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Scabies

Clinical features

• Intense itching (worse with warmth and at night)

• Erythematous papular rash

• Usually on hands and wrists

• Common on male genitalia

• Also occurs on elbows, axillae, feet and ankles, nipples of females

• Diagnosis by microscopic examination of skin scrapings

Treatment: for all types of scabies

• Permethrin 5% cream (adults and children >6 months) or

• Benzyl benzoate 25% emulsion (dilute 50:50 with water if under 10 yrs; if <2 yrs dilute 1:3)

Method for application

• Apply to clean, dry cool skin of whole body from jawline down (preferably at night time). Include under nails, flexures and genitalia. Apply to face and hair if involved.

• Leave permethrin overnight (min 8 hrs) and benzyl benzoate 24 h and wash off.

• Repeat in 1 wk.

• Complete change of clothes and bed linen: wash in hot water after treatment and hang in sun. Wash any soft toys.

• Treat all family members and contacts even if free of symptoms.

• A topical antipruritic (e.g. crotamiton cream) can be used for persistent itch (usu. up to 3 wks).

• Can use sulphur 5% cream or crotamiton 10% cream daily for 3 days in children <2 yrs.

  Note: Lindane 1% lotion is an alternative, esp. for genital scabies.

Norwegian scabies (profuse infestation with crusting)

• Add ivermectin 200 mcg/kg (o) as single dose. Consult dermatologist.

Scrotal pain

Serious problems include testicular torsion, strangulation of an inguinoscrotal hernia, a testicular tumour and a haematocele, all of which require surgical intervention. A varicocele can cause discomfort—examine in standing position.

Scrotal pain/discomfort: diagnostic strategy model

Probability diagnosis

• Trauma including haematoma, haematocele

• Torsion of a testicular appendage

• Varicocele

Serious disorders not to be missed

• Vascular:

  • testicular torsion

• Infection:

  • acute epididymo-orchitis/orchitis

  • fulminating necrotising cellulitis

  • psoas abscess

  • tuberculosis

• Cancer:

  • testicular neoplasm

Other:

• strangulated inguinoscrotal hernia

• acute hydrocele

Pitfalls (often missed)

• Referred pain (e.g. spine, ureteric colic, abdominal aorta)

Rarities:

• idiopathic scrotal oedema

• filariasis

Key investigations

Useful investigations include:

• FBE

• urine analysis, microscopy and culture

• Chlamydia detection test

• ultrasound

• technetium-99m scan.

Torsion of the testis versus epididymo-orchitis

With torsion of the testicle there is pain of sudden onset, described as severe aching sickening pain in the groin that may be accompanied by nausea and vomiting. With epididymo-orchitis the attack usually begins with malaise and fever. The testicle soon becomes swollen and acutely tender; however, elevation of the scrotum usually relieves pain in this condition while tending to increase it with a torsion.