Crusted Scabies and Facial Involvement in Adults
Yes, crusted scabies can definitely occur on the face in immunocompromised adults, and facial/scalp involvement should be specifically treated in these patients.
Clinical Presentation in Immunocompromised Adults
Crusted scabies (Norwegian scabies) is a severe, highly contagious variant that occurs primarily in immunocompromised, debilitated, or malnourished individuals, with the skin harboring thousands to millions of mites rather than the typical 10-15 mites seen in ordinary scabies 1.
Unlike ordinary scabies in healthy adults where the scalp and face are typically spared, crusted scabies frequently involves these areas in immunocompromised patients. 2 Specifically:
- The hairline, neck, temple, and forehead are commonly infested in immunocompromised adults with crusted scabies 3
- Scalp involvement has been documented in institutionalized elderly and immunocompromised patients with crusted scabies 2
- The condition presents with thick yellow-brown crusts, hyperkeratotic plaques with clear boundaries, and deep fissures that can appear anywhere on the body including the face 4, 5
Why Facial Involvement Occurs
The massive mite burden (thousands to millions of organisms) in crusted scabies allows for widespread distribution across all body surfaces, overcoming the typical anatomical sparing pattern seen in immunocompetent adults 1, 6. Immunosuppression from conditions like HIV, hematologic malignancies (such as adult T-cell leukemia/lymphoma), chronic corticosteroid use, or other immunosuppressive medications creates the permissive environment for this extensive infestation 7, 8.
Treatment Implications
Aggressive combination therapy is required for crusted scabies with facial involvement:
- Topical permethrin 5% cream applied daily for 7 days, then twice weekly until cure, INCLUDING the scalp, face, and all body areas 1
- Oral ivermectin 200 μg/kg on days 1,2,8,9, and 15, taken with food 1, 9
- The multiple-dose ivermectin schedule addresses the massive mite burden and limited ovicidal activity of the medication 1
Critical Pitfalls to Avoid
- Do not use single-application permethrin as recommended for ordinary scabies—this will fail in crusted scabies 1
- Do not skip facial and scalp treatment in immunocompromised adults, even though these areas are typically spared in healthy adults 3, 2
- Do not use topical therapy alone without oral ivermectin—the mite burden and thick crusts make monotherapy insufficient 1
- Avoid lindane in immunocompromised patients due to neurotoxicity risk 1, 9
Monitoring and Isolation
Patients with crusted scabies require isolation to prevent institutional outbreaks, as this form is far more contagious than typical scabies 1, 5. All close contacts must be treated simultaneously 1, 9. The condition carries high mortality risk primarily from secondary bacterial sepsis 5.