Primary lesions are comma-shaped or irregular burrows or tracks about 3 to 4 mm in length with a scale at the entrance point and a papulovesicle at the distal point where the mite is located (see Photos 41-43).
1. Generalized small urticarial papules that are intensely pruritic. These occur about a month after infestation and are part of the immune reaction. Scraping these papular lesions in search of organisms is a worthless exercise (see Photo 44).
2. Excoriations are frequent and widespread (see Photo 44).
3. Impetiginization is frequent from secondary infection of excoriations (see Photo 44).
4. Lichenification and eczematous change may arise from persistent and repeated scratching (see Photo 44).
5. Warty, thick gray scaling crusts occur in crusted (Norwegian) scabies.
As the immune response becomes active during the second month, the primary burrows begin to show inflammation and become pruritic. General itching, especially bothersome at bedtime, increases and small intensely uncomfortable urticarial papules are present. Many cases show prominent immediate dermographism, which only adds to their discomfort. Persistent scratching causes excoriation, secondary infection, lichenification, and eczematous change. These patients often are simply unable to sit still during the examination process.
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