Ep 159 Scabies: Tiny but Mite-y

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My opportunities for observing scabies were extensive in the Confederate Army.

Our soldiers were badly fed, badly clothed, soap was scarce, and army itch, as it was denominated, was painfully plenty.

Army itch is nothing more than scabies, with eczema or impatigo or ecstema or some other dermatosis superadded.

In 1862, in the Confederate service, I became the subject of Sarcoptes hominis.

At the same time, several generals and some very elegant ladies of my acquaintance were my fellow sufferers.

At first, the itching was not only not unpleasant, but was positively delightful.

Very soon, however, the pruritis became terrific.

I often awoke at night exhausted and panting from violent scratching begun in my sleep.

I lacerated the skin with my nails to abate the tortured itching, for the smarting pain of the abraded surface was far preferable to the praritis.

Sulfur ointment relieved me entirely in three days.

The only difference I can discover between the army itch and scabies, as it is met with in civil practice, is a difference in degree.

Soldiers frequently neglect to apply for treatment until they are completely covered with the eruption, and in such cases, it is sometimes so marked by lacerations made by the patient's nails and by secondary eruptions that it would be difficult to recognize the disease.

It is not surprising that the disease should cover a larger extent of the surface and appear upon the outside of the limbs as well as in the flexures, when we consider the crowded manner in which soldiers live in their tents or barracks and the carelessness that exists among them in regard to personal cleanliness.

That's a little harsh, isn't it?

It is a little harsh.

So, those were quotes from the American Civil War about scabies, which was apparently very endemic, very prevalent throughout both armies, throughout the towns where the armies passed through.

And those quotes themselves were from a couple of places.

One, the first one was from the book The Itch, Scabies, by Errol Craig.

And the second was from an article by Cropley from 2006 titled The Army Itch, a Dermatological Mystery of the American Civil War.

Mystery, was it?

Was it?

Was it?

I think the mystery was concluded to be like, it was scabies.

Scabies.

It was definitely scabies.

It was really, really bad scabies.

And like, probably combined with just the general grossness that accompanied everything.

I can only imagine.

I mean, I feel like I remember quotes from our typhoid episode, and it was just like pooping near water sources and stuff like that.

It was just...

Pooping in holes was our very first episode.

But probably applies.

It was also, yeah, scabies was also prevalent during World War One, blah, blah, blah.

All the wars.

You know, that's jumping ahead of things.

Hi, I'm Erin Welsh.

And I'm Erin Almond Update.

And this is this podcast will kill you.

If you haven't guessed it, we're talking about scabies.

It's all just sabies today.

Scabies.

Scabies.

I

am really excited for this because we haven't done something like this in quite a while, it feels like.

You know how when we were doing Norovirus, you were like, I was so nauseous recording this episode.

I have never been so itchy.

recently when I actually did have lice

and it really like made me feel like I, I was like, do I have, do I have lice again?

Like, I, I was so, so, so, like, I'm surprised that I don't have wounds from how much I was scratching myself

reading about skeeties.

Um,

I did not feel that itchy, and I don't know why.

I don't know.

Maybe because the history?

I mean, but there were like a lot of excerpts about the itchiness.

I guess maybe I didn't read read as much about like the, these widespread outbreaks,

but people certainly talked a lot about the the itch and also like how enjoyable like that's something that I found really strange is that like that's not the first firsthand when I was talking about how enjoyable it was to itch or to scratch the itch.

Yeah.

Um, that's not the only time I encountered that sentiment.

How interesting.

And then somebody else was like, anyone who actually had scabies probably does not agree with this.

And like, so that's like just what doctors would say about it back then?

But like, yeah, I, I don't know.

I mean, maybe I, I do, I will say that when I had really bad poison ivy,

that first hit of the hot water from the shower head and it would just itch

scratch it in such a delightful way, but then it would lead to uncontrollable itching.

Yeah.

Yeah.

Some maybe I can relate.

Anyway,

speaking of itching and scratching, it's quarantining time.

It's quarantiny time.

What are we drinking this week?

We're drinking the itch, Eric.

The itch.

The itch is, you know, this episode is coming out early December.

I feel like it's nice cozy times.

So we're doing a cozy drink to hopefully soothe any sort of itchy feeling you have.

It is essentially it's like gingerbread vibes is what we're going for.

So we've got rye whiskey, we've got a little bit of orange juice, a little bit of ginger ale, and then like a spiced syrup with molasses and spices.

It's going to be so yummy and cozy so that you can cuddle up by the fire and scratch your itches.

You can find the full recipe for that quarantini as well as our non-alcoholic placeburta on our website, thispodcastwikadi.com and on all of our socials.

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we'll take a quick break and then talk about the biology of scabies

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I have to just start this way because it was one of those moments of, you know, when you see something in one place and then you can't stop seeing it everywhere?

Yeah.

So we just recorded our episode on strep pyogenes and scarlet fever.

So ready for this?

I'm ready.

The first paper I read about scabies, it was a review in The Lancet from 2006.

It was a great paper.

They start off, literally start off the paper saying, I'm going to quote here, quote, scabies is a neglected parasitic disease that is a major public health problem in many resource-poor regions.

It causes substantial morbidity from secondary infections and post-infective complications, such as acute.

post-streptococcal glomerulonephritis.

Oh,

gee.

I know.

And now everyone knows that that is.

It's when your kidneys get attacked by your own self after a strep infection, which is a major complication of scabies infection.

So let's get into it, shall we?

Yeah.

Okay.

But like, why?

Is it just because strep is one of our, is on many people all the time?

Yeah, it's because impotigo, which is the main like superficial skin infection caused by strep,

is the main risk factor for post-strep glomerulonephritis.

And scabies is a major risk factor for a whole bunch of like secondary skin infections, but skin infections are mostly caused by either staph or strep.

And so if it's strep, then you get this.

Oh my goodness, it's terrible.

Let's get into it.

Yeah.

So scabies is an infection of your skin, but it's an infection of your skin, not with a bacteria, not with a virus, but with a mite called Sarcoptes scabiae, variant hominous.

And I feel like people might not know what the heck a mite is.

So a mite is an arachnid, which means it's more closely related to spiders and ticks than like mosquitoes or other insects.

But I feel like when you look at pictures of, especially these particular mites, they look more like tardigrades, like water bears.

Absolutely do.

Yeah.

They're kind of cute.

Yeah.

Maybe not as cute as like a louse, but pretty cute.

Yeah, I don't know.

I kind of feel like they're cuter than a louse, but

you can be your own judge.

So they have this like little head.

You can barely even see that they have a head.

They kind of just have these little chompy mouth parts.

And then this really big, fat, chunky body with these little rolls of like toddler legs that don't look like they should be able to touch the ground.

And then they have little hairs coming off of them.

Yeah.

And I don't know.

They're kind of cute.

But when I say that they're pictures right now.

Right.

right?

Especially all of the like generated images that aren't like real pictures of them under a microscope.

They're, they're really cute.

They like the face app.

What's it called?

Yeah.

One of the Instagram face filters.

Put it on.

Once you put the filter on the mite, it is, it is much cuter than the louse.

I, I take back my, my earlier claim.

Uh, they do have a lot of spikes on them.

They have a lot of little hairs.

Yeah.

But this one, oh, that must be computer generated.

Yeah.

It's like on the skin it's very cute and i'm like awhile right it looks like a little teddy bear like a toddler they're very cute anyways they're also incredibly tiny and aaron you asked before we recorded yeah can you see these mites

and that paper that 2006 review paper in the lancet described them as quote at the limit of human visibility And of course, every paper cites how big they are, but I have a real hard time conceptualizing how tiny something is when you give me a number.

So, here is your concept, Erin, of how small they are.

Ready?

Okay, great.

Size 12 font.

We all know that size, right?

Did you know that that size, like font sizes are based on measurements?

And size 12 font is a unit of measure called a pica.

I learned a lot on Wikipedia.

It's just over four millimeters.

That's how big size 12 font is.

These mites are size one font.

I'm not sure what you mean by 12, like what do you mean?

If you typed on a piece of paper and printed out size 12 font,

it would be four millimeters each letter.

Oh, each letter would be four millimeters.

Gotcha.

Yeah.

Okay.

Yeah.

So mites are, if you type into your computer and change it to size one font, that's how big a mite is.

So, okay, but like.

like an H or like a C or like a period or an A common C specific of questions.

Yeah, like I, I mean, because an H

is very different than a period.

So, like, what?

So, not a period, like a letter.

Right.

Like a letter, like a, like a typical letter in

size one font.

Type it into your computer.

You can see it.

If 0.4 millimeters, and there's a range.

So maybe like an M or an H.

I don't know.

There's a range.

And the males are half that size.

So the males are even tinier.

Okay, I'm doing it with a T because that was the first one that came up.

There you go.

One.

I can't see it.

Yeah.

If I zoom in, I can see it.

Exactly.

I wrote the word scabies in size 12, and then I wrote it in size 1 next to each other just to keep that in my mind for this whole episode.

So they are very, very, very, very small.

0.4 millimeters is the average size for a female mite.

And the female mites are the ones who actually cause disease.

So these mites, Sarcoptis scabiae, variant hominess, is a human-specific mite.

There are a lot of different mites in the same genus Sarcoptes that cause disease in other animals.

And much like our friends, the lice, they tend to be very species-specific.

So every species of animal has our own species of mites.

We also have lots of other mites that live on us called dermodex mites, and these tend to not cause disease, but sarcoptes sure does.

And their life cycle cycle goes a little something like this.

Adult males and females find each other on our skin.

They mate, and then the male dies.

And the female then burrows herself into our skin.

And conveniently, we've talked about our skin layers relatively recently on our retinoids episode.

So these mites are staying incredibly superficial, only in that epidermal layer.

So that very first layer of our skin.

And even within those layers of the epidermis, they only go to like about the middle part of our epidermis.

So they're really superficial.

But in order for something so tiny to burrow underneath our skin, they spit out an enzyme that essentially dissolves our skin cells.

And then that's what they eat.

So they feed on our dissolved skin goop.

Yeah, it's kind of like maggots in that way.

Sort of, yeah, exactly.

Just really small.

And they're really efficient.

They burrow pretty quickly.

It takes them about 30 minutes to make their little nest.

And in their little nest, in their burrow, in our epidermis, they lay a whole bunch of eggs.

How much is a whole bunch?

I knew you were going to ask.

So we'll do some Aaron math to tell you exactly.

They lay, some sources say like one to three or two to four.

So we'll call it an average of two eggs every day.

Okay.

And those eggs take like three or four days to hatch.

And they live underneath our skin for about four to six weeks.

And after the eggs hatch.

They lay two eggs a day, every day for four to six weeks.

Oh, I see.

Yeah.

Yeah.

Okay.

So that's about, if you call it an average of two eggs a day for an average of five weeks, it's about 70 or so eggs that each female mite is depositing.

And then at the end of that four to six weeks, they're just like, peace out.

Oh, okay.

Yep.

They die.

They're dead.

Okay.

A few questions here.

Give it to me.

When they hatch, where do they hang out there?

Do they have to find their own burrow?

Do they just go down the skin a bit?

Like what?

What's going on?

Great question.

So when they hatch, they're, of course, like larvae, or they call them like proto-nymphs.

So they have to eat our skin goop and then molt and grow two more times before they become adults.

And then they will go out onto the surface of our skin and find a mate of their own.

And that process takes a couple of weeks, so like 10 to 14 days to go from hatched egg to adult.

And in theory, they could do this on your body or on another human body if they're transferred to another host.

Because the female is laying eggs continuously for that chunk of time, this can be like a growing infection.

It's not self-limited.

It can be, but the average mite burden is surprisingly only about 5 to 15 mites per person, which is a lot lower than something like the louse burden can be.

And it's honestly a lot lower than I expected.

A lot of this probably has to do with our immune response to the mites.

And we'll get into that in a little bit more detail.

However, there is also a condition called crusted scabies.

And in that situation, a person can be infected, unfortunately, with hundreds, if not thousands of mites

because they essentially can just grow and continue to grow unchecked by our immune system.

Okay.

Ooh, yeah.

How does that

play into this?

Okay.

Okay.

Yeah.

If there's any good news, aside from the fact that most of the time the mite burden is relatively low, transmission also tends to require body contact and is not as much reliant on fomites.

So like bedding or clothing or things like that, which you might think of with things like body lice.

It's a little bit easier to transmit that way.

Yeah.

They only live for a couple of days max off of the body, but most of the time, because the mite burden is relatively low, there's not a lot of transmission that happens from things like bedding or clothing.

It usually takes 15 to 20 minutes of skin-to-skin contact for mite transmission to happen.

Got it.

Yeah.

And it has to be the female mite.

Yeah, it's the female mites that are causing the disease that are the ones actually burrowing into our skin and causing disease.

What proportion of eggs are male and female?

I have no idea.

What a fun question.

No clue.

Can scabies,

sorry, I can't.

I love it.

I love when I can see on your face that you're just like, I have so many questions.

I do.

Can scabies mites, are they known to transmit any pathogens?

Exhibitions.

No, not any pathogens to humans that we know of.

Thank you.

Okay.

So as this mite burrows into our skin, as I kind of alluded to, it really does kind of set off our immune system in a way that's really important.

We heard in our first hand account just how itchy scabies can be.

But I just said that the mite burden itself is usually relatively low.

And it turns out that the itchiness and the main symptoms that people get from a scabies infection are actually caused by a hypersensitivity reaction to the mites, to the mites themselves and to the feces, to the poop that the mites are leaving in their burrow.

Just like fleas, right?

Fleas can do that.

Poison ivy, Erin.

You mentioned the itch from poison ivy and how you like very specifically have like reactions to hot water and things like that.

This is the same type of hypersensitivity reaction, which also means that this itch is not limited to the places where the mites are.

The itch is everywhere.

It's a generalized, incredibly itchiness because it's a hypersensitivity reaction everywhere.

The mites themselves most often infect places like your wrists, the like interwebs between your fingers or toes,

the areas underneath your waistband, armpits, groin,

places like that, places that are kind of like little areas that are easy for them to like nestle their way in.

And sometimes you can see the areas where scabies actually infest.

And then when you can see them, they're described as like this one little kind of nodule or vesicle, this one area where the mite has actually made its burrow.

And then a little curvy, very short little curvy burrow that just looks like either a red or a dark or a gray or a purple kind of line.

And then maybe a little vesicle in the place that the mite is now living, like at the end of her burrow.

Okay.

But most of the time you can't see that at all.

And what you see instead are scratch marks all over a person's body from itching.

You can see other like nodules that appear are other bumps that are all a part of your immune response to these mites and to all of the antigens that these mites are producing.

And the itch tends to happen weeks after the initial infection.

It's not like right away.

Unless you've been infected with mites before, in which case, immediately will you feel itchy as soon as that mite makes her home.

Yep.

That,

I mean, it makes sense.

Yeah.

It makes sense.

It does.

I had no idea.

Weeks to mount an immune response is wild.

Yeah.

Yeah.

Yeah.

Be honest.

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Now, there is another phenomenon I mentioned: crusted crusted scabies.

And this is what happens when there are very large numbers of mites that can establish an infection.

But in this case, there is very often an association with some kind of immunodeficiency, whether that's HIV, whether it's topical or systemic steroid use, whether it's people who are on immunosuppressive medication because of an organ transplant, or maybe they are malnourished.

lots of different potential reasons that you could end up with crusted scabies.

But these situations are very, very severe because what happens is that there are so many mites that you end up with these severe like plaques where the skin is growing.

It becomes hyperkeratotic, which is that very thick, very scaly like plaques and scales.

And these can flake off and they harbor a lot of mites, which is why it's more easy for things like bedding or clothing to serve as a source of infection in these cases.

Got it.

Okay.

In all cases of scabies, there's a very high risk of secondary infection, which means everywhere that you're scratching and there's a break in the skin, it's really easy for bacteria like streptococcus and staphylococcus to get into those wounds and then cause either skin infections or especially in the cases of crusted scabies, more severe infections like bloodstream infections and sepsis and even death.

So scabies is kind of a big deal, especially because as we'll talk about later, it's still really, really prevalent.

There seems like there are many different options for treatment.

There are.

What are those options?

And is there any, are there like treatment resistant mites or scabies?

Yeah, there are.

So most of the treatment options, and there are a lot of different kinds, most of them are topical, which means that they're lotions, creams that you're putting on all over your body.

Because again, you're not sure exactly where the mites are most of the time.

So the treatment really has to go kind of everywhere.

And there are things like permethrin.

That's what we use most commonly here in the States.

Benzylbenzoate is another one or sulfur compounds.

And these are all generally very effective, but there are a number of different things that can contribute to either them being difficult to implement.

Like some of these require multiple applications multiple times a day for multiple days in a row, which can be sometimes difficult to do.

And some of them can cause a lot of other skin reactions, like they can be itchy, they can cause stinging and burning and be really uncomfortable to put on.

Then there is also insecticide resistance, especially to things like permethrin.

So yes, we do see some resistance.

And this is something that can also be induced.

Like if you are repeatedly applying it, especially maybe not to all surfaces of your body, things like that, then you can have resistance start to appear.

But most of the time we still rely on topical treatments.

There is an oral treatment as well.

Everyone's heard of it now.

It's ivermectin.

I knew you were going to say that.

Ivermectin is a phenomenal option.

We've talked about it on this podcast before because we use it for a lot of other parasitic diseases, especially worms.

That's what it's mainly used for.

This tends to be used for things like crusted scabies, which requires both oral and topical treatment because it's so severe.

It also can be used as a second line if you treat someone with a topical and it doesn't seem to go away, or in areas where you have really, really high prevalence of scabies, then sometimes oral ivermectin is used as what's called mass drug administration.

So giving it to an entire community to try and really wipe out scabies.

But there's a couple things that are important to know about scabies and the treatment for scabies.

First is that again, sometimes people don't have symptoms of scabies for weeks because it takes weeks for that itch to first appear.

But even after someone is treated, it can take weeks for their symptoms to get better.

And that's again, in part because so many of these symptoms are due to our immune response to the mite antigen.

So these treatments are wiping out the mites, but they're not necessarily treating the symptoms of the itch themselves.

Okay.

Reinfection can also happen because especially when we use topical treatments, mites can hide in some places, like under the fingernails.

And so that's why sometimes it's hard to know: are the symptoms still there because the mites are still there, or just because the symptoms haven't gotten better in a couple of weeks.

But usually, if it's not better in a couple weeks, then you have to think: is there a re-infection, or was it not scabies to begin with?

Gotcha.

So, Aaron, yeah, why

do we scratch?

Why do we itch?

Why do we scratch?

Why does scratching relieve an itch?

I have no idea.

I actually can't believe that's the first time that you've asked me that question.

I know.

Like, we've talked about itching before.

I don't know.

What does it, what does it do?

I mean, it's got to be releasing some like neurotransmitters, right?

That are, that are interacting with whatever the receptors are that are causing us to feel that itch.

Then scratching somehow does something to help relieve that.

But I don't know.

Yeah.

And like, what an interesting episode.

Yeah.

Just itching.

Yeah.

I, yeah, because like if, if it's something that's immune mediated, something that's like driven by, you know, like we, we control that.

Our bodies control that.

Is it adaptive?

Is right evolutionarily.

Now I'm thinking like, what is the

benefit of an itch?

I mean, there's probably many different things.

Like if there's maybe if you feel a mosquito or something on your body, I don't know.

Right.

Oh, that's such an interesting question.

I don't know.

And now I need to look into it.

I didn't research itching, Erin.

I wish I sorry well just like it's you know like how the itch is described as pleasurable at first or like to scratch it is pleasurable at first and like why does it feel good to have your back scratched your arms scratched you know like what yeah those head scratchers and head sculpts scratchers those are yeah i don't know what an interesting question aaron we're gonna have to look into it yeah we will okay well but i would like to know yeah

Where did these babies come from?

No, I mean, like, are you going to answer that?

I don't know.

They're just with us.

I'm going to answer something.

Okay.

Let's take a quick break and we'll see what I talk about.

Today, you can't define the word scabies without mentioning the mite that causes the itch.

And in that same vein, you can't describe that mite, Sarcoptis scabiae hominis, without including that it causes skin infestations in humans.

The mite and the itch are indivisible, entwined, inseparable.

But that hasn't always been the case.

I love that.

Aaron, I was like, I'm feeling that that's not how it always was.

You know how I love a leading statement.

I love it.

For centuries, the itch and the might stood separately in the eyes of medicine with no clear causal relationship between the two.

And I call out medicine specifically.

because that's where the confusion remained about the cause of scabies until shockingly late in the history of medicine.

Okay.

Among the lay people, the peasants, the commoners, scabies was well known for thousands of years to be caused by a creature and that it was the creature moving from person to person that spread the itch.

I love this story already.

I am bought in.

When the mite was finally widely recognized by medicine to cause the itch with a capital I, as it was kind of known, it was like scabies was known as the itch.

The itch, right.

It wasn't like

of all the things that itch itch you, this was the one.

The one.

Yeah.

Yep.

Capital I.

And this recognition marked a huge turning point in the history of science and medicine.

It called into question concepts like the humoral theory of disease or spontaneous generation, where life just comes spontaneously out of the maggots on the meat.

Inorganic material.

Exactly.

Yep.

Yeah.

Which both of which had been accepted as truth, or at least had been leading leading causes of explaining the world around us for hundreds, if not thousands of years.

The recognition of the might-causing scabies led to contentious rivalries with public humiliation, prize money, and medical demonstrations.

It could even be argued that the might-itch connection primed the scientific world to accept Louis Pasteur's germ theory of disease in the following decades.

Stop it, Aaron.

I know.

Would you have have believed that this little mite had this much up its little mighty sleeve?

I certainly had no idea.

I love it.

But before we get into this mite revolution, as I am calling it, let's travel back to where it all began.

But where and when that is, we don't fully know.

Surprise.

No surprise.

One hypothesis suggests that humans and early human ancestors have been infected for millennia with this mite, and that other Sarcoptis scabiae varieties evolved from our human mite.

So for instance, the mite that causes one type of mange in dogs and other canids was thought to jump from humans to dogs after domestication.

But another hypothesis suggests the opposite happened, that when we welcomed dogs into our lives, we also welcomed a hitchhiking mite that adapted to live on us and cause us to itch.

Okay.

I don't know.

As far as I could tell, how humans and mites got acquainted with one another has yet to be fully resolved.

And maybe it will be by the time we do our mange episode, which we will be doing at some point in the future.

Don't worry, we did not.

This is not mange erasure.

This is not wombat mite erasure.

We're going to cover all of the wildlife animal mange scabies situations at some point.

And as to the question of when people first described scabies, the itch, it's also less than fully resolved.

So some people point towards a line in Leviticus in the Old Testament suggesting that the Hebrew term zaroth, which meant some sort of skin malady, actually meant the itch or scabies or was referring to that.

Others say that it was the ancient Romans who distinguished scabies from other skin conditions.

And in fact, the term scabies comes from the Latin scabari, scabberi, meaning to scrape or to scratch.

Much later, the might genus name sarcoptes comes from the Greek word sarcs for flesh and coptian for to smite or cut.

Gobble gobble gobble skin.

Yep.

Gobble, gobble gobble.

The ancient Romans also proposed what would have been and actually remains, as you mentioned, Aaron, an effective treatment for scabies, sulfur with liquid pitch.

Others still say, nah, the Romans got it wrong.

It was actually in ancient China that the first true scabies description was made.

And not only that, but unlike the Old Testament and ancient Rome, which just made note of the skin condition itself, the itch itself, this early medical text from China in the 500 CE included mention of the parasite.

Quote, the itchy scabies sores always contain a tiny worm.

We can extract it with a needle and see its worm-like shape when it is dropped into water.

End quote.

Well, that's weird.

I think when we think of worm, we think of like earthworm.

And I think that's not necessarily what, because the worm pops up a lot in descriptions of skaties over the years.

But does worm not, I mean, because the burrows are sometimes described as like serpigyanous, which to me, I mean, that's like snake-like, but I think of that as kind of wormy.

But I, is a worm not always kind of like long and wiggly?

I mean, if it's so tiny, like, can you even tell?

It's just like no, that's what, that's what I think is weird.

I mean, because our other demodex mites are longer.

Their bodies are like a little kind of more tubular.

Tubular, total.

But these mites are just so round.

I just, but I don't know.

Maybe worms were different.

Also, this is translated.

So like, I don't know if

worm, if that is the closest approximation to.

Yeah.

Yeah.

Yeah.

Unfortunately, as is the case for so much of the history of medicine, information from the non-Western world rarely makes it into reviews about this topic.

And so it's really like, is, you know, is the worm the closest approximation?

Is that the right translation?

I don't really know whether that perception in terms of the worm causing the itch remained the predominant view, right?

Like that's, but we do have that text.

In any case, in European medical writings, the mite wasn't really mentioned alongside scabies.

Like scabies was just itch, right?

The itch.

The itch was thought to be caused by what other than a humoral imbalance.

Humoral imbalance.

And thus treated with all sorts of horrid little things like purges, foul-smelling salves, bloodletting, and so on.

Meanwhile, though, in the non-medical crowd, people knew what was up.

Like peasant women, quote unquote, knew that you could extract little bits from the skin to relieve the itch, a practice disregarded by medical men for being vulgar.

A medical text from the 11th century in the Middle East says, quote, the little flesh worms which crawl under the skin of the hands, legs, and feet and there raise pustules full of water are called sirens, esoabat and esoab.

So small are these animals that they can hardly be seen by the keenest of vision.

End quote.

I mean, I would agree with that.

It's true.

Size one font.

Size one.

Saint Hildegard of Bingen, do you remember her from our migraines episode?

So she wrote about her visions and some people have said that these were migraine aura, not actually like, you know, or like aura inspired these visions.

Right, right, right.

So she wrote around the 12th century that, quote, there is another mint, which is large.

It is hot rather than cold.

This should be crushed and placed above and around the place where the surin or snevelsin are hurting the person with their nibbling, and they will die, as the coldest of the same mentha major is rather bitter and therefore kills the above-mentioned little worms, which are born in the human flesh.

Hmm.

End quote.

So it's a little bit of spontaneous generation there.

A little bit of worms.

Yeah.

Worms are a thing.

Yeah, I guess so.

Yeah.

It might just be like bugs, you know, like these little critters.

Yeah, maybe, maybe that's what they mean by worms, huh?

Yeah.

Interesting.

And these passages I think are really interesting because they show two things, right?

They show that people definitely observed the mites, even if they called them worms, in association with the itch.

Right.

But they didn't necessarily make the link that they caused the itch.

Like there's not necessarily a causal relationship.

Right.

Like

they're there.

They're there.

And the itch is there.

But they're also like, if you get rid of them, you'll feel better.

But also in some of these, it seems like they're describing the mite as arising from the itch, if that makes sense, like a product of the itch.

Interesting.

Yeah.

Over the next few centuries, a few passages here and there allude to the possibility that the mite could be the cause of this itch, but they were overshadowed by the predominant belief that the mite was not related to scabies and that scabies was caused by a humoral imbalance.

As to how it could be contagious, which it was recognized to be, that was explained simply by that the bad scabies humors contained in the blood could reach the skin and transfer it to other people that way.

You know, kind of love when you have an explanation for everything that just involves

fluid.

But the tide started to turn in the 17th century with two major advancements.

Number one, the first known depiction of an infectious organism.

And number two, the quote, first comprehensive description of an infectious organism causing disease, end quote.

Scabies.

Scabies?

Scabies.

This is the first one.

Comprehensive description of an infectious organism causing disease.

Scabies.

Scabies, according to this book.

And a few other things I've come across in papers.

Yeah.

Wow.

Yeah.

I never knew that, Eric.

I, me either.

I never suspected scabies.

It kind of makes sense, though, because they're bigger.

Exactly.

So they're easier.

Like, yes, you still need a microscope to really see them well.

But like, if you have better eyes than me, maybe you can see them without, or even just like a a magnifying glass, which they had back then.

But like, what about like

lice and like typhus?

Yeah, that's fair.

But I mean, it sounds like scabies were, it could have, it feels like it could have been either.

Yeah, exactly.

Yeah.

Well, okay, so in 1657, using an early microscope, physician August Hauptmann published a description of the scabies mite, including an illustration.

A little oval, six-legged, tiny thing with four long hook things coming out of its rear.

It's a very interesting, very interesting

drawing too, with only six legs.

I mean, let me see if I can find a picture of this, Erin.

Okay.

Oh,

isn't it cute?

It's very cute.

Yeah.

It really doesn't look that much like a.

It's not very detailed, but

it's got the little things shooting out of its right.

I don't know.

I don't know what those are.

It's cute, though.

Not perfect.

But it was the second advancement that would really get things going.

In 1687, Italian physician Giovanni Cosimo Bonamo, who was 24 at the time, and scientist Diacinto Sestoni, who was 50, wrote a letter to Francesco Redi, a well-known naturalist.

And in this letter, Bonamo described how, while working as a physician on a ship carrying enslaved individuals, he saw men removing small little bits from each other's skin to help relieve their itch.

He also saw poor women picking out little pieces of material from their kids' skin using a needle.

And what makes Bonamo's observations unique is not that he was the first physician to witness this practice and note it, it's that he thought there might be something more to it and actually followed it up with research.

He enlisted the help of his father's colleague, Sistone, who had the good fortune of possessing a microscope.

Using this microscope, they examined the material that came from their patient's itchy skin and found mite after mite, even mites laying eggs, like they watched mites laying eggs.

Whoa.

And they noted that these creatures behaved like insects and they reproduced.

They laid eggs and they lived in burrows in the skin, causing the itch.

not coming to life because of the itch, not there randomly.

These mites, they hypothesized, were the direct cause of the itch, which had haunted and plagued humanity for millennia.

Wow.

They weren't the first to describe this though, right?

Like they literally watched people picking mites out of each other's skin.

Everyone was like, get, dude, we knew this.

Get with the program.

Like,

welcome.

Welcome to the club.

So I think in that, in that regard, it's not necessarily fair to say that they were the first to make this connection, but they were the first in a scientific, formalized setting, the first to describe this mite, its life cycle, its characteristics, and to link it to the itch that these mites caused.

How interesting, Erin.

Right?

Yeah.

And this makes it the first official description of an infectious disease and its causative agent.

And again, this is 1687.

So well, well before germ theory.

Right.

Way, way, way before.

Yeah.

It's it's pretty cool.

Yeah.

But also, like, what the heck took so long?

Right.

If everyone else knew it.

Why did it take so long for someone to actually note it down?

Like, first, for a scientist to write about this might-itch causal relationship, and second, for the scientific community to embrace it.

Because even though Bonamo enlisted the help of a renowned naturalist in getting this observation out there, he was like, Hey, can you like, I'm going to release this pamphlet.

Can you put your name on it and maybe write a few extra things?

And then that'll help get a wider distribution.

So, people think it's legit.

Yeah.

People were like, nah, it was largely rejected for another hundred years.

There are several reasons I think contributed to this.

And the first one is practical.

So like you said, Erin, the mites burrow is not directly where the itchy sores tend to arise.

It's a little bit farther away.

So it's not as clear that the two would be linked.

Okay, fair.

Yeah.

Okay.

True.

But the other main reason is simply the conservative nature of science.

For millennia, learned men discarded the wisdom of peasants or women or non-learned folks in general as not scientifically valid without giving it due consideration.

And this superiority prevented them and still does in some ways today from exploring ideas outside of the box.

And science in general is pretty rigid when presented with new information that conflicts with established facts, which is not necessarily a bad thing.

Any new data, especially data that challenge the laws of nature, like the humoral theory of disease, should be checked and replicated and only then integrated into the body of knowledge.

This is part of what makes science trustworthy, this need for a consensus.

Of course, that's no excuse for closed-mindedness and gatekeeping, which unfortunately are other hallmarks of science.

So, the concept that a tiny bug caused this dreadful itch went against everything that scientists knew and learned about how diseases worked.

Bonamo and Sistone anticipated this rejection.

And so, this is is why they had this ready

lend his name to this pamphlet.

But I want to read you a quote from this because I think it is, well, it's just really, it's interesting.

Quote, having frequently observed that the poor women, when their children are troubled with the itch, do with the point of a pin, pull out of the scabby skin little bladders of water.

and crack them like fleas upon their nails and that the scabby slaves in the bagno at leghorn do often practice this mutual kindness upon one another, it came into my mind to examine what these bladders might really be.

I quickly found an itchy person, and asking him where he felt the greatest and most acute itching, he pointed to a great many little pustules not yet scabbed over, of which picking out one with a very fine needle and squeezing from it a thin water, I took out a very small white globule scarcely discernible.

Observing this with a microscope, I found it to be a very minute living creature in shape resembling a tortoise, of whitish color, a little dark upon the back, with some thin and long hairs, of nimble motion, with six feet, a sharp head, with two little horns at the end of the snout.

End quote.

I love that.

A tortoise.

A little tortoise.

I could see that.

Yeah.

Yeah.

And they go on to describe how they looked at more mites.

They talk about treatment and contagiousness.

And they deliver this direct conclusion, Quote, from this discovery, it may be no difficult matter to give a more rational account of the itch than authors have hitherto delivered us.

Like, you can't do better than this, essentially.

Right.

Yeah.

It being very probable that this contagious disease owes its origin neither to the melancholy humor of Galen, nor the corrosive acid of Silvius, nor the particular ferment of Van Helmont, nor the irritating salts in the serum or lympha of the moderns, but it is no other than the continual biting of these animal cules in the skin, by means of which, some portion of the serum oozing out through the small apertures of the cutis, little watery bladders are made, within which the insects continuing to gnaw, the infected are forced to scratch, and by scratching increase the mischief and thus renew the troublesome work, breaking not only the little pustules, but the skin too, and some little blood vessels, and to making scabs, crusty sores, and such like filthy symptoms.

End quote.

So,

I, there are so many little pieces in that description that I loved, Erin.

Yeah.

Right.

Like so, so, so many.

I just, the, the increase the mischief, thus renewing the music.

Increase the mischief.

Like, it's like they're little and they're biting there.

Like it just, it's so many pieces of it.

And it does make so much logical sense too, even though like they're technically a little bit wrong because it's like hypersensitivity reaction, but like it is such a logical, it is such a logical description of what they saw and what is going on yeah and i love how they're like it's not the humorous bro it's not

this like yeah it's not that limbs it's not that humor it's not the other humor you were thinking about no i already thought about it

right they're just like it's this and like they keep going with it they're not just like yeah there's a mite in the skin clearly they're like no dude the mite is there and it's biting and then it keeps biting and it makes a little pustule and then you itch at it and then you scratch it and then you push it in further and then it keeps biting and now you've broken the skin like they just they keep going and going.

It's so good.

And it's all laid out there.

So it's so straightforward that it must have been widely accepted and settled things once and for all, right?

But no, never.

Of course not.

Never, ever, ever.

Never.

The resistance largely came in the form of, well, but the worms have nothing to do with the itch.

They grew up out of the disease tissue, like you see with maggots and rotted meat, right?

What a weird, like, I know that we have to like take our, our modern brains out of this, but like, what a weird thing to think.

It's a hard, it's harder to do when you're literally confronted with ample evidence of this for millennia.

Yeah.

I mean, yeah.

And those voices of resistance drowned out this well-reasoned explanation for nearly 100 years after this pamphlet was published.

Wow.

Eventually, though, with more interest in the might and the itch, the accepted knowledge began to shift.

And a good number of these publications directly mentioned how they observed quote-unquote like peasant and village elders extracting the mite from the skin, saying that this knowledge has existed and has been passed down for a very long time, but it's only just now finding its way into the scientific literature.

And it would take a final push to put the last shred of doubt to rest.

In the early 1800s,

I know, right?

At the Hotel Saint-Louis in Paris, which was Escabies Hospital, two factions emerged about the cause of the condition.

On the pro-mite side was the director, Jean-Louis Alibert, and on the other, François Vincent Raspiel.

Things came to a boil when a challenge was issued.

Find the might and receive your reward, which was 300 francs or fail and live with your shame forever.

So

Raspiel set up a public demonstration.

This is the anti-mite side, where he pretended to find the mite and was like, oh my gosh, it's actually here.

This is incredible.

And then was like, psych, I planted it.

It's just a cheese mite.

It's like he had someone plant

a cheese mite, like too much time on your hands.

Oh my God.

I just, what?

I know.

Can you imagine?

Also, I love imagining someone in the 1800s going, psych, psych.

This is like a public demonstration.

Like, I want to know how well it was attended.

Was it advertised?

Was he just like on, just like randomly on the sidewalk on a Tuesday?

I also now want to know more about cheese mites.

So I

agree.

Okay.

There's so many mites in the world.

What is a cheese mite and how many have I?

And I guess that was the, the, I suppose, the humiliating moment for the pro-mite side.

He was like, just kidding.

It's a cheese mite.

I mean, it doesn't, it seems humiliating for him, but I wasn't there.

So I don't know.

All right, no, let's, we, benefit of the doubt for this whole scenario.

But the pro-miters would get the last laugh in 1834 when medical student Simon Francois Renucci was like, you know what?

I'm, I am going to find this.

Like I know that this, that scabies is caused by a mite.

And I'm going to show everyone.

And so he gathered a bunch of doctors together and was like, I'm doing this demonstration here.

And he pulled a mite from a patient in front of everyone and was like, here it is.

I found it.

It's a little bit in the burrow, a little bit away, which is a great illustration of this historic moment with Renucci holding up the mite for all to see, which just like cracks me up because I'm like,

you can't see it.

Size one font.

But it's like triumphantly with his arm in the air.

And this demonstration, this like, I found the mite, here is it, here it is in this person.

I don't know how it took so long for this to happen.

Yeah.

But this was the start of a monumental shift away from the humoral theory of disease.

And this isn't like, this isn't the thing that made people go, oh, maybe we should question

a combination of things.

Right.

It sort of was like, it was part of the transition away from that.

The rest of the 1800s saw Ferdinand Ritter von Hebra, who I mentioned in our lupus episode.

So he was an early scientific dermatologist.

Because like I come across these names and I'm like,

sounds familiar.

Where are you coming from?

And then I just like search our transcripts.

He distinguished the might caused scabies from other itchy skin conditions, which had been called scabies in the past.

And that was probably part of what led to this like long confusion.

It was just like, if you're itchy, it's called scabies.

Right, right, right.

It was the itch, but now it's like it is the might.

Yes.

Yeah.

And then this also helped on the treatment front to determine which ointments were or were not effective.

And the early 20th century marked a jump forward in our understanding of scabies epidemiology.

As you can imagine, scabies mites love a war.

They love chaos.

And World War II, with its crowded barracks, offered a great opportunity for these little guys to infest to their hearts' content.

And infest they did.

And they didn't just get under the soldier's skin.

By the 1940s, between one and two million people in the british isles had scabies

this was a problem in need of a serious solution and kenneth mellenby who was a british entomologist felt up to the task so he directed a series of experiments where he exposed human quote-unquote volunteers who were primarily conscientious objectors so this was like they refused to join the war effort.

And so he proposed this as like, oh, show your service to the country

in another way.

Yeah.

And it's interesting because I think there has been, of course, some

criticism of this, you know, even with the ethics at the time.

I do think it's relevant to note that he was morally opposed to experimentation on what he felt were not true volunteers, like people in prison or people who couldn't really say no, like children and so on.

So that part is interesting to me, but I also don't know how much power conscientious objectors had to say no.

Yeah, I don't know enough.

I don't know the context enough for that.

But in any case, he directed a series of experiments where he exposed these conscientious objectors to various items like blankets, towels, pants, shirts, socks, underwear that had been used by people infested with scabies to see how long it would take to cause an infection.

Okay.

For centuries, scabies had the reputation of being super, duper contagious.

Like all you had to do to get it was touch a blanket used by a person with scabies, look at someone who had scabies.

Like it was just like, whoa, the most contagious thing ever.

But Mellenby's experiments showed that this was not the case.

He found it near impossible to get any of his volunteers infected, much to their relief, I imagine.

And when they did get infected eventually, it took weeks for symptoms to show.

Which, as you mentioned, Aaron, yep.

And it was much sooner, though, if you had had scabies before.

So it would be like six weeks or 24 hours.

Right.

That's it.

Yeah.

And he even tried it on himself.

Quote, my own experience was typical.

I allowed a mite to burrow into my own wrist and observed it, almost like a pet, for two months.

Each day the tunnel was enlarged, eggs were located in the burrow, but I had no skin reaction.

It was only in the fifth week that a redness was observed around the mite and that skin irritation became obvious.

End quote.

Interesting.

He also found that scabies could only be transmitted by a female mite, not eggs, not immature mites, and that female mites don't live very long

outside of the human body.

And this meant that the Ministry of Health could better spend their time and money tracking down contacts of affected individuals and treating them rather than destroying or disinfecting blankets and bedding.

Oh my gosh, yes, that's so good.

Public health.

Right?

Resource management.

Despite his work, the misconception of scabies as a super contagious condition remains to this day.

And I think it contributes to the stigma that scabies carries with it.

Scabies as a medical condition is extremely uncomfortable and can be dangerous in some occasions.

But that's just one part of the story for the hundreds of millions of people around the globe that develop scabies every year.

Shame, social isolation, avoidance, these are common experiences in people with scabies, and they can discourage a person from seeking treatment or informing other people about exposure.

And while we have treatment that is for the most part effective, while we have control measures, we still need to really improve on actually putting those in place, which means decreasing the stigma associated with scabies.

And so on that note, Erin, can you tell me where we are with scabies today?

I would love to right after this break.

Globally, the World Health Organization estimates that at any given moment, 200 million people worldwide are affected by scabies, with over 400 million people affected cumulatively each year.

It's like 400 million cases each year.

Yeah.

And it's everywhere.

It is everywhere that humans are.

There is scabies.

But even with all of that knowledge, Our data is actually really cruddy.

And there is a real need for better evaluation and better monitoring.

While scabies exists everywhere, it exists differently in different places across the globe.

In most high income countries, we see it in sometimes in outbreaks in places like hospitals, nursing homes, among homeless populations, though it can also occur sporadically, right?

Like anybody can potentially get scabies.

But in developing and under-resourced areas of the world, both urban and rural areas, prevalence can sometimes be as high as 10%.

And in some regions, in some studies, prevalence has been as high as 20 to 30% and over 50% in children who tend to be even more affected than adults.

So this is a huge, huge problem worldwide, not only because like we've talked about a lot so far, like this is a very potentially painful, very bothersome infection, super, super itchy.

Also, the itching is much, much worse at night.

And that is something that I could not find data on as to like, why does the itch, why is the itch so much worse at night?

But it is.

But scabies is also a massive risk factor for things like secondary bacterial infections.

And we, I mentioned it at the very, very top, but this causes also not just the infections themselves, but then morbidity and mortality from things that happen as a result of those infections.

One paper estimated that up to 10% of kids with scabies end up with renal damage.

And that renal damage is not from the mites, it's from the bacterial infections that get in because of the mites.

Right.

Like I had no idea that it was such a big deal.

Me either.

It's also really common to misdiagnose this in the US and across the globe.

In one paper, up to 45% of people in the US, even at dermatology offices, were misdiagnosed the first time that they came in and saw a physician.

What is a common misdiagnosis?

It could be eczema.

It could be just atopic dermatitis.

It could be just any kind of nonspecific itchiness.

Got it.

Lots of different things.

And also interesting and very depressing fact, again, I just, scabies felt so much bigger to me than I realized.

The Global Burden of Disease Study, which is this big study, I've cited it multiple times.

They try and look at like overall burdens of a whole bunch of different diseases.

So a report from 2015 on scabies specifically estimated that scabies contributes more disability adjusted life years than something like atrial fibrillation, which is really common and most people have probably heard of it.

Yeah.

So it has a huge amount of disability associated with it.

But This paper also estimated that mortality due to scabies was zero, which if you think about it, is not entirely true because we know that especially crusted scabies can contribute to superimposed infections that can lead to sepsis that absolutely can be deadly.

And things like post-strep glomerulonephritis or rheumatic heart disease can also be a consequence of infections that are a consequence of scabies.

So it's just overall a much bigger deal.

And the World Health Organization knows that, luckily.

And so as of 2017, scabies are actually considered a neglected tropical disease, along with a number of other ectoparasites.

And their 2030 targets are to do a few different things to try and really address scabies.

First, they're trying to integrate mass drug administration anywhere that prevalence of scabies is higher than 10%,

which sounds, I mean, sounds both low and high.

Like imagining 10% of a population infected with scabies sounds awful.

Yeah.

But it also in terms of like mass drug administration campaigns seems low.

But I think part of that is because people can be asymptomatic and treatment can take such a long time and things like that.

Right.

So anywhere that, which also means that we need better data because we don't necessarily know everywhere where prevalence might be 10% or greater.

And it seems like that is where most of the research on scabies is actually happening and where the focus really seems to be is on epidemiological level research.

Like where is it?

What is the prevalence really?

And how can we then use public health measures to get control of this disease?

Because we have treatments.

We have options.

We're just not maybe implementing them in the most effective way currently.

So that's where we stand with scabies today.

It's such a huge, it's such a huge problem.

It really is.

I just, I feel like I did not recognize it.

I think also, Erin, you mentioned the like stigma that's associated with it.

That's a huge.

like it is very real and that is real everywhere across the globe.

That's real in developing countries.

That is definitely real here in the U.S.

I have seen that firsthand where if somebody comes into a hospital with scabies, they are treated differently than somebody who doesn't have scabies.

And that's a problem.

100%.

There's a lot of, I think, preconceived notions about scabies that then leads to this sort of treatment that is perpetuates stigma and shame and isolation and all these things.

Right.

It's seen as like something that is dirty or something like that.

Exactly.

Yeah.

Not true.

Literally any person can get scabies.

If you have skin, human skin, you can get scabies.

Yeah.

Yeah.

That's that's what it is.

Bottom line.

Well, if you'd like to learn more about scabies, we have a lot of information for you.

We do.

I have a handful of papers, but the place where I got most of my information was a great book, which I already mentioned called The Itch, Scabies by Errol Craig.

And it's all about scabies.

So there's a lot of information there.

And then there's, again, I want to shout out that paper by Cropley from 2006 called The Army Itch, A Dermatological Mystery of the American Civil War.

I have a number of papers.

I said already there was a Lancet article review from 2006 just called Scabies.

It was great.

Really nice overview.

There was one from the Journal of the American Academy of Dermatology from 2020 called Ectoparasites, Scabies.

That was another good one.

And honestly, there's a bunch of other papers that are reviews.

There's that Global Burden of Disease study from 2015.

And we'll post the list of sources from this episode and every single one of our episodes on our website, thispodcastwillkillyou.com, under the episodes tab.

Thank you to Blood Mobile for providing the music for this episode and all of our episodes.

Thank you to Liana Scolacci and Tom Breifogel for the audio mixing.

Thank you to everyone at Exactly Right.

And thank you to you, listeners.

We hope you're not too itchy after listening to this episode.

And we hope you learned something about scabies.

We certainly did.

And a big thank you, as always, to our wonderful, excellent, fantastic, lovely patrons.

We appreciate your support.

It means the world to us.

Thank you.

It really does.

Thank you so much.

Well, until next time, wash your hands.

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