Beruflich Dokumente
Kultur Dokumente
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
1
ABSTRACT
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
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)
Dosage
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
Contraindication
Advantages
Effective, well
tolerated, safe
Disadvantages
Permethrin
5% cream
Lindane
1% lotion or
cream
Cramps,
dizziness,
seizures in
children
Benzyl
benzoate
25% ointment
Can cause
severe skin
irritation
Precipitated
sulfur
2%-10%
precipitate
in petroleum
base
Ivermectin
Pills
Itching and
stinging on
application
Questionable
efficacy
Second application
often routinely
prescribed 1 week
after the first
application
Withdrawn in
the European
Union because
of neurotoxicity
concerns
Not currently
available in
Canada, approved
in Europe
Not available in
Canada, often used
on scabies nodules
in children
Expensive
Comments
Not approved in
many countries
Recommended Therapy
Classical scabies
Two applications of
permethrin 5% or benzyl
benzoate
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
Superinfected
scabies
Pregnancy or Breastfeeding
Permethrin, benzyl benzoate, and sulphur appear to be safe,
although evidence is limited.15 Oral ivermectin is contraindicated.
Children
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
Ivermectin is
contraindicated in
children <15 kg
Ivermectin is
contraindicated
Comments
Keratolytic agents
must be used
Antibiotherapy
(antibiotics) before
topical treatment
Institutional
outbreaks
Condition
Simultaneously treat
all cases and all
exposed people
Risk of post-streptococcal
glomerulonephritis and systemic
sepsis
Formation of an outbreak
management team
Potential Causes
Management
Cutaneous irritation
Overtreatment
Intensive use of emollient
Eczematization
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
http://www.skintherapyletter.com/ipad/support.html
ABSTRACT
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
Introduction
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
antiprotease).1-3
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
skininformation.com
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Patient sites:
AcneGuide.ca
DermatologyCare.ca
HandEczema.ca
MohsSurgery.ca
SkinCancerGuide.ca
UnwantedFacialHair.ca
BotoxFacts.ca
EczemaGuide.ca
HerpesGuide.ca
PsoriasisGuide.ca
SkinCoverup.com
ColdSores.ca
FungalGuide.ca
Lice.ca
PsoriaticArthritisGuide.ca
Sweating.ca
CosmeticProcedureGuide.ca
GenitalWarts.ca
MildCleanser.ca
RosaceaGuide.ca
StaphInfection.com
SkinPharmacies.ca
Pharmacist Edition
www.SkinTherapyLetter.com
www.SkinTherapyLetter.ca/fp
www.SkinPharmacies.ca
Update on Drugs
EDITOR-IN-CHIEF
Stuart Maddin, MD
ASSOCIATE EDITORS
Hugo Degreef, MD, PhD
Jason Rivers, MD
Name/Company
Approval Dates/Comments
Murad Alam, MD
Kenneth A. Arndt, MD
Jan D. Bos, MD
Alastair Carruthers, MD
Jeffrey S. Dover, MD
Boni E. Elewski, MD
http://www.accessdata.fda.gov/drugsatfda_docs/label/2012/202833lbl.pdf
Barbara A. Gilchrest, MD
Mark Lebwohl, MD
James J. Leydon, MD
Harvey Lui, MD
Howard I. Maibach, MD
Larry E. Millikan, MD
Ted Rosen, MD
Alan R. Shalita, MD
Wolfram Sterry, MD
Richard Thomas, MD
John Voorhees, MD
Guy Webster, MD
Klaus Wolff, MD
University of Vienna, Vienna, Austria
Vismodegib capsule
Erivedge
Genentech
Roche Group
Curis, Inc.
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.