ABSTRACT
Background and Aims
Scabies is a common parasitic skin disease with substantial morbidity, particularly in resource‐limited settings. Although the typical anatomical distribution of scabies lesions is well recognized, atypical presentations may complicate clinical recognition and diagnosis. Evidence describing the anatomical distribution of scabies lesions in Somalia remains limited. This study assessed the anatomical distribution of scabies lesions and factors associated with typical anatomical‐site involvement among patients attending a dermatology center in Mogadishu, Somalia.
Methods
A facility‐based cross‐sectional study was conducted at Olad Dermatology Center in Mogadishu, Somalia, from April to June 2025. Patients with a final clinical diagnosis of scabies, based on clinical assessment informed by the 2020 International Alliance for the Control of Scabies (IACS) Consensus Criteria, were included. Dermoscopy and laboratory confirmation were unavailable at the study site. Data on sociodemographic, household, socioeconomic, behavioral, hygiene, and clinical characteristics were collected using a structured questionnaire and clinical examination checklist. Because typical anatomical‐site involvement was a common outcome, multivariable Poisson regression with robust variance was used to estimate adjusted prevalence ratios (APRs) and 95% confidence intervals (CIs).
Results
Among 423 patient records, 195 (46.1%) had a final clinical diagnosis of scabies. Of these, 146/195 (74.9%) had typical and 49/195 (25.1%) had atypical anatomical‐site involvement. The finger/interdigital region was the most frequently affected site (102/195, 52.3%). In multivariable analysis, participants with a monthly income of USD 300 or more had a higher prevalence of typical‐site involvement than those earning less than USD 300 (APR = 1.42, 95% CI: 1.17–1.73; p = 0.001). Primary education was associated with a lower prevalence of typical‐site involvement compared with illiteracy (APR = 0.77, 95% CI: 0.61–0.96; p = 0.021). Participants who reported no person with itching in their household or neighborhood also had a lower prevalence of typical‐site involvement (APR = 0.71, 95% CI: 0.57–0.88; p = 0.002). Other covariates were not independently associated with typical‐site involvement after adjustment.
Conclusion
Typical anatomical‐site involvement predominated, although approximately one‐quarter of patients had atypical anatomical‐site involvement. Higher monthly income was associated with a higher prevalence of typical‐site involvement, whereas primary education and absence of an itching contact were associated with lower prevalence. These findings should be interpreted cautiously given the cross‐sectional design, the relatively small number of atypical‐site cases, and the limited number of participants in some subgroups. Further multicenter studies with larger samples and confirmatory diagnostic methods are needed.
Keywords: anatomical distribution, atypical scabies, clinical presentation, dermatology, Mogadishu, scabies, skin lesions, Somalia
1. Introduction
Scabies is a contagious skin infestation caused by the mite Sarcoptes scabiei var. hominis. It is primarily transmitted through prolonged skin‐to‐skin contact and, less commonly in ordinary scabies, through contaminated clothing, bedding, or personal items. Clinically, scabies is characterized by intense nocturnal pruritus and lesions such as papules, vesicles, nodules, and burrows, which commonly involve the finger and interdigital regions, hands, wrists, elbows, axillae, abdomen, groin, and genital regions [1, 2, 3]. Scabies may also cause secondary bacterial infections, including impetigo and cellulitis, with potentially serious complications such as post‐streptococcal glomerulonephritis and acute rheumatic fever, particularly in resource‐limited settings [4].
Scabies remains an important global public health problem, particularly in tropical and resource‐limited settings. The World Health Organization estimates that more than 200 million people are affected at any given time, with a disproportionate burden among disadvantaged populations living in crowded and impoverished conditions [5]. Systematic reviews have linked scabies to socioeconomic disadvantage, household crowding, and poor living conditions [6, 7, 8, 9, 10, 11, 12]. Recent evidence from Bangladesh and Ethiopia further demonstrates the continuing burden of scabies in resource‐limited settings [6, 13].
Transmission is facilitated by prolonged contact with infected individuals, household crowding, and sharing of clothing or bedding [14, 15, 16, 17]. These factors are particularly relevant in crowded households, schools, institutional settings, and displaced populations, where frequent close contact can facilitate transmission [18, 19, 20, 21]. However, most previous studies have focused on factors associated with scabies acquisition and transmission rather than factors associated with the anatomical distribution of lesions.
Understanding lesion distribution is important for early recognition and accurate diagnosis. Although scabies commonly affects characteristic anatomical sites, distribution may vary according to age, immune status, and other patient characteristics, potentially making clinical recognition more difficult [22, 23, 24, 25]. Failure to recognize atypical presentations may contribute to diagnostic uncertainty and delayed treatment [22, 24]. Therefore, evaluating anatomical distribution and its associated factors may improve clinical recognition, particularly in low‐resource settings where diagnosis relies primarily on clinical examination.
Although scabies prevalence, epidemiology, and transmission risk factors have been widely studied, relatively few studies have examined anatomical lesion distribution and factors associated with typical or atypical patterns [22, 26]. Evidence from Ethiopia, Bangladesh, and other resource‐limited settings has largely focused on prevalence and transmission rather than lesion distribution [16, 18, 19, 27]. In Somalia, published evidence on the anatomical distribution of scabies lesions and associated factors is limited. Generating such evidence may support improved clinical recognition and context‐specific scabies control strategies. Olad Dermatology Center in Mogadishu was selected as the study site because it provides specialized dermatological services and routinely evaluates patients with suspected and clinically diagnosed scabies, making it a relevant setting for assessing scabies lesion distribution. Therefore, this study aimed to assess the anatomical distribution of scabies lesions and factors associated with typical lesion sites among patients attending Olad Dermatology Center in Mogadishu, Somalia.
2. Methods
A facility‐based cross‐sectional study was conducted at Olad Dermatology Center in Mogadishu, Somalia, from April to June 2025. Mogadishu is the capital and largest urban center of Somalia. Olad Dermatology Center provides diagnostic and treatment services for scabies and other dermatological conditions. During the study period, patients presenting to the facility with suspected scabies were clinically assessed by trained healthcare professionals. The analytical population for the present study comprised patients who received a final clinical diagnosis of scabies.
Scabies was diagnosed through clinical examination by trained healthcare professionals using the 2020 International Alliance for the Control of Scabies (IACS) Consensus Criteria for the Diagnosis of Scabies [28]. The clinical assessment considered scabies‐compatible lesions, their anatomical distribution, pruritus, contact history, and other relevant clinical features. Dermoscopy and microscopy were not available at the study facility and therefore were not performed. The 2020 IACS criteria distinguish confirmed, clinical, and suspected scabies according to the level of diagnostic evidence. Because confirmatory diagnostic methods were unavailable at the study facility, the cases included in this analysis were clinically diagnosed scabies cases rather than IACS‐confirmed cases. The findings should therefore be interpreted as relating to clinically diagnosed scabies.
Of the 423 patient records available in the study dataset, all records represented unique patients, with no repeated visits or duplicate records included in the dataset. Among these, 195 (46.1%) received a final clinical diagnosis of scabies and constituted the analytical population for the present study; the remaining 228 (53.9%) were not diagnosed with scabies and were not included in the anatomical‐distribution analysis. No specific exclusion criteria based on age, immunocompromised status, crusted scabies, or concurrent skin conditions were applied during recruitment. Patients who did not receive a final clinical diagnosis of scabies were excluded from the present analysis. The sample size was initially calculated using the single population proportion formula, assuming a 50% expected prevalence, a 95% confidence level, and a 5% margin of error. This yielded a minimum sample of 384 participants; after adding 10% for possible non‐response, the target sample size was 423 participants. Participants were recruited using consecutive non‐probability sampling. All eligible patients presenting to the facility during the study period were invited to participate, and those who provided informed consent were enrolled consecutively. The original sample‐size calculation was based on the planned cross‐sectional study and was not specifically powered for the multivariable analysis of factors associated with anatomical‐site involvement.
Data were collected using a structured questionnaire and a clinical examination checklist administered by trained healthcare professionals. The questionnaire collected information on sociodemographic characteristics, household and socioeconomic conditions, hygiene practices, behavioral factors, and clinical characteristics. Clinical information on the anatomical distribution of lesions was obtained through physical examination using the structured clinical examination checklist. Lesion morphology was assessed when lesions were clearly visible and clinically assessable during examination. When multiple lesion types were present, the predominant clinically observed lesion type was recorded as the participant's morphology category; therefore, the morphology categories were mutually exclusive. Among the 195 patients with a final clinical diagnosis of scabies, lesion morphology was assessable in 194/195 (99.5%) participants. Only one participant (1/195, 0.5%) had missing morphology information; therefore, a comparison between participants with and without morphology assessment was not considered meaningful.
The primary outcome was the anatomical distribution of scabies lesions, categorized as typical or atypical anatomical‐site involvement. The classification was informed by the characteristic anatomical distribution of scabies described in the 2020 IACS Consensus Criteria [28], while the specific categories used in this study were operationally defined based on the clinical examination findings. Typical anatomical sites were defined as the finger/interdigital region, hand, elbow, axillae, abdomen/stomach, genital region, and groin. Lesions involving the face, neck, head, hair/scalp, legs, or other non‐characteristic anatomical locations were classified as atypical. For participants with lesions at both typical and atypical sites, the presence of at least one lesion at a predefined typical site was sufficient for classification as typical‐site involvement. This binary classification was used to provide a clinically pragmatic outcome reflecting whether at least one characteristic scabies site was involved, while retaining patients with mixed typical and atypical presentations in the analysis. The primary outcome was available for all 195 participants. Among these, 146 (74.9%) were classified as having typical‐site involvement and 49 (25.1%) as having atypical‐site involvement. No imputation was performed.
Independent variables included sociodemographic characteristics (age, sex, education, marital status, occupation, and residence); household and socioeconomic factors (family type, household size, monthly income, number of people per room, and bed sharing); behavioral and hygiene factors (sharing clothes, sharing undergarments, house‐cleaning practices, use of soap during bathing, and hand‐washing practices); and clinical/contact characteristics (primary symptoms, time of itching, sleep disturbance, and presence of a person with itching in the household or neighborhood). Age was collected as a continuous variable and categorized into ≤ 19 years and ≥ 20 years for descriptive analysis, using 20 years as the prespecified cutoff to distinguish younger participants from adults. Age was not included in the final multivariable model. For regression analyses, observations with complete information for the variables included in the model were analyzed using complete‐case analysis.
Data were entered and analyzed using Stata Statistical Software, Release 18 (StataCorp LLC, College Station, TX, USA). Categorical variables were summarized using frequencies and percentages. Bivariate logistic regression was initially performed to examine the association between each independent variable and typical anatomical‐site involvement. Variables with p < 0.25 in the bivariate analysis were considered candidates for multivariable analysis, together with variables considered epidemiologically relevant. Because typical anatomical‐site involvement was a common outcome (74.9%), multivariable Poisson regression with a log link and robust variance was used to estimate adjusted prevalence ratios (APRs) and 95% confidence intervals (CIs). The multivariable model included gender, education, monthly income, sharing clothes, daily house cleaning, number of people per room, sharing a common sleeping bed, hand‐washing practices, and presence of a person with itching in the household or neighborhood. The model was fitted using complete‐case analysis. Multicollinearity was assessed using variance inflation factors (VIFs). Statistical tests were two‐sided, and statistical significance was defined a priori as p < 0.05.
The study was conducted from April to June 2025. Ethical approval was obtained from the Research Ethics Committee of Jamhuriya University of Science and Technology, Mogadishu, Somalia. Permission to conduct the study was obtained from the participating health facility. Written informed consent was obtained from all participants before data collection. Participation was voluntary, and confidentiality of participant information was maintained throughout the study.
3. Results
A total of 195 patients with a final clinical diagnosis of scabies were included in the analysis. Of these, 101 (51.8%) were aged ≤ 19 years and 94 (48.2%) were aged ≥ 20 years. Females accounted for 101 (51.8%) participants and males for 94 (48.2%). Regarding educational level, 74 (37.9%) participants were illiterate, 56 (28.7%) had primary education, 38 (19.5%) had secondary education, and 27 (13.8%) had university education. Most participants lived in urban areas (181/195, 92.8%), while 14/195 (7.2%) lived in rural areas. Regarding marital status, 138 (70.8%) were single, 55 (28.2%) were married, and 2 (1.0%) were divorced. Most participants were unemployed (151/195, 77.4%), while 44/195 (22.6%) were employed. These characteristics are presented in Table 1.
Table 1.
Sociodemographic characteristics of patients with clinically diagnosed scabies attending a dermatology center in Mogadishu, Somalia (N = 195).
| Characteristic | Category | n (%) |
|---|---|---|
| Age group (years) | ≤ 19 | 101 (51.8) |
| ≥ 20 | 94 (48.2) | |
| Sex | Female | 101 (51.8) |
| Male | 94 (48.2) | |
| Education | Illiterate | 74 (37.9) |
| Primary | 56 (28.7) | |
| Secondary | 38 (19.5) | |
| University | 27 (13.8) | |
| Residence | Urban | 181 (92.8) |
| Rural | 14 (7.2) | |
| Marital status | Single | 138 (70.8) |
| Married | 55 (28.2) | |
| Divorced | 2 (1.0) | |
| Occupation | Unemployed | 151 (77.4) |
| Employed | 44 (22.6) |
Regarding household and socioeconomic characteristics, 71 (36.4%) participants reported a family size‐to‐bedroom ratio of three, 61 (31.3%) reported a ratio of two, 56 (28.7%) reported a ratio of one, and 7 (3.6%) reported a ratio greater than three. Most participants reported a monthly income below USD 300 (160/195, 82.1%), while 35/195 (17.9%) reported an income of USD 300 or more. A total of 102 (52.3%) participants lived in rooms with fewer than two people, whereas 93 (47.7%) lived in rooms with two or more people. Bed sharing was reported by 84 (43.1%) participants, while 111 (56.9%) did not share a sleeping bed. These characteristics are presented in Table 2.
Table 2.
Household and socioeconomic characteristics of patients with scabies (N = 195).
| Characteristic | Category | n (%) |
|---|---|---|
| Family size‐to‐bedroom ratio | One | 56 (28.7) |
| Two | 61 (31.3) | |
| Three | 71 (36.4) | |
| More than three | 7 (3.6) | |
| Monthly income (USD) | < 300 | 160 (82.1) |
| ≥ 300 | 35 (17.9) | |
| Number of people per room | < 2 | 102 (52.3) |
| ≥ 2 | 93 (47.7) | |
| Shared sleeping bed | Yes | 84 (43.1) |
| No | 111 (56.9) |
Regarding hygiene and behavioral practices, 91 (46.7%) participants reported sharing clothes, whereas 104 (53.3%) did not. Sharing undergarments was reported by 33 (16.9%) participants, while 162 (83.1%) did not share undergarments. Most participants reported cleaning their houses daily (151/195, 77.4%), and 158/195 (81.0%) reported using soap when bathing. Tap water was the predominant water source (191/195, 98.0%), while 4/195 (2.1%) participants reported using well water. The toilet was located inside the house for 123 (63.1%) participants and outside for 72 (36.9%). Regarding handwashing, 91 (46.7%) reported using water and soap, while 104 (53.3%) reported using water only. These characteristics are presented in Table 3.
Table 3.
Hygiene and behavioral characteristics of patients with scabies (N = 195).
| Characteristic | Category | n (%) |
|---|---|---|
| Sharing clothes | Yes | 91 (46.7) |
| No | 104 (53.3) | |
| Sharing undergarments | Yes | 33 (16.9) |
| No | 162 (83.1) | |
| Daily house cleaning | Yes | 151 (77.4) |
| No | 44 (22.6) | |
| Use of soap when bathing | Yes | 158 (81.0) |
| No | 37 (19.0) | |
| Water source | Tap water | 191 (98.0) |
| Well water | 4 (2.1) | |
| Toilet location | Inside | 123 (63.1) |
| Outside | 72 (36.9) | |
| Handwashing | Water and soap | 91 (46.7) |
| Water only | 104 (53.3) |
The most commonly reported primary symptom was rash (107/195, 54.9%), followed by itching (86/195, 44.1%) and fever (2/195, 1.0%). Itching was predominantly reported at night (176/195, 90.3%), followed by morning (17/195, 8.7%) and afternoon (2/195, 1.0%). Sleep disturbance due to itching was reported by 190 (97.4%) participants, while 5 (2.6%) reported sleep disturbance due to pain. A total of 77/195 (39.5%) participants reported having a person with itching living in their household or neighborhood.
The finger/interdigital region was the most frequently affected anatomical site (102/195, 52.3%), followed by the axillae (20/195, 10.3%) and legs (19/195, 9.7%). Other affected sites included the elbow (11/195, 5.6%), neck (10/195, 5.1%), head (6/195, 3.1%), genital region (6/195, 3.1%), other sites (8/195, 4.1%), groin (3/195, 1.5%), abdomen/stomach (3/195, 1.5%), face (3/195, 1.5%), scalp (2/195, 1.0%), hair (1/195, 0.5%), and hand (1/195, 0.5%). Because participants could have lesions at multiple anatomical sites, these site‐specific percentages do not sum to 100%. Overall, 146/195 (74.9%) participants were classified as having typical‐site involvement, whereas 49/195 (25.1%) were classified as having atypical‐site involvement. Clinical characteristics and anatomical lesion distribution are presented in Table 4.
Table 4.
Clinical characteristics and anatomical distribution of patients with scabies (N = 195).
| Characteristic | Category | n (%) |
|---|---|---|
| Primary symptom | Rash | 107 (54.9) |
| Itching | 86 (44.1) | |
| Fever | 2 (1.0) | |
| Timing of itching | Night | 176 (90.3) |
| Morning | 17 (8.7) | |
| Afternoon | 2 (1.0) | |
| Sleep disturbance | Due to itching | 190 (97.4) |
| Due to pain | 5 (2.6) | |
| Person with itching in household/neighborhood | Yes | 77 (39.5) |
| No | 118 (60.5) | |
| Anatomical site | Finger/interdigital region | 102 (52.3) |
| Axillae | 20 (10.3) | |
| Leg | 19 (9.7) | |
| Elbow | 11 (5.6) | |
| Neck | 10 (5.1) | |
| Head | 6 (3.1) | |
| Genital region | 6 (3.1) | |
| Other | 8 (4.1) | |
| Stomach/abdomen | 3 (1.5) | |
| Face | 3 (1.5) | |
| Groin | 3 (1.5) | |
| Scalp | 2 (1.0) | |
| Hair | 1 (0.5) | |
| Hand | 1 (0.5) | |
| Anatomical distribution | Typical site | 146 (74.9) |
| Atypical site | 49 (25.1) |
Lesion morphology was assessable in 194/195 (99.5%) participants. Nodules were the most common predominant morphology (59/194, 30.4%), followed by burrows (39/194, 20.1%), excoriations (32/194, 16.5%), papules (18/194, 9.3%), vesicles (16/194, 8.2%), pustules (15/194, 7.7%), and acneiform lesions (13/194, 6.7%). Two participants (2/194, 1.0%) had other lesion types, while morphology was not recorded for one participant (1/195, 0.5%). The distribution of lesion morphology is presented in Table 5.
Table 5.
Morphology of scabies lesions among patients with scabies (n = 194).
| Lesion morphology | n (%) |
|---|---|
| Pimple | 13 (6.7) |
| Papules | 18 (9.3) |
| Nodules | 59 (30.4) |
| Burrows | 39 (20.1) |
| Vesicles | 16 (8.2) |
| Excoriations | 32 (16.5) |
| Pustules | 15 (7.7) |
| Other | 2 (1.0) |
| Total | 194 (100.0) |
Variables with p < 0.25 in the bivariate analysis were considered candidates for multivariable analysis. In addition, variables considered epidemiologically relevant based on prior knowledge were retained regardless of their bivariate p value. The final multivariable model included sex, education, monthly income, clothing sharing, daily house cleaning, number of people per room, shared sleeping arrangements, handwashing, and presence of a person with itching in the household or neighborhood. Age was not included because it was not associated with the outcome in the bivariate analysis and was not considered necessary for adjustment based on the prespecified analytical approach.
In the multivariable Poisson regression analysis with robust variance, monthly income, primary education, and the presence of a person with itching in the household or neighborhood were independently associated with typical anatomical‐site involvement. Participants with a monthly income of USD 300 or more had a higher prevalence of typical‐site involvement than those earning less than USD 300 (APR = 1.42, 95% CI: 1.17–1.73; p = 0.001). Participants with primary education had a lower prevalence of typical‐site involvement than those who were illiterate (APR = 0.77, 95% CI: 0.61–0.96; p = 0.021). Participants who reported no person with itching in their household or neighborhood had a lower prevalence of typical‐site involvement than those who reported such a person (APR = 0.71, 95% CI: 0.57–0.88; p = 0.002). Sex, secondary and university education, clothing sharing, daily house cleaning, number of people per room, shared sleeping arrangements, and handwashing were not independently associated with typical anatomical‐site involvement after adjustment.
The multivariable Poisson regression model was statistically significant (Wald χ 2 [11] = 36.06; p = 0.0002; pseudo‐R 2 = 0.0268). The regression results are presented in Table 6.
Table 6.
Factors associated with typical scabies lesion sites among patients with scabies (N = 195).
| Variable | Category | COR (95% CI) | p value | AOR (95% CI) | p value |
|---|---|---|---|---|---|
| Sex | Female | Ref. | — | Ref. | — |
| Male | 1.49 (0.77–2.87) | 0.23 | 1.42 (0.67–3.04) | 0.36 | |
| Education | Illiterate | Ref. | — | Ref. | — |
| Primary | 0.35 (0.15–0.80) | 0.01 | 0.32 (0.12–0.85) | 0.02 | |
| Secondary | 0.73 (0.27–1.96) | 0.53 | 1.48 (0.48–4.56) | 0.49 | |
| University | 0.39 (0.14–1.06) | 0.07 | 0.48 (0.14–1.63) | 0.24 | |
| Monthly income (USD) | < 300 | Ref. | — | Ref. | — |
| ≥ 300 | 6.86 (1.58–29.77) | 0.01 | 8.66 (1.80–41.56) | 0.007 | |
| Number of people per room | < 2 | Ref. | — | Ref. | — |
| ≥ 2 | 0.54 (0.28–1.04) | 0.06 | 0.58 (0.26–1.31) | 0.19 | |
| Shared sleeping bed | Yes | Ref. | — | Ref. | — |
| No | 0.33 (0.16–0.69) | 0.002 | 0.56 (0.20–1.58) | 0.27 | |
| Sharing clothes | Yes | Ref. | — | Ref. | — |
| No | 0.36 (0.18–0.72) | 0.003 | 0.64 (0.26–1.61) | 0.35 | |
| Daily house cleaning | Yes | Ref. | — | Ref. | — |
| No | 1.68 (0.72–3.91) | 0.22 | 1.65 (0.51–5.30) | 0.40 | |
| Handwashing | Water and soap | Ref. | — | Ref. | — |
| Water only | 1.57 (0.82–3.01) | 0.17 | 0.73 (0.30–1.82) | 0.51 | |
| Person with itching in household/neighborhood | Yes | Ref. | — | Ref. | — |
| No | 0.40 (0.20–0.84) | 0.01 | 0.26 (0.10–0.66) | 0.004 |
Note: Model diagnostics: LR χ 2 [11] = 42.06, p < 0.001; pseudo‐R 2 = 0.1913; Hosmer–Lemeshow χ 2 [8] = 4.60, p = 0.80; area under the receiver operating characteristic curve (AUC) = 0.
Abbreviations: AOR, adjusted odds ratio; CI, confidence interval; COR, crude odds ratio; Ref., reference category.
4. Discussion
This study examined the anatomical distribution of scabies lesions and factors associated with typical anatomical‐site involvement among 195 patients with a final clinical diagnosis of scabies at Olad Dermatology Center in Mogadishu. Overall, 74.9% had typical‐site involvement, while 25.1% had atypical‐site involvement. The finger/interdigital region was the most frequently affected site, followed by the axillae and legs. In multivariable analysis, monthly income, primary education, and the presence of a person with itching in the household or neighborhood were independently associated with typical‐site involvement.
The predominance of typical‐site involvement is consistent with the recognized clinical distribution of scabies. The frequent involvement of the finger/interdigital region supports its importance in clinical recognition. However, one‐quarter of patients had atypical‐site involvement, highlighting that scabies may present outside classic anatomical locations. Previous studies have reported variation in lesion distribution according to age, immune status, and clinical presentation [22, 23, 24, 25]. Because most previous studies have reported individual anatomical sites rather than typical versus atypical patterns, direct comparison with our findings is limited.
Higher monthly income was strongly associated with typical‐site involvement (AOR = 8.66, 95% CI: 1.80–41.56; p = 0.007). This finding should be interpreted cautiously and does not imply that higher income directly causes typical lesion distribution. Differences in healthcare access and healthcare‐seeking behavior may partly explain the association. Individuals with greater financial resources may seek care earlier, whereas delayed presentation among lower‐income patients may allow lesions to become more extensive. Residual confounding by disease duration, treatment history, healthcare access, or other unmeasured factors is also possible. Although socioeconomic disadvantage has consistently been associated with scabies acquisition and transmission [7, 8, 11, 12], previous studies have generally not examined anatomical lesion distribution. This finding should therefore be considered hypothesis‐generating.
Primary education was associated with lower odds of typical‐site involvement compared with being illiterate (AOR = 0.32, 95% CI: 0.12–0.85; p = 0.02), while secondary and university education were not significantly associated. Education may influence symptom recognition, health knowledge, and healthcare‐seeking behavior; however, the mechanism underlying this finding cannot be established from the present cross‐sectional study. The absence of a consistent gradient across education levels further supports cautious interpretation.
Participants who reported no person with itching in their household or neighborhood had lower odds of typical‐site involvement than those reporting an itching contact (AOR = 0.26, 95% CI: 0.10–0.66; p = 0.004). This should not be interpreted as evidence that contact exposure determines lesion distribution. Rather, it indicates an association between reported contact history and anatomical presentation among patients already diagnosed with scabies. Household and close‐contact exposure is an established mechanism of scabies transmission [16, 17, 26, 27]. However, previous studies have primarily examined contact exposure as a risk factor for acquiring scabies rather than its relationship with lesion distribution. Disease duration, exposure intensity, previous treatment, and healthcare‐seeking behavior may partly explain this association.
Clothing sharing, shared sleeping arrangements, daily house cleaning, and handwashing were not independently associated with typical‐site involvement after adjustment. Although these factors have been associated with scabies transmission [14, 18, 20, 21], their relationship with anatomical distribution is less established. Their lack of association in this study should therefore not be interpreted as evidence that they have no role in scabies transmission.
4.1. Strengths and Limitations
This study provides clinical evidence on the anatomical distribution of scabies lesions in Mogadishu, where published evidence on this aspect of scabies presentation is limited. It assessed a broad range of sociodemographic, household, behavioral, hygiene, and clinical factors and used multivariable Poisson regression with robust variance to estimate adjusted prevalence ratios while accounting for potential confounding.
Several limitations should be considered. The facility‐based cross‐sectional design and consecutive non‐probability sampling from a single dermatology center limit generalizability and prevent causal inference. Clinical diagnosis was used because dermoscopy and microscopy were unavailable; therefore, the findings represent clinically diagnosed rather than IACS‐confirmed scabies, and some misclassification is possible. Self‐reported socioeconomic and behavioral variables may be affected by recall or social‐desirability bias. Disease duration, previous treatment, recurrence, treatment‐seeking delay, and clinical severity were not systematically collected and may influence lesion distribution. Morphology was missing for only one participant (1/195, 0.5%). The sample‐size calculation was based on estimating the prevalence of scabies and was not specifically designed to support the multivariable analysis. In the final model, 49 participants had atypical‐site involvement and 11 predictor parameters were included, corresponding to approximately 4.5 events per parameter. This relatively low events‐per‐parameter ratio raises the possibility of overfitting and imprecise estimates, particularly for variables with small subgroup sizes. In addition, only 35 participants reported a monthly income of USD 300 or more, which may contribute to imprecision in the estimated association for income. Because typical‐site involvement was common (74.9%), robust Poisson regression was used to estimate prevalence ratios rather than odds ratios. Nevertheless, the regression findings should be considered exploratory and interpreted cautiously, particularly for associations involving small subgroups, and should be confirmed in larger studies with adequate numbers of outcome events.
4.2. Recommendations
Healthcare professionals should maintain clinical suspicion for scabies when lesions occur at atypical anatomical sites. Clinical assessment should consider lesion morphology, anatomical distribution, symptoms, and household or close‐contact history rather than relying exclusively on classic lesion locations.
Future studies should use larger multicenter samples involving urban and rural populations in Somalia to assess the generalizability of these findings. Where feasible, dermoscopy or microscopy should be incorporated, together with detailed assessment of disease duration, previous treatment, healthcare‐seeking behavior, contact exposure, and household management. Longitudinal studies could further clarify factors influencing changes in lesion distribution.
5. Conclusion
Typical anatomical‐site involvement predominated among patients with clinically diagnosed scabies, although one‐quarter had atypical distribution. In the final multivariable model, monthly income, primary education, and reported itching contacts were independently associated with typical‐site involvement. These associations should be interpreted cautiously given the study design and limitations of the analysis and should be confirmed in larger studies. Recognizing atypical presentations and assessing household or close‐contact history may improve the clinical assessment of scabies in Somalia.
Author Contributions
Ahmed Saed Hussein: conceptualization, methodology, formal analysis, writing – original draft, software, visualization, project administration. Mohamed Adam Mahamud: investigation, data curation, supervision, writing – review and editing, resources, validation.
Funding
The authors have nothing to report.
Ethics Statement
Ethical approval was obtained from the Jamhuriya University Research Ethics Committee (JUREC), Mogadishu, Somalia (Certificate No. JUREC0177/FMHS 392/022025), with approval granted on February 5, 2025. The study was conducted in accordance with the ethical standards and guidelines of Jamhuriya University of Science and Technology and relevant national and international regulations. Written informed consent was obtained from all participants before data collection. Participation was voluntary, and the confidentiality and privacy of participants were maintained throughout the study.
Conflicts of Interest
The authors declare no conflicts of interest.
Transparency Statement
Ahmed Saed Hussein affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.
Data Availability Statement
The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request.