Scabies in Emergency Medicine Medication

  • Author: Amy L McCroskey, MD; Chief Editor: Robert E O'Connor, MD, MPH   more...
 
Updated: Oct 6, 2010
 

Medication Summary

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

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Scabicides

Class Summary

Treatment options include either topical or oral medication. Topical options include permethrin cream (drug of choice), lindane, benzyl benzoate, crotamiton lotion and cream, sulfur, Tea tree oil, or oil of the leaves of Lippia multiflora Moldenke, a shrub found growing in West Africa Savannah. Oral options include ivermectin (not approved by FDA for treatment of scabies). A second course of treatment is often recommended 7-10 days later because of some developing larvae that may survive the initial treatment.[15]

Special population recommendations are as follows:[3]

  • Infants - Permethrin 5% cream (>2 months age) (Ivermectin and lindane contraindicated)
  • Children - Permethrin 5% cream, benzyl benzoate 12.5%
  • Pregnant and breastfeeding women - 6% sulfur (Ivermectin, permethrin, and lindane contraindicated)
  • Crusted or Norwegian scabies - Oral ivermectin (may require 3-7 doses, or in combination with a topical scabicide depending on the severity of the infection[5] ); hyperkeratosis treated with a keratolytic agent (5-10% salicylic acid in petrolatum) improves penetration of the topical agent[5]

The Centers for Disease Control and Prevention recommends treatment with either permethrin lindane or ivermectin. Permethrin is the drug of choice in the United States and the United Kingdom, but it is not available in France. In some studies, it has been shown to be more effective than a single dose of oral ivermectin, although it has equivalent efficacy when 2 doses of ivermectin are used at time zero and 2 weeks later. In severe cases, a topical medication may be used with oral medication (ivermectin).

A 2007 Cochrane Review that focused on interventions for treating scabies recommended the following:[19]

  • Topical permethrin appeared to be the most effective treatment for scabies.
  • Topical permethrin appeared more effective than oral ivermectin, topical lindane, and topical crotamiton.

Drug resistance is emerging as a concern with repeated administration.

  • Clinical resistance has not been documented for permethrin use, but it has been documented in 2 people with crusted scabies who had repeated regimens of multiple doses of ivermectin.[5]
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Permethrin cream 5% (Elimite)

 

CDC recommends as first-line treatment.

Drug of choice particularly for infants >2 months old and small children.

Highly effective, minimally absorbed and minimally toxic.[15]

Even after successful treatment, post scabietic nodules and pruritus may persist for months. In vitro resistance and treatment failures have been documented. Most expensive of all topical scabicides.[3]

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Lindane (Kwell, gamma benzene hexachloride)

 

Stimulates nervous system of parasite, causing seizures and death. Considered second-line treatment if other agents fail or are not tolerated. Not very safe in children due to transcutaneous absorption leading to neurotoxicity. The systemic absorption rate of lindane is 10 times greater than permethrin, and its serum levels are more than 40 times higher.[14] Overall, permethrin is a safer choice.

Sulfur in petrolatum (2 -10%, with 6% preferred, cream or ointment)

 

Not FDA approved for treatment of scabies. The oldest antiscabietic. One of a few scabicidal treatments that may be used safely in very small children (< 2 mo) and in pregnant women.[14, 20] Sulfur is messy, malodorous, stains clothes, and requires repeat applications, thus reducing compliance.[20] Sulfur should only be used when a patient cannot tolerate permethrin, lindane, or ivermectin.[20] It is inexpensive and can be used for mass therapy in resource-poor economies.[20]

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Crotamiton 10% cream or lotion (Eurax)

 

For the treatment of scabies. Mechanism of action is unknown. Weak antipruritic agent. Success rates vary 50-70%.[3]

Benzyl benzoate

 

Ester of benzoic acid and benzyl alcohol. Neurotoxic to mites. Not available in the United States[4] and not FDA approved as a scabicide, but used in Europe. Cheaper alternative to other treatments.[3]

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Ivermectin (Mectizan, Stromectol)

 

Binds selectively with glutamate-gated chloride ion channels in invertebrate nerve and muscle cells, resulting in paralysis and cell death. Half-life is 16 h; metabolized in liver. Single oral dose has similar efficacy to permethrin and may be most successful in patients with immunodeficiency or crusted scabies,[16] and in patients with skin conditions that should not use topical medications. Not FDA approved for the treatment of scabies.

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Contributor Information and Disclosures
Author

Amy L McCroskey, MD  Resident Physician, Department of Emergency Medicine, Wayne State University Detroit Medical Center, Detroit Receiving Hospital

Amy L McCroskey, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Student Association/Foundation, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Adam J Rosh, MD  Assistant Professor, Department of Emergency Medicine, Wayne State University/Detroit Receiving Hospital

Adam J Rosh, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Joseph A Salomone III, MD  Associate Professor and Attending Staff, Truman Medical Centers, University of Missouri-Kansas City School of Medicine; EMS Medical Director, Kansas City, Missouri

Joseph A Salomone III, MD is a member of the following medical societies: American Academy of Emergency Medicine, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Jeter (Jay) Pritchard Taylor III, MD  Compliance Officer, Attending Physician, Emergency Medicine Residency, Department of Emergency Medicine, Palmetto Health Richland, University of South Carolina School of Medicine; Medical Director, Department of Emergency Medicine, Palmetto Health Baptist

Jeter (Jay) Pritchard Taylor III, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Robert E O'Connor, MD, MPH  Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

References

  1. Scabies fact sheet. Atlanta. Centers for Disease Control and Prevention. 2005;[Full Text].

  2. Rinnert K. Infectious diseases: Occupational exposures, infection control, and standard precautions. In: Tintinalli J, Kelen G, Stapczynski S, eds. Emergency Medicine: A Comprehensive Study Guide. 6th ed. New York: The McGraw-Hill Companies Inc; 2004:1005/13.

  3. Karthikeyan K. Treatment of scabies: newer perspectives. Postgrad Med J. Jan 2005;81(951):7-11. [Medline].

  4. Chosidow O. Clinical practices. Scabies. N Engl J Med. Apr 20 2006;354(16):1718-27. [Medline].

  5. Currie BJ, McCarthy JS. Permethrin and ivermectin for scabies. N Engl J Med. Feb 25 2010;362(8):717-25. [Medline].

  6. Hay RJ. Scabies and pyodermas--diagnosis and treatment. Dermatol Ther. Nov-Dec 2009;22(6):466-74. [Medline].

  7. Feldmeier H, Heukelbach J. Epidermal parasitic skin diseases: a neglected category of poverty-associated plagues. Bull World Health Organ. Feb 2009;87(2):152-9. [Medline].

  8. Heukelbach J, Wilcke T, Winter B, Feldmeier H. Epidemiology and morbidity of scabies and pediculosis capitis in resource-poor communities in Brazil. Br J Dermatol. Jul 2005;153(1):150-6. [Medline].

  9. Sardana K, Mahajan S, Sarkar R, et al. The spectrum of skin disease among Indian children. Pediatr Dermatol. Jan-Feb 2009;26(1):6-13. [Medline].

  10. Hicks MI, Elston DM. Scabies. Dermatol Ther. Jul-Aug 2009;22(4):279-92. [Medline].

  11. Feldmeier H, Jackson A, Ariza L, et al. The epidemiology of scabies in an impoverished community in rural Brazil: presence and severity of disease are associated with poor living conditions and illiteracy. J Am Acad Dermatol. Mar 2009;60(3):436-43. [Medline].

  12. Lawrence G, Leafasia J, Sheridan J, et al. Control of scabies, skin sores and haematuria in children in the Solomon Islands: another role for ivermectin. Bull World Health Organ. Jan 2005;83(1):34-42. [Medline].

  13. Brook I. Microbiology of secondary bacterial infection in scabies lesions. J Clin Microbiol. Aug 1995;33(8):2139-40. [Medline].

  14. Scheinfeld N. Controlling scabies in institutional settings: a review of medications, treatment models, and implementation. Am J Clin Dermatol. 2004;5(1):31-7. [Medline].

  15. Fliders DC, Schweinitz PD. Pediculosis and Scabies. Accessed May 24, 2009. American Family Physician, American Academy of Family Practice. Jan 15, 2004;[Full Text].

  16. Schumann-Gable, N. Dermatology. In: Custer J, Rau R. The Johns Hopkins Hospital:The Harriet Lane Handbook. 8. 18th. Philadelphia, PA: Mosby Elevier; 2009:229-230.

  17. Neynaber S, Wolff H. Diagnosis of scabies with dermoscopy. CMAJ. Jun 3 2008;178(12):1540-1. [Medline].

  18. Hong MY, Lee CC, Chuang MC, Chao SC, Tsai MC, Chi CH. Factors related to missed diagnosis of incidental scabies infestations in patients admitted through the emergency department to inpatient services. Acad Emerg Med. Sep 2010;17(9):958-64. [Medline].

  19. Strong M, Johnstone PW. Interventions for treating scabies. Cochrane Database Syst Rev. Jul 18 2007;CD000320. [Medline].

  20. Hay RJ. Pyoderma and scabies: a benign association?. Curr Opin Infect Dis. Apr 2003;16(2):69-70. [Medline].

  21. Cydulka RK, Hancock M. Dermatologic presentations. In: Marx JA, Hockberger RS, Walls RM, eds. Rosen's Emergency Medicine Concepts and Clinical Practice. Vol 2. 6th ed. Philadelphia, PA: Elsevier's Health Sciences; 2005:1854-1855/118.

  22. Fraser V, Elward A. Infection control and isolation recommendations. In: Green G, Harris I, Lin G, Moylan K, eds. The Washington Manual of Medical Therapeutics. 363(9412). ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2004:675.

  23. Feldmeier H, Singh Chhatwal G, Guerra H. Pyoderma, group A streptococci and parasitic skin diseases -- a dangerous relationship. Trop Med Int Health. Aug 2005;10(8):713-6. [Medline].

  24. Burkhart CG. Scabies: an epidemiologic reassessment. Ann Intern Med. Apr 1983;98(4):498-503. [Medline].

  25. Chosidow O. Clinical practices. Scabies. N Engl J Med. Apr 20 2006;354(16):1718-27. [Medline].

  26. Currie BJ, Harumal P, McKinnon M, Walton SF. First documentation of in vivo and in vitro ivermectin resistance in Sarcoptes scabiei. Clin Infect Dis. Jul 1 2004;39(1):e8-12. [Medline].

  27. Dourmishev AL, Dourmishev LA, Schwartz RA. Ivermectin: pharmacology and application in dermatology. Int J Dermatol. Dec 2005;44(12):981-8. [Medline].

  28. Elgart ML. Scabies. Dermatol Clin. Apr 1990;8(2):253-63. [Medline].

  29. Epstein E, Orkin M. Orkin M, Maibach HI, Parish LC, eds. "Scabies: Clinical Aspects" in Scabies and Pediculosis. J.B. Lippincott: Schwartzman RM; 1977.

  30. Fitzpatrick TB, Eisen AZ, Wolff K, et al, eds. Scabies. In: Dermatology in General Medicine. 4th ed. McGraw-Hill: 1993:1812-1813.

  31. Forrester MB, Sievert JS, Stanley SK. Epidemiology of lindane exposures for pediculosis reported to Poison Centers in Texas, 1998-2002. J Toxicol Clin Toxicol. 2004;42(1):55-60. [Medline].

  32. Habif TP. Scabies. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 3rd ed. Mosby-Year Book; 1996:445-53.

  33. Heukelbach J, Feldmeier H. Ectoparasites--the underestimated realm. Lancet. Mar 13 2004;363(9412):889-91. [Medline].

  34. Kabrhel C, Binder W. Clinical pearls: a 37-year-old man with a rash... Acad Emerg Med. Jul 2003;10(7):776-9. [Medline].

  35. Otero L, Varela JA, Espinosa E, et al. Sarcoptes scabiei in a sexually transmitted infections unit: a 15-year study. Sex Transm Dis. Dec 2004;31(12):761-5. [Medline].

  36. Parish LC. Infection control and isolation recommendations. In: Orkin M, Maibach HI, Parish LC, eds. "History of Scabies" in Scabies and Pediculosis. Schwartzman RM: J.B. Lippincott; 1977:675.

  37. Ramos-e-Silva M. Giovan Cosimo Bonomo (1663-1696): discoverer of the etiology of scabies. Int J Dermatol. Aug 1998;37(8):625-30. [Medline].

  38. Schleicher SM, Stewart P. Scabies: The mite that roars. Emerg Med. 1997;6:54-8.

  39. Walton SF, Holt DC, Currie BJ, Kemp DJ. Scabies: new future for a neglected disease. Adv Parasitol. 2004;57:309-76. [Medline].

  40. Wendel K, Rompalo A. Scabies and pediculosis pubis: an update of treatment regimens and general review. Clin Infect Dis. Oct 15 2002;35:S146-51. [Medline].

 
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Scabies mite. Courtesy of William D. James, MD.
Scabies mite scraped from a burrow (original magnification, 400X). Courtesy of Audra Malerba, DO.
Scabies. Courtesy of William D. James, MD.
In crusted scabies, sections show multiple mites (arrows) within the hyperkeratotic stratum corneum (H&E, original magnification 100X). The epidermis is spongiotic. Courtesy of Audra Malerba, DO.
In routine scabies, a single mite is seen. Eosinophilic spongiosis may be present (H&E, original magnification 400X). Courtesy of Audra Malerba, DO.
Norwegian scabies. Courtesy of William D. James, MD.
Scabies on the leg. Courtesy of William D. James, MD.
Erythematous vesicles and papules are present on torso extremities, some with adjacent linear excoriations. Courtesy of Audra Malerba, DO.
Scabies on the buttocks. Courtesy of William D. James, MD.
Scabies on the hand. Courtesy of William D. James, MD.
Scabies on the penis. Courtesy of William D. James, MD.
Scabies on the penis. Courtesy of Hon Pak, MD.
 
 
 
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