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Undue suffering from scabies

Dr. Delwar Hossain Mahrufa, 3 years old girl came with the compliant of itchy patches over upper back of left thigh and buttock. She has been suffering from it for last two and a half years. During this period she was on treatments including antibiotics, anti-fungal, antihistamines, vitamins, and steroids etc. She was seen by one General Practitioner (GP), seven pediatricians and four dermatologists during this period even then she didn't get any cure. Reasonably her parents were very upset, frustrated, worried and helpless. They were crying in my office with utter dismay. They lost their trust on Bangladeshi doctors. At her six months of age she developed few pink patches over her right buttock and thigh. She was first attended by a GP next door to their house. He diagnosed her having "allergy" and put her on antibiotic, antihistamine and systemic steroid. She got partial remission with this treatment. She did not see further improvement instead of several visits to that GP. Then she decided to visit a child specialist. And thus her chamber ping pong started. It was revealed from history that her parents had itchy body too at the same time Mahrufa developed "allergy". This important clue was not revealed by the busy GP and subsequent specialists. All of them missed the diagnosis and treated the patient wrongly for last two and a half years! Consequently patient has to pay the mistakes in the form of prolong suffering, misusing huge scarce money, incurring side effects of drugs and putting the family in utter distress. Scabies is a parasitic disease caused by itch mite (Sarcoptes scabiei vas hominis). It can affect any age group but very common in extremes of age. It is very common dermatologic condition in our country. It constitutes about 15% to 25% of total new cases in dermatologic out patient department. It is clinically characterized by itchy pimples over limbs, trunk, breast and genitals. Sometimes it could affect whole body including head, face in case of infant. At this typical stage its diagnosis is very easy and about 85% of scabies patients are of this type. In another 15% cases presentation may be different where not only GP but also dermatologists face problems in diagnosing scabies as is seen frequently. In this atypical form, it may be characterized by (1) simply itchy body without any lesions development or (2) there may be only few pustules or boils on limbs and trunk or (3) multiple ulcers on the limbs and trunk or (4) simply few patches on the body as is seen in our case or (5) at times it can be complicated by bacterial infections, eczema and wrong treatments making the diagnosis very difficult. And these are the forms of scabies where physicians usually fail to diagnose and manage it properly. Scabies is usually an acute disease e.g. it can cause suffering only for days to weeks. But some times, particularly, in case of missed diagnosis and complicated atypical form, patient may suffer for months to years. I have many patients suffering from more than ten years! It is a highly contagious disease and is transmitted by casual contact in social intercourse e.g. handshake, hugging, sitting side by side (in bus, class room, stadium, waiting room etc), playing together, sharing bed and clothes etc. Usually several members of the same family are found affected simultaneously due to this contagiousness. Another important point is its incubation period which is usually four to eight weeks and that's why sequential suffering for years by the members of the same family is observed frequently. Treatment of scabies is important not only to cure the patients but also to protect the patient's kidney from damage. Scabies is an extremely itchy condition which facilitates it to be complicated by some very common bacteria. They infect skin and damage kidney reactively. Treatment of scabies is very easy and cheap. Scabicide is the drug of choice and is produced and marketed by many of our national pharmaceutical companies. But it is important to be remembered that not only patient but also its contact (even if they remain normal) should be treated simultaneously. Otherwise not only patients but also their families will prone to suffer prolong by a well developed vicious cycle. Prevention is sometimes very difficult in modern life style. Direct contact is the only way of transmission and patient and its utensils are the only source. Protective immunity does not develop and that's why same person can get it every time he / she come in contact with patients / utensils. However, good personal hygiene plays an important role in controlling its spread and more over use of scabicide render the patient "non-infectious" within hours. I examined Mahrufa carefully. I found only few annular patches on her left upper posterior thigh and buttock. I did not find anything in her to justify the drugs she received. Instead her history suggested me to clinch the diagnosis of scabies. I prescribed scabicide for the patient and her parents. Unfortunately parents did not use it, only the patient did. Within two weeks patient improved markedly but did not get cure. Then I explain again to parents who share the same bed to use the drug simultaneously. Since their daughter improved much with simple treatment and within two weeks it worked as self rewarding and they were convinced that their baby will get cure if only they follow my instruction (I found them surprised to get this treatment and reluctant to receive). One month later they came back with smiling face and two packets of sweetmeats to share their great relief and joys with me! This time they did not even hesitate to inform me that they considered me a made doctor and were skeptical with my method of treatment! Few mistakes had been done with this patient. (1) First is misdiagnosis and wrong treatment. This is rampant in our country due to lack of evidence based practice at all level. (2) Second is not properly evaluated by the specia