🦠 TOACS FCPS Station · Rash on Sole and Foot in Scabies

Nelson Β· 22nd Ed Β· β€œScabies in infants: papules, vesicles, pustules on palms, soles, and scalp – often misdiagnosed; burrows may be absent; treat with permethrin 5% cream (include scalp and face, avoid eyes)”
⏱️ 7 minutes · Examiner-led · Observed station
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πŸ“· Clinical Photograph – Scabies Rash on Sole and Foot

Clinical photograph showing papules, vesicles, and scaling on the sole and foot of an infant, characteristic of scabies in young children
Figure 1 Β· Scabies in Infant Β· Sarcoptes scabiei

πŸ” Key clinical features (infantile scabies):

  • βœ“ Papules, vesicles, pustules – on palms, soles, and scalp
  • βœ“ Burrows may be absent – in infants and young children
  • βœ“ Intense pruritus – worse at night, may be irritability
  • βœ“ Secondary excoriations and crusts
  • βœ“ Family history – other household members may have pruritus

πŸ“‹ Clinical scenario (examiner prompt)

A 9‑month‑old infant is brought in with a rash on the feet and hands that has been present for 3 weeks. The mother reports the infant is irritable and not sleeping well, with intense scratching at night. On examination, there are erythematous papules, vesicles, and pustules on the palms, soles, and some on the scalp. There are also excoriations and crusts. No burrows are visible. The mother also reports that she and her older child have had itchy rashes for the past month.

Papules, vesicles on soles Intense nocturnal pruritus Involvement of palms, scalp Family history of itch

πŸ§‘β€βš•οΈ Examiner tasks Β· TOACS

1. Identify the diagnosis from the clinical image and context.

2. Describe the clinical features (infantile scabies – papules/vesicles/pustules on palms, soles, scalp; nocturnal pruritus; lack of burrows).

3. Explain the etiology and transmission (Sarcoptes scabiei, mite burrow, close contact, family spread).

4. Discuss diagnosis and management (permethrin 5% cream, treat all contacts, bedding, ivermectin for resistant/crusted).

⚠️ Key concept: In infants and young children, scabies often presents with papules, vesicles, and pustules on the palms, soles, and scalp, and burrows may be absent. Nocturnal pruritus and family history of itch are crucial clues. Treatment is permethrin 5% cream applied to the entire body, including scalp and face (avoid eyes), and washed off after 8-14 hours. All household and close contacts must be treated simultaneously.

🎯 Expected answers (for examiners)

  • β€’ Diagnosis: Scabies (infantile scabies) – Sarcoptes scabiei infestation
  • β€’ Clinical features: Papules, vesicles, pustules on palms, soles, and scalp; intense nocturnal pruritus; excoriations; lack of classic burrows in infants; family members often affected
  • β€’ Transmission: Direct skin-to-skin contact; mites can survive 48-72 hours off the host
  • β€’ Diagnosis: Clinical; mineral oil scraping of papule or burrow (if present) β†’ mites, ova, scybala; dermoscopy may show 'delta wing' sign
  • β€’ Treatment – First-line: Permethrin 5% cream (Elimite) – apply to entire body from neck down (infants: include scalp, face, avoid eyes), wash off after 8-14 hours; repeat in 7 days
  • β€’ Treat all household and close contacts simultaneously, even if asymptomatic
  • β€’ Wash clothing/bedding in hot water (54Β°C) or store in plastic bag for 72 hours
  • β€’ Resistant/crusted scabies: Oral ivermectin (200 ΞΌg/kg) + permethrin
πŸ“Œ Infantile scabies – key points:
β€’ Classic burrows are often absent – look for papules/vesicles on palms, soles, scalp
β€’ Nocturnal pruritus – intense itching, worse at night
β€’ Family history – almost all household members have pruritus
β€’ Treatment: Permethrin 5% cream (include scalp and face, avoid eyes)
β€’ Treat all contacts – simultaneous treatment prevents reinfestation
β€’ Pruritus may persist for 2-4 weeks after successful treatment (hypersensitivity)

⚑ Quick FCPS‑style MCQ

An infant presents with papules, vesicles, and pustules on the palms, soles, and scalp with intense nocturnal pruritus. The mother and sibling also have itchy rashes. The most likely diagnosis and first-line treatment are:

A. Atopic dermatitis – topical steroids B. Scabies – permethrin 5% cream (include scalp and face) C. Tinea corporis – topical antifungals D. Contact dermatitis – avoid irritants

πŸ“Œ Topic summary Β· Scabies in Infants (Rash on Sole/Foot)

Pathogen
Sarcoptes scabiei (mite)
Classic presentation
Burrows, nocturnal pruritus
Infants/young children
Papules/vesicles on palms, soles, scalp
Transmission
Skin-to-skin contact
First-line treatment
Permethrin 5% cream (body + scalp in infants)
Contacts
All household members treat simultaneously
FeatureScabies (Infantile)
AgeInfants and young children (often <2 years)
Typical skin findingsPapules, vesicles, pustules on palms, soles, scalp; excoriations; burrows may be absent
PruritusIntense, worse at night; can cause irritability, poor sleep
Family historyAlmost always – household members have pruritus
DiagnosisClinical; mineral oil scraping (mites, ova, scybala); dermoscopy
Treatment – First-linePermethrin 5% cream – apply to entire body (including scalp, face, avoid eyes) for 8-14 hours, repeat in 7 days
ContactsAll household and close contacts must be treated simultaneously
Crusted scabiesPermethrin + oral ivermectin (200 ΞΌg/kg), repeated in 7-14 days
Post-treatment itchMay persist 2-4 weeks (hypersensitivity reaction); topical steroids if needed
Source: Nelson Textbook of Pediatrics 22nd Ed Β· : Arthropod Bites and Infestations Β· TOACS FCPS station.