european guideline of scabies

8/10/2019 European Guideline of Scabies

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MANAGEMENT OF SPECIFIC INFECTIONS

European guideline for the managementof scabies

G R Scott

Department of Genitourinary Medicine, Edinburgh Royal Inrmary, Edinburgh, LaurestonPlace, Edinburgh

Transmission of the mite (Sarcoptes scabiei) occursby protracted direct body contact; although incrusted scabies (Norwegian scabies), transmissionalso occurs via infected clothing or bedding.

Mites are capable of burrowing into the stratumcorneum of a contact person within one hour.

Hypersensitivity to proteases in mite faecal mattergenerates both local and distant hypersensitivityreactions.

DIAGNOSIS

Clinical

. The main symptom is itch, which usuallydevelops 26 weeks after infestation. In a re-infected person the itch recurs within 14 days

. Examination reveals characteristic silvery lineswith a mean length of 0.5 cm, which may beseen in the skin where the mites have

burrowed. Typical sites include between thengers and on the sides of hands and feet, onwrists, extensor surface of the elbow, femalenipples, penis and scrotum, anterior axillaryfolds

. Papules or nodules, which result from itching,often affect the genital area

. The clinical manifestations of crusted scabiesare described below.

Indication for testing

This is important in, at least, the index patientbefore taking far-reaching epidemiological mea-sures, e.g. epidemic in an institution:

. Direct microscopic examination of a potassiumhydroxide mount of a supercial epidermalskin sample (`skin snip) obtained with a

scalpel from the end of a burrow. Experienced clinicians may probe a burrow

with a needle to obtain material for directmicroscopic examination

. Direct examination of skin for mites using anepiluminescence stereomicroscope has also

been described1.

MANAGEMENT

Indication for routine STD examination

. History of risk behaviour for STD in a sexuallyactive patient with scabies.

Indications for therapy

. Characteristic clinical ndings

. High-risk contacts: persons with protracted orfrequent skin contact (e.g. via the hands)should be treated whether or not they havesymptoms

. Low-risk contacts: persons with indirect con-tact (e.g. via bedding) only require treatmentin cases of crusted scabies (see below).

Recommended regimensEfcacy, tolerability and cost guide the specicchoice of therapy. The quality of evidence compar-ing one treatment with another is poor2,3. ACochrane review has been performed4: one largeand one small trial indicated no difference in theclinical cure rates of topical permethrin andlindane treatment, whereas treatment with perme-thrin had an advantage in two small trials. The dataon topical treatment with benzyl benzoate, crota-miton, allethrin, malathion (and ivermectin) arelimited. Oral treatment with ivermectin has been

evaluated510, but has been associated withdeaths1113. It has not been licensed in any countryfor treatment of scabies in humans and is thereforeonly considered for the treatment of crusted scabies(see below) and when appropriate topical treat-ment is not possible.

. Permethrin 5% (once for 812 hours) is effectiveand well-tolerated1416, but cost can be aproblem. In some countries permethrin 2.5%is used in children


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guidelines recommend that lindane beavoided in21: (a) premature children; (b)children below the tenth percentile of growth;(c) children with epilepsy; (d) children withpre-existent generalized skin disorders such aseczema

. Benzyl benzoate 25% (thrice, for 24 hours each

day) appears to be effective, but is said torequire application on three successive days22.One study combining benzyl benzoate 22.5%with disulram 2% showed cure after a singleapplication 23. For children use of 10% benzyl

benzoate is advocated in some countries17,22.Benzyl benzoate may cause irritant dermati-tis22

. Sulphur (633%) in various preparations canact as an antiscabietic24. It is effective, verycheap and safe, but stains clothing andrequires application on three successive days

for 24 hours each day. Other options: (a) crotamiton 10%, but it

appears to be less effective than permethrinand lindane3,17,25 ; (b) allethrin, a syntheticpyrethroid17,26; (c) malathion 0.5%2730.

Addendum on treatment procedure

. Before applying lindane: no bathing or showerbefore treatment unless the skin needs to becleaned. If the patient does wash beforetreatment, one hour should elapse for the skin

to dry properly before applying the lotion,because of increased absorption of lindanewhen applied to damp skin, and hence risk oftoxicity

. Treatment instructions: patients should beprovided with written instructions, whichshould include the amount of drug to beapplied. Apply lotion/cream to the entire skinfrom the jawline downwards including allfolds, groin, navel, external genitalia and theskin under the nails. In babies, the skin of theface and scalp should also be treated (trans-

mission is possible from contact by breastfeed-ing). If the patient applies the lotion/cream

him/herself, the hands should not be washedafter application. Attention should be given toapplication at the tips of the ngers and underthe nails (especially in crusted scabies). If thelotion/cream is applied by someone withoutscabies, that person should wear (medical)disposable gloves. If there is any doubt as to

whether or not a patient will apply the lotion/cream according to instructions, a secondapplication is recommended, preferably soonafter the rst

. Hygienic measures: after completion of treat-ment, use fresh bedding and clothing. Poten-tially contaminated clothes and beddingshould be washed at high temperature(>508C) if possible, or may be kept in one ormore plastic bags for at least 72 hours, becausemites separated from the human host diewithin that time

. In some parts of Europe legal requirementsdictate the choice of rst-line treatment (seeTable 1).

Special situations

Pregnancy/lactation. Permethrin, benzyl benzoate (applied thrice),

and sulphur (applied thrice) appear to be safein pregnancy although the evidence tends to

be anecdotal20,25,27,31.

Crusted scabies (Norwegian scabies). Crusted scabies is seen in immunocompro-

mised persons, e.g. AIDS patients32,33, inpersons with neurological disturbance andthose conned to long-term institutions

. Clinical signs typically consist of hyperkerato-tic/crusted plaques, papules and nodules,particularly on the palms of the hands andthe soles of the feet, although areas such as theaxillae, buttocks and scalp may also beaffected. Occasionally there may be psoriasi-form or eczematous lesions with ne, powder-

like scaling and redness, generally on a dryskin

Scott. Management of scabies 59

Table 1. Scabies treatment protocol options, as stated by law in the Russian Federation

Concentration

Medication Adults ChildrenNumber of applications/day(duration of medication) Days of treatment

Hygienic measures:on day x

Benzyl-benzoate 20% 10% 1 (24 hours) Day 1 and 4 Day 5Sulphuric ointment 2033% 510% 1 (24 hours) Day 15 (17) Day 6 (8)(I) Sodium hyposulphite

(Na2S2O3, 5H2O)solution*

60% 40% 1 Day 1 and 2 Day 3

plus(II) Hydrochloric acid

(HCl) solution*6% 4% 1 Day 1 and 2 Day 3

Application of solution I should be followed, after allowing solution I to dry for 10 minutes, by application of solution II

*Demianovitch method. The procedure can be repeated once after 3 days.


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. Diagnosis by direct microscopy of skin sam-ples is straightforward in view of the largenumbers of mites and eggs in the scales

. Combined topical and oral treatment isthought to be the best option, if ivermectin isavailable (other oral antiparasitic drugs, i.e.thiabendazole and ubendazole, may also be

effective3,34). Topical treatment is with twoapplications of permethrin 5% or lindane 1%to the entire skin, including the head. Perme-thrin can be applied more than twice, ifnecessary. This may be alternated withkeratolytic therapy, e.g. emollients or bathing.Oral treatment with ivermectin (total of 23doses every 12 weeks) is given at a dose of0.2 mg/kg

. Because of the increased risk of transmission tocontact persons, strict isolation should beobserved until cure is achieved. Care needs

to be exercised with recently handled or usedpersonal possessions. Active epidemiologicalmeasures to ensure treatment of all contactsare necessary

. Complication of crusted scabies: bacterial sepsis.

FOLLOW UP

. It should be explained to patients that aftertreatment some itching might persist forseveral weeks, especially in atopic individuals.

. Symptomatic relief may be obtained from a

topical antipruritic, e.g. crotamiton and/or atopical corticosteroid.

. A test of cure (direct microscopy, not usingpotassium hydroxide, for living/movingmites) may be performed, especially in crustedscabies.

RESISTANCE

. Resistance to lindane, though rare, has beendescribed35,36. Biologically speaking, resistancecan be expected with any drug if used

frequently within a given population.

COMPULSORY NOTIFICATION

. In some European countries, scabies should benotied to the Health Authorities.

References

1 G, Fabbrocini G, Delno M. Epiluminescence microscopy: anew approach to in vivo detection of Sarcoptes scabiei. ArchDermatol 1997;133:7513

2 Brown S, Becher J, Brady W. Treatment of ectoparasiticinfections, review of the English language literature 19821992. Clin Infect Dis 1995;20(suppl):S1049

3 Elgart ML. A riskbenet assessment of agents used in thetreatment of scabies.Drug Safety 1996;14:38693

4 Bigby M. A systematic review of the treatment of scabies.Arch Dermatol2000;136:3879

5 Meinking TL, Taplin D, Hermida JL, Pardo R, Kerdel FA.The treatment of scabies with ivermectin. N Engl J Med1995;333:2630

6 Youssef MY, Sadaka HA, Eissa MM, el-Ariny AF. Topicalapplication of ivermectin for human ectoparasites. Am JTrop Med Hyg 1995;53:6523

7 Feal-Cortizas C, Abajo P, Aragues M, Garcia-Diez A,Dauden E. Dose evaluation in the treatment of scabies with

oral ivermectin .J Eur Acad Dermatol Venereol 1997;9(suppl):S191

8 Chouela EN, Abeldano AM, Pellerano G, et al. Equivalenttherapeutic efcacy and safety of ivermectin and lindane inthe treatment of human scabies. Arch Dermatol 1999;135:6515

9 Usha V, Gopalakrishnan Nair TV. A comparative study oforal ivermectin and topical permethrin cream in thetreatment of scabies. J Am Acad Dermatol 2000;42:23642

10 Del Giudice P, Marty P. Ivermectin. A new therapeuticweapon in dermatology? Arch Dermatol 1999;135:7056

11 Barkwell R, Shields S. Deaths associated with ivermectintreatment of scabies. Lancet1997;349:11445

12 Coyne PE, Addiss DG. Deaths associated with ivermectintreatment for scabies. Lancet 1997;350:21516

13 Burkhardt CN, Burkhardt CG. Ivermectin: a few caveats arewarranted before initiatin g therapy for scabies. ArchDermatol 1999;135:154950

14 Schultz MW, Gomez M, Hansen RC, et al. Comparativestudy of 5% permethrin cream and 1% lindane lotion for thetreatment of scabies. Arch Dermatol 1990;126:16770

15 Meinking TL, Taplin D. Safety of permethrin vs lindane forthe treatment of scabies. Arch Dermatol 1996;132:95962

16 Franz TJ, Lehman PA, Franz SF, Guin JD. Comparativepercutaneous absorption of lindane and permethrin. ArchDermatol 1996;132:9015

17 Krause W. Epizoonosen. In: Petzoldt D, Gross G, eds.Diagnostik und Therapie sexuell ubertragbarer Krankheiten.Leitlinien 2001 der Deutschen STD-Gesellschaft. Berlin:Springer Verlag, 2001;1924

18 Taplin D, Rivera A, Walker JG, Roth WI, Reno D, MeinkingT. A comparative trial of three treatment schedules (2, 6 and1224 hours) for the eradication of scabies. J Am AcadDermatol 1983;9:5504

19 Rasmussen JE. Lindane. A prudent approach.Arch Dermatol19987;123:100810

20 Centers for Disease Control and Prevention. 1998 Guide-lines for treatment of sexually transmitted diseases. MMWR

Morb Mortal Wkly Rep 1998;47(RR-1):111621 Van Voorst Vader PC, Van der Meijden WI, et al. (eds)

Sexually Transmitted Diseases: Netherlands Diagnosis andTherapy Guidelines. Utrecht: Stichting SOA-Bestrijding,1997[http://www.soa.nl]

22 Haustein UF, Hlawa B. Treatment of scabies with perme-thrin versus lindane and benzyl benzoate. Acta DermVenereol (Stockh)1989;69:34851

23 Landegren J, Borglund E, Storga rds K. Treatment of scabieswith disulram and benzyl benzoate emulsion: a controlledstudy.Acta Derm Venereol (Stockh) 1979;59:2746

24 Avila-Romay A, Alvarez-Franco M, Ruiz-Maldonado R.Therapeutic efcacy, secondary effects, and patient accept-ability of 10% sulfur in either pork fat or cold cream for thetreatment of scabies. Pediatr Dermatol 1991;8:64

25 Fo lster-Holst R, Rui T, Christophers E. Die Skabiestherapieunter besonderer Bertu cksichtigung des fru hen Kindesal-ters, der Schwangerschaft und Stillzeit. Hautarzt 2000;51:713

26 Paasch U, Haustein UF. Management of endemic outbreaksof scabies with allethrin, permethrin and ivermectin. Int JDermatol 2000;39:46370

60 International Journal of STD & AIDS Volume 12 Supplement 3 October 2001
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27 Scott G. National guideline for the management of scabies.In: Radcliffe K, Ahmed-Jushuf, Cowan F, Fitzgerald M,Wilson J, eds. UK national guideline on sexuallytransmitted infections and closely related conditions. SexTransm Inf1999;75(suppl 1):S767

28 Hanna NF, Clay JC, Harris JRW.Sarcoptes scabiei infestationtreated with malathion liquid. Br J Vener Dis1978;54:354

29 Burgess I, Robinson RJF, Robinson J, Maunder JW, Hassan

Z. Aqueous malathion 0.5% as a scabicide: clinical trial. BMJ1986;292:1172

30 Bennett CE, Keefe M, Reynolds JC. Perceptions of theincidence of scabies and efcacy of treatment in U.K.hospitals. Br J Dermatol 2000;143:13378

31 Judge MR, Kobza-Black A. Crusted scabies in pregnancy.BrJ Dermatol 1995;132:1169

32 Corbett EL, Crossley I, Holton J,et al. Crusted (`Norwegian)scabies in a specialist HIV unit: successful use of ivermectinand failure to prevent nosocomial transmission. Genitourin

Med 1996;72:1151733 Nandwani R, Pozniak AL, Fuller LC, Wade J. Crusted

(`Norwegian) scabies in a specialised HIV unit (a protocol,bathing included). Genitourin Med 1996;72:4534

34 Nocera T, Huet P, Danduran d M, Guillot B. Value of (oral)

ubendazole in the treatment of scabies. Eur J Dermatol1996;6:1545

35 Purvis RS, Tyring SK. An outbreak of lindane-resistantscabies treated successfully with permethrin 5% cream. J

Am Acad Dermatol 1991;25:10151636 Roth WI. Scabies resistant to lindane 1% lotion and

crotamiton 10% cream.J Am Acad Dermatol1991;24:5023

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european guideline of scabies

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