A 4-month-old HIV-positive infant staying at an orphanage presented with papular lesions all over the body (Fig. 1) and crusted scaly lesions over the palms and soles over a period of two months (Fig. 2). Several other inmates had also developed similar lesions. A clinical diagnosis of crusted scabies was made and all the inmates of the orphanage, including this patient, were treated with 5% permethrin.

Fig. 1 Popular lesions of scabies.

Fig. 2 Crusted scaly lesions over sole.

Crusted or Norwegian Scabiesis is seen in an immunocompromised host. AIDS, leprosy, lymphoma, Down syndrome and being elderly are risk factors for crusted scabies. Crusted scabies begins with poorly defined erythematous patches that quickly develop hyperkeratotic plaques diffusely over palmar and plantar regions. Itching may be minimal or absent. Differential diagnosis for crusted scabies include seborrhoeic dermatitis (greasy, scaly, erythematous papular dermatitis usually involving the face, neck, retroauricular areas, axillae and diaper area), Langerhans cell histiocytosis (associated with localized or generalized lymphadeno-pathy, hepatosplenomegaly, chronic ear discharge, pulmonary infiltrates and bone lesions), psoriasis (demarcated scaly lesions, pinpoint bleeding on removal of a scale, Koebner response and characteristic nail changes), and ichthyosis vulgaris (scaly lesions predominantly in the extensor aspects of the extremities, keratosis pilaris and hyperkeratosis of the palms and soles). Demonstration of the mites in skin scraping differentiates crusted scabies from other conditions.