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Clinician’s Corner: Scabies

Now that you are done scratching your head after the past three weeks, it is time to get the rest of you scratching!

Caused by the mite: Sarcoptes scabei .

Mostly affects the folds of the skin behind the knee and others, bellybutton and scrotum. Spread by direct, prolonged, skin-to-skin contact with a person who has scabies.  Transmitted through direct contact, and frequently sexual contact. Can survive off a human host 24-36 hours under normal conditions of heat and humidity.  Increased humidity prolongs survival off the host. Can be transmitted through towels, bed linens and sleeping bags.  Is a problem for the military servicemen.

Clinical presentation:

  • Severe itching and an inability to sleep.
  • Lesions between webs of fingers, wrists, buttocks, elbows, groin & scalp.

Diagnosis:

  • Look for burrows made by the mite, and skin scrapings. Short irregular mark, 2-3 cm long and the width of a hair.
  • The diagnosis of scabies is confirmed by detecting scabies mites, eggs, or feces with a microscope.

Permethrin 5%

Elimite cream 5%: treatment of scabies – DRUG of CHOICE available in 60 gm tubes

Warnings/Precautions /Adverse Effects

  • Not recommended if nursing.
  • Can be used in children over age 2 months.
  • Caution with asthmatics.

Patient Education

  • Thoroughly massage cream from the head to the soles of the feet.  Rarely do scabies affect the heads of adults. They may infest the infants or geriatrics around the hairline.
  • Remove cream by washing off in bathtub or shower after 8 to 14 hours.
  • One application is generally curative.  (half a tube is sufficient for 1 adult)
  • Patients may experience itching after treatment, rarely a sign of treatment failure. Living mites after 14 days would indicate that re-treatment is necessary

Ivermectin (Stromectol®) oral tablets.   May be a safe and effective treatment for scabies, although not FDA-approved for scabies. Consider for patients who have failed treatment with or who cannot tolerate FDA-approved topical medications for the treatment of scabies. Might be a good option for nursing homes or large families, where head to toe treatment of each patient is impractical.

After successful treatment, patients may continue to itch for several weeks.

  • A steroidal cream will help resolve the dermatitis.
  • Short course of corticosteroids, like prednisone will also decrease itching.
  • Oral antihistamines like diphenhydramine (Benadryl) might be of some benefit to relieve itching.
  • If no relief of itching, recheck for reinfestation.

Worst of the worst: Crusted scabies or “Norwegian scabies” — occurs only in people with a weakened immune system (such as HIV infection, lymphoma, or other conditions). This condition may also affect older adults or those with Down syndrome.  Ivermectin or permethrin 5% are used to treat this condition. Lesions appear as large, crusty red patches or bumps on the skin