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GENITAL SKIN CONDITIONS

Lice and scabies Asymptomatic individuals may notice lice on themselves or rust-
coloured spots on their underclothes. Examination may reveal
asymptomatic, bluish macules (maculae caeruleae) in the infected
Chris Bignell
area; these lesions are thought to represent sites of louse bites.
Although crab lice are fairly sedentary, infection may spread from
the genital area to the trunk, the axillae, the thighs and, occa-
sionally, the eyelashes. Scratching may cause secondary bacterial
Abstract
Scabies and pubic lice are parasitic infections of the skin that can be infection in the skin.
transmitted during the intimacy of sexual intercourse. The principal
symptom for both infections is itching. The diagnosis is established by Scabies
clinical examination, supplemented by microscopy for scabies. A single The adult mites of S. scabiei have a rounded body, four pairs of
application of permethrin cream is the treatment of choice for both infec- legs and are barely perceptible to the naked eye. They tunnel into
tions. Recent sexual partners should also receive treatment. the stratum corneum of the epidermis and feed on cellular
material. Eggs are laid by fertilized females in the burrows. The
Keywords infestations; itching; pediculosis; permethrin; scabies eggs hatch into larvae, which crawl out of the burrow and
progress through nymphal stages to adults.1,2 The cycle from egg
to adult is completed in 10e13 days. Scratching, bathing and
Pediculosis pubis and scabies are cutaneous infections that can immunological reaction combine to prevent all but a few larvae
be transmitted during sexual intercourse. surviving to adulthood. Typically, an infected adult with scabies
 Pediculosis pubis is caused by the pubic louse (crab louse), carries about 10e15 mature mites in the skin.2 Unlike pedicu-
Phthirus pubis. losis, scabies is seen in all age groups with no peak in prevalence
 Scabies is caused by the mite Sarcoptes scabiei. in young adults, confirming that non-sexual skin contact is an
These obligate human parasites live on or within the skin, and important mode of transmission. Certain patient groups can
sexual intercourse provides the necessary physical intimacy for develop a severe form of scabies called crusted scabies, which is
transmission; hence, they are considered as STIs. Their presence highly infectious and characterized by hyperkeratosis and
in young adults should prompt screening for concomitant STIs. a much higher burden of mites.3 It is seen in extremely physically
Condoms do not provide protection. Non-sexual skin-to-skin incapacitated individuals and patients with immune dysfunction
contact (holding hands) is important in scabies transmission. (including those with HIV). Secondary bacterial infection of the
Acquisition of scabies or pediculosis from shared bedding or skin can occasionally cause significant morbidity.
clothing appears to be uncommon.
The incidence and prevalence of these infections are not Clinical features: the mite causes generalized itching that is char-
recorded in the UK and pharmacies sell effective treatment acteristically most intense at night. The rash is polymorphic.3,4
directly to the public. The reported number of cases treated in GU Symptoms develop after 3e6 weeks in primary infection and
Medicine clinics has been declining over the past 10 years, falling result from the development of an immune response to the mite.
from 6496 cases in 1999 to 2232 cases in 2008. Symptoms develop rapidly on re-infection. Individuals with crusted
scabies have milder itching but a much more dramatic skin rash.3
Clinical features and diagnosis The pruritic lesions are typically distributed on the:
Pediculosis  interdigital web spaces of the hands
P. pubis is morphologically distinct from the other two species of  flexor surface of the wrists
louse that infect humans e the head louse, Pediculus capitis, and  extensor aspect of the elbows
the body louse, Pediculus humanus. The pubic louse is short and  buttocks and genital area in males
has a width greater than its length. Enlarged claw-like middle  anterior axillary folds
and hind legs emerge close together from the anterior abdomen,
giving it the appearance of a crab (Figure 1). Adult females lay
eggs encased in a hard shell, fixed to the base of hairs. Devel-
opment from egg through nymphal stages to adult takes 2e3
weeks.1,2 Crab lice are slowly mobile, feed on human blood and
seldom survive more than 24 h once removed from their host.
Pubic lice are not known to transmit any disease.

Clinical features: the predominant symptom of pediculosis is


itching, which develops following allergic sensitization. Adult lice
and their eggs (nits) are easily visible to the naked eye.

Chris Bignell FRCP is Consultant Physician in Genitourinary Medicine at


Nottingham City Hospital, Nottingham, UK. Competing interests: none
declared. Figure 1 Crab louse.

MEDICINE 38:6 306 2010 Elsevier Ltd. All rights reserved.


GENITAL SKIN CONDITIONS

 periumbilical region.
Several types of lesion occur in scabies.3,4
 The characteristic lesion of scabies is the burrow (Figure 2) e
a short, wavy, dirty-looking line, often extending from an
erythematous papule and usually located on the fingerwebs,
wrists, elbows or penis.
 Small, erythematous, often excoriated papules attributed to
feeding larvae and nymphs may occur at all of the above sites
(Figure 3).
 Firm, reddish, nodular lesions may occur on the glans penis,
penile shaft, scrotal skin, elbows and axillary folds. Viable mites
are seldom found in these nodules, which may persist long after
treatment.
 Excoriation of scabetic lesions is common, together with
eczematization and secondary infection, which may consider-
ably alter the appearance of the lesions.
 The crusted form of scabies has a scaling, psoriasiform
appearance and may be widespread.

Diagnosis: a pruritic rash involving the hands, trunk and male


genital area is suggestive of scabies, particularly when there is
a history of itching in a sexual partner or close domestic contact.
Demonstration of the mite confirms the diagnosis. Mites, ova and
faecal pellets may be identified by low-power microscopy of Figure 3 Erythematous papule.
material from skin lesions obtained by scraping, curettage or
shave biopsy (Figure 4). A magnifying glass can be helpful for controlled trials comparing the effectiveness of malathion with
selecting an unexcoriated burrow, and a tiny vesicle containing permethrin.
the mite may be seen at one end. The burrow is moistened and  Crotamiton (10% cream) is a less effective scabicide, but may
the skin gently scraped with a scalpel blade until the top layer of be used to ameliorate persistent itch.
skin is removed. The material is collected on a glass microscope  A sedating antihistamine at night may be helpful to relieve the
slide and a cover slip added before microscopy. itch in scabies.
 Lindane was a popular topical treatment for both lice and
Management scabies, but has been discontinued in the UK because of toxicity.
 Ivermectin, though not licensed in the UK, is an oral treatment
Choice of therapy for scabies that may have a place in the management of scabies
Choice of therapy may be determined by local policy.2,5 epidemics in long-term care facilities and in treating crusted
 Permethrin (5% cream) and malathion (0.5% aqueous lotion) scabies.
provide effective therapy against developmental stages and adults A single, properly applied application of cream or lotion is
in pediculosis and scabies. Topical permethrin appears to be the usually adequate. In usual forms of scabies in adults, treatment
most effective treatment for scabies, is the treatment of choice in the should be applied to the whole body surface, including the neck,
UK and is safe for pregnant women.5 Malathion has been scalp and ears, and left on for 8e12 h, usually overnight. Patients
successfully used since the 1970s. There are no published should be informed that resolution of the irritation and skin lesions

Figure 4 Material from skin lesions is obtained by scraping, curettage or


Figure 2 The pathognomonic lesion of scabies is the burrow. shave biopsy.

MEDICINE 38:6 307 2010 Elsevier Ltd. All rights reserved.


GENITAL SKIN CONDITIONS

associated with scabies may take several weeks and that reap- 2 Leone PA. Scabies and pediculosis pubis: an update of treatment regi-
plication of the scabicide is not routinely necessary. Treatment mens and general review. Clin Infect Dis 2007; 44 (suppl. 3): S153e9.
failure is suggested by the persistence of original skin lesions for 3 Walton SF, Currie BJ. Problems in diagnosing scabies, a global disease
more than 3 weeks after treatment, the development of new lesions in human and animal populations. Clin Microbiol Rev 2007; 20:
or finding a live mite on microscopy. Worsening of itching may 268e79.
occur with some topical therapies because of allergic dermatitis. 4 Chosidow O. Scabies and pediculosis. Lancet 2000; 355: 819e26.
5 Strong M, Johnstone P. Interventions for treating scabies. Cochrane
Bedlinen and clothing Database Syst Rev 2007; (3): Art. No.:CD000320.
After treatment patients should be advised to decontaminate
bedlinen, towels and clothing by machine-washing.
Practice points
Contacts
Both pediculosis and scabies are transmitted only by intimate
C Young adults with pediculosis or scabies should be screened
physical contact. It is important to treat sexual partners and, in
for other STIs
the case of scabies, close household contacts, to prevent re-
C The itch of scabies is characteristically most intense at night
infestation. A C The diagnosis of scabies should be considered in debilitated
patients with crusted psoriasiform rash
C Adequate coverage of the whole body is achieved with 60 g of
REFERENCES permethrin 5% cream
1 Morse SA, Ballard RC, Holmes KK, et al. In: Atlas of sexually C Patients should be warned that the genital lesions and itch in
transmitted diseases and AIDS. 3rd edn. Oxford: Elsevier Science, scabies may take several weeks to resolve after treatment
2003.

MEDICINE 38:6 308 2010 Elsevier Ltd. All rights reserved.