Dr Mattias Larsson. Photo courtesy of Family Medical Practice
Dr Mattias Larsson*
Some time ago I had a couple of siblings, a four-year-old girl and six-year-old boy, visiting Family Medical Practice due to skin rash and itch. It started on the girl about two months ago.
When the rash was detected on their daughter’s trunk about two months earlier the parents took her to a local doctor who diagnosed allergic dermatitis and treated with steroid cream. The cream decreased the rash and itch for a while, but then the rash spread faster, and she scratched causing local infections with pus. The parents took her to a dermatologist who diagnosed eczema and skin infection. She got stronger steroid cream, antihistamine and topical antibiotic treatment. The treatment had some effect, but the area affected by the rash still expanded. When her brother also started to develop a rash, they used the same cream on him. Again, there was some temporary relief, but it didn’t stop spreading the rash. So the parents took both kids to a third doctor who diagnosed a fungal infection and treated both siblings with fungal cream and steroids. Like before it only gave some temporary relief.
Quite desperate, the parents came to Family Medical Practice. The paediatrician listened carefully to the disease history and observed the kids constant scratching, indicating an intense itch. When examining the skin, a pimple-like skin rash with clear lines and pathways could be detected which, combined with the history, led to a clear diagnosis: Scabies.
Scabies is caused by the mite Sarcoptes scabiei burrowing into the epidermis and triggering an inflammatory response leading to intense itching and rash. The mites reproduce in the skin, laying eggs that hatch within a few days. Those larvae are spread over the body by scratching and then touching other parts of the body. The scabies mite spreads by direct skin-to-skin contact with a person who has scabies or contact with contaminated objects as sheets or clothes. The parents suspected that she might have been infected during a sleepover at a friend’s house. Scabies is found worldwide and affects people of all races and social classes.
The skin is the body's largest organ with a complex structure comprising distinct layers that undergo a continuous cycle of renewal and regeneration. In infants, the skin renews every 14 days, while for teenagers it's around 28 days. In middle age, it takes between 28-42 days, and for individuals over 50, it can take up to over 80 days. The skin is constantly reacting to external factors, where sometimes immune cells are activated, causing a rash.
Correct condition was diagnosed only after suffering intense itch for two months. — Photo shutterstock.vn
It is often tricky to correctly diagnose rashes as the response to infections and allergies might be similar. Many child infections such as measles, rubella, roseola and hand foot and mouth disease come with rash. Also, contact dermatitis, allergic reactions and eczema are very common. Fungal infection might trigger allergic dermatitis and be misdiagnosed; also eczema makes the skin more susceptible to fungal infections. For eczema and allergic dermatitis, treatment with steroid creams are common as it decreases the immune response, and hence symptoms like rash and itch. That’s why the siblings initially improved with the steroid cream treatment. However, for infections such as fungal conditions and scabies, it might make it worse as the immune response is weakened.
The siblings were prescribed oral ivermectin, a potent antiparasitic medication effective against the scabies mite. One dose first, with a second after about a week to eradicate new mites from hatched eggs. They were instructed to clean all sheets, clothes and other objects that could be contaminated at sixty degrees. The parents also wanted to have treatment in case they were infected, and that was arranged with instruction on how to use it in case of symptoms.
After the first round of treatment both siblings improved, the rash and itch disappeared. However, in the girl the rash and itch reappeared after some weeks, and the parents took her back to FMP. As the first line of treatment was successful but there was relapse a second treatment was added, Permethrin, a topical cream. She then could recover completely. Family Medical Practice
*Dr Mattias Larsson is a paediatric doctor at Family Medical Practice and associate professor at Karolinska Institutet and has long experience in research on infectious diseases. He has worked with the Oxford University Clinical Research Unit and the Ministry of Health of Vietnam. He is fluent in English, Swedish, Vietnamese, German, and some Spanish.
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