A 45-year-old man with
AIDS presented with extensive
erythema and scaling involving the face, trunk, and upper and lower extremities, and mild nail dystrophy. The patient had been diagnosed with
psoriasis 2 years previously, and at the time of presentation was using
emollients and topical
corticosteroid creams with little improvement. He was receiving
zidovudine,
lamivudine,
trimethoprim/sulfamethoxazole,
acyclovir,
rifabutin, and
hydroxyzine. Pertinent laboratory data included CD4 lymphocytes (10 cells/mm(3)), viral load (32,000 copies per mL) white blood cell count (3.4 x 10(3)/microL),
hemoglobin (13.5 g/dL), and platelets (204 x 10(3)/microL). Because of the extensive eruption and lack of response to topical agents, the patient was started on
acitretin 25 mg daily. The patient had shown no signs of improvement 4 weeks later and was noted to have brownish gray crusted plaques involving the beard area, neck, upper part of the back, arms, trunk, genitals, and thighs in addition to his
erythroderma (Figure 1 and Figure 2). Microscopic examination of scales from the upper part of the back revealed numerous
scabies mites and eggs. He was then treated with
lindane shampoo on the scalp and beard area and
permethrin 5% cream to the body. The patient returned 2 weeks later with some improvement after thrice-weekly applications of this regimen; however, scrapings from the trunk once again revealed live
scabies mites. Microscopic examination of scales that had fallen on the
examination table revealed multiple mites and eggs. The patient was then given
permethrin 5% cream, which he applied 3 times a week for 2 weeks, and 1 dose of oral
ivermectin, 200 micro/kg. This resulted in a marked decrease in crusting and scaling. With resolution of the
scabies lesions, the patient displayed marked
erythema and scaling of the trunk and extremities consistent with generalized
psoriasis (Figure 3). Treatment with
acitretin resulted in gradual resolution of the
erythroderma. A few months later, the patient presented with nodules on the upper part of the back, which on biopsy revealed a
scabies mite (Figure 4).