An 8-month-old infant presented with a 30-day history of intensely pruritic nodules on the right axilla, chest and abdomen. His parents also reported the recent onset of itching, particularly at night. Despite various topical treatments, the lesions persisted. On examination, the child had excoriated, erythematous papular and nodular lesions (Fig. 1 and video). Laboratory tests revealed leukocytosis with eosinophilia. Although a biopsy was declined, clinical findings supported a diagnosis of nodular scabies. Initial treatment with 5% permethrin lotion was applied overnight and repeated after one week but was discontinued due to irritation. As nodules remained, a 6% sulfur ointment was applied in two cycles. After eight weeks, topical steroids were introduced for post-scabietic nodules, along with a two-week course of 0.1% topical tacrolimus, with good results.
Nodular scabies is a chronic and less common variant of scabies, characterized by persistent, itchy, reddish-brown nodules. It primarily affects individuals in overcrowded or low-income areas.1 Biopsy and laboratory tests are not required for diagnosis, although dermoscopy or the Müller test can help detect mites or burrows. Other insect bites should be ruled out.2 Treatment typically involves permethrin, and alternative therapies such as topical steroids and tacrolimus are effective for managing post-scabietic nodules.3
