Dr Srinivas Babu Kathi
Over the past decade scabies has been recognized as “neglected tropical disease” by World Health Organization. Human scabies a common infestation, has a worldwide distribution with a variable impact and presentation depending on the clinical situation.
KEYWORDS: Scabies, Diagnostic criteria, Control of Scabies, Psora,Homeopathic approach
REVIEW OF LITERATURE: The discovery in 1687 of the itch mite marks scabies as the first disease of man with known cause.1 The itch mite Sarcoptes scabiei or Acarus scabiei is an extremely small, globular arthropod just visible to the naked eye.The female parasite borrows into the epidermis where it breeds and causes the condition known as scabies or itch.1
INCIDENCE: It is common cause of itching dermatosis infesting ~ 300 million persons worldwide3. It is common in children , highest prevalence below 5 years of age but can occur at any age. No sex preponderance.3 The human acarus is morphologically indistinguishable from the animal variety but it is quite distinct physiologically. Therefore, animal scabies cannot flourish on the human skin3.
RISK FACTORS: Overcrowding, Poor hygiene, Low socio economic status are predisposing factors.4
MODE OF TRANSMISSION: Close contact with infested person.This is often due to sleeping in the same bed or by children playing with each other or nursing an infested person.Contaminated clothes an bedlinen.1
War, natural calamities , social or religious congregations provide good opportunities for the mite to spread and cause epidemics.
LIFE CYCLE OF SARCOPTES SCABIEI : The itch mite is just visible to the naked eye, measuring 0.4mm in size .1Gravid female mites, measuring ~ 0.3 mm in length, burrow superficially beneath the stratum corneum, depositing 3 or fewer eggs per day. Nymphs mature in ~2 weeks and then emerge as adults to the surface of the skin , where they mate and re-invade the skin of the same or another host.Transfer of newly fertilized female mites from person to person occurs mainly by intimate contact. Generally, these mites die with in a day or so in the absence of host contact.3
SITE OF LESIONS: Sites involved are inter-digital webs, flexor aspect of wrist, ulnar border of forearm, elbows , anterior axillary folds, umbilicus and periumbilical area, medial aspect of thighs, genitalia , lower part of the buttocks , knees and ankles.In infants , palms , soles, face and scalp are common sites.4
Burrows are pathognomic lesions of scabies which appears as S thread like greyish to darkline, few millimeters long with a vesicle at one end where mite is present.4
The disease also affects the breasts in women and genitals in men.
- A linear or curvilinear papule caused by a burrowing scabies mite2.
- The itching and rash associated with scabies derive from a sensitization reaction directed against the excreta that the mite deposits in its burrow.An initial infestation remains asymptomatic for up to 6 weeks, and a re-infestation produces a hypersensitivity reaction without delay.3
- Burrows become surrounded by infiltrates of eosinophils, lymphocytes, and histiocytes, and a generalized hypersensitivity rash later develops in remote sites.
- The multiformity of lesions consist of vesicles, papules, pustules, crust and excoriations which are secondary to scratching excited by the intense itching.6
- The classical symptom is intense pruritus especially at night in bed.5
- Characteristic burrows are not seen in crusted scabies, and patients usually do not itch, although there infestations are highly contagious.3
- Scabies should be considered in patients with pruritis and symmetric polymorphic skin lesions in characteristic locations, particularly if there is a history of household contact with a case.5
- Even after successful treatment, itch can continue and occasionally nodular lesions persist.2
If a mite is demonstrated, one needs no diagnostic criteria. Typical lesions on the penis and nipple, the presence of burrows even without a mite and inter-digital lesions are almost diagnostic. Severe pruritus, especially at night, of short duration or in family members is also very suggestive.5
Burrow identification (Ink method): The suspected burrow is smeared with blue or black fountain pen ink and then wiped off with an alcohol swab after some time. The dye that enters the burrows is highlighted as a dark line.5
Microscopic examination: The burrow is scraped with 15 no. blade and examine the material with 10% KOH or mineral oil under light microscope. Presence of mite, egg or fecal concretions (scybala) confirms diagnosis of scabies.5
DIAGNOSIS OF SCABIES:.
The main diagnostic features of scabies are1:
(1) the patient complains of itching which is worse at night .
- Examination reveals follicular lesions at the affected site.
- Secondary infection leads to crusted papules and pustules.
- The diagnosis is probable if the other members of the household are affected.
- Confirmation of the diagnosis may be made by searching for the parasite in the skin debris under microscope.
Under dermoscope, mite in burrow resembles “jet with contrail”.5
- For pruritic localized or generalized rash: In infants: Papular urticaria, infantile acropustulosis, In children: Papular urticaria, insect bite reactions, atopic dermatitis, animal scabies. In adults: acute generalized lichen planus, adverse drug reactions, contact dermatitis, pediculosis pubis, pediculosis corporis, different forms of prurigo, In elderly: Dermatitis herpetiformis, senile pruritis, delusional parasitosis.5
- For pruritic nodules: Urticaria pigmentosa, papular urticaria (insect bite), and pseudolymphoma.5
Therapy: Permethrin (5%) cream is treatment of choice (single overnight application below neck all over the body with a second application after an interval of a week). It is the treatment of choice for infants (application includes head and neck also). Sulfur and crotamiton are safe in pregnancy.5
Pruritus may persist for up to 1-2 weeks after the end of effective treatment.5
Intralesional triamcinolone 5-10 mg/ml in each lesion is used for nodular scabies besides routine scabies treatment.5
CONTROL OF SCABIES:
In the control of scabies, it is essential to treat all members of the affected household simultaneously whether or not they appear to be infested. Before commencing the treatment the patient is given a good scrub with soap and hot water.1
- BENZYL BENZOATE: Is an effective sarcopticide.It should be applied with a paint brush or shaving brush to every inch of body below the chin including the soles of the feet and allowed to dry.In the case of babies, the head must also be treated,the application should be repeated after 12 hours,and after a further 12 hours a bath given and all underclothes, clothes and sheets changed and washed.Not more than two applications of benzyl benzoate should be given per week as excessive use can cause an irritant dermatitis.1
- HCH: 0.5 to 1.0 % strength of gamma-HCH (lindane) in coconut oil or any vegetable oil or vanishing cream.1
- TETMOSOL: A 5% solution, three daily applications are recommended.1
- SULPHUR OINTMENT: 2.5 to 10 % daily for 4 days is a cheap remedy.1
HOMEOPATHIC WAY OF UNDERSTANDING THE CONCEPT OF PSORA:
“The oldest monuments of history” says Hahnemann,”shows the Psora even then in great development. Moses, 3400 years ago pointed out several varieties. In Leviticus , he speaks of bodily defects which must not be found in a priest who is to offer sacrifice, malignant itch is designated by word Garab, which the Alexandrian translators, translated with Psora agria, but the Vulgate with “Scabies jugis”.The Talmudic interpreter, Johnathan, explained it as dry itch spread over the body.
Psora is identical, therefore with the ancient form of leprosy, with the “St. Anthony’s Fire” or malignant erysipelas which prevailed in Europe for several centuries and then re-assumed the form of leprosy, through the leprosy which was brought back by the returning crusaders in the 13th century.7
Psora has thus become the most infectious and most general of all the chronic miasms,” says Hahnemann.The disease, by metastasis from the skin, caused by external palliative treatment, attacks internal organs and causes a multitude of chronic diseases the cause of which is generally unrecognized.7
Hahnemann’s teaching is thus elucidated and confirmed by pathology.The infectious, parasitic, primary and typical micro-organisms of Psora, driven from the skin by local treatment, finds a ready route to deeper tissues, structures and organs through the capillaries, the lymphatic and glandular systems and the nervous system. Here it develops its secondary specific form and character according to its location and the predisposition and environment of the individual, giving rise to a vast number of secondary symptoms.8
Psora is the most ancient, most universal, most destructive, and yet most misapprehended chronic miasmatic disease, has become mother of all thousands of incredibly various(acute), chronic(non-veneral) disease. At least seven- eights of all chronic maladies spring from it as their only source. Psora or itch disease, is beside this the oldest and most hydra-headed of all the chronic miasmatic diseases.9Treatment of psora depends upon the stage with which the patient is suffering.To treat the primary manifestations of psora, a small dose of sulphur is abundantly sufficient to cure the infection.But if suppression has taken place sulphur alone is not sufficient, a well selected anti-psoric remedy to be selected.In Homoeopathy a remedy is selected by considering patient as a whole by process of individualization.
HOMEOPATHIC APPROACH :
Skin dry and scaly like parchment white and pasty, black vesicles and burning pain.11 Anxiety, restlessness, fastidious, prostration, burning and cadaveric odours are prominent characteristics.10 Burning pains, the affected parts burn like fire, as if hot coals were applied to parts >by heat, hot drinks, hot applications.11Worse cold.
This is great Hahnemannian Anti-psoric11.To be thought of when there is a paucity of symptoms to prescribe on, a latent condition of the symptoms due to psora.10 Its action is centrifugal- from with in outward-having an elective affinity for the skin, where it produces heat and burning, with itching, made worse by heat of bed12. Dirty, filthy people, prone to skin affections.Aversion to being washed, always < after a bath.Skin affections that have been treated by medicated soaps and washes.11
Itching not relieved by scratching worse in bends of elbows and knees.12 Eruptions about genitals, lips and mouth, face and body. Moist eruptions that pour out a watery fluid, or thick, yellow, purulent fluid.10 Worse evenings, washing, dampness, after sweat.Better by warmth of bed, hot applications, cold bathing, after sleep.11
The skin of a causticum person is of a dirty, white sallow.Burning, rawness and soreness are characteristic.Soreness in folds of skin, back of ears, between thighs.12
Agg on becoming cold, from getting wet or bathing.11
The skin is very sensitive: a sore feeling in skin.Scaly eruptions on a moist base.Sensation of burning, in the skin, burning after scratching.Itching, burning, crawling, stinging < when warm in bed,< scratching.10 Ailments accompanied by profuse desquamation.Yellow mucous and serous discharges.12
Persons who have never fully recovered from the exhausting effects of some previous illness.11 Sluggishness, laziness, turgescence, these are characteristics.10
Itching worse on evening, when warm in bed and better from cold.Moist skin, hot perspiration, burning pain, offensive discharge.11
Dirty, dingy look. Intolerable itching. Eruptions especially on scalp and bends of joints with itching, worse from warmth of bed.11Ailments from suppressed itch or other skin diseases. Eruptions disappear in summer, return in winter. Carrion like odour of discharge.11 Worse change of weather, from cold. Better heat, warm clothing,summer.12
- Park, Park’s Textbook of preventive and social medicine, 26th edition,M/S Banarsidas Bhanot.
- Davidson’s principles and practice of medicine, 23rd
- Harrison’s principles of internal medicine, 17th edition, volume 2.
- Y. P. Munjal, API textbook of medicine, 10th edition,volume 1.
- DM Thappa, Essentials in dermatology, 2nd edition, Jaypee brothers medical publishers.
- Ralph Bernstein, M.D ; Homeopathy elementary dermatology, B.Jain publishers.
- Stuart close; The genius of homeopathy lectures and essays on homeopathic philosophy; B.Jain publishers.
- James Tyler Kent, lectures on homeopathic philosophy, B.Jain publishers.
- Samuel Hahnemann, The chronic diseases their peculiar nature and their homeopathic cure,B.Jain publishers.
- 10..J.T Kent, Lectures on homeopathic Materia medica, B.Jain publishers.
- H.C Allen, Allen’s keynotes, 10th edition, B.Jain publishers
- William Boericke,M.D, Boericke’s new manual of homeopathic materia medical, 3rd revised and augmented edition, B.Jain publishers(P) LTD.
Dr. Srinivas Babu Kathi
Professor & HOD ,Dept. Homeopathic Pharmacy
Hamsa Homeopathy Medical College Hospital & Research Centre
Dr. Sirigadha Spandana Internee Batch 2017
Dr. Nagula Taraswi Internee Batch 2017