Classical scabies
|
||
Indications
|
Recommended
therapy
|
Alternative
therapy
|
Infants
< 2 months
|
Sulphur 6% in petroleum ointment base /
calamine
·
For 3 days, rinse
off after 24 hours then reapply
·
Treat whole body
including the face (avoid eyes and mouth)
·
Bath taken in
between application
|
Crotamiton 10%
• Apply once daily for 5 days 1,2,5,8
|
Children
2 months
- 2 years
|
*Permethrin 5% (NOT available
for JPL)
·
Apply from neck down to the soles of feet, wash off after 8-14 hours
·
1 application is
generally curative2
·
If there is any
signs of new mites, repeat application after one week2.
|
Sulphur 6% in petroleum ointment base / calamine OR
·
For 3 days, rinse
off after 24 hours then reapply
·
Treat whole body
including the face (avoid eyes and mouth)
Crotamiton 10%
• Apply once daily for 5 days 1,2,5,8
|
Children
2 - 12 years
|
Benzyl benzoate (EBB) 12.5%
• Apply after bath, whole
body neck and below
• Rinse off after 24 hours
• Apply for 2-3 consecutive days, with bath taken in between
application
• Repeat application within 5 days for severe cases (rarely
practised) 1,2,6
• Alternatively, 3 applications at 12-hourly interval (rarely
practised) 2
·
Itching may persist up to 2 weeks after successful treatment. Avoid
further treatment and consider topical corticosteroid2.
|
*Permethrin 5% (NOT available for JPL)
· Apply from neck
down to the soles of feet, wash off after
8-14 hours
· 1 application is generally curative2
· If there is any signs of new mites, repeat
application after one week 2,6,8. (Our CPG recommends for a repeat after 1 week)
Crotamiton
10%
·
Apply once daily for up to 5-7 days 1,2,5,8
|
Adults
> 12 years
|
Benzyl benzoate (EBB) 25%
·
Apply after bath,
whole body neck and below
·
Rinse off after
24 hours
·
Apply for 2-3
consecutive days, with bath taken in between application
·
Repeat
application within 5 days for severe cases (rarely practised) 1,2,6
·
Alternatively, 3 applications at 12-hourly interval (rarely
practised) 2
·
Itching may
persist up to 2 weeks after successful treatment. Avoid further treatment and
consider topical corticosteroid2.
|
*Permethrin 5%
· Apply from neck
down to the soles of feet, wash off after
8-14 hours
· 1 application is generally curative2
· If there is any signs of new mites, repeat
application after one week 2,6,8. (Our CPG recommends for a repeat after 1 week)
Crotamiton
10%
· Apply once daily
for 5 days1,2,5
|
Pregnancy/ Lactation
|
Permethrin 5%
· Apply from neck
down to the soles of feet, wash off after
8-14 hours
· 1 application is generally curative2
· If there is any signs of new mites, repeat
application after one week 2,6,8. (Our CPG recommends for a repeat after 1 week)
|
Topical sulphur 6-33% [Uptodate: Scabies] OR
Sulphur 10-25% compound [BMJ] OR 6% sulphur in calamine/ petrolatum [Topical 2018]
|
*Permethrin is agent of choice due to ease,
effectiveness and safety. The limiting factor in the use of
permethrin is its cost and Prescriber Category1 7, 8
In general: 1
·
Topical treatment
must be applied to the entire skin surface, from jawline downwards including
all body folds, groin, navel and external genitalia, as well as the skin under
the nails (especially crusted scabies).
·
In adults with
classical scabies, treating the face is controversial, but in babies, the face
must be treated, because transmission may occur from breastfeeding.
·
At any time during
treatment, medications should be re-applied if it is washed off i.e. after hand
washing.
· If the treatment is applied by
someone without scabies, this person should wear medical gloves during
application.
·
Patients 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.
·
After completion of
treatment, patients should use fresh, clean bedding and clothing. If possible, potentially
contaminated clothes and bedding should be washed at high temperature
(>50°C) 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.
·
Immediate treatment
for the patient (treat secondary infection first, as most scabicides are
irritant). 8
Availability: 6
·
Permethrin 5%
lotion (A/KK )
·
Crotamiton 10%
cream (B)
·
Calamine with 6%
Precipitated Sulphur Lotion (C)
·
Emulsion Benzyl
Benzoate (EBB) 25% (C+)
Contraindications and side effects: 1
Medicine
|
Contraindication(s)
|
Side Effects
|
Permethrin 5%
|
-
|
Itching &
burning/stinging sensation on application
|
Sulphur 6% in petroleum
ointment base / calamine
|
-
|
o
Messy, malodorous, stain clothing
o
May cause irritant contact dermatitis
|
Crotamiton 10%
|
Avoid massive &
prolonged use in pregnant women and infants
|
Irritant contact
dermatitis
|
EBB 10-25%
|
·
Pregnant women
·
Breast feeding women
·
Infants less than 2 years
|
o
Skin irritation and burning sensation.
o
May casue conjunctivitis if exposed to eyes.
o
May worsen/cause post-scabetic eczematous reaction.
|
Treatment of itch in scabies 1
·
Itching usually persists for about 1-2 weeks after
successful treatment but it should be evaluated if prolonged.
·
Causes of persistent itching include cutaneous irritation, allergic
contact dermatitis to medicaments, post-scabetic eczema or possible treatment
failure.
·
The treatment includes:
i. Antihistamines (recommended
for night dose): Chlorpheniramine, diphenhydramine (use with caution in < 2
years old).
ii.
Corticosteroids: topical or short course of oral steroids (depending on
the severity).
iii.
Emollients: regular application of emollients for dry and eczematous
skin.
References:
1.
CPG of Scabies in
Adults and Children 2015
2.
Drug Information
Leaflet
3.
www.uptodate.com
4.
Centres for Disease
Control and Prevention (CDC)
5.
British National
Formulary for Children, BNFC 76 (September 2018 – Mac 2019)
6.
Formulari Ubat KKM (Accessed
online on 8 July 2019)
7.
Treatment of scabies: newer perspectives. Postgrad
Med J 2005;81:7–11
8.
Pediculosis and Scabies: A
Treatment Update. Am
Fam Physician. 2012 Sep 15;86(6):535-541.
9.
Topical
Preparations Counselling Guide for Pharmacist, 1st Edition, 2018
8. BMJ Best Practice [Scabies, updated 19 June 2018]
9.
Nodular Scabies
|
||
i) Children
<2 years
|
Crotamiton 10% (Medical
Supervision)
·
2-3 times daily for
5-7 days 1,8
|
· Add topical
corticosteroids of mid potent to potent for a short duration of 2 weeks 1
|
ii) Children
<12 years
|
Crotamiton 10%
·
2-3 times daily
for 7-14 days 1,8
|
|
Crusted scabies
|
||
> 2 years
(EBB)
> 5 years
(Ivermectin)
|
Permethrin 5%
· apply daily for 7 days then twice weekly until cure2
· Alternatively, 2-3 days for 1-2 weeks4
PLUS
Oral Ivermectin
· PO 200 mcg/kg single dose and repeat after 2 weeks1
· Not for children below 5 years old or <15kg,
avoid in pregnant and lactating mother1
PLUS
Keratolytics
· Apply keratolytic (salicylic acid ointment) to
hyperkeratotic areas1
|
Oral Ivermectin
· PO 200 mcg/kg single dose and repeat after 2 weeks1
OR
Benzyl benzoate (EBB) 25%
· Several applications of benzyl benzoate1
· Apply daily for 7 days then twice weekly until cure2
PLUS
Keratolytics
· Apply keratolytic (salicylic acid ointment) to
hyperkeratotic areas1
|
Availability:
·
Permethrin 5% lotion (A/KK )
·
Crotamiton 10% cream (B)
·
Calamine with 6% Precipitated Sulphur Lotion (C)
·
Emulsion Benzyl Benzoate (EBB) 25% (C+)
References:
- CPG of Scabies in adults and children 2015
- Drug Information Leaflet
- www.uptodate.com
- Centres for Disease Control and Prevention (CDC)
- BNF for Children (September 2015-2016)
- Formulari Ubat KKM (Accessed online on 8 July
2019)
- Treatment
of scabies: newer perspectives. Postgrad
Med J 2005;81:7–11
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