Tiny, itchy red dots! Yowser!
All correctional medical people should be able to recognize scabies by sight.
Just to review, scabies is a tiny mite that burrows beneath the skin and causes intensely itchy lesions. Since the mite wanders (as little animals will do), scabies tends to spread with time, and can be passed from individual to individual. Weirdly, scabies does not cause lesions above the neck, probably because of the increased blood supply there. If you are interested, you can find more detailed information on scabies in Wikipedia.
Scabies is found commonly in correctional facilities. Both nurses and practitioners need to be able to spot scabies, hopefully before it spreads throughout a housing dorm!
Diagnosing Scabies
Fortunately, scabies is pretty east to diagnose just by looking at it–no other rash really looks like it. A typical scabies infestation has the following characteristics:
1. Pinpoint red dots.
2. That are intensely, drive-you-crazy, itchy.
3. They tend to spread.
4. And are not found above the neck.
If you see a rash that meets all of those characteristics, it’s scabies more than likely. You can double-check the diagnosis by doing skin scrapings and examining them under the microscope. But you can also use your treatment as a diagnostic test. If the treatment cures the rash, it was scabies. If not; then do the scrapings or look for another cause (like a treatment failure, discussed below).
Treating Scabies
Scabies has two effective treatments, permethrin 5% cream (Elimite) and ivermectin tablets (Stromectol). Permethrin is the treatment that historically has been most commonly used, mostly because it has been less expensive than ivermectin. Permethrin cream is used like this: The patient takes 30 grams of the cream and rubs it into every square inch of their skin from the neck down, including hard-to-reach places like between the toes, the soles of the feet, their backside etc. The cream is left on for 8 hours and then is washed off. This process is repeated in one week.
The problem with permethrin is that it is easy to miss a spot which gives the scabies a safe haven to survive and keep going. In corrections, the best way to avoid a treatment failure like this is to have medical personnel watch the inmate apply the permethrin to make sure they do it right. If you do this, you will find that almost nobody applies the permethrin correctly if not observed.
Ivermectin is much simpler. It comes as a 3 mg tablet. The dose for treating scabies is 200mcg/kg. If you do the calculations for a standard sized adult male (like me), the dose calculates out to 4 tablets, given one time. This dose is repeated in two weeks. No cream. No watching the application. Simple. The main reason permethrin has been historically used rather than ivermectin has been the cost, but that recently changed. A couple of months ago, permethrin cream dramatically jumped up in price.
Which is Cost-Effective?
The most recent acquisition cost of 30 grams of generic permethrin 5% cream is $23.00.
The current acquisition cost of four tablets (3 mg) of brand name Stromectol is $18.44.
Ivermectin is not only easier to give as a treatment for scabies, it is also less expensive! Think about adding it to your formulary as a treatment for scabies.
(Different pharmacies often charge different prices for the same drugs, so be sure to check the exact prices with your pharmacy).
Has your facility had an infestation of scabies? How did you handle it?
I am wondering if scabies can develop a resistance to permethrin treatment as has happened in some head lice cases.
Also, the first areas that I have noticed scabies appearing is usually in the antecubital fossa area or polpliteal fossa, presumably because of increased moisture in any skin fold or crease. I don’t really know for sure but that is my experience.
That is interesting about the head and neck not being involved.
I have not heard of scabies resistance. However, ivermectin is also being used to treat resistant cases of lice, as well!
We have traditionally used permethrin for the treatment of scabies. When we identify scabies, we isolate the resident during their treatment, which consists of having the resident apply the cream, changing out their uniform/linens, rinsing off after 8-14 hrs, and new uniform/linens are given when they come out of isolation. In therory, we are killing off any live mites with the initial treatment and containing the spread to other resident by isolating them during treatment.
My question is how quickly does the oral Ivermectin take effect? Do you isolate residents for any length of time? Is there a period of time when residents might be contageous after treatment?
thanks for your comments
I checked Uptodate, The Prescriber’s Letter, The Medical Letter and MDConsult and none of them give a specific isolation time. I know that schools will allow a student to return to school as soon as they have been treated. In the case of permethrin, this is when the cream has been washed off, as you said. In the case of ivermectin, I guess this would be as soon as they swallowed the pills.
So there is no “standard.” Maybe send them back to the dorm 12 hours after they take the pills?
Bryan, I posed this question to our state epidemiologist and this is her response:
Jeff,
I was able to find this reference:
Control measures for multiple cases of non-crusted scabies should consist of heightened surveillance for early detection of new cases, proper use of infection control measures when handling patients (e.g. avoidance of direct skin-to-skin contact, handwashing, etc.), confirmation of the diagnosis of scabies, early and complete treatment and follow-up of cases, and prophylactic treatment of staff, other patients, and household members who had prolonged skin-to-skin contact with suspected and confirmed cases. Skin-to-skin contact with scabies patients should be avoided for at least 8 hours after treatment. In addition, an institution-wide information program should be implemented to instruct all management, medical, nursing, and support staff about scabies, the scabies mite, and how scabies is and is not spread. Epidemiologic and clinical data should be reviewed to determine the extent of the outbreak and risk factors for spread.
I looked at sites from other countries where ivermectin is frequently used for scabies, and I’ve come to the conclusion that there just are no guidelines on how long to keep a patient isolated after ivermectin treatment. I think you could safely use either 8 hours (as for the topical) or 24 hours (which is more conservative, and hopefully do-able in the institutions) and nobody can fault you.
great feedback, I really appreciate your advice!
Pingback: Six Months Later–Top Posts | We discuss all aspects of medicine practiced in jails, prisons and juvenile facilities
This is a great idea and one that we just started here at Davis County after reading your article and we have in fact used this protocol one time already. Just a note however on your calculation on the number of pills to give. Our pharmacist said that at 200 mcg/kg, we need to give 5 of the 3mg tabs for an average 165# person then add or subtract 1 tab for every 33#’s of weight above or below that weight. So we have added Ivermectin to our formulary with those instructions.
unfortunately the most popular treatment at the facility where I work is denial by the medical department. As a result, it’s spread to several dorms.
Denial? Do you mean denying that the inmates have scabies–or denying authorization for treatment?
Denial that they have it. They deny a whole lot of staph too. It’s not the company that provides care that won’t treat it. It’s the people running the medical department at this location that don’t seem to want to be bothered.
I hate typing on a phone. It’s bad when you get your own name wrong!
They mostly ignore complaints, and give them antifungal cream and hydrocortisone and become annoyed when they are of course still complaining a month later. It’s spread of course and the cycle continues.
Pingback: Cost of ivermectin
Pingback: Cost of permethrin
Pingback: Permethrin cream price
Pingback: Permethrin cost
Pingback: Permethrin price
Pingback: Ivermectin price
Pingback: How much does permethrin cream cost
Dr. Keller, We are serving a humanitarian mission in refugee camps in Iraq. Scabies is rampnt in our camps. Any suggestions?
We are from Davis County ourselves and I am a nurse. I am looking for the most effective treatment and what the reinfection rate might look like?
I am unaware of any outright cheap options (from a third world perspective). The easiest option would be to treat each case you see with a dose of ivermectin. Reinfections and treatment failures can be recognized by fresh, new lesions after treatment.
My most recent review of up to date notes studies that state 1 dose peemethrin up to 91% effective, vs 79% ivermectin. After 2 doses separate, the cure rates are similar. I would think for isolated cases perthrin is still a good first line treatment due to safety and tolerability.. With outbreaks, an oral med like ivermectin makes the most sense.