Lice and Scabies Treatment Update

Lice & Scabies:
Treatment Update
Karen Gunning, et. al.
Introduction
Pediculosis & scabies
• Ectoparasites
Most common symptom

• Pruritus
Overdiagnosed by anxious patients

• Patients use over-the-counter medications without an office evaluation
Appropriate clinical diagnosis

• Reduce treatment-resistant lice
Pediculosis
Lice
• Obligate, blood-sucking parasites

• Infest the human head, body and pubic region
Transmission
• Close contact
• Fomite transmission  rare
Female Lice
• Survive up to a month
• Lay 8-10 eggs per day
• Eggs hatch & mature into adults in 20 days
Pediculosis
Clinical Presentation Diagnosis
• Pruritus: A delayed hypersensitivity • 1 live louse on visual inspection

reaction → may take 4-6 weeks to • Head lice using lice comb found in the
develop hair behind the ears & back of the neck
• Pruritus → Scratching → Excoriations • Body lice found in the seams of
& cellulitis clothing
• Affecting patients who live in crowded • Pubic lice found in the pubic region
condition and poor hygiene.
• Lice found in 1 family member →
Entire family examined
Pediculosis
General mechanism of
pharmacological • Neurotoxicity, suffocation & dissolution
treatment
Insecticidal agents • Neurotoxicity resulting in paralysis of the lice
• Suffocation via “coating” the lice

Non-insecticidal agents • Dissolution of the wax covering the exoskeleton of the lice
Pediculosis
Pediculosis
Key to an Effective Treatment

Recognizing effectiveness in
destroying viable eggs 
dictate if retreatment is
necessary
Pediculosis
Non-ovicidal
• Permethrin, pyrethrins, benzyl alcohol, dimethicone, oral
ivermectin & isopropyl myristate
• Repeat application 7-10 days later → Complete eradication
Ovicidal
• Malathion, spinosad & topical ivermectin
• One treatment is enough for complete eradication
Pediculosis
Permethrin & Pseudo-resistance

pyrethrins/piperonyl butoxide • Poor adherence, incorrect product
resistance use & reinfestation
• Significant
• Geographic distribution of resistant
lice is not well-known
Pediculosis
• Washing hair with ordinary shampoo,

moistening hair with leave-in
conditioner, combing hair with wide-
tooth comb until detangled and combing
Wet combing hair with lice comb
• Time consuming
• Cure rates vary (47-75%)
Pediculosis
• Water & regular conditioner 
Several substances that Most effective in removal of nits
• Vinegar, formic acid solution, nit-
remove nits removal conditioners, water,
regular conditioner & almond oil
Items that come into

direct contact with the • Should be washed until 54o C
head within 2 days
before treatment
Scabies
Sarcoptes scabiei
• Mating on the surface of the skin. Male mite dies, Female mite
burrows under the skin to lay eggs
• Egg production 1-3 eggs daily & larvae emerge 2-3 days after
• Larvae matures after 2 weeks  New mites mating.
Transmission
• Direct skin-to-skin contact

• Fomites
Scabies
Risk factors
• Overcrowded living conditions

• Poor hygiene
• Poor nutritional status
• Homelessness
• Dementia
• Sexual contact
• Living in a tropical region
Scabies
Clinical presentation
• Intense, generalized pruritus that is worse at night. It is a

delayed hypersensitivity reaction to mite feces  not
develop for up to 6 weeks but symptoms occur more
quickly with reinfestations
• Found on finger webs, wrist flexors, elbows, axillae,
buttocks, genitalia & breasts
• Pathognomonic finding: Burrows
• Primary lesions: Erythematous, pruritic papules, pustules,
vesicles & nodules
• Secondary lesions: Excoriations, eczematization &
pyoderma
Scabies
• Considered in patients with a history of pruritic,
papular rash in typical distribution & pruritus in
close contacts
Diagnosis • Confirmed: Mites, eggs, or fecal pellets using
microscope found in skin scraping suspended in
oil
• 45% of cases  Reliance on history & physical

examination findings
• Evidence supporting empiric treatment if a patient
Misdiagnosis presents with pruritus and typical lesion on at least
two body sites or other household members also
have pruritus
Scabies
Treatment Post-treatment symptoms
• Permethrin 5% cream • Misdiagnosis, treatment failure, or

• Correct application: All areas of treatment-related skin irritation
the body (neck down), remain on
the skin for 8-14 hours/overnight,
washed off & reapplied in one
week
• Itch may continue up to 2 weeks,
even after appropriate treatment
Scabies
Oral ivermectin Environmental control measures:

• Dose: 200 mcg/kg, 2 doses 14 days apart • Washing items at a temperature of 50oC
• 2nd line therapy • Drying in a hot dryer
• Isolation in a sealed plastic bag for a
week for item that cannot be machine
washed

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Lice & Scabies:

Most common symptom

Overdiagnosed by anxious patients

Appropriate clinical diagnosis

• Obligate, blood-sucking parasites

• Pruritus: A delayed hypersensitivity • 1 live louse on visual inspection

Insecticidal agents • Neurotoxicity resulting in paralysis of the lice

• Suffocation via “coating” the lice

Key to an Effective Treatment

Permethrin & Pseudo-resistance

• Washing hair with ordinary shampoo,

Items that come into

• Direct skin-to-skin contact

• Overcrowded living conditions

• Intense, generalized pruritus that is worse at night. It is a

• 45% of cases  Reliance on history & physical

Treatment Post-treatment symptoms

• Permethrin 5% cream • Misdiagnosis, treatment failure, or

Oral ivermectin Environmental control measures:

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