INFESTATIONS

Dra. Palabrica

SCABIES
Epidemiology
* Human skin infestation caused by the penetration of the obligate human
parasitic mite Sarcoptes scabiei var. hominis into the epidermis
o Arthropod of the order Acarina
* ~over 300 million people worldwide are infected
* Affects all socioeconomic classes
* Women and children
* More prevalent in urban areas, esp in overcrowded regions
* Incidence has been increasing for the past decades responsible for
major outbreaks in nursing homes, prisons and hospital wards
* Transmission: close personal contact
o Can live off the human skin for up to 3 days possibility of infection
through fomites
Etiology and Pathogenesis
* Has 4 pairs of legs and measures 0.3 mm in diameter
* Cannot fly or jump; lives its entire 30-day life cycle in and on the
epidermis
* Average number of mites a host may harbor: 20
o In crusted scabies (Norwegian scabies): host may harbor over a million
mites
* Who are at risk of developing crusted scabies?
o Elderly
o Patients with medication-induced immunosuppression

Clinical Findings
* Pruritus and rash:
o May take 6-8 weeks to develop after initial exposure to the mite
o Subsequent exposure results in development of itchiness and rash
within a couple of days
* Pruritus is severe and worst at night

* Lesions appear as red, scaly, sometimes crusted (excoriated) papules

and nodules that favor interdigital webs, sides of the fingers, volar
aspects of the wrists and lateral palms, elbows, axillae, scrotum, penis,
labia and the areolae
* Crusted scabies
o Hyperkeratotic plaques develop diffusely on the palmar and plantar
regions, with thickening and dystrophy of the toenails and fingernails
o Rest of the skin: xerotic
o Pruritus variable and may be absent
o Over a million mites populate the skin
* Pathognomonic lesion: burrow thin, thread-like, linear structure 110mm in length; tunnel caused by the movement of the mite in the
stratum corneum
o Best seen in the interdigital webs, wrists or elbows
* Vesicles and bullae may develop, particularly on the palms and fingers
* Erythematous to violaceous pruritic nodules in the axillae and flanks of
the trunk in children; on the scrotum in men
o Can remain for many weeks after the successful eradication of the mite
infection
* Infants
o Face and scalp can be infested
When should you suspect scabies?
o Facial sparing ( in adults and older children)
o Family or household members are also affected
o Poor response to topical antibiotics
o Transient response to topical steroids
Diagnosis
* Definitive dx: microscopic identification of the scabies mites, eggs or
fecal pellets (scybala)
o Placing a drop of mineral oil over a burrow and then scraping
longitudinally with a number 15 scalpel blade along the length of the
burrow, scrapings are then applied to a glass slide and examined under
the microscope
Differential Diagnosis
* Atopic dermatitis
* Insect bite reactions
* Contact dermatitis
* Dishydrotic eczema
* Drug eruption
* Psoriasis
* Bullous pemphigoid

Treatment
* Adults
o Topical scabicides
Entire skin surface, except face and scalp
Intertriginous areas, genitalia, periungual regions, behind the ears
* Children and patients with crusted scabies
o Face and scalp should also be treated
* Permethrin 5% cream
o First line treatment
o Leave on for 8-14 hours then rinse
o May need to repeat in 7 days
* Lindane 1% lotion: not for less than 2 y/o
* Others
o Crotamiton 10% cream
o Precipitated sulfur 5-10%
o Benzyl benzoate 10% lotion
o Oral ivermectin 200ug/kg: single oral dose, repeated in 10-14 days
The only oral but highly effective scabicide; however, its not FDA
approved for treatment of scabies
* Patients must be advised that rash and pruritus may persist for up to 4
weeks even after adequate treatment
* Treatments to alleviate the pruritus and rash once scabicide treatment is
completed
o Topical steroids
o Antihistamines
o Short course of systemic steroids
Prevention
* Household members should also be treated
o To prevent spread
o Other members may be harboring the mite during the asymptomatic
incubation period
* Bed sheets, pillow cases, towels and clothes worn during the past 5 days
should be washed and dried in the hot cycle, or be dry cleaned; carpets
and upholstery should also be vacuumed
o To prevent re-infection with fomites
* No need to treat pets because they do not harbor the human scabies
mite
Complications
* Secondary impetiginization common
o Responds well to topical or oral antibiotics
* Lymphangitis and septicemia in crusted scabies
* Post-strep glomerulonephritis from scabies-induced pyodermas caused
by Strep pyogenes

BEDBUGS
* Cimex lecturalius
* Nocturnal feeder that stays hidden during the day
o In cracks and crevices of headboards
o In picture frames
o Behind loose wallpaper
o Any other dark place that accommodates its flattened body
* Bedbugs are attracted to the warmth and carbon dioxide production of
their victim
* Usually complete their meal in a matter of minutes and then return to
hiding
* Can survive for 1 year or more without feeding, but they usually seek a
blood meal every 5-10 days
* Can be spread in clothing and baggage of travelers and visitors, on
second hand mattresses and via laundry
* Bites are usually painless and may be overlooked unless a large
numbers of bites are present
o Multiple and may be overlooked unless large numbers of bites are
present
o breakfast, lunch and dinner row of 3 bedbug bites
* Reaction to bites:
o Wheals and papules, often with a small hemorrhagic punctum at the
center
o May also have bullous reactions to bites
Complications
* Secondary bacterial infections secondary to excoriation
Treatment
* Minimal symptomatic treatment of bites
* Good local wound care to prevent pruritus and secondary infection
o If with secondary infection: topical antiseptic lotion or antibiotic cream
o Topical corticosteroid for pruritus
* Hire a professional exterminator to eradicate the insects

PEDICULOSIS CAPITIS (HEAD LICE)

Epidemiology
* Occur worldwide
* Most common in school-aged children
* Spread by close physical contact as well as by sharing of head gear,
combs, brushes and pillows
* Affects all levels of society and all ethnic groups
Etiology and Pathogenesis
* Adult louse is 1-2mm long, elongated, flattened dorsoventrally and
wingless
* Have 3 pairs of clawed legs adapted for grasping hairs; can travel up to
23cm per minute
* Louse larva (nymph or instar); looks like a mini adult louse
* Adult louse must take a blood meal before copulation
* Females can produce 5-10 eggs a day during her life span of 30 days
* Typically survive only 1-2 days away from the scalp
* Nits can survive up to 10 days away from the scalp

Clinical Findings
* Confined to the scalp with nits most often found in the occipital and
retroauricular regions
* Live nits placed in close proximity to the scalp because the egg is reliant
on warmth and moisture for incubation
o Distance of nit from the scalp along the hair is evidence of duration of
the infestation
If >1cm from the scalp, likely that the infection is no longer active
and that the nits are not fertile
* Most common symptom: itchiness
o Result of hypersensitivity reaction to the saliva produced by the louse
during feeding
o Fecal material may also contribute
* Clue to diagnosis: patients scratching their head
* Other s/sx: excoriations; lymphadenopathy; conjunctivitis
Diagnosis
* Finding live adult lice, immature nymphs and/or viable-appearing eggs
confirms the diagnosis

o Fine combing hair that has been saturated with water and conditioner
Treatment
* Pediculicides: most effective treatment
o Should not be used in children less than 2 years
o Pyrethrins
o Malathion lotion 0.5%
o Lindane shampoo 1%
Usually applied and left on for 10 minutes before rinsing (except for
malathion which is left for 8-12hr)
o May repeat treatment in 7-10 days to kill recently hatched nymphs
* Wet combing using fine-toothed comb; every 3-4 days for a total of 2
weeks
o Lice are temporarily immobilized by water, hence wetting the hair
allows easier removal by combing
* Occlusive or suffocation methods
o Petroleum jelly or mayonnaise
* Oral ivermectin
Treatment Failures
* Only definite evidence of treatment failure is the presence of adult
organisms
o Suspected if live lice are still present 12-14 hours after treatment
* Possible contributors
o Changes in formulations
o Dilution of the pediculicide to an ineffective concentration when applied
to wet hair
o Application of subtherapeutic doses or duration in an attempt to
conservative
o Reinfestation from untreated contacts
Prognosis and Clinical Course
* May persist for many years if it remains untreated
Prevention
* All household members should be examined and treated
* Clothing and bedding should be used using the hot cycle or dry cleaned
* Combs and brushes may be washed in very hot water and may be
coated with pediculicide first
* Floors, play areas and furniture should be vacuumed to remove any
hairs with viable eggs attached