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Volume 17 Number 3 March 2012

Indexed by the US National Library of Medicine and PubMed

Management of Scabies
Gentiane Monsel, MD1 and Olivier Chosidow, MD, PhD2
Department of Dermatology, Saint Louis Hospital, Paris, France
Universit Paris-Est Crteil Val de Marne and Assistance Publique-Hpitaux de Paris,
Department of Dermatology, Henri Mondor Hospital, Crteil, France

Scabies is a common contagious parasitic dermatosis. Transmission of the mite Sarcoptes scabiei var hominis generally occurs by
skin-to-skin contact, but with crusted scabies it may also occur through fomites, such as infected clothing or bedding. Diagnosis is
usually clinical. A 2010 updated Cochrane review concluded that management of scabies is based on topical scabicides, mainly 5%
permethrin. However, oral ivermectin, although not licensed in many countries, may be useful, particularly for patients who cannot
tolerate or comply with topical therapy and in institutional scabies epidemics. Patients should also receive detailed information about
the infestation to limit further spreading. Cases resulting from close physical or sexual contact, even without symptoms, should be
systematically treated. Hygienic measures should be taken after treatment is completed. Patients should be followed to confirm cure,
including resolution of itching, which may take up to 4 weeks or longer.
Key words: benzyl benzoate, ivermectin, permethrin, scabicides, scabies

Scabies is a common parasitic infection caused by the mite

Sarcoptes scabiei var hominis, arthropod of the order Acarina. The
worldwide prevalence has been estimated at about 300 million
cases annually, although this may be an overestimate.1 In general,
transmission occurs by direct skin-to-skin contact. In crusted
scabies, transmission may also occur through infected clothing
or bedding. Skin eruption with classical scabies is attributable to
both the infestation and a hypersensitivity reaction to the mite.
Moreover, because the eruption is usually itchy, prurigo and
superinfection are common.
The main symptom is pruritus that typically worsens at night,
and it is often associated with itching experienced by other family
members in the household or amongst people in close physical
contact with an infested individual. The lesions are commonly
located in the finger webs, on the flexor surfaces of the wrists, on
the elbows, in the axillae, and on the buttocks and genitalia. The
elementary lesions are papules, burrows, and nodules. In crusted
scabies, clinical signs include hyperkeratotic plaques, papules and
nodules, particularly on the palms of the hands and the soles of
the feet, although areas such as the axillae, buttocks, scalp, and
genitalia in men, and breasts in women may also be affected.1
The definitive diagnosis relies on the identification of mites.
Multiple superficial skin samples should be obtained from
characteristic lesions by scraping with a scalpel. The specimens
are examined under a microscope, looking for mites, eggs, empty
eggs, and scybala. Failure to find a mite is common and does not
rule out scabies.1 New methods such as dermoscopy or adhesive

tape test may increase the sensitivity of skin scraping tests and
limit false-negative results.2,3 However, comparing the accuracy
of different tests for diagnosing scabies remains elusive without a
criterion standard.4
Scabies may be endemic in indigenous communities with a
high rate of superinfection, which implies the need for specific
management. Here, we describe the management of scabies in
Western countries.
Indication for Therapy
People with scabies and their close physical contacts, even
without symptoms, should receive treatment at the same time.
Prescriptions must be provided for all household members and
sexual partners.
Patient Education
Patients should receive detailed verbal and written information
about scabies infestation.5 Infested individuals should be advised
to avoid close physical contact until they and their sexual partners
have completed treatment.
Treatment Options
Topical and oral products are available, although rigorous studies
to guide their use are lacking. Whether oral or topical treatment
is more advantageous for improved efficacy, tolerance or
convenience remains unknown.6-9 Table 1 summarizes the doses
and side effects of common agents used in scabies management.

ALSO IN THIS ISSUE: Silk Fabrics in the Management of Atopic Dermatitis (page 5) & Update on Drugs (page 8)

Topical treatment includes permethrin, lindane, benzyl benzoate,

esdpalltrine (bioallethrin), crotamiton, and precipitated sulfur.
Topical scabicides have neurotoxic effects on mites and larvae.
Despite the varied methodological quality of trials, a recent
meta-analysis suggested that topical permethrin is the most
effective.6 Oral ivermectin interrupts the gamma-aminobutyric
acid-induced neurotransmission of many parasites (including
mites). However, oral ivermectin is not licensed in most countries.
It must be given at 200 g/kg as a single dose in patients >2 years
of age and >15 kg. A second dose is necessary 2 weeks later due
to the lack of ovicidal action of the drug.1,10 Because ingestion of
food increases the bioavailability of ivermectin by a factor of 2,11
taking it with food might enhance the penetration of the drug
into the epidermis. Finally, topical permethrin is reasonable as
first-line therapy. If permethrin is not available (e.g., in France),
benzyl benzoate may be used. Oral ivermectin is a good but more
expensive alternative; however, this agent may be preferred for
patients who cannot tolerate topical therapy or are unlikely to
adhere to such a therapeutic regimen.1,10 In classical scabies, the
combination of topical therapy and oral ivermectin has never
been compared with either treatment alone. Table 2 presents
strategies of treatment according to the clinical picture.


Treatment Regimen

Additional Measures
Scabies is considered to be a sexually transmitted disease,
therefore, patients should undergo routine examination for
sexually transmitted infection.12
Patients must receive detailed information about scabies
infestation and therapeutic options, including the amount of
drug to be used and proper administration. Topical treatment
must be applied to the entire skin surface, including the scalp,
all folds, groin, navel, and external genitalia, as well as the skin
under the nails. In adults with classical scabies, treating the face
is controversial, but in babies, the face must be treated, because
transmission may occur by breastfeeding. Hands should not
be washed during therapy, otherwise the treatment should be
reapplied. If the treatment is applied by someone without scabies,
this person should wear medical gloves during administration.
After the completion of treatment, patients should use fresh,
clean bedding and clothing. If possible, potentially contaminated
clothes and bedding should be washed at high temperature
(>50C) or kept in a plastic bag for up to 72 hours, because mites
that are separated from the human host will die within this time
period. The use of insecticidal powder or aerosol products should
be reserved for materials or objects that cannot be washed.13



Effective, well
tolerated, safe



5% cream

Rinsed off after

8-12 hrs


1% lotion or

Rinsed off after 6 hrs

Pregnant women, Effective,

infants, seizure

seizures in


25% ointment

Rinsed off after 24 hrs

(once or several times)

Can cause
severe skin

Esdpalltrine 0.6% aerosol

10% ointment

Rinsed off after 12 hrs

Pregnant women Effective,

and infants (limit inexpensive
duration of use
to 12 hrs)
People with
Well tolerated,
safe for infants


in petroleum



Rinsed off after 24 hrs

and then reapplied
every 24 hrs for the
next 2 days (with a
bath taken between
each application
200 g/kg repeated on
day 14

Rinsed off after 24 hrs

and then reapplied for
an additional 24 hrs

Itching and
stinging on


Second application
often routinely
prescribed 1 week
after the first
Withdrawn in
the European
Union because
of neurotoxicity
Not currently
available in
Canada, approved
in Europe

Not available in
Canada, often used
on scabies nodules
in children

Safe for infants, Questionable

pregnant and efficacy, skin
breastfeeding irritation

Children <15 kg; Good patient

pregnant or


Table 1: Drugs commonly used to treat scabies



Editor: Dr. Stuart Maddin Volume 17, Number 3 March 2012

Not approved in
many countries

With classical scabies, the time course for the eradication of

parasites after treatment is not known, but there is some concern
that patients receiving oral ivermectin may remain contagious
longer than those receiving topical therapies.1,10
Special Treatment Considerations (Table 2)
Scabies complicated by impetigo requires combined antiseptic
and antibiotic therapy against Streptococcus pyogenes and
Staphylococcus aureus. Oral ivermectin is preferred if skin is
Crusted Scabies
Management of crusted scabies generally necessitates admission
to the hospital and isolation of the patient because of the risk of
transmission to people in physical contact. Active epidemiological
measures to ensure treatment of all individuals in contact are
necessary. Hyperkeratosis is treated with a keratolytic agent. The
nails are cut short and brushed with a scabicidal agent.13 The
combination of topical and oral therapy is advised,14 although
Clinical Conditions

Recommended Therapy

Classical scabies

Two applications of
permethrin 5% or benzyl

Crusted scabies

Several applications of
permethrin or benzyl
benzoate with repeated
doses of oral ivermectin
Permethrin or benzyl
benzoate (limit duration of
use to 12 hrs)
Permethrin, benzyl
benzoate (limit duration of
use to 12 hrs), and sulfur
Oral ivermectin is preferred
if skin is affected

Children <2 years

of age


Pregnancy or Breastfeeding
Permethrin, benzyl benzoate, and sulphur appear to be safe,
although evidence is limited.15 Oral ivermectin is contraindicated.
Permethrin may be used in infants. Benzyl benzoate and
esdpalltrine are safe in children <2 years of age, but duration of
use should be limited to 12 hours. Ivermectin is not approved for
children <15 kg.
Institutional Outbreaks
Management of institutional outbreaks has never been
evaluated. The control of institutional outbreaks relies on
prompt recognition of the index case, formation of an outbreak

Alternative Therapy

Additional Measures

Two doses of oral

ivermectin, 200 g/kg
(at days 1 and 14)

Ivermectin is
contraindicated in
children <15 kg
Ivermectin is

Treat clinical cases as

for classical and crusted
Table 2: Treatment of scabies by clinical features or situation


Keratolytic agents
must be used

People in close physical contact,

even without symptoms, should
receive treatment at the same
Control the spread of scabies

Treat the face, except

mouth and eyes

Treat scabies nodules with


(antibiotics) before
topical treatment



evidence is lacking regarding efficacy. Topical treatment may be

repeated. Dosing and frequency of administration is based on the
severity of infection. The required number of doses of ivermectin
remains uncertain, but depending on infection severity, 3 to 7
doses have been proposed.10 A test of cure may be performed for
crusted scabies.

Simultaneously treat
all cases and all
exposed people

Risk of post-streptococcal
glomerulonephritis and systemic
Formation of an outbreak
management team

Potential Causes


Cutaneous irritation

Intensive use of emollient
Intensive use of emollient
Contact dermatitis
Topical steroid
Treatment failure
Poor compliance: inappropriate or insufficient treatment Further scabicide application
Resistance to scabicide
Change scabicide
Reinfestation or relapse
Further scabicide application
Psychogenic pruritus
Delusions of parasitosis
Psychiatric referral
Nonparasitic dermatosis
Treat the underlying cause
Table 3: Causes of persistent itching after scabicide therapy and suggested management (table adapted from reference 13)
Editor: Dr. Stuart Maddin Volume 17, Number 3 March 2012

management team, determining the extent of the outbreak and

risk factors for transmission, immediate implementation of
infection control practices, adequate education of all involved
individuals, simultaneous treatment of cases and all exposed
people, and concomitant environmental disinfection.16
Patients should understand that after treatment is completed,
itching may persist for several weeks, especially in atopic
individuals. If itching continues after 4 weeks, the cause should
be reinvestigated (Table 3). Symptomatic relief may be achieved
with an emollient. A test of cure is not usually required with
classical scabies.
Scabies is a frequent, contagious dermatosis. Its management
is sometimes complex and updated treatment guidelines
are useful.12,17 Patients and people in close physical contact
with infested individuals should receive detailed information
from healthcare providers, because treatment failure is often
attributable to poor compliance or incorrectly carrying out
instructions of prescribed therapy. Decision-making for
topical or oral treatment may vary by situation. Randomized
controlled trials comparing topical treatment to oral ivermectin
demonstrating a high level of evidence are needed.
1. Chosidow O. Clinical practice. Scabies. N Engl J Med. 2006 Apr 20;354(16):
2. Dupuy A, Dehen L, Bourrat E, et al. Accuracy of standard dermoscopy for
diagnosing scabies. J Am Acad Dermatol. 2007 Jan;56(1):53-62.

3. Walter B, Heukelbach J, Fengler G, et al. Comparison of dermoscopy, skin

scraping, and the adhesive tape test for the diagnosis of scabies in a resourcepoor setting. Arch Dermatol. 2011 Apr;147(4):468-73.
4. Albrecht J, Bigby M. Testing a test: critical appraisal of tests for diagnosing
scabies. Arch Dermatol. 2011 Apr;147(4):494-7.
5. Scabies fact sheet. Atlanta: Centers for Disease Control and Prevention,
2005. Available at: http://www.cdc.gov/ncidod/dpd/parasites/scabies/factsht_
scabies.htm. Accessed: December 15, 2011.
6. Strong M, Johnstone P. Interventions for treating scabies. Cochrane Database
Syst Rev. 2007(3):CD000320.
7. Hu S, Bigby M. Treating scabies: results from an updated Cochrane review.
Arch Dermatol. 2008 Dec;144 (12):1638-40.
8. Le Cleach L, Chosidow O. Commentary on Interventions for treating scabies.
Evidence-Based Child Health: A Cochrane Review Journal. 2011 Nov;6(6):
9. Steer AC, Kearns T, Andrews RM, et al. Ivermectin worthy of further
investigation. Bull World Health Organ. 2009 Oct;87(10):A; author reply B.
10. Currie BJ, Mc Carthy JS. Clinical therapeutics. Permethrin and ivermectin for
scabies. N Engl J Med. 2010 Feb 25;362(8):717-25.
11. Guzzo CA, Furtec CI, Porras AG, et al. Safety, tolerability, and pharmacokinetics
of escalating high doses of ivermectin in healthy adult subjects. J Clin
Pharmacol. 2002 Oct;42(10):1122-33.
12. Scott GR, Chosidow O. European guidelines for the management of scabies,
2010. Int J STD AIDS. 2011 Jun;22(6):301-3.
13. Chosidow O. Scabies and pediculosis. Lancet. 2000 Mar 4;355(9206):819-26.
14. Alberici F, Pagani L, Rattu G, et al. Ivermectin alone or in combination
with benzyl benzoate in the treatment of human immunodeficiency virus
associated scabies. Br J Dermatol. 2000 May;142(5):969-72.
15. Mytton OT, McGready, Lee SJ, et al. Safety of benzyl benzoate lotion and
permethrin in pregnancy: a retrospective matched cohort study. Br J Obstet
Gynecol. 2007 May;114(5):582-7.
16. Bouvresse S, Chosidow O. Scabies in healthcare settings. Curr Opin Infect Dis.
2010 Apr;23(2):111-8.
17. Workowski KA, Berman S. Centers for Disease Control and Prevention (CDC).
Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm
Rep. 2010 Dec;17;59(RR-12):1-110.

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Editor: Dr. Stuart Maddin Volume 17, Number 3 March 2012

Silk Fabrics in the Management of Atopic Dermatitis

Giampaolo Ricci, MD1; Iria Neri, MD2; Lorenza Ricci2; Annalisa Patrizi, MD2
Department of Pediatrics, University of Bologna, Bologna, Italy
Division of Dermatology, Department of Internal Medicine, Geriatrics and Nephrology, University of Bologna, Bologna, Italy

Many factors may worsen atopic dermatitis (AD) including sweating, skin infections, food, inhalant allergens, climatic conditions,
stress, and chemical or physical irritants. Especially in children, clothing can be an effective barrier against flare-inducing factors
and persistent scratching, allowing more rapid improvement of the eczematous lesions. On the contrary, some fabrics used for
clothing may exacerbate skin conditions due to their rough fibers, such as wool and nylon. Conventional silk has smooth fibers that
are generally woven for textiles in the manufacturing of clothes, but this material is not particularly useful in the management of
children with AD since it reduces transpiration and may cause discomfort. Herein, we evaluate the data concerning a special silk
fabric (MICROAIR DermaSilk) shown to be suitable for patients with AD. The unique properties of this knitted silk allow the skin
to breathe and lack irritative potential. Moreover, this fabric is treated with a water-resistant antimicrobial finish known as AEGIS
AEM 5772/5. This novel knitted silk fabric appears to be useful in managing children with AD due to its non-irritating and
antibacterial features. Additionally, a synthetic silk-like fabric (DermaTherapy) has received US FDA clearance as a Class I medical
device and is commercially available as bedding; their use by AD patients has shown interesting results.
Key words: antibacterial activity, atopic dermatitis, child, eczema, fabric, silk

Atopic dermatitis (AD) is the most frequent chronic inflammatory
skin disease of childhood. AD usually starts during the first
few years of life, commonly following a chronically relapsing
course. Many factors are known to worsen or trigger the disease,
including perspiration, food and inhalant allergens, climatic
factors, skin infections due to Staphylococcus aureus (S. aureus),
stress, and chemical or physical irritants1. Recent investigations
have shown that one of the most important pathogenetic factors
is skin barrier impairment due to alteration of structural
proteins (e.g., filaggrin) or enzyme imbalance (e.g., protease and
In the management of AD, an effective therapeutic program
requires a multifaceted approach that incorporates control of
skin inflammation, identification and elimination of triggering
factors, and implementation of strategies aimed at improving the
alterations/defects of the skin barrier.
Clothing can be an effective barrier against persistent scratching,
allowing more rapid improvement of the eczematous lesions
and limiting exposure to bacterial pathogens that can cause
skin infections. On the contrary, certain fabrics used for clothing
can exacerbate AD in some patients, which may be attributable
to their rough fibers (e.g., wool and nylon), whereas silk fibers
are generally smooth. However, conventional silk fabric used
for the manufacturing of clothing is not particularly practical
in managing children with AD, since it reduces transpiration
and may cause discomfort or irritation when in direct contact
with the skin.4
The Silk
Silk, in its natural state, consists of single long threads secreted by
the silkworm Bombyx mori and is made up of a double filament
of protein material (fibroin) glued together with sericin, an
allergenic gummy substance that is normally extracted during
the processing of the silk threads. Each silk thread is comprised
of filaments that are more than 800 meters in length. Thread

fibers are strong, perfectly smooth, and cylindrical, therefore,

minimizing friction on the skin. Degumming represents a key
process in the manufacturing of silk threads, whereby the sericin
is completely removed and the silk fibers gain their characteristic
sheen, softness, and flexibility.
Management of AD with DermaSilk
A new type of silk fabric made of breathable and slightly elastic
knitted silk is commercially available (MICROAIR DermaSilk,
thereafter referred to as DermaSilk) and may be beneficial in
children with AD. Moreover, this fabric is treated with a durable
water-resistant antimicrobial finish that prevents odors and
inhibits bacteria survival, including S. aureus.5,6
In a previous blind study6 we recruited 46 children experiencing
AD in acute phase: 31 patients received special silk clothes that
were worn for 1 week but changed daily; another 15 children
(the control group) wore cotton clothing. Moisturizing creams
or emulsions were the only topical treatment permitted in both
groups. The overall severity of AD was evaluated using the
SCORAD index (SCORing Atopic Dermatitis, a clinical tool for
assessing AD severity). In addition, the local score of an area
covered by the silk clothing was compared with the local score of
an uncovered area in the same child. All patients were evaluated
at baseline and 7 days after. At the end of the study, a significant
decrease in AD severity was observed in the children who wore
the silk garments (mean SCORAD decrease from 43 to 30;
P=0.003); the mean clinical score of the control group was not
significantly different from the first examination (SCORAD score
changed from 47 to 46). In contrast, the improvement in the mean
local score of the covered area (from 32 to 18.6; P=0.001) was
significantly higher than that of the uncovered area (from 31 to
26; P=0.112). At the second examination, the mean local score
of the uncovered area was not statistically significant, decreasing
from 31 to 26. In summary, the lesions in the uncovered area
worsened in 2 children (11%), were stable in 10 (55%), improved

Editor: Dr. Stuart Maddin Volume 17, Number 3 March 2012

in 3 cases (17%), and much improved in the remaining 3 (17%).

Similar results were demonstrated later by Koller et al.7
In a subsequent investigation8 we attempted to evaluate in vivo
the antibacterial properties of this special fabric treated with
AEGIS AEM 5572/5 (AEGIS), which had already been shown
in vitro to exhibit antibacterial activity.5 The study population
consisted of 12 children affected by AD with symmetrical
eczematous lesions on the antecubital areas and 4 patients
without any cutaneous disease served as controls. Children were
asked to wear for 7 days two tubular garments that were changed
daily. Microbiological examinations were conducted through
samples obtained with standard culture swabs and by means of
quantification of bacterial agents using agar plates at baseline,
after 1 hour, and after 7 days. A significant improvement in mean
value of the clinical SCORAD index was observed in both the
covered skin areas compared with the values obtained at baseline.
These decreases in values were from 7.3 to 4.4 (P=0.002) after
7 days in the area covered by the treated fabric and from 7.1 to
5 (P=0.019) in the symmetrical area covered by the untreated
fabric. Reductions in the mean number of CFU/cm2 (number of
colony forming units per cm2 of surface area) occurred but were
similar in both areas.
The data confirmed that the reduction in bacterial colonization
is associated with a clinical improvement of eczema. However,
our analysis showed that even though the silk fabric treated with
AEGIS exhibited in vitro antibacterial properties, we were unable
to demonstrate such activity in vivo. A possible explanation may
be the difficulty in maintaining sufficient adhesion between
the fabric and the skin or that bacterial colonization is strongly
influenced by the integrity of the skin barrier and the use of
Another investigation that evaluated the efficacy of antimicrobial
silk clothing in the treatment of AD observed comparable efficacy
to topical corticosteroid treatment.9 In a bilateral comparison
study, 15 children were recruited and instructed to wear clothing
made of special silk fabric (DermaSilk) on the left side of the
body and cotton on the right side. Only the right side of the body
was treated daily with a topical corticosteroid (mometasone)
for 7 days. The efficacy of these two treatments was measured
with a modified Eczema Area and Severity Index (EASI) score
and evaluation by the patients/parents, as well as physician
assessment at baseline and after 7 and 21 days. No significant
differences were noted between the skin of the right (DermaSilktreated) and left (treated with cotton and topical corticosteroid)
Another research group has explored the clinical efficacy of
DermaSilk with and without AEGIS antimicrobial finish on
eczema severity and pruritus.10 Thirty patients aged 3 to 31
years having active AD with eczematous lesions on the arms, but
without any sign of infection, were enrolled in a randomized,
double-blind study. Patients received a set of four pairs of
knitted silk tubular sleeves distinguished by different colors of
seams. Only one pair of sleeves was treated with AEGIS, which
was unknown to patients/parents and investigators.10 Patients
were evaluated at baseline and after 7, 14, 21, and 28 days using
multiple methods (i.e., photographic assessment, local modified
SCORAD index for the arm only, and patient/parent estimation

of pruritus with a visual analogue scale). Study findings reported

reductions in mean local SCORAD index scores (after 28 days) in
both treatment groups, i.e., arms exposed to both DermaSilk and
unmodified silk sleeves. However, the DermaSilk group showed a
consistent decline in scores (mean SCORAD decreased from 47
to 36 in the first 2 weeks and to 26 after an additional 2 weeks),
whereas the unmodified silk group experienced a significant
reduction only in the first 2 weeks of the study (mean SCORAD
changed from 47 to 38 in the first 2 weeks and to 36 after an
additional 2 weeks). Also, the DermaSilk group exhibited greater
reduction in pruritus.
Synthetic Silk-like Fabric (DermaTherapy)
Due to the favorable data demonstrated by the use of special
silk fabrics in AD management, a synthetic silk-like fabric
has also been developed. DermaTherapy received 510(k)
clearance from the US FDA as a Class I medical device for use
by patients susceptible to or who have mild atopic dermatitis.11
The manufacturer asserts the material is highly durable and
provides therapeutic benefits that are attributable to its ability to
minimize friction due to the smooth texture of the fibers, which
are composed of approximately 50% polyester and 50% nylon.
In addition, the fabric may inhibit bacterial growth by wicking
away moisture from the surface of the bedding, resulting in drier
conditions.12 The threads are produced with continuous-filament
fibers that create a planar surface, reducing skin irritation.
Moreover, a durable antimicrobial finish is applied to the fabric
to prevent bacterial infections. Kurz et al13 showed that the use of
silk-like bedding in subjects with mild to moderate AD reduced
disease severity at 8 weeks, including pruritus scores, and partial
improvements in the quality of life index were also observed.
The hypersensitivity of atopic skin may be improved or worsened
with the use of certain textiles. The itching produced by direct
contact with wool in patients with AD is a common source of
irritation that is likely produced by the spiky nature of the fibers.
In contrast, clothes made of knitted silk have unique beneficial
properties that reduce friction, allow the skin to breathe, and
absorb perspiration and serous exudates (up to 30% of its
weight without becoming damp6), which may be an important
factor in maintaining the moisture balance of the skin. The use
of novel knitted silk fabrics appears to be a promising adjunct
in the management of children with AD. As well, synthetic silklike bedding may offer therapeutic benefits that are attributable
to their non-irritating and antibacterial properties. Further
investigations to confirm the utility of these novel fabrics in AD
are warranted.
1. Novak N, Leung DY. Advances in atopic dermatitis. Curr Opin Immunol. 2011
2. De Benedetto A, Agnihothri R, McGirt LY, et al. Atopic dermatitis: a disease
caused by innate immune defects? J Invest Dermatol. 2009 Jan;129(1):14-30.
3. Irvine AD, McLean WH, Leung DY. Filaggrin mutations associated with skin
and allergic diseases. N Engl J Med. 2011 Oct 6;365(14):1315-27.
4. Inoue A, Ishido I, Shoji A, et al. Textile dermatitis from silk. Contact Dermatitis.
1997 Oct;37(4):185.
5. Gettings RL, Triplett BL. A new durable antimicrobial finish for textiles.
In: AATCC Book of papers. American Association of Textile Chemists and
Colorists National Technical Conference, p.259-61 (1978).

Editor: Dr. Stuart Maddin Volume 17, Number 3 March 2012

6. Ricci G, Patrizi A, Bendandi B, et al. Clinical effectiveness of a silk fabric in the

treatment of atopic dermatitis. Br J Dermatol. 2004 Jan;150(1):127-31.
7. Koller DY, Halmerbauer G, Bock A, et al. Action of a silk fabric treated with
AEGIS in children with atopic dermatitis: a 3-month trial. Pediatr Allergy
Immunol. 2007 Jun;18(4):335-8.
8. Ricci G, Patrizi A, Mandrioli P, et al. Evaluation of the antibacterial activity
of a special silk textile in the treatment of atopic dermatitis. Dermatology.
9. Senti G, Steinmann LS, Fischer B, et al. Antimicrobial silk clothing in the
treatment of atopic dermatitis proves comparable to topical corticosteroid
treatment. Dermatology. 2006;213(3):228-33.

10. Stinco G, Piccirillo F, Valent F. A randomized double-blind study to investigate

the clinical efficacy of adding a non-migrating antimicrobial to a special silk
fabric in the treatment of atopic dermatitis. Dermatology. 2008;217(3):191-5.
11. U.S. Food and Drug Administration. Medical Devices. January 2007 510(k)
Clearances. Available at: http://www.accessdata.fda.gov/SCRIPTs/cdrh/
devicesatfda/index.cfm?db=pmn&id=K061242. Accessed January 25, 2012.
12. National Eczema Association. EASE Program. Seal of acceptance fabrics.
Available at: http://www.easeeczema.org/product_directory/fabrics.htm.
Accessed: January 25, 2012.
13. Kurtz EJ, Yelverton CB, Camacho FT, et al. Use of a silklike bedding fabric in
patients with atopic dermatitis. Pediatr Dermatol. 2008 Jul-Aug;25(4):439-43.


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Editor: Dr. Stuart Maddin Volume 17, Number 3 March 2012

Update on Drugs
Stuart Maddin, MD

University of British Columbia, Vancouver, Canada

Hugo Degreef, MD, PhD

Catholic University, Leuven, Belgium

Jason Rivers, MD

University of British Columbia, Vancouver, Canada



Approval Dates/Comments

Ingenol mebutate gel

(0.015%, 0.05%)
Leo Pharma Inc.

The US FDA approved ingenol mebutate gel (derived from

the Euphorbia peplus plant) in January 2012 for the topical
treatment of actinic keratosis (AK). The 0.015% formulation is
used once-daily on the face and scalp for 3 consecutive days, and
the 0.05% gel is used once-daily on the trunk and extremities
for 2 consecutive days. The treatment course may be completed
in 2-3 days. In phase III studies, 60-68% of patients with AKs
on the face and scalp experienced 75% reduction of existing
lesions vs. 7-8% with placebo; in treating AKs of the trunk
and extremities 44-55% showed 75% reduction vs. 7% for
placebo. Ingenol mebutate-treated patients experienced 37-47%
complete clearance of lesions on the face and scalp and 28-42%
on the trunk and extremities. The most common adverse events
were local skin reactions, such as erythema, flaking/scaling,
crusting, and swelling. Potential ocular side effects following
exposure include severe eye pain, eyelid edema, eyelid ptosis, and
periorbital edema. For more information:

Murad Alam, MD

Northwestern University Medical School, Chicago, USA

Kenneth A. Arndt, MD

Beth Israel Hospital

Harvard Medical School, Boston, USA

Wilma Fowler Bergfeld, MD

Cleveland Clinic, Cleveland, USA

Jan D. Bos, MD

University of Amsterdam, Amsterdam, Holland

Alastair Carruthers, MD

University of British Columbia, Vancouver, Canada

Bryce Cowan, MD, PhD

University of British Columbia, Vancouver, Canada

Jeffrey S. Dover, MD

Yale University School of Medicine, New Haven, USA

Dartmouth Medical School, Hanover, USA

Boni E. Elewski, MD

University of Alabama, Birmingham, USA


Barbara A. Gilchrest, MD

Boston University School of Medicine, Boston, USA

Christopher E.M. Griffiths, MD

University of Manchester, Manchester, UK

Aditya K. Gupta, MD, PhD, MBA/MCM

University of Toronto, Toronto, Canada

Mark Lebwohl, MD

Mt. Sinai Medical Center, New York, USA

James J. Leydon, MD

University of Pennsylvania, Philadelphia, USA

Harvey Lui, MD

University of British Columbia, Vancouver, Canada

Howard I. Maibach, MD

University of California Hospital, San Francisco, USA

Jose Mascaro, MD, MS

University of Barcelona, Barcelona, Spain

Larry E. Millikan, MD

Tulane University Medical Center, New Orleans, USA

Jean Paul Ortonne, MD

Centre Hospitalier Universitaire de Nice, Nice, France

Ted Rosen, MD

Baylor College of Medicine, Houston, USA

Alan R. Shalita, MD

SUNY Health Sciences Center, Brooklyn, USA

Wolfram Sterry, MD

Humboldt University, Berlin, Germany

Richard Thomas, MD

University of British Columbia, Vancouver, Canada

Stephen K. Tyring, MD, PhD, MBA

University of Texas Health Science Center, Houston, USA

John Voorhees, MD

University of Michigan, Ann Arbor, USA

Guy Webster, MD

Jefferson Medical College, Philadelphia, USA

Klaus Wolff, MD
University of Vienna, Vienna, Austria

Skin Therapy Letter (ISSN 12015989) Copyright 2012 by

SkinCareGuide.com Ltd. Skin Therapy Letter is published 10 times
annually by SkinCareGuide.com Ltd, 1004 750 West Pender, Vancouver,
British Columbia, Canada, V6C 2T8. All rights reserved. Reproduction in
whole or in part by any process is strictly forbidden without prior consent of
the publisher in writing. While every effort is made to see that no inaccurate
or misleading data, opinion, or statement appears in the Skin Therapy
Letter , the Publishers and Editorial Board wish to make it clear that the
data and opinions appearing in the articles herein are the responsibility
of the contributor. Accordingly, the Publishers, the Editorial Committee
and their respective employees, officers, and agents accept no liability
whatsoever for the consequences of any such inaccurate or misleading
data, opinion, or statement. While every effort is made to ensure that drug
doses and other quantities are presented accurately, readers are advised
that new methods and techniques involving drug usage, and described
herein, should only be followed in conjunction with the drug manufacturers
own published literature. Printed on acid-free paper effective with Volume
1, Issue 1, 1995.
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Vismodegib capsule
Roche Group
Curis, Inc.

The US FDA approved vismodegib, a hedgehog pathway

inhibitor, in January 2012 for the treatment of adults
with advanced basal cell carcinoma (BCC). The drug is
administered orally once-daily and is indicated for patients
with locally advanced BCC who are not candidates for surgery
or radiation and for patients with metastatic BCC. Safety
and efficacy were evaluated in an international, single-arm,
multi-center study (ERIVANCE BCC) involving 96 patients
with locally advanced or metastatic BCC. In patients treated
with vismodegib, 30% with metastatic disease experienced
a partial response and 43% with locally advanced BCC
showed a complete or partial response; median duration
of response was 7.6 months. The most common side effects
from therapy included muscle spasms, hair loss, weight
loss, nausea, diarrhea, fatigue, distorted sense of taste,
decreased appetite, constipation, vomiting, and loss of taste
function in the tongue.
Drug News

A recent article published in the The New England Journal of Medicine* reported that
vemurafenib (Zelboraf), a BRAF enzyme inhibitor developed for the treatment of
late-stage melanoma (FDA-approved in August 2011), does not trigger the mutations
that cause squamous cell carcinoma (SCC), as previously suspected. However, it was
uncovered that the drug does accelerate the growth of SCCs in patients with RAS
mutations, likely resulting from photodamage. Between 15-30% of vemurafenibtreated patients have developed these secondary cancers, which are common with
BRAF inhibitor therapy. Vemurafenib induces apoptosis in melanoma cell lines by
interrupting RAS-RAF-MEK-ERK signaling, which is a major factor in the growth and
progression of human melanoma tumors. The researchers described that vemurafenib
stimulated mitogen-activated protein kinase signaling increased the proliferation of
cells with RAS mutations, thereby promoting the growth of cutaneous lesions with such
oncogene mutations. Co-administration of an MEK inhibitor in lab mice resulted in a
91% reduction in tumor development. Accordingly, this study suggests that addition of
an MEK inhibitor to vemurafenib therapy in patients with RAS mutations could inhibit
the emergence of secondary tumors.
*Su F, Viros A, Milagre C, et al. RAS mutations in cutaneous squamous-cell carcinomas in patients treated
with BRAF inhibitors. N Engl J Med. 2012 Jan 19;366(3):207-15.

Editor: Dr. Stuart Maddin Volume 17, Number 3 March 2012