, and the scalp [Figure 1]a and [Figure 1]b. Microscopic examination of scales revealed numerous scabies mites.
Figure 1: (a and b) Large, yellow-erythematous hyperkeratotic scaly plaques on the trunk, extremities, face, and scalp

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Histopathologic examination revealed crusted epidermis containing numerous mites with superficial invasion of epidermis leading to erosions [Figure 2]a.
Figure 2: (a) Crusted mites in epidermis with superficial invasion and erosion (H and E, ×100), (b) Nuclear inclusion bodies with ground glass nuclei and multinucleation of infected keratinocytes (H and E, ×200), (c) Direct detection of HSV-1 in fluorescence cycling green with simultaneous amplification of the positive control. (Red curve: patient, Pink curve: standard control, and Blue line: NTC-negative control)

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The patient was diagnosed with crusted scabies. Subsequently, she was treated with topical permethrin 5% cream, which she applied 7 times a week, because of lack of oral ivermectin in our region. Moderate improvement of hyperkeratosis resulted.

The patient developed fever (39°C) and punched out erosions on the face and tongue and clusters of vesicles on the neck appeared on the fourth day of admission. The lesions spread and gradually involved the anterior and posterior surface of the trunk and arms [Figure 3]a and [Figure 3]b. Tzanck smear of this punch out lesions was positive for herpes virus.
Figure 3: (a and b) Punched out erosions on the face and clusters of vesicles on the neck, arms, and trunk

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Histopathologic examination revealed superficial erosions, keratinocytes with glassy appearance of nuclei, and multinucleated giant cells suggestive of viral inclusion bodies [Figure 2]b. Real time polymerase chain reaction (PCR) for herpes simplex virus (HSV) was performed by ready-to-use molecular detection HSV-1/2 RG PCR kit (Qiagen) and showed positive result (Ct 21.60, standard control Ct 35.42) [Figure 2]c. The diagnosis of KVE was confirmed by these tests. Culture from skin lesions and blood culture were positive for Staphylococcus aureusand Citrobacter. The laboratory results revealed anemia, and the erythrocyte sedimentation rate was elevated up to 90 mm/h. The patient was treated with intravenous (IV) colistin (4.5 million units BD), vancomycin (1 g BD), and ciprofloxacin (400 mg IV BD) for bacterial superinfection, and acyclovir 1500 mg/d for herpes infection. However, 2 days later, her condition deteriorated, hemoglobin level decreased from 9.8 to 7.3 g/dl, and creatine phosphokinase and lactic dehydrogenase levels were increased. The patient was transferred to internal medicine clinic for hemolysis due to sepsis. She was treated with IV meropenem (1 g three times daily (TDS)), vancomycin (1 g twice daily BD), and acyclovir. She was released 2 weeks later in good condition.

   Discussion Top

Crusted scabies is a severe form of skin infestation. Unlike conventional scabies, pruritus in crusted scabies may be mild or absent. Because of to the atypical clinical presentation, the diagnosis is frequently delayed.[1]

Several underlying diseases may predispose patients to crusted scabies including acquired immune deficiency syndrome (AIDS), HTLV1 infection, T-cell lymphoma, leukemia, Down syndrome, iatrogenic immunosuppression, heavy ethanol use, past leprosy, moderate immunosuppression in transplant recipients, systemic lupus erythematosus, rheumatoid arthritis, diabetes melitus, malnutrition, various neuropathies,[2] and topical corticosteroids.[8]

Reactive keratinocytic hyperplasia marked by fine lamellar desquamation, and commonly, palmoplantar hyperkeratosis and nail involvement result from colonization of epidermis by mites.[1],[4]

Accordingly, clinical presentation of the disease may lead to misdiagnosis with other inflammatory, non-infectious dermatosis such as erythrodermic psoriasis, hyperkeratotic eczema, and T-cell lymphoma as seen in our case.[1] Crusted scabies must be considered in any patient with generalized erythrodermic scaling dermatitis.

Our patient was previously misdiagnosed as psoriasis, and at the time of her visit to our clinic, she was receiving topical clobetasol propionate and oral MTX. She had then developed punched out lesions consistent with eczema herpeticum and had been treated with intravenous acyclovir.

KVE is commonly described as painful, edematous, and disseminated vesiculopustules on the skin affected with a pre-existing skin disease. These lesions progress to painful punched out erosions that are susceptible to secondary bacterial colonization.[6]

KVE has been described in atopic dermatitis (eczema herpeticum), Darier's disease, pemphigus, pityriasis rubra pilaris, Hailey–Hailey disease, cutaneous T-cell lymphoma, seborrheic dermatitis, psoriasis, Wiskott–Aldrich syndrome, congenital ichthyosiform erythroderma, and Sezary syndrome.[6],[7],[9] To our knowledge, only three crusted scabies patients with KVE have been reported till date. These patients had a history of cutaneous lymphocytic leukemia, renal transplantation, and diabetes mellitus, respectively;[3] however, the patient cited in this case had no past medical history of any such diseases.

KVE is a potentially life-threatening condition because of secondary sepsis or underlying disease.[2]

Patients with crusted scabies have usually an underlying immunosuppressive disease. However, 40% of the patients lack an identifiable risk factor.[2] Skin breakdown related to crusted scabies and herpes infection was the most likely source of bacteremia.

In conclusion, crusted scabies remains a debilitating condition with potentially high mortality. The mortality rate of crusted scabies has been reported to be up to 50% over 5 years.[2] A delay in diagnosis and treatment leads to spreading of the infestation with increasing risk of sepsis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

This study was supported financially by the Tehran University of Medical Sciences, Tehran, Iran.

Conflicts of interest

There are no conflicts of interest.

   References Top

Sunderkotter C, Feldmeier H, Fölster-Holst R, Geisel B, Klinke-Rehbein S, et al. S1 guidelines on the diagnosis and treatment of scabies - short version. J Dtsch Dermatol Ges 2016;14:1155-67.  Back to cited text no. 1
Roberts LJ, Huffam SE, Walton SF, Currie BJ. Crusted scabies: Clinical and immunological findings in seventy-eight patients and a review of the literature. J Infect 2005;50:375-81.  Back to cited text no. 2
Shaw K, Smith S. Driscoll M. Scabies herpeticum: Crusted scabies with herpes simplex superinfection. G Ital Dermatol Venereol 2017;152:192-3.  Back to cited text no. 3
Yelamos O, Mir-Bonafé JF, López-Ferrer A, Garcia-Muret MP, Alegre M, Puig L. Crusted (Norwegian) scabies: An under-recognized infestation characterized by an atypical presentation and delayed diagnosis. J Eur Acad Dermatol Venereol 2016;30:483-5.  Back to cited text no. 4
Jungbauer FH, Veenstra-Kyuchukova YK, Koeze J, Kruijt Spanjer MR, Kardaun SH. Management of nosocomial scabies, an outbreak of occupational disease. Am J Ind Med 2015;58:577-82.  Back to cited text no. 5
Vora RV, Pilani AP, Jivani NB, Kota RK. Kaposi varicelliform eruption. Indian Dermatol Online J 2015;6:364-6.  Back to cited text no. 6
[PUBMED]  [Full text]  
Fujii M, Takahashi I, Honma M, Ishida-Yamamoto A. Kaposi's varicelliform eruption presenting with extensive skin lesions and sepsis. J Dermatol 2017;44:1180-1.  Back to cited text no. 7
Bilan P, Colin-Gorski AM, Chapelon E, Sigal ML, Mahé E. [Crusted scabies induced by topical corticosteroids: A case report]. Arch Pediatr 2015;22:1292-4.  Back to cited text no. 8
Lehman JS, el-Azhary RA. Kaposi varicelliform eruption in patients with autoimmune bullous dermatoses. Int J Dermatol 2016;55:e136-40.  Back to cited text no. 9


  [Figure 1], [Figure 2], [Figure 3]


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