Are scabies and impetigo “normalised”? A cross-sectional comparative study of hospitalised children in northern Australia assessing clinical recognition and treatment of skin infections

Abstract

Background

Complications of scabies and impetigo such as glomerulonephritis and invasive bacterial infection in Australian Aboriginal children remain significant problems and the overall global burden of disease attributable to these skin infections remains high despite the availability of effective treatment. We hypothesised that one factor contributing to this high burden is that skin infection is under-recognised and hence under-treated, in settings where prevalence is high.

Methods

We conducted a prospective, cross-sectional study to assess the burden of scabies, impetigo, tinea and pediculosis in children admitted to two regional Australian hospitals from October 2015 to January 2016. A retrospective chart review of patients admitted in November 2014 (mid-point of the prospective data collection in the preceding year) was performed. Prevalence of documented skin infection was compared in the prospective and retrospective population to assess clinician recognition and treatment of skin infections.

Results

158 patients with median age 3.6 years, 74% Aboriginal, were prospectively recruited. 77 patient records were retrospectively reviewed. Scabies (8.2% vs 0.0%, OR N/A, p = 0.006) and impetigo (49.4% vs 19.5%, OR 4.0 (95% confidence interval [CI 2.1–7.7) were more prevalent in the prospective analysis. Skin examination was only documented in 45.5% of cases in the retrospective review. Patients in the prospective analysis were more likely to be prescribed specific treatment for skin infection compared with those in the retrospective review (31.6% vs 5.2%, OR 8.5 (95% CI 2.9–24.4).

Conclusions

Scabies and impetigo infections are under-recognised and hence under-treated by clinicians. Improving the recognition and treatment of skin infections by clinicians is a priority to reduce the high burden of skin infection and subsequent sequelae in paediatric populations where scabies and impetigo are endemic.

Author summary

Scabies and impetigo are common skin infections in children across the developing world as well as in disadvantaged populations living in developed countries. In previous studies including Australian Aboriginal and Pacific Islander children the rates of impetigo and scabies were amongst the highest described worldwide. The complications of these skin conditions include invasive bacterial infection, chronic kidney disease and potentially chronic heart disease and thus the burden of sequelae is significant. There are simple therapies which are efficacious in treating scabies and impetigo yet there has been little progress in reducing the burden of complications in endemic settings. We demonstrate in this study that scabies and impetigo, in a region with high prevalence of these conditions, are often not recognised by clinicians and appropriate treatment is not prescribed as a result of this. This is likely because clinicians ‘normalise’ skin infection where it is highly prevalent and therefore do not offer therapy unless specifically asked. The findings of this study have significant implication for health policy in regions with high prevalence of scabies and impetigo where focus should be put on improving health care worker recognition and awareness as well as exploring alternative strategies to individual case management of skin infection. Moreover future research should be directed at exploring the barriers to clinician recognition and treatment of these conditions and assessing specific strategies to ameliorate these.