A 67-year-old HIV-infected man presented with hyperkeratotic lesions on the hands and nails (Fig. 1a, b). He had a history of HIV-associated encephalopathy with persistent cognitive and motor deficits. HIV seropositivity was discovered in 1998 (CDC Stage C3). The patient had undetectable HIV load and CD4 count = 166/mmc load, following a PI-based therapy.

Fig. 1
figure 1

Clinical presentation of crusted scabies on the hands and nails. a, b Hyperkeratotic lesions and thick skin. c, d Full recovery after treatment

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Differential diagnosis included exacerbation of psoriasis, atopic eczema, paraneoplastic syndrome or mycotic infection. Examination of skin scrapings from crusted plaques revealed the presence of mites. Localized crusted (Norwegian) scabies was diagnosed. The patient was treated with topical permethrin (5 %) every 3 days for 2 weeks in combination with emollients and antikeratolytics. Oral ivermectin (200 μg/kg/dose) was also given in three doses (days 1, 2 and 8) [1]. After 1 month, there was a complete recovery of lesions (Fig. 1c, d).

Crusted (Norwegian) scabies is a rare, highly contagious skin parasitic infestation. The disease is usually reported in immunocompromised patients, such as people with HIV/AIDS, malignancies or those receiving immunosuppressive drugs [2]. Despite the severity of the disease, there is significant variability in the clinical presentation [3]. Crusted scabies is usually generalized in various parts of the body surface, but localized forms may also occur [4]. Progressively overlapping layers of hyperkeratosis and thick skin may produce the unusual clinical manifestations as seen in this patient. Thus, clinicians should be vigilant about localized presentation of crusted scabies especially in immunosuppressed patients [5]. A delay in diagnosis and treatment leads to dissemination of the infestation with increasing risk of sepsis and death, as well as scabies nosocomial outbreaks.