Surrepticius Scabies, Unraveling Atypical Presentations and Complications

Global Perspectives on Scabies

Scabies, a prevalent mite infestation caused by Sarcoptes scabiei var. hominis, is a global ectoparasite dermatosis. In 2017, the World Health Organization classified scabies as a neglected tropical disease, emphasizing its impact on public health. Recognizing and treating individuals affected by this condition is crucial not only for managing the patient but also for preventing the transmission of the disease within the community.

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A definitive diagnosis of scabies is established when mites, eggs, or feces (referred to as scybala) are identified. However, for the purpose of scabies research, the International Alliance for the Control of Scabies (IACS) introduced diagnostic criteria in 2018. These criteria include confirmed, clinical, and suspected diagnoses of scabies, providing a standardized framework for healthcare providers during patient evaluations.

The clinical features and management of scabies vary, and understanding the distinct presentations is essential. Classic scabies is characterized by characteristic burrows, often found in the web spaces of the fingers and toes. On the other hand, scabies surrepticius represents a non-classic and atypical manifestation, making the diagnosis challenging. To aid in the identification of scabies, the IACS criteria are applicable not only to research but also to clinicians aiming to establish a confirmed, clinical, or suspected diagnosis.

A confirmed diagnosis of scabies necessitates the visualization of mites, eggs, or feces. This is often achieved through skin scrapings or other diagnostic procedures. On the clinical front, a diagnosis can be established by observing genital lesions in men or classic burrows in individuals with pruritus and close contact with someone displaying classical scabetic lesions. The latter may involve individuals with a history of itching and the presence of classical lesions in typical distributions. Such criteria provide a comprehensive approach to diagnosing scabies, acknowledging both the clinical and research perspectives.

For a suspected diagnosis of scabies, specific criteria are outlined, requiring either one historic feature and typical lesions or both historic features and the presence of atypical lesions or an atypical distribution of skin lesions. This comprehensive approach ensures that clinicians consider a range of factors in their evaluation, contributing to a more accurate diagnosis.

Once a diagnosis of scabies is established, the treatment is paramount not only for the patient but also for close contacts. Topical medications, such as permethrin 5% cream, or systemic drugs like ivermectin, are commonly used, and sometimes a combination of both. The treatment frequency and duration may vary, with classic scabies typically managed through two treatments performed weekly to biweekly. However, crusted scabies may require multiple topical and oral antiscabetic treatments, along with topical keratolytic therapy.

It’s crucial to consider potential complications, such as bacterial impetiginization or infection, which can occur and may necessitate systemic antimicrobial therapy in addition to scabies-directed treatment. In cases where patients fail to respond to treatment with topical or oral scabicide therapy, clinicians should explore various potential causes, including inadequate treatment, reinfection, mite resistance, delusions of parasitosis, or the development of a new non-scabetic dermatosis.


In addition to scabies-directed treatment, symptomatic pruritus relief is essential. Systemic antihistamines and oral/topical corticosteroids may be used for this purpose. However, it’s crucial to monitor patients closely and consider individual variations in response to treatment.

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In conclusion, scabies is a significant dermatological concern with global implications. The diagnostic criteria proposed by IACS provide a valuable framework for both research and clinical practice, ensuring a comprehensive approach to identifying, treating, and managing scabies. Awareness of the diverse clinical presentations and potential complications is essential for healthcare providers in delivering effective care and preventing further transmission within communities.

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