Correspondence

Scabies

N Engl J Med 1995; 332:611-612March 2, 1995

Article

To the Editor:

The Images in Clinical Medicine entitled “Norwegian Scabies in a Patient with AIDS” (Sept. 22 issue)1 are superb, but I take issue with the use of the term “Norwegian” scabies. “Crusted” scabies is appropriate,2 whereas “Norwegian” is truly derogatory and should be discarded, just as “mongolism” has been replaced by “Down's syndrome.”

Lawrence Charles Parish, M.D.
1819 J.F. Kennedy Blvd., Philadelphia, PA 19103

2 References

1. 1

   Spach DH, Fritsche TR. Norwegian scabies in a patient with AIDS. N Engl J Med 1994;331:777-777
   Full Text | Web of Science | Medline

2. 2

   Parish LC, Lomholt G. Crusted scabies: alias Norwegian scabies. Int J Dermatol 1976;15:747-748
   CrossRef | Medline

To the Editor:

The hyperkeratotic plaque-like lesions of Norwegian scabies shown in a patient with AIDS1 are very representative. Since 1983, we have diagnosed Norwegian scabies in 6 of 1100 patients with AIDS. We reported an outbreak of common scabies that originated in 2 patients with AIDS who had Norwegian scabies, affecting a total of 35 people.2

In our experience, the treatment of such severe scabies needs to be more intensive and prolonged than is suggested by Spach and Fritsche. To soften the hyperkeratotic lesions and allow the entry of lindane or permethrin, we suggest a whole-body application of either, although we prefer lindane and have not observed any toxic effects with its use. The lotion is administered twice a day as a bath, followed by salicylic acid and petroleum-jelly ointment, further applications of lindane, and petroleum jelly when severe scaling develops. The lindane lotion may need to be applied twice a day for three days each week over a three-week period.

Once Norwegian scabies is cured, no prophylaxis is necessary, although if a complete resolution is not achieved, a nosocomial outbreak may occur such as the one we described a few years ago.2

Bonaventura Clotet, M.D.
Guillem Sirera, M.D.
Carles Ferrandiz, M.D.
Hospital Universitari“Germans Trias i Pujol”, 08916 Badalona, Spain

2 References

1. 1

   Spach DH, Fritsche TR. Norwegian scabies in a patient with AIDS. N Engl J Med 1994;331:777-777
   Full Text | Web of Science | Medline

2. 2

   Sirera G, Rius F, Romeu J, et al. Hospital outbreak of scabies stemming from two AIDS patients with Norwegian scabies. Lancet 1990;335:1227-1227
   CrossRef | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: We thank Dr. Parish for his comments about the term “Norwegian scabies” and agree that “crusted scabies” is more appropriate. Although this change in terminology was proposed in 1976,1 most articles since then have continued to refer to Norwegian scabies. Our use of the term was in no way intended to be derogatory. Instead, we chose the term because it is still used predominantly in the medical literature and thus was more likely to be recognized by the diverse readers of the Journal.

The experience of Dr. Clotet and colleagues points up an extremely important aspect of this disorder. At least six additional outbreaks have been described,2,3 and no clearly optimal treatment regimen has been established.2 Although our patient had complete resolution of his scabies (with no recurrence) after five total-body treatments of permethrin, we agree that in some instances more aggressive therapy may be required. Our patient also received keratolytic agents before the permethrin treatment; these agents are generally recommended in patients with hyperkeratotic lesions, to improve the penetration of the scabicide. Experience has shown that patients with substantial skin damage may have more systemic absorption of lindane and that lindane-associated neurotoxic effects may develop as a result. Because one would expect increased systemic absorption of lindane through the deep cutaneous fissures that often occur in patients with this type of scabies, we would caution against using lindane in patients with such fissures. Moreover, in one outbreak of common scabies that originated in a patient with Norwegian (crusted) scabies, resistance to lindane was documented in seven patients.3 To the best of our knowledge, no resistance has been associated with permethrin treatment thus far.

David H. Spach, M.D.
Thomas R. Fritsche, M.D., Ph.D.
University of Washington, Seattle, WA 98122

3 References

1. 1

   Parish LC, Lomholt G. Crusted scabies: alias Norwegian scabies. Int J Dermatol 1976;15:747-748
   CrossRef | Medline

2. 2

   Lam S, Brennessel D. Norwegian scabies and HIV infection -- case report and review of the literature. Infect Dis Clin Pract 1993;3:169-173
   CrossRef | Web of Science

3. 3

   Purvis RS, Tyring SK. An outbreak of lindane-resistant scabies treated successfully with permethrin 5% cream. J Am Acad Dermatol 1991;25:1015-1016
   CrossRef | Web of Science | Medline

Citing Articles (3)

Citing Articles

1. 1

   L. A. Lettau. (2000) The Language of Infectious Disease: A Light-Hearted Review. Clinical Infectious Diseases 31:3, 734-738
   CrossRef

2. 2

   LARRALDE, MIJELSHON, GONZALEZ, MORA, CONSTANTAKOS. (1999) VERMECTIN-RESPONSIVE CRUSTED SCABIES IN FOUR PATIENTS. Pediatric Dermatology 16:1, 69-70
   CrossRef

3. 3

   Mary E. Wilson. (1998) SKIN PROBLEMS IN THE TRAVELER. Infectious Disease Clinics of North America 12:2, 471-488
   CrossRef