Scabies Treatment

How do you get rid of them? Currently the most common treatment in the westernized world is a 5% permethrin cream that is usually applied to from the neck down and left on over night. Getting rid of scabies also requires washing all used clothes and bedding in hot water, and thoroughly drying them on high heat in a machine dryer. Perhaps what needs to be stressed the most about treating for scabies, is that everybody who has had significant exposure to scabies needs to be treated, or else the risk of re-infection is usually quite high.

When to treat

Treating in the daytime - I think this is a good way to have your treatment fail. It's so easy to wash your hands, and forget to reapply the treatment, or perhaps exert yourself and sweat it off. Do yourself a favor (and everybody else) and treat at night.

A decision about when to treat should consider the following:

• Is there is enough medication available for everybody who needs treatment? In isolated places, a scabies outbreak can deplete the local pharmacy's supply of medication. Additionally, it should be determined if anybody who requires treatment is unable to afford medication, and appropriate action taken.
• The time required to properly do laundry and clean the environment* must be considered. It can take a long time to do the cleaning associated with treating for scabies, but it has to be done promptly and thoroughly – you don't want to risk re-infection.
• Apply the treatment before going to bed. This minimizes that chances that the treatment will fail by accidental removal by the washing of hands, or some other activity.
• Treat as soon as possible. The longer treatment is delayed, the more likely scabies are to spread and multiply, and the harder they are to eliminate.

Who to treat

Be aware! - that permethrin is extremely toxic to aquatic and amphibious life.

• Treat everybody who has signs of scabies.
• All "hands on" contacts should receive treatment. Anybody who has had physical contact with somebody who has scabies must be treated.
• Those with substantial exposure to scabies must be treated. People who live in the same house as somebody who has scabies should be treated. Also, anybody who has had substantial contact with items used by somebody with scabies needs to be treated. An example substantial contact is changing the sheets of somebody with scabies, or wearing their clothes.

Mass treatment

Treatment of an entire facility (school, workplace, care facility etc.) should be considered when:

• Scabies cases have shown up in different areas of a facility (class, floor, unit etc.).
• One case of scabies has been identified, and many others (2-10%) who have been exposed, have shown signs of scabies for at least four weeks.
• If scabies was not controlled during the initial treatment, and new cases have been identified.
• If a single case of Norwegian/crusted scabies* is present.

Because it takes time, money, and energy to treat for scabies, it's important, when a lot of people may need to be treated, to attempt to verify a diagnosis of scabies by a test*. If multiple testing results are negative, and symptoms still resist among a number of patients two weeks after treatment, then an alternative diagnosis to scabies should be considered.

Note: mass treatment should include household members of those who have had hands-on contact*, or substantial exposure* to, to an infected individual or environment

Treatment

Fingernails - This is an important place to treat. It's a natural place for scabies to be: you scratch, and pick them up under your finger nails. Make sure you clip them or apply scabicide underneath them using a soft brush (such as an old toothbrush). Children and treatment - I believe that most children need to be supervised while putting on treatment. Success depends on meticulous application, and many children just don't have the mental focus to apply a lotion thoroughly.

Tip: Inside seemingly empty scabicide containers there's still quite a bit of lotion. Don't throw these containers out. You can cut the containers open and use the residual lotion to re-treat areas where lotion may have come off. If you have enough empty containers they might even contain enough lotion to treat a child or infant. The following instructions apply to the use of a 5% permethrin cream. Success of permethrin cream, when properly applied, is 90-95% effective.

• Take a bath or a shower before treatment; this is done in order to remove excess skin and oils from the body, so that the lotion penetrates more effectively.
• Warm skin – just out of a shower or bath – has a lot of blood in it which can carry away the active ingredient in the scabicide; wait until skin cools before applying the cream.
• Discontinue the use of topical steroids (e.g. Cortisone cream), until after treatment is completed.
• Fingernail and toenails should be clipped
• Apply treatment, paying special attention to the belly button/navel. Massage into areas of thick skin, such as the soles of the feet and other calluses. Be, very thorough, making sure to apply between the toes, on the perineum and genitals, and on the back where it can be difficult to reach. Pay special attention to any skin folds, and make sure you apply cream under the nails (a soft brush, such as an old toothbrush can help with this).
• Do not stint on treatment - make sure that you are well covered with the treatment; remember, permethrin works by absorbing into the skin, not coating it. The usual adult dose is 30 grams.
• Reapply treatment to any area where it may have come off. For instance, if you wash your hands, reapply treatment to them. It's best to be relatively inactive during the treatment, this is why treating before sleep is ideal.
• Use clean bedding and clothing after the treatment is applied.
• Remove cream after 8-14 hours (follow instructions supplied with scabicide).
• Wear clean clothes after treatment is completed. Do not wear the same clothes that were worn while treating; likewise, change bedding and towels etc. used during treatment.

After treatment

It's hard to tell if you've gotten rid of scabies! This is one of the most frustrating aspects of scabies. I can only emphasize that the symptoms of scabies ought to gradually decline over the 7-10 days after treatment. A strong resurgence of itching or visual symptoms usually means that the treatment has failed. Important! Symptoms may persist or even intensify after treatment. Symptoms should improve gradually within 7-10 days after treatment. Persistent symptoms are due to the body's reaction to the dead, or dying mite. If symptoms haven't improved within this time, it's likely that the treatment has failed, reinfection has occurred, or the original diagnosis of scabies was incorrect. Consider either re-treating or getting another diagnosis.

Antihistamines and topical steroids creams will minimize resistant post-treatment symptoms of scabies; however, minimizing symptoms can mask treatment failure or reinfection; therefore, in order to gain evidence for treatment success or failure, a temporary break from using antihistamines and steroids should be seriously considered a week after treatment. Also, it should be noted that steroids can worsen a scabies infection*.

Employees and students may return to school or work after finishing treatment; however, before returning, it's a good idea to inquire if everybody who was supposed to treat have actually followed through on their treatment.

Environment

According to the studies I've read, the major mode of transmission for scabies is via person to person contact, and transmission from the environment a minor risk in comparison.

I'm not sure I buy this. Perhaps it's just my natural paranoia, but my intuition is that environment plays significant role in transmission, especially in the cool moist climate I live in. I'd like to see more studies about environmental transmission.

Mites are susceptible to dehydration, so their survival time is dependent on humidity and temperature. Several studies have shown mites can survive 2-5 days at normal indoor temperatures and humidity; however, under these conditions a mite is usually only able to infect for only the first 1-2 days. Under higher humidity and/or cooler temperatures, mites may survive and be infectious for longer than 1-2 days.

• If possible, keep your house warmer than normal for a day or two before treatment and during treatment, or if you have access to a dehumidifier, use it.

Laundry

Laundry - I think it's a good idea after doing laundry, to use as little of it as possible for the 7-10 days after treatment. Keep as much in isolation as possible. This will save you a lot of work if you have to re-treat. Water temperature of wash - Although high water temperature has been recommended numerous times in my reading, and that's why I include the recommendation here, it seems to me that a thorough drying at high heat should be more than sufficient to kill scabies.

• Use gloves while handling laundry, if you are doing your laundry before you treat.
  
• Wash all clothing, bedding, and towels (including dish towels) and face cloths used in the past week. Water temperature should be 50 degrees C (120 f) for at least 10 minutes. Everything should be dried completely at high heat.
• Clothing in closets and drawers, that has not been worn or handled in the week prior to treatment, by anybody who has scabies, or by anybody who has had significant exposure to scabies, does not need to be laundered or isolated.
• Non-washables can either be dry cleaned or put into the dryer for 20 minutes on HIGH HEAT. Clean laundry can be disinfected in the same way. This can reduce the burden of laundry during a treatment.
• Non-washable items such as shoes, coats, and stuffed animals worn or touched in the last week may be isolated (usually in plastic bags) at room temperature or hotter for a week. Alternatively, items can be put in the freezer for 12 hours.

Personal items

• Creams, ointments, lotions, and cosmetics, used by a symptomatic individual within the past two weeks should be discarded, or sealed and isolated for two weeks.

Cleaning the environment

Covering upholstered furniture - It's a hassle, and unsightly, but it's probably a good idea. Again, this is more important in moist conditions than dry ones. Vacuuming furniture thoroughly and, perhaps, turning the heat up (drying scabies to death) might be sufficient, but you can't be certain. Flipping your mattress - this is to get any mites that might have escaped vacuuming further away from you. Mites move pretty well on the body (about 2.5 cm a minute), but I'd imagine fabric really slows them down. Also, the more energy they have to spend on moving, the sooner they'll die. Ideally, the environment should be cleaned both before and after treating for scabies. However, since many people don't have the time and energy to do this, it seems reasonable to do the majority cleaning after treatment has completed; this minimizes the possibility of spreading scabies to the environment while cleaning it, and then catching them again from that same environment after treating. Bathrooms and bedrooms are an exception, and should be cleaned before and after treatment, because they are likely sites for transmission immediately after removing the treatment by bathing.

• Mop floors, vacuum carpeted floors and upholstered furniture.
• Upholstered furniture should be covered in plastic for 7 days.
• Flip your mattress

The hard truth - given that permethrin is 90-95% effective, and that the environment isn't a super effective way to transmit scabies, then, the most likely way for a treatment to fail - and my experience backs this up - is by reinfection from somebody else. If your treatment fails, especially if it fails two, or three times (not uncommon), you may find yourself becoming very anti-social until your confidence in your environment has been restored.

Reasons for Treatment Failure

Reinfestation

Reinfestation is usually due to the following reasons:

• Inadequate cleansing, resulting in continued exposure to infested materials such as bedding, clothing, personal items, and furniture
• Failure to identify and treat symptomatic individuals
• Failure to treat infested but non-symptomatic individuals (usually those who have had significant exposure to scabies)
• Failure to report/elicit reports of symptom persistence a week after treatment
• Lack of surveillance for additional scabies cases after treatment

Inadequate treatment application

• Poor application of scabicide
• Failure to reapply medication when it has been removed from the body during the treatment period
• Removing scabicide before required period of time (usually 8 – 14 hours for permethrin)

Scabicidal resistance

• Cases of scabicidal resistance have been documented, but the extent to which the scabies mite may have developed resistance to permethrin is not clear