840 Clinical Letters DOI: 10.1111/j.1610-0387.2011.07743.

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2011 (Band 9) The Authors Journal compilation Blackwell Verlag GmbH, Berlin JDDG 1610-0379/2011/0910
Clinical Letter
A 55-year-old woman presented with
persistent nodules, pruritus and secon-
dary scratch lesions. Two months earlier
she had been diagnosed with scabies by a
practice-based dermatologist, and trea-
ted with permethrin accordingly (three
times at intervals of one week), and with
topical steroids to alleviate the pruritus.
The presumed source of infection was
the patients father, who had received
home care from the patient and two other
relatives also suffering from scabies. At
the time of consultation, the patients
father was already deceased; therefore, a
reinfection was unlikely.
The diagnosis of scabies was supported,
though not proven, by a histological ex-
amination of a punch biopsy from the
gluteal region, showing an interface der-
matitis with eosinophilia. Dermatologi-
cal examination revealed multiple nodu-
les in the gluteal and genital regions with
diameters of up to 1 cm, as well as mul-
tiple erythematous macules and papules
on the lower extremities, and scratch ar-
tifacts on the left upper leg, left upper
arm, and back. The general medical ex-
amination was normal.
A punch biopsy from the gluteal region
was taken. On serial sections, a mite
was seen within the stratum corneum
(Figure 1). The dermis was edematous,
with a dense eosinophilic inflammatory
infiltrate.
The patient was treated systemically with
Ivermectin 12 mg (0.2 mg/kg) on day 1,
and topically with permethrin 5 % on
day 1 and 8. The pruritus was treated
symptomatically with cetirizine 10 mg in
the morning and hydroxyzine 25 mg in
the evening.
After seven days, skin status and pruritus
had improved considerably, and the pati-
ent was discharged. On follow-up seven
months later, the patient reported to be
still free of symptoms.
Nodular scabies is an infrequent manife-
station of scabies, which presents with
pruritic, red-brown nodules, especially
in the genital, gluteal and axillary regi-
ons, persisting for weeks or months after
successful scabies treatment. Earlier stu-
dies have shown that mites and mite
parts are generally absent from scabietic
nodules [1]. Thus, scabietic nodules are
regarded to be caused by a delayed hy-
persensitivity reaction to the female
mite, its eggs and scybala deposited in
the epidermis [2], rather than by an ac-
tive infection.
However, in our case, a whole mite
was seen in serial sections of a nodule
(Figure 1c) and the patient, who had
been refractory to anti-inflammatory
therapy, responded to the anti-scabietic
therapy with complete restitution of
both pruritus and skin lesions. The persi-
stence of mites or mite parts in scabietic
nodules has also been observed by
others. In a series of histopathological
sections from 27 patients with nodular
Nodular scabies: hypersensitivity
reaction or infection?
Johanna Christina Czeschik, Lisa Huptas, Dirk Schadendorf,
Uwe Hillen
Department of Dermatology, University Hospital Essen, Germany
scabies, mite parts were found in 6 cases
(22 %) [3]. In addition, a complete re-
mission of steroid refractory nodules and
pruritus in nodular scabies has been de-
scribed before under an anti-infectious
regimen with permethrin [4].
Current German guidelines for the treat-
ment of scabies advocate the use of topical
corticosteroids [5]. Our case and earlier
observations document that patients with
nodular scabies, which was refractory to
topical, intralesional and systemic cortico-
steroid therapy, can be successfully treated
by an anti-scabietic regimen. Thus, at
least in some cases an active infection is
the causative factor. Therefore we suggest
to differentiate nodular scabies (active in-
fection) from persistent papules/nodules
(hypersensitivitiy reaction). Histologic ex-
amination of a nodule is helpful in diffe-
rentiating nodular scabies from persisting
papules/nodules, and serial sections may
be necessary to detect the mite.
If papules or nodules persist after stan-
dard therapy of scabies, we suggest a
Figure 1: Histological examination of the biopsy of a nodule, H&E. (a) 20. (b) 40. (c) Cross
section with a mite in the stratum corneum, 400.
Clinical Letters 841
The Authors Journal compilation Blackwell Verlag GmbH, Berlin JDDG 1610-0379/2011/0910 JDDG | 10

2011 (Band 9)
procedure according to the algorithm
shown in Figure 2.
According to the guidelines of the Ger-
man Dermatological Society (DDG)
[5], scabies is treated with 5 % perme-
thrin, which has shown to be the most
effective treatment in a recent Cochrane
review [6]. A systemic therapy with iver-
mectin results in a slightly inferior suc-
cess rate (95 % vs. 97.8 %) when ap-
plied twice in an interval of two weeks
[7, 8], but is more effective than lindane
and benzyl benzoate [6]. In Germany,
ivermectin is not approved for the
therapy of scabies, but is recommended
in cases of therapy resistance, scabies
norvegica sive crustosa and immuno-
compromised patients [5]. <<<
Correspondence to
PD Dr. med. Uwe Hillen
Klinik fr Dermatologie
Universittsklinikum Essen
Hufelandstr. 55
D-45122 Essen
Tel.: 0201-723-2494
Fax: 0201-723-5412
E-mail: uwe.hillen@uk-essen.de
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Figure 2: Therapeutic algorithm for nodular scabies.