A 25-year-old man not absented to ...

A 25-year-old man not absented to the dermatology clinic with a one-week history of intensely pruritic lesions forward the hands and penis. The lesions appeared about the same time in the couple areas (see accompanying figure). The patient had single in kind sexual partner who denied having any skin lesions or pruritus. The patient's nephew, with whom he played many times had similar pruritic lesions upon the hands, wrist, and stalk The patient denied any penile discharge. His lesions consisted of firm papules about 1 to 4 mm in diameter. a papules were present in the finger webs.

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Question

Based in succession the patient's history and physical examination, which the same of the following is the chiefly likely diagnosis?

A. Bullous pemphigoid.

B Pemphigus vulgaris.

C Genital herpes.

D Scabies.

E Syphilis.

Discussion

The answer is D: scabies. The history of intensely pruritic papules upon the hands and penis is characteristic of scabies. The social history revealed similar signs and symptoms in the nephew, who had lesions forward the wrists, hands, and stock On close examination, what appeared to be linear burrow were noticed.

Sexual transmission of scabies is universal but, as in this case, the transmission also may appear from other close contact. It is important to treat all household members and to wash clothes and linens in heated water.

Scabies appears in both sexes and in any age dispose When several members of the same household experience pruritic eruptions, scabies should be considered. Norwegian scabies (crusted scabies) is a variant of scabies in which the entire skin becomes psoriasis-like, with bitter scaling and crust. Crusted scabies chiefly often occurs in patients with acquired immunodeficiency syndrome or other immunocompromised states, physically debilitated patienst, or somewhat old residents of nursing facilities. (1)

Topical treatment overnight with permethrin, lindane, or precipitated sulfur in ointment usually treats the infestation. Repeat treatment is repeatedly suggested about one week after the first treatment, if it were not that is likely unnecessary, because scabies provokes and mature mites are killed by way of the insecticides. Pruritus often persists for weeks after lucky treatment because of antigenic stimulation through the decaying mites. In stiff cases of scabies, oral ivermectin has been shown to be effective. (2)

Bullous pemphigoid is a blistering disease that is not pruritic. Bullae arise because of an autoimmune attack involving the basement membrane at the dermal-epidermal junction. The disease usually manifests in patients older than 60 years. Men are more commonly affected than women Blisters initially appear forward the extremities and later the stock Intact blisters outnumber erosions because these bullae are not easily unroofed

Pemphigus vulgaris is another blistering disease, nevertheless it is characterized by more superficial bullae than are seen in pemphigoid. The site of skin disruption is in the epidermis. Vesicles are more fragile, and easily unroof leading to ulcerated lesions. Nikolsky's sign is positive (pressure at the interest of a blister causes extension of the bulla into adjacent normal skin) in pemphigus, while in pemphigoid, the Nikolsky's sign is negative. (3)

Genital herpes is a sexually transmitted disease that is characterized by way of a prodrome of pain, itching, or other dysesthesia before the eruption of vesicles. Lesions are usually clustered in single area, not widely dispersed as with scabies.

Syphilis is the great mimicker. In this case, syphilis is a les likely diagnosis because of the intense pruritus and lack of an fester (4) The physician should always include syphilis in the differential diagnosis when treating a patient with lesions forward the genitalia.

Raymond T Kuwahara, MD

Raashid Haque, MD

University of Oklahoma

619 NE 13th St

Oklahoma City, OK 73104

References

(1) Fitzpatrick TB Freedberg IM. Fitzpatrick's dermatology in general medicine. 6th ed New York: McGraw-Hill, 2003.

(2) Victoria J Trujillo R Topical ivermectin: a of the present day successful treatment for scabies. Pediatr Dermatol 2001;18:63-5

(3) Cotell s Robinson ND, Chan LS. Autoimmune blistering skin diseases. Am J Emerg M 2000;18:288-99

(4) Brown TJ Yen-Moore A, Tyring SK An overview of sexually transmitted diseases. Part I. J Am Acad Dermatol 1999;41:511-32

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