SCABIESAugust 25, 2015

Soriano, CharlesUy, Karl FrancisSGENERAL DATADV2 year old 6 monthsMaleRoman Catholic52 Engineering st. GSK Village Project 8, Quezon CityCPSpapules on hands and feetCHIEF COMPLAINTSHistory of Present Illnessmultiple erythematous papules on both handsintense pruritus, more at nightconsulted at visiting medical mission given diphenhydramine syrup (12.5mg/5ml) 2.5ml TID3 weeks PTC2 weeks PTCmultiple erythematous pruritic papules on both hands with excoriationsno feverconsulted at local health clinic given cetirizine (5mg/5ml) 2.5ml OD, and permethrin cream OD 1 week PTCpruritic papules with excoriations extended to both feet and anterior leg CONSULTSPERSONAL HISTORYPregnancy Problemsno hypertension, no infection, no diabetesDeliveryDOB: January 8, 2013Gestational age: 39 weeksType of delivery: Low Transverse Caesarian section secondary to failure of descentNeonatal Complications/Illnesses: noneSNUTRITION HISTORYFeedingBreastfeeding - birth to 7 monthsFormula feeding - 7 months until presentVitamin Supplement - CeelinPresent diet and age started:Cereal, fruits and vegetables - 7 monthsmeat and table foods - 12 monthsFeeding Problems: noneSPsycho-Motor/ Language:Regard- unrecalledSocial mile- 2 monthsTurned over- 5 monthsCrept- 6 monthsSat aided- 7 monthsSat alone- 8 monthsWalked independently- 12 months1st words- 9 monthsPut 3 words together- 1 year oldGROWTH AND DEVELOPMENTSGROWTH AND DEVELOPMENTDevelopmental Levela. General behavior- playful, activeb. Habits- no thumbsucking, no nail bitingc. Sleep pattern- sleeps around 9 PM and wakes up around 6 AMSIMMUNIZATION HISTORYC. ImmunizationsBCGat birthHepatitis B1 doseHib3 dosesOPV3 dosesDTP3 dosesMeasles1 doseMMR1 doseRotavirusNONEHepatitis ANONEPCVNONEVaricellaNONEInfluenzaNONESPAST MEDICAL HISTORYD. Previous Illness:No AllergiesNo previous hospitalizationsNo Accidents/InjuriesNo previous surgeriesSFAMILY HISTORY(+) hypertension - maternal grandmother(+) Diabetes - maternal grandmother(-) Bronchial asthma(-) Allergy(-) PTB SSOCIAL AND ENVIRONMENTAL HISTORYlives in a 1 storey, well lit, well ventilated house 4 household members ( 2 siblings, eldest)younger brother has the same symptoms as the patientDrinking water is distilled, no nearby water reservoirGarbage is collected and segregated twice a weekNo nearby factories, no exposure to smoke of cigarette at homeSREVIEW OF SYSTEMSHEENT- no eye/nose/ear dischargeCardiovascular- no fainting spellsRespiratory- no cough, no coldsGastrointestinal: no abdominal pain, no vomiting, no diarrhoeaGenitourinary- no hematuria, no pyuriaMetabolic- no heat/cold intoleranceMusculoskeletal- no swelling, no limited motion of extremitiesNervous System- no convulsionsSPHYSICAL EXAMINATIONTemperature: 36.5 CHeart rate: 117 bpmRespiratory rate: 22 cpmWeight: 14.1 kg (z > 0) Length: 91 cm (z < 0)Head circumference: 49 cm (z > 0)Chest circumference: 52 cmAbdominal circumference: 50 cmSPHYSICAL EXAMINATIONGeneral Appearance: awake, alert, oriented, unkempt, not in cardio-respiratory distressSkin- warm, moist skin, good skin turgor, (+) multiple erythematous papule with crusting and excoriations over both hands, feet, and anterior legsLymph nodes- no cervico-lymphadenopathyHead- normocephalic, no head lesionsEyes- no lid lesion, anicteric sclera, pink palpebral conjunctiva, pupils 2-3mm, equally reactive to light and accommodationSPHYSICAL EXAMINATIONEars - normal set ears, no aural discharge, no tragal tenderness, nonhyperemic ear canal, intact tympanic membraneNose - nasal septum midline, pink nasal mucosa, no congestion of turbinates, no dischargeOral Cavity- moist lips, pink moist buccal mucosa, no oral ulcers, tonsils not enlarged, non-hyperemic posterior pharyngeal wallChest examination- symmetric chest expansion, no visible retractions, normal breath soundsHeart and Vascular- adynamic precordium, normal rate, regular rhythm, no audible murmurSPHYSICAL EXAMINATIONAbdomen- flat abdomen, normoactive bowel sounds, soft, nontender, no palpable massGenitals- SMR 1, no gross lesionsExtremities- warm; full and equal pulses; CRT 2 wk after treatment and new lesions are occurring, the patient should be reexamined for mites. Nodules are extremely resistant to treatment and may take several months to resolve. The entire family should be treated, as should caretakers of the infested child. Clothing, bed linens, and towels should be thoroughly laundered.

PERMETHRIN synthetic pyrethoid that is lethal to mites and has low toxicity to humans- FOR LICE, treat only those who are symptomatic. For SCABIES, TREAT EVEN THOSE WHO ARE AYSMPTOMATIC-may cause pruritus, hypersensitivity, burning, stingin, erythema and rashLINDANE also effective, has low incidence of adverse effects (slight local irritation including eczematous eruptions, rash and conjunctivitis; repeated use causes contact dermatitis) BUT DUE TOAVAILABILITY OF LESS TOXIC AGENTS, LINDANE IS RARELY USED AS FIRST LINE-contraindicated in premature infants and those with seizure disorders. USE WITH CAUTION with drugs that lower seizure threshold. SYSTEMATICALLY ABSORBED. Risk of toxic effects is greater in young children; use other agents in infants, young children and during pregnancy.CROTAMITON 10% LOTION applied to the netire body from the neck down once a day for 3-5 consecutive daysSULFUR 2-10% in petrolatum applied OD and washed off after 24 hours; applied for three consecutive daysIVERMECTINMANAGEMENTAll household contact, symptomatic or not, should be treated at the same time.Clothing, towels and bed sheets should be changed and washed in hot water, dried under the sun and ironed.SSecondary bacterial infecton should be trated with oral antibiotics or mupirocin ointmentTopical mild glucocorticoids may be applied on non infected areas with eczematous dermatitsNOCTURNAL PRURITUS MAY BE RELIEVED WITH SEDATING ANTIHISTAMINES (ie. Hydroxyzine and Diphenhydramine)

In contrast to lice, there are fewer randomized controlled trials of products to treat scabies. Most studies were conducted using lindane as the comparator. There is no clear evidence of resistance to permethrin 5% cream for classic scabies, despite heavy use over the previous two decades, and it remains the first-line treatment.Physicians should educate patients on correct application of permethrin cream, reminding them that the cream should be applied to all areas of the body from the neck down, kept on overnight or for eight to 14 hours, washed off, and reapplied in one week.

Patients should be educated that they may continue to have itching for up to two weeks, even after appropriate and effective treatment. There is evidence for empiric treatment if a patient presents with pruritus and lesions typical of scabies in at least two body sites, or if there are others in the patient's household with pruritus.

A single dose of oral ivermectin at 200 mcg per kg and repeated at day 14 also is considered an option for first-line treatment of classic scabies by the CDC, although cost and availability often relegate it to second-line therapy if treatment with topical permethrin is unsuccessful.

Environmental control measures for scabies include washing sheets and clothing at 140F (60C) and drying in a hot dryer. For items that cannot be machine washed, isolation in a plastic bag for at least 72 hours is sufficient. Other environmental measures such as pesticide sprays or powders are not recommended. Vacuuming may be helpful, although there is little direct evidence of benefitCOMPLICATIONSEczematous dermatitisImpetigoEcthymaFolliculitisFurunculosis,CellulitisSSecondary bacterial infecton should be trated with oral antibiotics or mupirocin ointmentTopical mild glucocorticoids may be applied on non infected areas with eczematous dermatitsNOCTURNAL PRURITUS MAY BE RELIEVED WITH SEDATING ANTIHISTAMINES (ie. Hydroxyzine and Diphenhydramine)

In contrast to lice, there are fewer randomized controlled trials of products to treat scabies. Most studies were conducted using lindane as the comparator. There is no clear evidence of resistance to permethrin 5% cream for classic scabies, despite heavy use over the previous two decades, and it remains the first-line treatment.Physicians should educate patients on correct application of permethrin cream, reminding them that the cream should be applied to all areas of the body from the neck down, kept on overnight or for eight to 14 hours, washed off, and reapplied in one week.

Patients should be educated that they may continue to have itching for up to two weeks, even after appropriate and effective treatment. There is evidence for empiric treatment if a patient presents with pruritus and lesions typical of scabies in at least two body sites, or if there are others in the patient's household with pruritus.

A single dose of oral ivermectin at 200 mcg per kg and repeated at day 14 also is considered an option for first-line treatment of classic scabies by the CDC, although cost and availability often relegate it to second-line therapy if treatment with topical permethrin is unsuccessful.

Environmental control measures for scabies include washing sheets and clothing at 140F (60C) and drying in a hot dryer. For items that cannot be machine washed, isolation in a plastic bag for at least 72 hours is sufficient. Other environmental measures such as pesticide sprays or powders are not recommended. Vacuuming may be helpful, although there is little direct evidence of benefitPREVENTIONAvoid direct skin contact with a person infested with scabiesAvoid using items such as clothes and linens used by a person with scabiesAll household members should be treated at the same time as the patient to prevent getting the mites againClean the house regularlySSecondary bacterial infecton should be trated with oral antibiotics or mupirocin ointmentTopical mild glucocorticoids may be applied on non infected areas with eczematous dermatitsNOCTURNAL PRURITUS MAY BE RELIEVED WITH SEDATING ANTIHISTAMINES (ie. Hydroxyzine and Diphenhydramine)

In contrast to lice, there are fewer randomized controlled trials of products to treat scabies. Most studies were conducted using lindane as the comparator. There is no clear evidence of resistance to permethrin 5% cream for classic scabies, despite heavy use over the previous two decades, and it remains the first-line treatment.Physicians should educate patients on correct application of permethrin cream, reminding them that the cream should be applied to all areas of the body from the neck down, kept on overnight or for eight to 14 hours, washed off, and reapplied in one week.

Patients should be educated that they may continue to have itching for up to two weeks, even after appropriate and effective treatment. There is evidence for empiric treatment if a patient presents with pruritus and lesions typical of scabies in at least two body sites, or if there are others in the patient's household with pruritus.

A single dose of oral ivermectin at 200 mcg per kg and repeated at day 14 also is considered an option for first-line treatment of classic scabies by the CDC, although cost and availability often relegate it to second-line therapy if treatment with topical permethrin is unsuccessful.

Environmental control measures for scabies include washing sheets and clothing at 140F (60C) and drying in a hot dryer. For items that cannot be machine washed, isolation in a plastic bag for at least 72 hours is sufficient. Other environmental measures such as pesticide sprays or powders are not recommended. Vacuuming may be helpful, although there is little direct evidence of benefitPLANPermethrin 5% cream, apply from neck down then leave for 12 hours. Apply to all members of the housesulfur soap (Erasul) BIDIterax (Hydroxizine diHCl) (2mg/ml) 2.5ml TIDimmerse clothes, curtains, blankets, bedsheets in hot water and iron well Follow-up after 6 daysSFOLLOW-UP (July 27, 2015)S: (+) decreased papules, (-) pruritus, (-) fever, (-) appearance of new skin lesionsO: hyperpigmented dry, crusted papules over the hands, feet, and anterior legsA: Scabies, resolvingP: follow-up anytime if with appearance of new skin lesionsS