Emeka had been itching for three months on long-term steroids for asthma. What looked like eczema on his hands turned out to be crusted scabies — a severe form that develops when the immune system is suppressed. It required specialised treatment and strict isolation measures.
Security guard, Mushin. Presented with 3 months of generalised intense itch — worst at night — with a thickened, crusted rash on the hands and wrists, and widespread small papules. On long-term oral steroids for asthma. Skin scraping revealed massive mite burden. Diagnosed: crusted scabies.
Crusted (Norwegian) Scabies — ImmunocompromisedEmeka had been on prednisolone for his asthma for over a year when the itch started. His doctor at the local clinic examined the crusted skin on his hands and said: "This looks like eczema — use this cream." The cream was a potent topical steroid. The itch worsened.
Three months later, Emeka could not sleep more than 90 minutes before the itch woke him. His colleagues at the security firm were beginning to itch too. His wife was itching. His supervisor sent him home.
At Mascot Healthcare, the doctor examined him with gloves. The hand crust was removed and a skin scraping sent for microscopy. The result: enormous numbers of Sarcoptes scabiei mites — hundreds visible in a single field. Diagnosis: crusted scabies.
Crusted (Norwegian) scabies develops when the immune response to Sarcoptes scabiei is impaired — as in those on corticosteroids. The mite burden is thousands of times higher than in ordinary scabies, making it far more contagious and harder to treat.
Severe itch across the whole body — worse at night; disrupting sleep for 3 months.
The dorsum of both hands had thick, hyperkeratotic, scaly crust — containing massive numbers of mites.
Small red papules across the trunk, abdomen, and limbs.
On long-term steroid tablets for chronic asthma — impairing the immune response that normally limits mite numbers.
Had been treated with more topical steroids for presumed eczema — significantly worsening the mite burden.
Topical betamethasone cream — prescribed for presumed eczema; dramatically increased mite burden by suppressing local immune response.
Oral prednisolone (ongoing for asthma) — necessary for asthma management; contributed to mite proliferation by suppressing systemic immunity.
Antihistamines — multiple courses; temporary itch reduction only.
Antiseptic soap — hygiene; no acaricidal effect.
Emeka was managed with the crusted scabies protocol: an oral treatment given on several set days combined with a medicated cream applied daily and then weekly. A softening cream was applied to the crusted areas to soften the crust and help the medicated cream penetrate.
He was advised to self-isolate for the first 24 hours after starting treatment. All close contacts (wife, work colleagues who had developed symptoms) were identified and treated at the same time with the standard medicated cream.
His existing oral asthma medication was reviewed in collaboration with his respiratory physician — reducing it was not possible given his asthma, but the cream he had been using was stopped.
Crusted (Norwegian) Scabies — immunocompromised secondary to long-term corticosteroid use (skin scraping: massive mite burden)
An oral treatment over several set days; a medicated cream daily then weekly; a softening cream; simultaneous contact treatment; isolation × 24 hours
Significant improvement by week 2. Skin scraping at week 4: no mites detected. All contacts cleared.
Crusted scabies cleared after the full treatment course. All close contacts treated and cleared. Emeka's sleep restored by week 2.
Crusted scabies is a medical emergency in terms of infection control — each crusted patient can infect dozens of contacts. Immunosuppressed patients with severe itch and skin crusting need scabies as the first differential, not eczema.
Topical steroids applied to crusted scabies are one of the most harmful misdiagnosis consequences in dermatology.
Itch + crusted skin + immunosuppression = scabies until proven otherwise. Never give steroids first.
Book an appointment at Mascot Healthcare, Akoka — same-day slots often available, 4.9★ rated.