Scabies (1 of 8)

Patient presents w/ pruritus & lesions suggestive of scabies

1 2 DIAGNOSIS Do clinical presentation No ALTERNATIVE & lab tests conﬁrm DIAGNOSIS scabies?

Yes

TREATMENT EVALUATION Yes FOR CRUSTED Does patient suﬀ er from SCABIES crusted scabies? See next page

Treat patient & all high risk contacts A Non-pharmacological therapy B Pharmacological therapy • Availability, eﬃ cacy, toxicity, cost & the patient’s age will guide the choice of therapy Any one of the following topical scabicides: 1st-line agents (if available): • Permethrin • Ivermectin (oral) 2nd-line agents: • Benzyl benzoate • Crotamiton FOLLOWUP • MIMSSee next page Ivermectin (topical) • Lindane • Malathion • Sulﬁ ram • Sulfur Symptomatic treatment • Antihistamine (oral)1 • Medium- or high-potency corticosteroid (topical)1 • Crotamiton (topical) Secondary bacterial infections ©• Treat w/ appropriate antibiotics1

1 Many oral antihistamines, medium- & high-potency topical corticosteroids, antibiotics & topical keratolytics are available. Please see prescribing information for speciﬁ c formulations in the latest MIMS. Not all products are available or approved for above use in all countries. Speciﬁ c prescribing information may be found in the latest MIMS.

B138 © MIMS 2019 1 prescribing information forspeciﬁprescribing c formulations inthe latest MIMS. Many oral antihistamines, medium- or high-potency topical corticosteroids, antibiotics & topical keratolytics are available. keratolytics antibiotics &topical corticosteroids, topical orhigh-potency medium- Many oralantihistamines, TREATMENT FOR NONCRUSTED NONCRUSTED TREATMENT REPEAT REPEAT SCABIES No

© B A Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not • infections bacterial Secondary • • • treatment Hyperkeratosis • plus • therapy Pharmacological therapy Non-pharmacological crusted scabies crusted or non-crusted for appropriately contacts all low&high risk &treat below described as scabies Treat crusted for patient • Symptomatic treatment Speciﬁ c prescribing information may be found in the latest MIMS. latest the in found be may information Speciﬁc prescribing Treat w/appropriate antibiotics Crotamiton (topical) corticosteroid (topical) orhigh-potency Medium- Keratolytic agent benzoate) (Permethrin/Benzyl (topical) Scabicide (oral)Ivermectin Antihistamine (oral) TREATMENT SCABIES CRUSTED FOR • patientRe-examine 2 weeks after of initialtreatment pruritus & skin lesions or lesions &skin pruritus Is thereimprovement in negative microscopy? microscopy? negative Scabies (2of8) 1 (eg Salicylic acid) (eg Salicylic EVALUATION FOLLOWUP 1

B139 MIMS 1 1 Yes TREATMENT IS IS TREATMENT NO FURTHER FURTHER NO NECESSARY © MIMS 2019 Please see see Please

SCABIES SCABIES • • ofLesions Distribution • • • • Lesions Secondary • • • • • • • • Lesions Primary • &Symptoms Signs • • Scabies Classical - Lesions are usually distributed on the palms & soles, & occasionally onthe face &scalp & occasionally onthe palms&soles, are usuallydistributed Lesions - Infants inthe adult &face are usuallynotinfected Scalp - - &older childrenAdults &eczematous infl erythema Scaling, ammation occur duetoexcoriation can orirritation infection ofsecondary Pustules are asign lesions Pinpoint erosions are the common most secondary orscratching are ofinfection aresult predominate the they picture clinical Often as successful treatment longafter May persist &may require intralesional corticosteroid injection - orcurrently toprior infestation reaction activescabies ahypersensitivity May be - Probably represent anexaggerated infl products tothe miteorits response ammatory - absent lesions these from are typically Mites - (eg & malegenitalia) are groin foundoncovered lesions axillary, areas often Most - - Nodules Vesicles Inthe infant: foundonthe orpustules may palms&soles be - commonly Most foundonthe finger webs - - Papules are small, often excoriated w/ hemorrhagic crusts ontop excoriated Papules are small,often crusts w/hemorrhagic - etc &remain bedding alivefor3 days onfurniture, liveforupto30 days can onahost emites - - common transmission is sexual Transmission & in adults, skin contact person direct by w/an infected is typically barracks) military conditions living (eg incrowded nursingliving homes, the immunocompromised inchildrenOccurs &inpersons more often <15 years, activeyoungadults, sexually hominis var scabiei the by mite:Sarcoptes iscaused Scabies - predominance w/nocturnal inapatient rash w/ahighlypruritic whopresents suspected shouldbe Scabies ormitefeces eggs confi on presentationclinical be & can is made based Diagnosis microscopic identifiby rmed cation of mites, Vesicles at ofthe the are usuallyseen burrow start - Vesicles &papules - Usually foundonthe palms&soles Inthe infant: - Usually foundonthe fi orscrotum penis buttocks, wrists, ofthe sides hands&feet, nger webs, - - length of0.5 cm w/amean burrows lined Patient silvery may have linear, orS-shaped curved - Burrows - - at which isusuallyworse night pruritus, isgeneralized symptom Primary Mite burden isonaverage aninitialepisode during 5-15mites/host Occurs inimmunocompetent patients & nipples scrotum, areola penis, groin, ankles, line,buttocks, umbilicus&belt folds, axillary &elbow), (wrist forearms Typically the down: occur from neck einterdigital the web fl spaces ofthe hands, exor ofthe surface pruritic 5-6 mmPersistent papules which measuring indiameter are fi dome-shaped &extremely erythematous rm, crusted scabies where alarge scabies are involved) amountcrusted ofparasites of in cases (especially ough there documentation, maypossible fomites is limited transmission by be predominance w/nocturnal lesions pruritic of contact whohas partner orsexual member w/family orifthere ofcontact person isahistory ifthere w/aninfected ishighlysuggested ahistory isalso Scabies is highlighted as adark line as is highlighted May enhance the absorbs the ink& the burrow w/blue orblack sighting fountain ofburrows inkbecause infection bacterial secondary scratching by or may destroyed have they been because seen may lesions not be & other primary Burrows sensitized previously been has occurs 3-6 weeks infestation Hypersensitivity but occurs in 1-3 days after the host w/ re-infestation because sensitized oncefeces) the becomes host & eggs (saliva, products tothe reaction mite&its hypersensitivity IV) adelayed by (type iscaused Pruritus - May be from a hypersensitivity reaction &rarely reaction contain ahypersensitivity from May be mites - © pinpoint which are vesicles Isolated fi- w/serous fllled presentuid may be 1 Scabies (3of8) DIAGNOSIS

B140 MIMS © MIMS 2019 • • Dermoscopy • • • IdentifiMicroscopic cation TestsDiagnostic • • • • • • • Presentation Clinical • • Scabies (Norwegian) Crusted • • • • • • burrow (“deltaburrow sign) wing” fiCharacteristic the which ofthe shape represents head adultfemale a mitewithin triangular nding isadark, eggs mites, skinburrows, toidentify used May be may confi therm diagnosis therapy ofscabicide asuccessful trial are butastrong suspicionremains, negative clinical When skinspecimens forprocurement aguide ofskinsamples as used may be Dermoscopy - - - eczematization without excoriations lesions orthe taken scrapping & the by newest burrows shouldbe Specimen isconfiDiagnosis microscopic identifi by rmed ormitefeces eggs cation ofthe mites, lymphadenopathy generalized are present &eosinophilia cases, In some &trunk scalp on the face, neck, w/fi oreczematous lesions patients mayOccasionally have psoriasiform eruptions ne, powder-like, scaling red, or feet tothe hands Patients may which orlocalized plaques present generalized may w/hyperkeratotic be crusted thickened &often discolored dystrophic, Nails may be - crusts defi onthe skin consistLesions poorly ofgeneralized, fi erythematous, ned, & scales covered plaques by ssured Itching absent may ormild be facilities care disorders orinresidents oflong-term Typically neurologic/mental occurs inimmunocompromised illness, patients systemic &inpatients w/severe Highly contagious w/the aff ofscabies form w/hundreds tomillionsofmites infested being person ected orkeratotic scabies crustosa scabies scabies, Boeck as known Also Crusted scabies: Psoriasis, palmoplantar keratoderma, seborrheic dermatitis seborrheic palmoplantar keratoderma, Psoriasis, scabies: Crusted acropustulosis of infancy cell Langerhans histiocytosis, Infants: conditionsImmune-mediated rosea) (eg bullouspemphigoid, pityriasis herpetiformis Dermatitis exanthems) viral tinea, impetigo, (egInfections folliculitis, nummular contact atopic eczema) dermatitis, dermatitis, bites, disorders (eg arthropod Pruritic © scabies crusted when diagnosing helpful the amount of keratinic hydroxide debris to decrease which is (KOH)10% potassium used may solution be directlyunder alight microscope viewed blade&may #15surgical w/asterile be placed onthe &thenA drop ofmineral lesion oilshouldbe scraped finger joints) verrucous appearance onbony prominences elbows, (eg thick, iliaccrest, Plaques have yellow-to-brown, 2 1 ALTERNATIVE DIAGNOSIS DIAGNOSIS (CONT’D) Scabies (4of8)

B141 MIMS © MIMS 2019

SCABIES • • Dissemination Control ofDisease Scabies Crusted • • • • • • • • TreatmentDisease • • • • Transmission ofDisease Prevention Patient Education - - patient &highrisk low contacts treated Both shouldbe ofthe patient’s washing etc Careful linens &towels, clothes, - Avoidance staff hospital by &gowns Use ofgloves skincontact: ofdirect - until cure isachieved isolation Strict ofthe patient observed shouldbe - oftransmissiontocontact risk there persons scabies isanincreased ofcrusted In the case cutshort enails shouldbe gloves disposable shouldwear the person person, Iftreatment anon-infected by isapplied - If the application patient after applies the treatment topical washed the him/herself, handsshouldnotbe &patient must cool &dry kept changeSkin into should be clothing clean application after navel,groin, ofthe tips fi scabies incrusted ngers &under the nailsespecially ApplyOlder childrenattention w/ particular the from down, neck & adults: to intensely folds, eg involved areas &mouth) &face (avoidthe around the scalp the eyes areas & young children:Infants covered should & if necessary,be e entire the surface from down neck include body - helpful may instructions be written the epatient about application thoroughly ofthe treatment, shouldbe educated &supplementation w/ treatment the end after ofappropriate Patient madeaware that shouldbe itching may forupto2-4 weeks persist Educate the patient &the patient’s treatment physical contacts close the about disease fl rugs, furniture, coats, toclean ere isnoneed manner inany orwalls special oors - - treatment after clothing clean/fresh orbedding shoulduse individual Infected - To undertaken help should be hygienic avoid fomites measure transmissionby patients Advise toavoid contact close until w/partner completion oftreatment - contact persons shouldavoid individuals skin-to-skin w/non-infected Infected re-infestation It &their physical contacts individuals isimportant close totreat at the infested the sametimetoavoid prevent spread to steps transmission&the necessary scabies about Patient physical contacts educated &close shouldbe © scabies ofcrusted in the case treatment onlyneed individual Persons contact tothe contacts: w/indirect infected risk Low (eg bedding) via ofthe presence regardless treated ofsymptoms should be Persons orfrequent contacts: skincontact w/protracted High-risk individual (eg the hands)w/the via infected &where applied toapplybe the treatment Verbal shouldinclude: instructions &written the how treatment applied, eamount tobe ofdrug should 72 hours forat bags least plastic Wash at high temperature or store potentially towels & themcontaminatedbedding in (>50°C) clothes, A NON-PHARMACOLOGICAL THERAPY Scabies (5of8)

SCABIES SCABIES • • • • therapies Other • Sulfi ram • • • • Sulfur • • • • Permethrin • • Malathion • • • • Hexachloride) Benzene (Gamma Lindane eff as tobe reported 1% lotionwas 5%Permethrin cream as ective Ivermectin • • • Crotamiton • • • • Benzoate Benzyl (Topical)Scabicides • • • • • (Oral) Ivermectin • (Topical)Keratolytics Secondary infections should be treated w/appropriate treated antibiotics shouldbe infections Secondary tohelp steroids given control topical may therapy be scabicide also after pruritus orhigh-potency Medium- © pruritus tohelpOral antihistamines given may alleviate be w/corticosteroids treated may completed therapy be scabicide scabies after Nodular Soap-containing monosulfi forscabies aprophylaxis as inthe past used ram have been - totreat human scabies used be May also conducted studies have notbeen Reproduction Treatment &pregnant women w/scabies optionforinfants Safe &eff application days butrequires on3consecutive ective, treatment known eoldest forscabies toxicity low Has neurotransmission of which todisruption leads channels of in voltage-gated insects Impairs sodium function eff as tobe shown been Has &more eff Lindane as ective than Crotamitonective 1st-lineRecommended treatment forchildren including pregnant &lactating &adults women Alternative forpatients where treatment w/Permethrin isnotappropriate application preparation isaneff of5%aqueous Overnight treatmentective option oftoxicity duetorisk scabies inpatientsNot recommended w/crusted Central inNorth, &inAsia &South America noted been has Lindane-resistant scabies 1%formulation isusuallyeff asingle6-hourtreatment after ective - properly,When used itisaneff scabicide ective ofneurotoxicity to risk analternative therapy onlyas inpatientsUsed intolerant ofother therapies orwhen other therapies due fail eff less tobe Appears than ascabicide Permethrin &Lindane as ective forsymptomatic relief butthere pruritus from used isconflMay be effi ofits icting evidence cacy forthe inchildren treatment useful scabies butmayMay be ofnodule require upto5 days oftreatment forpatients w/Ivermectin singletreatment w/relapses after used ofIvermectin Maybe aloneorincombination used w/SulfiMay be ram Different butnocomparative treatment used have data published regimens been have been Eff inthe managementective scabies ofPermethrin-resistant crusted Effi iscomparable than Permethrincacy Lindane w/topical &more superior ofmany neurotransmission parasites GABA-induced Interrupts ininstitutions epidemics inscabies used be May also - therapy diffi topical wouldbe istration ofhead-to-toe cult May have orwhen arole admin- inthe infestations &immunocompromised treatment patients, ofrefractory scabies optionforcrusted theCombination isconsidered therapy best tobe scabicides w/topical Eff treatment to1st-line/2nd-line patientsective optionforscabies unresponsive treatment scabies ofcrusted penetration forscabicide isnecessary w/keratolytics &scales ofcrust eremoval Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing B PHARMACOLOGICAL THERAPY Scabies (6of8)

B143 MIMS © MIMS 2019 rtmtn10% Crotamiton aaho 0.5% Malathion benzoate Benzyl Ivermectin Drug Drug Products listed above may not be mentioned in the disease management chart but have been been have but chart management disease the in mentioned be not may above listed Products lotion cream, emulsion topical emulsion 25% Available Strength w/ topical scabicide w/ topical & 15incombination ondays 1,2,8,9 PO ≥15 kg: 200 mcg/kg Adult &Childn Scabies Crusted in2 wks dose repeat then singledose, PO ≥15 kg: 200 mcg/kg Adult &Childn Scabies Classical placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults & non-elderly All dosage recommendations are for non-pregnant & non-breastfeeding women, women, &non-breastfeeding non-pregnant for are recommendations dosage All © Dosage Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not TOPICAL ANTIFUNGALS&ANTIPARASITES Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing after 7 days after application Repeat 24 hrly body Apply whole over Apply 8-12 hrly Antipruritic: 3-5 days Apply 24 hrly x application the last 24 hr after off &wash 2 times takingabathafter x Apply once 24 hrly Dosage Dosage Guidelines • Instructions Special • Reactions Adverse ANTHELMINTIC Scabies (7of8) No food should be taken for 2 hr before or after the taken dose orafter for2 hrbefore shouldbe No food tachycardia) edema, hypotension, postural eff lymphadenopathy, myalgia, (fever, arthralgia, ects pruritus, effthroat, cough); CNS somnolence); (headache, Other ects GI eff N/V, (diarrhea, ects eff Resp incliver enzymes); (sore ects

B144 MIMS • • • • Instructions Special • Reactions Adverse • • Instructions Special • Reactions Adverse • • Instructions Special • • Reactions Adverse Do not use on broken or secondarily infected skin infected onbroken notuse orsecondarily Do Avoid &mucous contact membranes w/eyes membranes oronexcoriatedmembranes skin mouth, mucous the near eyes, applied Should notbe face &ears Apply neck, including the scalp, tothe wholebody sensation, mild conjunctivitis stinging Irritation, oronexcoriatedmembranes skin mouth, mucous the near eyes, applied Should notbe drying bathing after & folds&creases body especially the down Apply from neck tothe wholebody irritation Occasionally for children insome used been has 10%soln - Not generally inchildren foruse recommended bathingimmediately after &drying the down, Apply from neck tothe wholebody ingestion excessiveconvulsions) ororal use following topical & Systemic (stimulation symptoms ofthe CNS dermatitis irritant occasionally ongenitalia &excoriations, sensation especially burning &mucous totheIrritant membranes, eyes countries Remarks Remarks © MIMS 2019

SCABIES SCABIES (Monosulfi ram) Sulfi ram 5%lotion, Permethrin Sulfur hexachloride) (Benzene Lindane Drug Products listed above may not be mentioned in the disease management chart but have been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults & non-elderly 25% soln 5% soap cream oint cream, 5%-10% 1% lotion emulsion 0.3% gel, Available Strength All dosage recommendations are for non-pregnant & non-breastfeeding women, are for & non-breastfeeding non-pregnant All recommendations dosage © TOPICAL ANTIFUNGALS&ANTIPARASITES (CONT’D) Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Please see the end of this section for reference list. reference for section this of end the see Please off 24 hr after 2-3 nights &wash Apply nightly for daysconsecutive application for2-3 Repeat cases): (severe Soln todry allow water &apply & Dilute w/2-3parts Adult &child: Soln: soap Use as Soap: offwash for 8-14 hrthen Apply &leave on Adult &child: ff o 8-12 hr then wash leave onfor gentle & massage ApplyLotion: w/ the nextday &repeat rinsing for 3 hrbefore Apply &leave on 3-10 yr: Child daysconsecutive x3 morning off the next rinse the evening, Apply in Adult: emulsion: 0.3% gel& Dosage Dosage Guidelines Scabies (8of8)

B145 MIMS • • • • • • • • Instructions Special • • Reactions Adverse • • Instructions Special • • Reactions Adverse • • Instructions Special • Reactions Adverse • Instructions Special • Reactions Adverse Do not use on broken or secondarily infected skin infected onbroken notuse orsecondarily Do Use w/caution inchildren <6 mth Avoid contact w/the eyes ofseizures a history Use w/caution inyoungchildren &inpatients w/ urethral meatus Avoid mucous membrane contact & w/face, eyes, to dry bathingapply skin toallow 1 hrafter orshowering ifbathing clean; tobe isnecessary, the skinneeds No bathing/showering application before unless necessary &consider if down tothe applying scalp, Children: the Apply from neck tothe wholebody down the Apply from neck tothe wholebody Adults: compromise, etc respiratory seizures, irritability, tremors, disorientation, giddiness, N/V, toxicity: ofLindane Signs weakness, have occurred seizures contact dermatitis, orstinging, Burning membranes Avoid mouth &other mucous contact w/the eyes, may treat the &scalp head Ifnecessary - the &face neck Apply below tothe wholebody stainclothingsilver) &can may discolor certain (eg metals Malodorous, &dermatitisSkin irritation applicationafter Patients alcohol shouldabstain from for16-48 hr Apply except tothe face &scalp wholebody w/ alcohol ingestion disulﬁ rash, Erythematous mayram reaction occur toextend face application & toscalp, May need - Apply except tothe the &face wholebody head itching swelling, redness, temporary orstinging, Mild burning ears ofyoungchildrenears Remarks © MIMS 2019