Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Lets hand it to the mites
- Jed Rowe (16 September 2005)
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Scabies and underlying diseases
- Prasanta Padhan (17 September 2005)
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"A high index of suspicion..."
- Eleanor Y Hatch (17 September 2005)
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Scabies in Elderly Population
- Pradip Sarda (18 September 2005)
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Washing bedlinen - does this blunt the message about compliance with permethrin application?
- Iain M Inglis (19 September 2005)
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Management of fomites is essential for scabies treatment
- Dr. Rajesh Chauhan, Dr. Akhilesh Kumar Singh, MD; Dr. Parul Kushwah, MBBS, MISCD (21 September 2005)
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Diagnosis and treatment of scabies in care homes for the elderly
- Derek J Ward, Heather May (21 September 2005)
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Resistant scabies and scabies crustosa with HIV/AIDS
- Ajoy Lawrence Dias (24 September 2005)
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Re: Management of fomites is essential for scabies treatment
- Dr. Rajesh Chauhan, Dr. Akhilesh Kumar Singh, Dr. Parul Kushwah. (25 September 2005)
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Scabies treatment
- Trevor R Julian (27 September 2005)
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Jed Rowe, Consultant geriatrician Moseley Hall Hospital, Birmingham, B13 8JL
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Scabies is an occupational disease for geriatricians like myself, but as a doctor with children of school age the presentation may be a little atypical. I've noticed that my hands are relatively spared. I wonder if this is due to treating my younger offspring for headlice with insecticidal shampoos. Alternatively perhaps the mites (six legged) don't like repeated exposure to isopropyl alcohol handwash. Competing interests: None declared |
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Prasanta Padhan, MD,SENOR RESIDENT IN INTERNAL MEDICINE JIPMER,PONDICHERRY,INDIA,605006
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Dear Editor, Scabies is very common in our country due to many risk factors as discussed in this article.But sometimes it may be a reflection of an underlying serious illness such as hematological malignancy.Patients with Down syndrome are also prone to recurrent scabies due to abnormalities of their immune system.Apart from HIV positive individuals,HTLV-1 infected patients also develop crusted scabies. Competing interests: None declared |
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Eleanor Y Hatch, Natural therapies practitioner Crookwell Natural Health Clinic, Crookwell, NSW, 2583 Australia
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The first two summary points in the article should be underlined or printed in bold. "1. A high index of suspicion is needed to diagnose scabies correctly 2. Consider scabies in any adult with widespread eczema or pruritus of new onset." Some thirty odd years ago, as a young woman recently divorced, with young children, I returned home from a family gathering holiday with itching hands which rapidly spread up my arms. I attended my local surgery and the young GP, after a somewhat brief look at my hands and arms, asked "Not sleeping too well?" "Well no...." I replied, about to tell him that the itching was worse at night and in the warmth of the bed. He nodded, smiled understandingly and pronounced "Neurodermatitis - classic case!" Off I went with a script for sedatives and a/ histamines. A month or so later, the itching had spread - torso, groin, etc and to my consternation my 5-year old son was now ripping away at himself. I returned to the surgery and as I was sitting in the waiting room, the about- to-retire GP walked past. "Hello", he said, "and what are you doing here?" Holding out my ripped apart hands, I said, "it's this itch, it seems to be getting worse" "Good Lord" he announced "scabies, haven't seen a case in years" Competing interests: None declared |
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Pradip Sarda, Specialist Registrar ,Geriatric Medicine Pilgrim Hospital ,Boston,Lincolnshire,PE21 9QS
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Presentation of scabies in elderly population seem to differ from younger population.In elderly people scabies normally does not affect fingers and toes ,on the otherhand abdomen and buttocks ,genital areas are more commonly affected .History taking may be difficult and elderly population .There should be high degree of suspicion for scabies in elderly population with pruritus, especially in care home population as they may require treatment as a group rather than individual. Competing interests: None declared |
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Iain M Inglis, GP The Medical Centre, Dog Lane, Bewdley, Worcestershire
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I read with interest your article and in particular was interested that you recommend that patients wash bed linen at 50 degrees C referencing the DTB. The DTB article actually suggests this for crusted scabies and seems to make a disctinction in this respect compared for 'ordinary scabies.' (my italics) I was taught that scabies lives on humans and not on bedclothes etc and that to mention hot baths, washing clothing and bed linen both imparts the incorrect message that scabies is part of uncleanliness and dilutes the importance of application of permethrin properly - all non-evidence based stuff but it seemed to make sense. Are you aware of any evidence that washing bedclothes etc helps or indeed does reduce compliance? Competing interests: None declared |
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Dr. Rajesh Chauhan, GP & Consultant, Communicable Diseases 309/9 A.V. Colony, Sikandra, Agra-282007. India, Dr. Akhilesh Kumar Singh, MD; Dr. Parul Kushwah, MBBS, MISCD
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Dear Editor, The article on scabies by Graham Johnston and Mike Sladden is quite elaborate and interesting [1]. Role of fomites is usually not being given the due consideration that it deserves vis a vis scabies. The mite finds a hiding place within the skin, but for time being may wander around on the bed linen. Sharing of beds and bed linen, blankets, sleeping bags etc are yet another source of catching scabies. While Permethrin will take care of the mites on the skin, simultaneous treatment is required for the ‘wandering’ mites left on the fomites. At the very first opportunity these ‘wanderers’ have the propensity to infect anyone who comes in their contact. Travel is frequent now-a-days and travelers may inadvertently share bed linen. For example, an airborne traveler may request for a blanket that might have been recently used by an infected patient before it gets a chance to be laundered. Bed linen unless properly laundered, can also help a snooping mite find a fresh burrowing place in the skin of an unsuspecting user. Hence proper laundering and hot ironing of fomites (and undergarments also) is a must in order to clear the scabies infection, along with simultaneous treatment of all members of the family with permethrin or any other substitute, to eradicate the infection. If fomites are left unattended, the infection may remain stubborn and re- infections may continue occurring despite appropriate permethrin applications on the skin. With regards. Reference: 1. Graham Johnston and Mike Sladden. Scabies: diagnosis and treatment. BMJ 2005; 331: 619-622 2. Iain M Inglis. Washing bedlinen - does this blunt the message about compliance with permethrin application? BMJ 19 September 2005. http://bmj.bmjjournals.com/cgi/eletters/331/7517/619#116846 Competing interests: None declared |
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Derek J Ward, Consultant in Communicable Disease Control Birmingham and Solihull Health Protection Unit, 142 Hagley Road, Birmingham, B16 9PA, Heather May
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Editor, The clinical review article on scabies by Johnston and Sladden was a welcome reminder to clinicians to consider and treat this often neglected condition.[1] However, we would like to comment on the epidemiology of scabies outbreaks in the UK and the treatments suggested by the authors. In contrast to the statement that infestation particularly affects children, our experience suggests that scabies outbreaks frequently affect residential and nursing homes for the elderly. During 2004, this unit was informed about 33 outbreaks in institutional settings within Birmingham and Solihull, of which 26 (78.8%) occurred in care homes for the elderly. Delayed diagnosis is a common finding, but the condition often presents atypically in this group due to physical limitations to the areas of the body that can be scratched. Inadequate treatment is an important factor in the persistence of an outbreak. However, current advice is to include the scalp, neck, face and ears in topical Permethrin treatment irrespective of age or immune status.[2] It is also worth noting that oral administration of a sedating antihistamine at night may be useful in the treatment of persistent itch following treatment. References: 1. Johnston G, Sladden M. Scabies: diagnosis and treatment. BMJ 2005;331:619-622. 2. British National Formulary 50. British Medical Association and The Royal Pharmaceutical Society of Great Britain. World Wide Web http://bnf.org/bnf/bnf/current/openat/index.htm Last accessed 21/09/05 Competing interests: None declared |
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Ajoy Lawrence Dias, senior house officer Hope Hospital, Salford M6 8HD
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Drs. Graham Johnston and Mike Sladder need to be complimented for a very comprehensive and interesting presentation on scabies: diagnosis and treatment [1]. They have mentioned the clinical signs and symptoms and the summary points are very much to be remembered. I would like to mention that generalised urticaria has been reported as an initial manifestation of scabies in literature [2,3]. Another issue to be remembered now is the growing incidence of scabies crustosa (formerly called Norwegian scabies) with the global epidemic of HIV. As mentioned in this article it is a disease of patients with compromised cellular immunity like in AIDS, Leprosy, lymphoma and also in elderly and patients with Downs syndrome. Patients with scabies crustosa should be isolated immediately and strict barrier nursing procedures introduced if transmission to others is to be avoided. Permethrin cream is the topical medication of choice but by itself topical treatment requires weeks of repeated application and failure rate is significant. Ivermectin is rapidly becoming treatment of choice for scabies crustosa. [4,5,6]. To minimise transmission risk topical permethrin treatment should also be instituted at the same time and continued until all scales and crusts are gone. Multiple courses of ivermectin may lead to the development of resistance in some cases [7]. With the ever increasing epidemic of AIDS globally, resistant scabies and scabies crustosa is bound to increase in the coming years. Effective scabicidals are the need of the hour to overcome and prevent scabies becoming a menace in the future. REFERENCES: 1.Graham Johnston and Mike Sladden.Scabies: diagnosis and treatment. BMJ 2005; 331:619-622. 2.Witkoski JA, Parish LC. Scabies: a cause of generalised urticaria. Cutis 1984; 33:277. 3.Chapel TA, Krugel L, Chapel J, Segal A. Scabies presenting as urticaria. JAMA 1981; 246:1440. 4.Marliere V, Roul S, Labreze C, Taieb A. Crusted (“Norwegian”) scabies induced by corticosteroids and treated successfully with ivermectin.J.Pediatr 1999; 135:122. 5.Corbett EL, Crossley I, Holton J et al. Crusted (“ Norwegian”) scabies in a specialist HIV unit: successful use of ivermectin and failure to prevent nosocomial transmission. Genitourin Med 1996; 72:115. 6. Taplin D, Meinking TL. Treatment of HIV-related scabies with emphasis on the efficacy of ivermectin. Semin Cutan Med Surg 1997; 16:235. 7.Curie BJ, Harumal P, McKinnon M, Walton S F. First documentation of in vivo and invitro ivermectin resistance in Sarcoptes scabiei. Clin Infect Dis 2004; 39: e8. Competing interests: None declared |
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Dr. Rajesh Chauhan, Consultant, Family Medicine & Communicable Diseases 309/9 A.V. Colony, Sikandra, Agra -282007. India., Dr. Akhilesh Kumar Singh, Dr. Parul Kushwah.
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Re- Management of fomites is essential for scabies treatment Dear Editor, Here is what we would like to add to our earlier letter to you on the subject. Firstly, it remains immaterial when deciding for treatment if any or all family members are symptomatic or not. The treatment with Permethrin or any other anti-scabetic drug should and must include all the family members. Finally, it is often seen that scabies does come to light in view of recurrent pyoderma (or multiple boils), which is not amenable to treatment until a course of antibacterials is followed by definite anti -scabetic management. Using anti-bacterials alone for the primary manifestation of multiple boils/ pyoderma would not be of any help. With regards. Competing interests: None declared |
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Trevor R Julian, GP 1A Lavender Grove, York, YO26 5RX
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Editor, Although I found the Clinical review on diagnosis and treatment of scabies by Johnston and Sladden[BMJ 17th Sept 2005] informative, I was disappointed by the lack of detail in the treatment section. Having emphasised the importance of compliance with treatment,the authors went on to say that the head and neck should be excluded from treatment in adults but not in children under two or the elderly. What age is elderly? This is contrary to the BNF [British National Formulary] and a local hospital patient leaflet which both state that everyone should have the head and neck treated. More importantly, the amount of cream to be used is not discussed at all. The manufacturer says 'up to 30g [1 tube]' for an adult and the BNF states 'up to 2 tubes'. The hospital leaflet says 3 tubes. As for children, the manufacturer says 'up to 4g' for a child from two months to one year .How do you apply 4g of cream over the entire body and face of a one year old? The BNF and this article both avoid child doses completely.It is implied that the cream is safe, but at what dose? Perhaps the new BNF for children will provide the answer. My patients ask that I diagnose correctly and then treat. I am no wiser on how to treat. Trevor Julian
Competing interests: None declared |
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