Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So, if you're ready, let's jump right in.
A 35-year-old man who is generally well was diagnosed with scabies three days ago and presents today with the chief complaint of, “I don't think that skin medicine that I was given worked. I'm still really itchy, and the rash looks the same.” He reports using topical permethrin as advised. Physical exam reveals excoriated papules in the interdigital area and scattered similar lesions throughout the axillary and groin regions. Microscope examination of skin scrapings support the scabies diagnosis. He is otherwise without new findings. The NP considers the following.
A. Another course of permethrin is advised to be used as soon as possible.
B. A skin biopsy should be performed today.
C. Low dose topical corticosteroids and an oral antihistamine should be prescribed.
D. A topical antibacterial is advised.
The correct answer here is C. Low dose topical corticosteroids and oral antihistamines should be prescribed.
Let's take a look. First, what kind of question is this? Given that the patient has been diagnosed and information in the question supports the original diagnosis of scabies and has been treated, this is in fact an evaluation question, or we're looking at response to care. So, let's take a look at some background information.
Scabies is a communicable skin disease that's caused by infestation with a host-specific mite. Close person-to-person, indeed, skin-to-skin contact is needed for infestation to occur. And in addition, contact with unwashed bedding and clothing used by a person with scabies can result in the disease. When we've all heard about those classic disease presentations of burrowing lesions with scabies in the interdigital spaces, in reality vesicular or papular-form lesions are more common and usually excoriated due to scratching. One thing that's a universal in scabies: people are itchy. It doesn't matter what the age is. The mites that cause scabies tend to burrow in warm places in the body. So think, yes, finger web folds. That's certainly part of it because that happens to be the warmest place on the hands. But go hunting. Go hunting. Look under the arms, in the groins or other skin folds, under the breast, through the genital. The diagnosis can be confirmed by microscopic examination of skin scrapings where the mites, their larvae, ova, and feces are identified. The intense itch reported with scabies is not in fact related to the infestation only, but is a hypersensitivity reaction to the mites, the eggs, and the waste. As a result, itching often continues for several weeks, even when treatment has been successful to kill all the mites and all the eggs. During a period of about 2 to 4 weeks post-treatment, the itch gradually wanes as the body removes the dead mites, eggs, and waste. The itch can be partially relieved with oral antihistamines such as hydroxyzine, diphenhydramine, something like an Atarax or a Benadryl. In addition, putting a low to medium potency topical corticosteroid over the egg areas will shall we say calm things down and make the person more comfortable. So, let's take a look now at the question and the answer choices.
A 38-year-old man who is generally well, was diagnosed with scabies three days ago. And today he presents with the chief complaint of “I don't think that skin medicine I was given worked. I was really itchy and the rash looks the same.” He reports using topical permethrin as advised. Physical exam reveals excoriated papules on the interdigital area and scattered similar areas to the axillary and groin region. Microscopic examination of the skin scrapings supports the scabies diagnosis. He's otherwise without new findings. The NP considers the following:
Option A. Another course of permethrin is advised to be used as soon as possible. This is not the correct option. What this does is this implies treatment failure. He was treated just three days ago, way too soon to deem treatment failure. If it is persistent for more than 2 to 4 weeks after treatment or if new burrow or papular-like rash lesions continue to appear, retreatment then should be considered.
Option B. A skin biopsy should be performed today. This is also not correct. His history and physical exam is consistent with the diagnosis of scabies. He's only three days into treatment with those classic findings. Skin biopsy would be appropriate perhaps if the diagnosis was in question. Maybe after multiple trials of failed therapy and emergence of atypical finding.
Option C. Of course we know that is the correct answer: Low dose topical corticosteroids and antihistamines should be prescribed. Indeed, the patient would have been spared this office if better advised on the continued intensity and duration of the itch associated with scabies, and medications to help with these symptoms were prescribed at the visit where the condition was diagnosed. Please, for humanitarian purposes, always make sure you give people with scabies an option to calm down their itch because they just feel as if they're going to lose their minds. So this person came in with what looked like it could have been a treatment failure from scabies. But once you know how the disease actually unfolds, even with treatment, you could say, Well, this was not treatment failure. We still have one more option to look at, of course, and we know it's not the correct answer because we already know C is correct, but D. A topical antibacterial is advised. This is not correct. On rare occasion, superimposed bacterial infection occurs with severe scabies. Usually, it presents with thick crusted lesions over the scabies lesions. The scabies has either not been treated, there's a severe infestation, or the treatment given was not successful. Usually, this is in a person with a degree of immunocompromise. In fact, the scenario that I propose is what the acute care RN has probably seen most often with scabies. But this is not the rule in the outpatient setting, particularly in an adult who, we are told in the scenario, is otherwise well. Remember every single word given to you in the clinical scenario in the stem or the body of the question is important.
What's the key takeaway? Knowledge of the course of disease is critical to clinical assessment diagnosis and treatment. As have been mentioned in other podcasts, in primary care, we typically see people with earlier disease making the presentation quite different from what you see in the acute care setting. On the family in the adult-gero primary care exams, you need to keep in mind outpatient treatment generally earlier in disease.
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