Norwegian Scabies in a Middle-aged Woman

A 34-year-old woman who was coinfected with HIV and hepatitis C virus complained of acute abdominal pain and generalized pruritus of 3 weeks' duration. She was noncompliant with her antiretroviral medications.

The patient had an abdominal hernia but was considered an unsuitable candidate for surgery. During the surgical evaluation, multiple discrete, papular lesions were noted on her back and upper arms. The next day, the lesions had progressed to confluent erythematous, slightly hyperkeratotic patches and plaques (A and B). She also had excoriations on her abdomen, between her fingers, and on her dorsal hands. Microscopic examination of skin scrapings placed in mineral oil revealed numerous scabies mites and their eggs (C and D).

Suspect scabies when extensive pruritic hyperkeratotic lesions develop in an immunocompromised patient. Norwegian scabies, first described in Norway in the mid 1800s, is a highly contagious form of the infestation that usually presents with thickened hyperkeratotic scales and crusting.

This patient's scabies infestation was treated with permethrin 5% cream, which was applied from the neck down and washed off 8 to 12 hours later. She was instructed to repeat this treatment after a week and follow up with her primary care physician. She declined antiretroviral therapy.