Once upon a time, in the little village of Dunkelkratz, there lived a woman named Mabel. Mabel taught third grade at Groovy Acres Elementary School.
One day Mabel had an itch. Nobody at home was itchy, just Mabel. She went to her ob.gyn., Dr. Livious, who told Mabel she had scabies, a nasty bug that burrows into the skin. Mabel felt very dirty, even though she showered every single day. The nurse sealed off the room where Dr. Livious had examined Mabel and disinfected it.
Mabel called her principal, Dr. Pollicy, and told him she couldn't come to Groovy Acres that day because she had scabies. Mabel got the scabies medicine Dr. Livious prescribed at Frendly Farmacy and rubbed it all over her body. Then she bought insecticide at the Happy Pliers hardware store and sprayed it onto all the walls in her apartment. After that Mabel took all her coats and dresses to Mr. Spotless, the dry cleaner, who promised that in 3 days Mabel could pick them up for $750.
But Mabel kept itching, so she visited Dr. Skrepping, her dermatologist. Dr. Skrepping examined Mabel, asked about the other people in her house, and told her she didn't have scabies. He suggested that she not apply the medicine to her skin for a fifth time and also that she wipe the insecticide off her walls.
Mabel called Groovy Acres right away to share the good news. Dr. Pollicy told her that he had already sent letters to the parents of all the families in Mabel's class to warn them that their children had been exposed to scabies and should see their doctors right away.
Soon afterward, Frendly Farmacy ran out of scabies medicine, the Happy Pliers ran out of insecticide, and Mr. Spotless the dry cleaner closed and retired to the Cayman Islands.
My most memorable teacher in medical school was a gravel-voiced ob.gyn. professor who liked to specify the consequences of mistakes.
"What's the worst that could happen if you did that?" he would growl. "The patient could die, Rockoff," he would say. "Is that bad?"
I was supposed to answer yes, that was bad.
Many mistakes have consequences, but there seems to be a widespread notion that the costs of getting a mere skin disease wrong don't amount to much. The Mabels of the world—you've met them, too—might say otherwise.
Here is what happens when an itchy Mabel visits a walk-in clinic: The doctor presumes that she is sexually active because she is breathing. He identifies her 3-inch linear excoriations as "burrows." He learns that she itches more at night.
QED: scabies.
And if it isn't, hey, what's the worst that could happen?
Actually, plenty: a gratuitous feeling of being unhygienic, unnecessary use of insecticides, ruinous dry-cleaning bills. And, oh yes—if it isn't scabies, not getting better.
The role of fomites in spreading scabies is not completely clear. Some sources say mites can live off the body for a couple of days; others, that fomites are "not very important."
All agree that close physical contact is the most likely source of scabies transmission.
I recall reading years ago in Kenneth Mellanby's "Scabies" that British army researchers in World War II had subjects sleep in beds where scabies sufferers had slept the night before. Few contracted it.
The upshot is that, although just thinking about scabies makes people feel repulsive and itchy, it's really hard to catch mites from shaking hands, hanging your coat next to someone else's in a closet, or sitting on fresh table paper in an exam room just vacated by a person whom somebody else thinks may have scabies.
It would be unrealistic to expect busy primary or urgent care physicians to become adept at reading mite scrapings. Still, it would be nice if the word got out that diagnosing scabies can be tricky; many other things cause itch at night, and an incorrect designation of scabies can lead to major problems: medical, social, even financial. Physicians unsure of the diagnosis should, at a minimum, advise patients that if two applications of a scabicide haven't made much difference, then what's needed is not a third one, but a new diagnosis.
Mabel, by the way, took a second job as a meter maid to cover her dry cleaning bills and lived happily ever after.