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Crusted Scabies

A 56-year-old woman with rheumatoid arthritis presented to the dermatology clinic with a 2-month history of an extremely itchy rash. For the previous 4 years, tofacitinib and methotrexate had been prescribed for her arthritis. On physical examination, large patches of erythematous skin with overlying scales, crusting, and deep fissures (arrows) were seen on the chest, upper arms, and neck (Panel A), on the abdomen, and on the buttocks and thighs (Panel B). Similar skin findings were noted on the hands, with sparing of the nails, as well as finger joint deformities from rheumatoid arthritis (Panel C). Microscopic examination of skin scrapings showed numerous mites and eggs (Panel D). Histopathological analysis of a skin-biopsy specimen also showed mites in the stratum corneum. A diagnosis of crusted scabies was made. Crusted scabies is a severe form of scabies that most commonly affects immunocompromised persons. The condition may be misdiagnosed as erythroderma, psoriasis, or atopic dermatitis. Crusted scabies is highly contagious, and anyone exposed to a person with the infection should be treated. Management of crusted scabies includes systemic therapy with ivermectin plus a topical agent. Treatment for this patient was initiated, and at follow-up 1 week later the symptoms had decreased in severity.
Yu-Jiao Sun, M.Med., and Hai-bo Gong, Ph.D.
Published August 6, 2025
N Engl J Med 2025;393: e8
DOI: 10.1056/NEJMicm2503141
VOL. 393 NO. 6


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