Delayed Recognition of Suspected Scabies with Secondary Impetiginization in an Adolescent Boarding-School Resident: A Case Report

Abstract

Scabies may remain unrecognized when chronic excoriation and secondary bacterial infection obscure its characteristic morphology and distribution. Diagnostic delay is particularly consequential in congregate living environments, where untreated close contacts may sustain transmission and reinfestation. A 15-year-old male student residing in an Islamic boarding school presented with a two-year history of recurrent pruritic lesions. Pruritus was worse at night, with a baseline numerical rating scale score of 7/10, and had initially involved the interdigital spaces. Two of his three roommates reported similar symptoms. Dermatological examination showed multiple bilateral papules and papulonodules involving the anterior lower legs, ankles, and dorsal feet, with excoriations, superficial erosions, adherent yellow-brown crusts, peripheral scaling, and post-inflammatory hyperpigmentation. Based on nocturnal pruritus, previous interdigital involvement, compatible symptoms among close contacts, and clinical findings, suspected scabies with secondary impetiginization was diagnosed. Dermoscopy and microscopic examination of skin scrapings were unavailable. Permethrin 5% cream was applied to the whole body from the neck down on 24 August 2026 and repeated on 31 August 2026. Oral loratadine was prescribed for pruritus. Localized impetiginized lesions were managed with 0.9% sodium chloride wet compresses followed by topical gentamicin three times daily for seven days. Close contacts received concurrent scabies treatment, and potentially contaminated clothing, bedding, towels, and other skin-contact items were cleaned or decontaminated. At follow-up on 4 September 2026, nocturnal pruritus and sleep quality had improved, no new lesions or burrows were identified, and erosions and crusting had substantially resolved. No treatment-related adverse effects were reported; however, longer-term recurrence and reinfestation could not be assessed because further follow-up was unavailable. Scabies should be considered in patients with chronic nocturnal pruritus and epidemiological exposure even when secondary excoriation and impetiginization dominate the visible eruption. Accurate clinical assessment, completion of a two-application permethrin regimen, concurrent treatment of close contacts, and environmental measures are important for interrupting transmission in congregate living settings.