Ectoparasitic Infections

24 Hour Natural Scabies Remedy Report

Scabies 24 Hour Natural Remedy Protocol

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Scabies (Sarcoptes scabiei)

The CDC-recommended treatment regimens for scabies include permetrin, lindane, and ivermectin (47). Effective alternatives include crotamiton, precipitated sulfur, and possibly benzyl benzoate (109). Even if they are asymptomatic, household contacts and sex partners from the previous month should be treated, as well. Bedding and clothing must be decontaminated and sexual contact should be avoided until partners are cured (47). A few small studies have shown permethrin to be more effective compared with lindane and crotamiton in clinical, parasitic, and subjective cure (109). One larger trial showed no difference between permethrin and lindane (110). Despite conflicting data, permethrin is

Table 2 RCT-Supported Treatment Options for Scabies

Placebo

Treatment

controlled?

Comments

Reference

Permethrin

No

More effective when compared with crotamiton, lindane; larger study showed no difference when compared to lindane

(111-115) (112, largest, 476 subjects)

Crotamiton

No

Comparison with lindane showed no difference, see comments for permethrin

(111,112)

Lindane

No

See comments for permethrin and crotamiton

(111,113-117)

Ivermectin

Yes

Showed no difference when compared

(117)

(the only

with benzyl benzoate or lindane

oral agent)

Sulfur

No

More effective when compared with benzyl benzoate

(118)

Benzyl

No

See comments for sulfur

(118)

benzoate

Abbreviation: RCT, randomized clinical trial.

Abbreviation: RCT, randomized clinical trial.

first-line treatment for scabies in adults and children over two months of age (47), a recommendation most likely based on clinical practice and reviews. Table 2 summarizes RCT-supported treatments for scabies.

Permethrin 5% cream should be applied once to affected areas and washed off 8 to 14 hours later (47). Advantages include a limited side-effect profile and safety for use by pregnant women and children. Adverse reactions include burning, stinging, and exacerbation of recurrence of pruritis (119). Permethrin is more expensive than lindane and crotamiton, and cost should be considered in choosing therapy. There have been a few documented cases of permethrin-resistant scabies (120) and the number may be much higher.

Lindane 1% should be applied one time and washed off six to eight hours later; some clinicians recommend a second application one week later. Generally, lindane is an appropriate alternative treatment for scabies; however, there have been reports of possible resistance (47) and there are multiple possible adverse side effects. Convulsions may occur if applied after a bath or in patients with extensive dermatitis (121). Lindane has also been associated with the development of aplastic anemia (122,123) and brain tumors in children (120), though data are few. Accidental ingestion can lead to lindane-induced central nervous system toxicity, manifested by headache, nausea, vomiting, tremors, convulsions, respiratory failure, coma, and death (124). It is possible that toxic side effects are due to overexposure or improper use. Lindane should not be used by patients with seizures or neurologic disease (119), pregnant or lactating women, or by children under two years of age (47). Exercise caution when prescribing this drug for any child weighing less than 50 kg (110 lbs.) (125). Because of the multiple and potentially lethal side effects, the FDA in 2003 issued a public health advisory concerning the use of topical lindane for the treatment of scabies and lice (125). Despite this advisory, due to its low cost, ease of administration, and high efficacy, the use of lindane will likely continue. Thus, to reduce the incidence of toxicity, clinicians must warn against overuse and educate patients about proper product application techniques.

Crotamiton 10% lotion/cream should be applied once, and reapplied 24 hours later, without washing between applications. The patient may bathe 48 hours after the final application (47). Some health-care providers suggest a five-day application (119,126). In nonrandomized trials, cure rates have been as high as 70% (127), although the only RCT studying crotamiton found it to be no more effective than lindane (111). Some health-care providers do not recommend using crotamiton because of the lack of toxicity data (127). There have been cases of crotamiton resistance (128).

Ivermectin, the only oral scabies treatment (100-200 mg/kg, and repeated in two weeks) is very useful for severe infection (47). Studies have shown cure after single dose, even for immunocompromised patients (129). A review of published clinical trials showed no consensus regarding most effective dosing regimens (130). Although one small randomized, placebo-controlled trial demonstrated the effectiveness of this drug (131), subsequent RCTs have shown that ivermectin is more beneficial than benzyl benzoate or lindane (109).

Epidemics occurring in nursing homes or hospitals must be controlled by treating the entire population at risk. In such epidemics, if topical agents fail, ivermectin may be considered (132). Tolerance is typically good; however one study demonstrated increased mortality with ivermectin treatment among elderly, debilitated persons (133); however, the authors failed to address the effect of confounding factors on the results. Therefore, the validity of this study is questionable (109). Case reports suggest usefulness in severe infection, although a single oral dose might be inadequate in this scenario (120,134). Anec-dotally, topical ivermectin has been used with success (127). Common side effects include headache, abdominal pain, and vomiting. Of note, ivermectin is not recommended for pregnant or lactating patients and its safety for children less than 15 kg (33 lbs) has not been determined (47).

Sulfur is the oldest known treatment for scabies. Currently, a 6% ointment of precipitated sulfur applied for three consecutive nights is used as alternative treatment for pregnant women and children under two months of age (47), or in situations in which other options are intolerable. This drug was shown to be more effective than benzyl benzoate in one RCT (135). Its advantages include low cost, but it is difficult to apply and can cause skin irritation.

Benzyl benzoate, 10% to 25% in a lotion, is applied for 24 hours on three to five consecutive days to treat scabies (120). Though it has been used for decades, its effectiveness has not been proven. Studies show it to be less effective than sulfur (135) and it has not been compared with permethrin (109). However, according to recent reports, benzyl benzoate may be helpful in certain cases of crusted scabies or in recurrent disease (127). Disadvantages include skin irritation and high treatment failure, possibly due to incorrect application. It should not be used by pregnant and lactating women, infants, and young children less than two years of age. Because of the lack of supporting data, and the ease, effectiveness, and availability of other options, this treatment is used rarely.

Malathion, an organophosphate acetylcholinesterase inhibitor, was once used to treat scabies. This agent has not been investigated in RCTs (109). Lack of data, bad odor, and the need for a long treatment period have caused this drug to fall out of favor.

As rash and pruritis may persist for up to two weeks after treatment, clinicians should re-evaluate patients with scabies after two weeks. Some health-care providers recommend retreatment after two weeks for patients who remain symptomatic, whereas others advocate for retreatment only if live mites are seen. Patients with initial treatment failure should be retreated with an alternative therapy (47).

Pediculosis Pubis (Phthirus pubis)

Currently, the CDC recommends treatment with permethrin, lindane, and pyrethins with piperonyl butoxide. Other options include malathion and, possibly, ivermectin. Most of these preparations were discussed in the previous section and will be described only briefly here.

Permethrin 1 % cream should be applied to the affected areas and rinsed off after 10 minutes (47). Higher cure rates are reported after a second application one week after the first (120). Permethrin is usually the first line of treatment, although resistance increases, which may present a problem (120).

Lindane 1% shampoo is also used topically, applied to the affected area, and washed off after four minutes. Lindane may have neurologic and hematolo-gic side effects and should not be used by children and pregnant and lactating women (47).

Another effective treatment is natural pyrethrins with piperonyl butoxide, applied to the affected area and washed off after 10 minutes (47). A second application one week later increases the cure rate (120). There are various vehicles available, including liquids, gels, and foams. Pyrethrin can provoke in respiratory distress in patients allergic to ragweed (120).

Malathion, a 0.5% lotion, should be applied and left in place for 8 to 12 hours, then washed off (85). As stated previously, malathion is not used frequently.

Oral ivermectin has been used in trials (126,136) but is not currently recommended for lice. A 0.8% ivermectin lotion was successfully applied to 25 patients with head lice. As with scabies, recent household contacts and sex partners must be treated, bedding and clothing must be decontaminated, and sexual contact should be avoided. If lice are seen at follow-up in one to two weeks, the patient should be retreated.

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