Scabies

Management
In adults, topical scabicides should be applied to the entire skin surface, excepting the face and the scalp, with special
attention to the intertriginous areas, the genitalia, periungual regions, and behind the ears. In children and those patients
with crusted scabies, the face and the scalp should be also treated. Patients must be also informed that even after
adequate scabicidal therapy, the rash and pruritus may persist up to 4 weeks; otherwise the may believe that the
prescribed treatments was unsuccessful, and then inappropriately overuse scabicidal medications. Topical steroids,
antihistamines and, if necessary, a short course of systemic steroids can be prescribed to alleviate the pruritus and rash
once the patient has completed the scabicide treatment.

The only oral but highly effective scabicide known to date is ivermectin. It is structurally similar to macrolidic antibiotics,
but no antibacterial activity. Its activity against the scabies is due to its high affinity for the gluminated-gated chloride ions
found in the peripheral nervous system of invertebrates. Ivermectin blocks the channel transmission across the nerve
synapse that uses γ-aminobutyric acid. This results in the paralysis and death of invertebrae parasites. In mammals,
these receptors are confined to the central nervous system and in normal condition the drug does not cross the blood-
brain barrier. It has been suggested that the conditions that disrupt the blood brain barrier may allow the drug to enters
the CNS. Therefore the drug should not be used in children younger than the age of 5 or weighing less than 15kg, or
during pregnancy or lactation. In crusted scabies, the combination of ivermectin and topical anti-scabicide is often used
due to the severity of infection.

Syndrome Recommended Drug Alternative Drug Comments

Classical scabies Two applications of topical permethrin5% Oral ivermectina (200 μg/kg/dose); two
applied in the evening and left on overnight; doses with food; day 1 and between days
day 1 and between days 8–15 8–15
OR
Topical benzyl benzoate 10–25%; day 1
and between days 8–15
Crusted scabies Both topical permethrin 5% each 2–3 days Topical benzyl benzoate 12.5–25% instead Keratolytic creams for
initially and oral ivermectina (200 μg/ kg/dose), of permethrin skin crusts
with food, for 3 (days1,2,8), 5 (days 1,2,8,9,15) Vigilance for the
or 7 (days 1,2,8,9,15,22) doses depending on development of sepsis
severity Appropriate infection
control measures
Close contacts A single application of topical permethrin 5% Oral ivermectina (200 μg/kg/dose), with
applied in the evening and left on overnight food, single dose
OR
Topical benzyl benzoate 10–25%, single
application
Institutional Treat clinical cases as above for classical and In refractory outbreaks consider treatment Look for ‘core transmitter’
outbreak crusted scabies and ALL potentially exposed of all residents with oral ivermectina index cases with crusted
residents, staff and visitors, as above for scabies.
contacts Attention to planning and
logistics of therapy.
Appropriate infection
control measures.
Endemic Multifaceted approach with educationand As above for classical and crusted scabies Look for ‘core transmitter’
community community involvement. Treat clinical cases as and contacts (community members) index cases with crusted
above for classical and crusted scabies and all scabies.
family/household members as above for Attention to planning and
contacts Consider treating all other community logistics of therapy.
members as above for contacts Sustainability requires
addressing underlying
issues of overcrowding
and access to health
hardware, health care and
education.
*Manson’s
*Fitzpatrick’s

Prevention
Individuals in close contact with the infected person should be treated with topical scabicide. Treatment should be
directed to prevent spread of the scabies, because the individuals may be harboring the scabies mite during the
asymptomatic incubation period. Additionally, to prevent the re-infection with formites, bed, sheets, pillow cases, towels,
and clothes worn during the past 5 days should be washed and dried in the hot cycle, or be dry cleaned. Because the
mite can live up to 3 days off of skin, carpets, and upholstery should be vacuumed.

Prognosis
Most cases of scabies can be cured without any long-term problems. Immunocompromised or institutionalized
individuals are at an increased risk for crusted scabies, which is associated with a less favorable outcome.

PP of Drugs
 Permethrin (Drug of Choice)
No formal pharmacodynamic studies on permethrin are reported in the literature, presumably because it was
developed as a contact insecticide rather than as a medicinal product. The synthetic pyrethroids delay closure of the
sodium channel, apparently by holding the activation gate in the open position. The effects of pyrethroids on the
central nervous system have led to the suggestion that they act via antagonism of gamma-aminobutyric acid
(GABA)-mediated inhibition, modulation of nicotinic cholinergic transmission, enhancement of noradrenaline release
or actions on calcium ions.
Uses: Scabies, pediculosis
Forms: Cream, liquid

 Ivermectin (Oral)
Synthetic macrocyclic lactone belonging to the avermectin group of antibiotics. It has no antibiotic activity but is
active against a number of endoparasites and ectoparasites of humans and animals.
-Class: anthelmintic
-Uses: strongyloidiasis (threadworm), onchocerciasis (“river blindness”, infection of roundworm) and other
roundworm infections, pediculosis, scabies.
-Mode of Action: Ivermectin kills the larval Onchocerca volvulus worms – microfilariae – that live in the
subcutaneous tissue of an infected person. It is believed to paralyse or kill the microfilariae gradually, so avoiding
the intense inflammatory responses induced when they die naturally. Ivermectin does not kill the adult worms but
suppresses the production of microfilariae by adult female worms for a few months following treatment, so reduces
transmission.
-Side effects: dizziness, loss of appetite, nausea, vomiting, stomach pain or bloating, diarrhea, constipation,
weakness, sleepiness, etc.
-contraindicated in patients with allergic sensitization or nervous system disorders and in women who are pregnant
or breastfeeding. Children younger than 5 years or weighing less than 15 kg should not be treated with ivermectin.
 Benzyl benzoate (Topical)
Benzyl benzoate is a synthetic compound that is produced from benzoic acid and benzyl alcohol. It is toxic to the
ectoparasites Sarcoptes scabiei hominis, Pediculus humanus capitis, P. humanus corporis and Pthirus pubis. It’s
also been used as insecticides.
Adverse effect: irritation of the skin with burning or stinging sensations.

 Lindane (lotion)  second line

Lindane is an organochlorine insecticide and fumigant which has been used on a wide range of soil-dwelling and
plant-eating (phytophagous) insects. It is commonly used on a wide variety of crops, in warehouses, in public health
to control insect-borne diseases, and (with fungicides) as a seed treatment. Lindane is also presently used in lotions,
creams, and shampoos for the control of lice and mites (scabies) in humans.
Lindane is absorbed through the chitin shell of adult mites & lice and causes death by inducing convulsions. The
drug is also lethal for ova. Repeat dosing should be avoided. Adverse effects including convulsions and irritation.
Lindane is not safe in children or neonates, because of increased transcutaneous absorption leading to possible
neurotoxicity. The systemic absorption rate of lindane is 10 times greater than that of permethrin, and its serum
levels are more than 40 times higher.

 Crotamiton (cream/lotion)
Scabicidal & antipruritic. The mechanisms of these actions are not known. The pharmacokinetics of crotamiton and
its degree of systemic absorption following topical application have not been determined.

 Precipitated sulfur
Keratolytic agents (drugs that are used to treat hyperkeratosis thickening of stratum corneum). Also have
antimicrobial or antiparacitic properties. Topical sulfur is one of only a few scabicidal agents that can be used safely
in very small children (< 2 mo) and in pregnant women.