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How to cite this article:

 Sokolova TV, Adaskevich UP, Malyarchuk AP, Lopatina YV. Scabious erythroderma - a rare clinical variant of scabies. Our Dermatol 

Online. 2018;9(4):355-362.

Submission:

 16.01.2018; 

Acceptance:

 10.05.2018

DOI:

10.7241/ourd.20184.1

Scabious erythroderma - a rare clinical variant of 

Scabious erythroderma - a rare clinical variant of 
scabies

scabies

Tatyana V. Sokolova

1

, Uladzimir P. Adaskevich

2

, Alexander P. Malyarchuk

1

,

Yulia V. Lopatina

3

1

Department of Skin and Venerial Diseases and Cosmetology, Medical Institute of Post-Graduate Education, Federal State 

Educational Institution of Higher Professional Education "Moscow State University of Food Production", Moscow, Russian 
Federation, 

2

Department of Dermatovenereology, Vitebsk State Medical University, Vitebsk, Belarus, 

3

Department of 

Entomology, Biological Faculty, M.V. Lomonosov Moscow State University, Moscow, Russian Federation

Corresponding author:

 Prof. Uladzimir P. Adaskevich, E-mail: vitebsk.derma@mail.ru  

 INTRODUCTION

Erythroderma is an inflammatory skin condition 

characterized by erythema and exfoliative dermatitis 

involving 90% and more of the entire skin surface. 

The initial lesions which are important keys for 

understanding the disease evolution are often 

occult [1]. The most common causes of erythroderma 

can include pre-existing dermatoses (psoriasis, 

atopic dermatitis, eczema, seborrhoeic dermatitis, 

lichen ruber pilaris, lichen ruber planus, pemphigus 

foliaceus, bullous pemphigoid), drug-induced eruption, 

lymphoma and leukemia, visceral neoplasias and other 

conditions [1-4].

Erythroderma is also a diagnostically relevant clinical 

manifestation of Norwegian scabies [1,5,6]. The latter 

was first described by Danielson and Boeck in Norway 

in 1848. Crusted scabies is another term used to name 

this condition. This name reflects the main clinical 

symptom of the disease – massive crusts which are 

formed in various areas of the skin surface. In addition 

to crusts and erythroderma, Norwegian scabiesis 

characterized by multiple burrow tracks, polymorphous 

eruption (papules, vesicles, pustules) and scales.

The etiology and peculiarities of the disease evolution 

have been quite competently systemized [5,7]. For the 

last two decades the cases of Norwegian scabies have 

ABSTRACT

Background: Erythroderma (exfoliative dermatitis) is an emergency condition in dermatology in which not less than 90% 

of skin surface is affected. The presenting features are erythema, skin scaling and itching, fever and lymphadenopathy. 

The most common cause of erythroderma is a preexisting dermatosis (psoriasis, atopic dermatitis, eczema, seborheic 

dermatitis, lichen rubra pilaris, lichen planus, pemphigus foliaceous), drug reactions, lymphoma, leukemia and visceral 

neoplasias. Erythroderma is a diagnostically relevant presenting feature of Norwegian scabies. The aim of investigation: Is 

to describe clinical peculiarities of scabious erythroderma as a special rare form of scabies, to assess the number of scabies 

mites on the patient and in his/her environment and to work out the criteria of differential diagnosis with Norwegian 

scabies.  Material and methods: We examined 5 patients with scabies and erythroderma as the main presenting 

feature. All patients were women aged from 42 to 89 years. The disease duration was from 8 months to 1 year. The 

causes of erythroderma were variable. Clinical and paraclinical methods of investigation alongside with dermatoscopy 

and microscopy were used. Results This is the description of a rare clinical form of scabies, scabious erythroderma. 

It is based on the analysis of the 5 cases of scabies, whose main clinical manifestation is diffuse erythroderma. The 

diagnostic criterias of scabious erythroderma and differential diagnosis of Norwegian scabies are given. The invasive 

potential of this form of the disease on the patient and beyond is evaluated for the first time.

Key words:

 Scabious erythroderma; Norwegian scabies; Dermatoscopy; The differential diagnosis

Original 

Article

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been described in HIV-infected patients [8-11], in 

elderly and disabled people [12,13] and rarely observed 

in cases of brain astrozytoma [14], drug addiction [15], 

Down syndrome, diffuse fatty liver disease, anemia, 

parenchymatous dystrophy of visceral organs, 

cachexia [16], bullous pemphigoid treated with systemic 

c orticosteroids [17], congenital erythroderma [18], 

in patients taking novel immunosuppressive agents 

tozilisumab [19] and cyclosporine [20], in case of skin 

exposure to pesticides [21]. Rare cases of Norwegian 

scabies are also described without associated pathology: 

in a 24-year-old man [22], in a pregnant woman [23], 

in children [24,25].

Massive crusts are the main symptom of Norwegian 

scabies. Their thickness varies from several millimeters 

to 2-3 cm. In some cases crust layers may cover 

considerable areas of the skin surface forming a solid 

horny shield which limits body movements and makes 

thempainful. The crust colour varies greatly from 

dirty gray with a mixture of blood to yellowish-green, 

grayish-brown or alabaster-white. The crust surface is 

rough, fissured and covered with verrucous rupia-like 

proliferations. Crusts usually appear at the preferable 

sites of burrows (hands, feet, elbows, buttocks and 

other localizations). The upper crust layer is firm, 

the lower one is friable. Between these two layers a 

great amount of adult and immature mites can be 

found. On the inner crust surface one can see tortuous 

depressions which correspond to scabies mite burrows. 

The crusts firmly adhere to the skin surface and, if 

forcibly removed, leave large weeping erosions. The 

burrows with in the crusts are “many-storied”. In the 

lower crustose layers, male and female mites, nymphs, 

larvae and eggs can be detected, and in the deep inner 

layers, dead mites and eggs, as well as empty egg shells 

are found. The number of mites on a sick patient is 

immense, so the Norwegian scabies is highly contagious 

with local epidemics breaking out around the patient.

Erythroderma is the second diagnostically relevant 

symptom of Norwegian scabies [6,13,16,26-31]. The 

cause of erythroderma in this case is considered to be 

Staphylococcus aureus colonizing mite burrows [32,33]. 

Staphylococcus aureus was found in mite burrows 

of an elderly patient with Norwegien scabies by 

scanning electron microscopy, bacterial analysis of 

burrow contents revealed Staphylococcus aureus and 

Staphylococcus haemolyticus. [34]. It is important to 

note the observation suggesting that erythroderma in 

Norwegian scabies arising on the background of both 

systemic and topical corticosteroid therapies appears 

earlier than in case when corticosteroid therapy is not 

administered [35,36].

Other diagnostically relevant criteria of Norwegian 

scabies are affected nails (nailplates easily crumble, 

they are grey with abumpy surface and not chededges, 

sometimes nail plates are completely lost and replaced 

by massive epidermal crustlike layers); enlargement 

of multiple lymph nodes (polyadenopathy); fever 

during the entire course of the disease; palmar-plantar 

hyperkeratosis; hair changes (dry, dull, ash-gray) up 

to alopecia; body malodour (reminiscent of sour 

dough) [6,26-31,37].

There are some case reports in medical literature 

describing highly contagious scabies with extensive 

erythroderma as the main clinical symptom [38,39]. 

This rare erythrodermic form of scabies is still 

insufficiently described in medical literature. That is 

why some authors, having found areas of hyperkeratosis 

(which are no crusts actually), diagnose such cases as 

Norwegian scabies [38-42]. In fact, the given form of the 

disease should be designated as scabious erythroderma. 

One can assume that there must be far more similar 

cases. Besides, it is recognized that Norwegian scabies 

may have a localized form with crusts developing only 

in certain areas of the skin surface [7,41,42].

The aim of our study was to describe peculiarities 

of the clinical course of scabious erythroderma as an 

independent rare variant of scabies, to estimate the 

number of mites on patients and in their surroundings 

and to work out criteria of differential diagnostics with 

Norwegian scabies.

MATERIALS AND METHODS

We observed 5 patients with scabies in whom 

erythroderma was the main clinical manifestation 

of the disease. All patients were women aged 42, 72, 

76, 84 and 89. The duration of the disease was from 

8 months to 1 year. The causes of the disorder were 

different in all the patients. The condition in the first 

patient (aged 42) developed on the background of 

systemic lupus erythematous. The complex therapy of 

this disease included prednisolone 60 mg/day during 

3 months. In two patients (aged 72 and 76) allergic 

contact dermatitis and then drug-induced reaction 

were erroneously diagnosed. During 8-9 months the 

patients received systemic antihistamine, desensitizing 

drugs and topical glucocorticosteroids. Erythroderma 

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appeared two months after topical application of 

corticosteroids. The forth case was a 84-year-old 

patient of psychoneurologic department. Many years 

the patient took systemic psychotropic drugs for 

schizophrenia, fluocinolon acetonide was applied 

topically. The fifth patient (aged 89), in whom allergic 

dermatitis and then drug-induced reaction were 

diagnosed, received systemic antihistamine drugs, 

topical corticosteroids during one year and then 

three-month course of betamethasone. Erythroderma 

appeared after 2 months of betamethasone injections.

In all cases the diagnosis of scabies was confirmed 

by laboratory investigations. The laboratory methods 

included mite removal with the help of a needle, 

burrow and lesional skin scrapings with lactic acid 

application, dermatoscopy performed with the help 

of the dermatoscope DELTA 20 and microscopy 

with USB-microscopes of various modifications. The 

number of burrows was counted visually and by means 

of dermatoscopy and then the parasitary index was 

determined. In the fifth patient the number of mites on 

the apparently normal skin and in erythrodermic lesions 

was counted in the field of a standard dermatoscope 

with the area of 1 cm

2

. The efficacy of scabies 

diagnostics by means of dermatoscopy and tape-test 

methods [43,44] was compared. In case of a tape test, 

a piece of transparent adhesive Scotch tape (2x5 cm) 

was applied on an affected site of the skin for several 

seconds and then quickly removed. The removed 

piece of tape was paced on the slide and viewed with 

the microscope. The quantities of mites in different 

stages of development were compared in two epidermal 

scrapings (from the abdomen and thigh) and in 4 

Scotch-tests (from the foot, chest, back, thigh). The 

number of mites around the patient was determined on 

the sheet where the patient was lying. For this purpose 

the adhesive tape (2x5 cm) was applied to ten different 

sites on the sheet.

As an example we describe a case of a patient with 

scabious erythroderma diagnosed in June 2013 

(Figs. 1-6). A 89-year-old patient admitted to hospital 

complained of the affection of the whole skin, 

moderate itch increasing in the evening and chills 

(in spite of high environmental temperature). The 

disease had lasted for one year. The patient did not 

connect any events with the onset of the disease and 

considered the skin changes to be a result of “allergy” 

(she had previously worked as a nurse). The first 

symptom of the disease was itch in the interscapular 

region. The itching sensation then gradually spread to 

other skin regions. The patient’s daughter who cared 

for her mother also complained of slight itch. Both 

Figure 1:

 Focal hyperkeratosis  on the buttocks in scabious 

erythroderma.

Figure 2:

 Mite burrows on the scalp at the frontal hair line in scabious 

erythroderma.

Figure 3:

 Mite burrows in the interscapular region in scabious 

erythroderma.

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women took antihistamine drugs and applied topical 

medicines against pruritus with no effects after this 

self-treatment. On admission to hospital the condition 

of the old patient was diagnosed as wide-spread allergic 

dermatitis. The patient was treated with antihistamine 

and desensitizing drugs and topical corticosteroid 

creams. Short-termin significant improvement 

was observed. The patient applied to 4 different 

doctors but the diagnosis remained the same and the 

treatment did not significantly differ from the previous 

one. The therapeutic measures brought no effect. 

Three months before admission to hospital the patient 

was administered 2 injections of betamethasone per 

month and topical corticosteroid creams (clobetasol, 

fluticasone). While the subjective perception of itch 

reduced, there appeared lesions of erythema which 

quickly spread and covered the whole skin surface 

creating the clinical picture of erythroderma. With 

the diagnosis “drug-induced eruption” the patient 

was admitted to hospital. The patient’s condition on 

admission was satisfactory, the body temperature was 

normal. The state of the inner organs and the revealed 

pathology in general corresponded to the advanced age 

of the patient. The regional lymphnodes were painless 

and not enlarged.

Local status. The process was of a universal character 

with erythroderma covering the whole skin surface 

of the body. The skin was dusky red, dry and in some 

areas scaling with signs of infiltration, pigmentation 

and lichenification. The skin felt warm, firm and 

rough. White dermographism was observed, but 

crusts were absent. In the areas of the intergluteal 

cleft (Fig. 1) and elbows there were foci of grey 

hyperkeratosis with firmly adherent scales. Scratch 

marks were hardly present. On the background of 

moderate facial hyperemia there were red infiltrated 

lesions on the forehead, chin, eyelids, ears, cheeks, and 

the vermillion border of the lips. The skin of the scalp 

was pale without any signs of inflammation. On the 

skin of the shoulders and lower legs there were small 

isles of normal skin. The inflammatory changes of the 

palmar and plantar surfaces were insignificant. Multiple 

fresh and destroyed burrows of various lengths were 

observed predominantly in the skin folds. The number 

of burrows detected without using a dermatoscope 

made up 186 on the palms, 81 on the soles and 34 on 

the areolas. Burrows in other skin regions were poorly 

visualized without a dermatoscope.

Laboratory data. Moderately elevated WBC count 

(13,6×10

9

/L), ESR 3 mm/h, hypoproteinemia 52 g/L. 

Other blood biochemistry values and urine analysis 

were within the normal range.

Figure 4:

 Mites outside the mite burrows in scabious erythroderma.

Figure 5:

 Mites in the apparently little-changed skin in the middle third 

of the shin in scabious erythroderma.

Figure 6:

 Scotch test (tape test) from the surface of bed linen: a – slide 

with the adhesive tape and visible parasitic elements,

∂ – Parasitic 

elements stuck to the tape (eggs, larva).

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Dermatoscopy. In all areas of the skin surface multiple 

mite burrows were found, including the face, frontal 

hairline on the head (Fig. 2), interscapular (Fig. 3) and 

pubic (Fig. 4) regions. Mites (from 5 to 30 on 1 cm

2

) 

were detected beyond the burrows (Fig. 4) even in only 

slightly changed areas (Fig. 5). The number of mites 

was the biggest in those areas of the skin surface where 

the inflammatory changes were the most dramatic 

ones. In order to compare the effectiveness of visual 

and dermatoscopic methods for detecting mites, the 

parasites were counted on the palm skin surface with 

the area of 4 cm

2

. Only female mites located in the 

burrows were visually detected (total 19). Twice as many 

mites (total 41) were found by means of dermatoscopy, 

including parasites beyond the burrows. Microscopy of 

skin scrapings yielded the following results (Table 1).

The number of parasitic elements clearly depended on 

the size of the skin area to be scraped. In scrapings from 

the thigh (6x8 cm) 17 parasitic elements were revealed 

and in scrapings from the abdomen the number of 

such elements was 25. Adult mites (male and female) 

prevailed (40,5%), eggs made up 33,3% of all parasitic 

elements, empty egg shells and larvae accounted for 

19,1% and 7,1% of elements, respectively. The obtained 

data show a high level of mite colonization in those 

areas of the skin surface which are only insignificantly 

affected in case of common scabies. The prevalence 

of female mites and empty egg shells in skin scrapings 

speaks for the presence of such burrows which, in case 

of common scabies, are usually found on the hands, 

wrists and feet.

For the diagnosis of scabies tape-tests were used. Their 

results are given in Table 2.

By means of tape-tests taken from 4 sites of the skin 

surface 15 mites in various stages of development were 

found. The adult mites (imago) dominated including 

6 female and 3 male mites. Larvae (6) and nymphs (1) 

were also detected, but there were no eggs or egg shells. 

Mites were found not only in sites of typical burrow 

localization (feet) but also in those areas of the skin 

surface where, in case of common scabies, elements 

of metamorphic stage of the life cycle are localized 

(abdomen, thigh, chest).

While comparing the effectiveness of dermatoscopy 

and tape-test methods a considerable advantage of 

dermatoscopy was evident. The number of mites 

revealed in 4 tape-tests on the area of 10 cm

2

 varied 

from 2 to 6 parasites. Dermatoscopy of the site with 

the same area revealed 35 mites on the foot, 12 on 

the abdomen, 22 and 15 on the thigh and chest, 

respectively.

Three tape-tests were made with the sheet on which the 

patient was lying (Fig. 6 a, b) which revealed 9 female 

mites, 6 male mites, 11 larvae, 1 nymph and 4 eggs. 

These results speak for a high invasive potential of this 

scabies form. All family members who cared for the 

patient also had scabies.

With regard to clinical, dermatoscopic and microscopic 

data the diagnosis of scabies in the form of scabious 

erythroderma was made. The patient was treated 

with benzyl benzoate ointment 20%. The next day 

the efficacy of the treatment was assessed in terms of 

mobility of parasites. Mobility was observed in 67% 

of mites extracted from the burrows and in 92% of 

mites removed from the apparently normal skin. In 

tape-tests taken from the patient’s sheet 23 mites of 

27 (85,2%) retained their mobility. Benzyl benzoate 

ointment was applied on the whole skin surface 

once a day in the evening for 7 days. Simultaneously, 

loratadine was administered. On day 8 a significant 

reduction of infiltration and hyperemia was observed 

and the number of mites on dermatoscopy decreased 

Table 1:

 Parasitic elements in epidermal scrapings

Site of scrapings

Female mites

Male mites

Larvae

Nymphs

Eggs

Egg shells

Total

Scraping from the thigh (6Χ8 cm)

6

6

0

0

3

2

17

Scraping from the abdomen (20Χ10 cm)

4

1

3

0

11

6

25

Total

10

7

3

0

14

8

42

Table 2:

 Parasitic elements in tape-tests taken in various areas of the skin surface

Site of scrapings

Femalemites

Male mites

Larvae

Nymphs

Eggs

Egg shells

Total

Foot

1

3

2

0

0

0

6

Abdomen

0

0

2

0

0

0

2

Thigh

4

0

0

0

0

0

4

Chest

1

0

1

1

0

0

5

Total

6

3

5

1

0

0

15