
==== Front
Am J Trop Med Hyg
Am J Trop Med Hyg
tpmd
tropmed
The American Journal of Tropical Medicine and Hygiene
0002-9637
1476-1645
The American Society of Tropical Medicine and Hygiene

39013382
tpmd240113
10.4269/ajtmh.24-0113
Images in Clinical Tropical Medicine
Unique Scabies Presentation in a Patient with Bullous Pemphigoid
Ran Delin
Bao Fangfang
Du Donghong *
Hospital for Skin Diseases, Shandong First Medical University; Shandong Provincial Institute of Dermatology and Venereology, Shandong Academy of Medical Sciences, Jinan, Shandong, China
Disclosure: The patients in this manuscript have given written informed consent to the publication of their case details.

Current contact information: Delin Ran, Fangfang Bao, and Donghong Du, Hospital for Skin Diseases, Shandong First Medical University; Shandong Provincial Institute of Dermatology and Venereology, Shandong Academy of Medical Sciences, Jinan, Shandong, China, E-mails: randecan@163.com, baofangfang2008@163.com, and dudh2010@126.com.

* Address correspondence to Donghong Du, Shandong Provincial Institute of Dermatology and Venereology, Shandong Academy of Medical Sciences, Jinan, Shandong, China. E-mail: dudh2010@126.com
16 7 2024
9 2024
16 7 2024
111 3 455456
22 2 2024
23 3 2024
© 2024, The author(s)
2024
https://creativecommons.org/licenses/by/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution (CC-BY) License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
==== Body
pmcA 73-year-old man sought evaluation for a pruritic, erythematous perineum lesion and hyperkeratotic crusted plaques involving the glans penis for 15 days. The physical examination was significant for perineal erythema with red papules, scrotum flushing, and hyperkeratotic crusted plaques involving the glans penis (Figure 1A). Because he was diagnosed with bullous pemphigoid (BP) 5.5 month earlier by histopathology (Figure 1C) and immunofluorescence microscopy (Figure 1D), the likely diagnosis was a BP resurgence. However, BP was stable with oral methylprednisolone tablets (24 mg/day), the primary BP lesions had resolved, and the autoimmune serologic profile and serial BP antibody testing (BP180 and BP230) were persistently negative. It is worth noting that combined therapy of methylprednisolone with mycophenolate mofetil was used for 4 months during BP treatment, and mycophenolate mofetil was discontinued 1 month before the current onset. A microscopic examination of the scrapings from lesions in glans penis demonstrated mites (Sarcoptes scabiei; Figure 1B). Ultimately, a diagnosis of scabies was made. Treatment with 10% sulfur ointment was effective after 3 days.

Figure 1. (A) Perineal erythema with red papules, scrotum flushing, and hyperkeratotic crusted plaques involving the glans penis. (B) Histopathology showed a subepidermal vesicles with abundant eosinophil infiltration in the papillary dermis. (C) Direct immunofluorescence showed a clear band of IgG and C3 deposition at the dermoepidermal junction (hematoxylin and eosin [HE] 40×). (D) microscopic examination of the scrapings from lesions in glans penis demonstrated mites (HE 100×).

Scabies is a skin infestation caused by a host-specific human scabies mite.1 BP is an autoimmune subepithelial bullous disease. However, the occurrence of scabies in patients with BP is relatively rare. A retrospective study revealed that 15 of 87 (17.2%) BP patients were diagnosed with scabies within 3 years of the initial BP diagnosis compared with 4.2% (11 of 261) of patients in the control group, which suggested an association between BP and scabies, but the basis for the association has not been established.2 In our patient with BP, we think prolonged use of methylprednisolone and mycophenolate mofetil may reduce the body’s immune system and increase susceptibility to infestation of S. scabiei. It is interesting to note that scabies lesion characteristics in glans penis were unusual.

Data Availability

The data that support the findings of this study are available from the corresponding author, D. Du, upon reasonable request.
==== Refs
REFERENCES

1. Sunderkötter C Wohlrab J Hamm H , 2021. Scabies: Epidemiology, diagnosis, and treatment. Dtsch Arztebl Int 118 : 695–704.34615594
2. Rozenblat M Halaj A Levi A Lapidoth M Ziv M , 2022. Bullous pemphigoid and scabies: Is there an association? J Drugs Dermatol 21 : 1009–1011.36074509
