GENITAL SKIN CONDITIONS
Lice and scabies
Chris Bignell
Abstract
Scabies and pubic lice are parasitic infections of the skin that can be
transmitted during the intimacy of sexual intercourse. The principal
symptom for both infections is itching. The diagnosis is established by
clinical examination, supplemented by microscopy for scabies. A single
application of permethrin cream is the treatment of choice for both infec-
tions. Recent sexual partners should also receive treatment.
Keywords infestations; itching; pediculosis; permethrin; scabies
Pediculosis pubis and scabies are cutaneous infections that can
be transmitted during sexual intercourse.
 Pediculosis pubis is caused by the pubic louse (crab louse),
Phthirus pubis.
 Scabies is caused by the mite Sarcoptes scabiei.
These obligate human parasites live on or within the skin, and
sexual intercourse provides the necessary physical intimacy for
transmission; hence, they are considered as STIs. Their presence
in young adults should prompt screening for concomitant STIs.
Condoms do not provide protection. Non-sexual skin-to-skin
contact (holding hands) is important in scabies transmission.
Acquisition of scabies or pediculosis from shared bedding or
clothing appears to be uncommon.
The incidence and prevalence of these infections are not
recorded in the UK and pharmacies sell effective treatment
directly to the public. The reported number of cases treated in GU
Medicine clinics has been declining over the past 10 years, falling
from 6496 cases in 1999 to 2232 cases in 2008.
Clinical features and diagnosis
Pediculosis
P. pubis is morphologically distinct from the other two species of
louse that infect humans e the head louse, Pediculus capitis, and
the body louse, Pediculus humanus. The pubic louse is short and
has a width greater than its length. Enlarged claw-like middle
and hind legs emerge close together from the anterior abdomen,
giving it the appearance of a crab (Figure 1). Adult females lay
eggs encased in a hard shell, fixed to the base of hairs. Devel-
opment from egg through nymphal stages to adult takes 2e3
weeks.1,2 Crab lice are slowly mobile, feed on human blood and
seldom survive more than 24 h once removed from their host.
Pubic lice are not known to transmit any disease.
Clinical features: the predominant symptom of pediculosis is
itching, which develops following allergic sensitization. Adult lice
and their eggs (nits) are easily visible to the naked eye.
Chris Bignell FRCP is Consultant Physician in Genitourinary Medicine at
Nottingham City Hospital, Nottingham, UK. Competing interests: none
declared.
MEDICINE 38:6
Asymptomatic individuals may notice lice on themselves or rust-
coloured spots on their underclothes. Examination may reveal
asymptomatic, bluish macules (maculae caeruleae) in the infected
area; these lesions are thought to represent sites of louse bites.
Although crab lice are fairly sedentary, infection may spread from
the genital area to the trunk, the axillae, the thighs and, occa-
sionally, the eyelashes. Scratching may cause secondary bacterial
infection in the skin.
Scabies
The adult mites of S. scabiei have a rounded body, four pairs of
legs and are barely perceptible to the naked eye. They tunnel into
the stratum corneum of the epidermis and feed on cellular
material. Eggs are laid by fertilized females in the burrows. The
eggs hatch into larvae, which crawl out of the burrow and
progress through nymphal stages to adults.1,2 The cycle from egg
to adult is completed in 10e13 days. Scratching, bathing and
immunological reaction combine to prevent all but a few larvae
surviving to adulthood. Typically, an infected adult with scabies
carries about 10e15 mature mites in the skin.2 Unlike pedicu-
losis, scabies is seen in all age groups with no peak in prevalence
in young adults, confirming that non-sexual skin contact is an
important mode of transmission. Certain patient groups can
develop a severe form of scabies called crusted scabies, which is
highly infectious and characterized by hyperkeratosis and
a much higher burden of mites.3 It is seen in extremely physically
incapacitated individuals and patients with immune dysfunction
(including those with HIV). Secondary bacterial infection of the
skin can occasionally cause significant morbidity.
Clinical features: the mite causes generalized itching that is char-
acteristically most intense at night. The rash is polymorphic.3,4
Symptoms develop after 3e6 weeks in primary infection and
result from the development of an immune response to the mite.
Symptoms develop rapidly on re-infection. Individuals with crusted
scabies have milder itching but a much more dramatic skin rash.3
The pruritic lesions are typically distributed on the:
 interdigital web spaces of the hands
 flexor surface of the wrists
 extensor aspect of the elbows
 buttocks and genital area in males
 anterior axillary folds
Figure 1 Crab louse.
306 2010 Elsevier Ltd. All rights reserved.
 GENITAL SKIN CONDITIONS

 periumbilical region.
Several types of lesion occur in scabies.3,4
 The characteristic lesion of scabies is the burrow (Figure 2) e
a short, wavy, dirty-looking line, often extending from an
erythematous papule and usually located on the fingerwebs,
wrists, elbows or penis.
 Small, erythematous, often excoriated papules attributed to
feeding larvae and nymphs may occur at all of the above sites
(Figure 3).
 Firm, reddish, nodular lesions may occur on the glans penis,
penile shaft, scrotal skin, elbows and axillary folds. Viable mites
are seldom found in these nodules, which may persist long after
treatment.
 Excoriation of scabetic lesions is common, together with
eczematization and secondary infection, which may consider-
ably alter the appearance of the lesions.
 The crusted form of scabies has a scaling, psoriasiform
appearance and may be widespread.

Diagnosis: a pruritic rash involving the hands, trunk and male

genital area is suggestive of scabies, particularly when there is
a history of itching in a sexual partner or close domestic contact.
Demonstration of the mite confirms the diagnosis. Mites, ova and
faecal pellets may be identified by low-power microscopy of
material from skin lesions obtained by scraping, curettage or
shave biopsy (Figure 4). A magnifying glass can be helpful for
selecting an unexcoriated burrow, and a tiny vesicle containing
the mite may be seen at one end. The burrow is moistened and
the skin gently scraped with a scalpel blade until the top layer of
skin is removed. The material is collected on a glass microscope
slide and a cover slip added before microscopy.
Management
Choice of therapy
Choice of therapy may be determined by local policy.2,5
 Permethrin (5% cream) and malathion (0.5% aqueous lotion)
provide effective therapy against developmental stages and adults
in pediculosis and scabies. Topical permethrin appears to be the
most effective treatment for scabies, is the treatment of choice in the
UK and is safe for pregnant women.5 Malathion has been
successfully used since the 1970s. There are no published
Figure 3 Erythematous papule.
controlled trials comparing the effectiveness of malathion with
permethrin.
 Crotamiton (10% cream) is a less effective scabicide, but may
be used to ameliorate persistent itch.
 A sedating antihistamine at night may be helpful to relieve the
itch in scabies.
 Lindane was a popular topical treatment for both lice and
scabies, but has been discontinued in the UK because of toxicity.
 Ivermectin, though not licensed in the UK, is an oral treatment
for scabies that may have a place in the management of scabies
epidemics in long-term care facilities and in treating crusted
scabies.
A single, properly applied application of cream or lotion is
usually adequate. In usual forms of scabies in adults, treatment
should be applied to the whole body surface, including the neck,
scalp and ears, and left on for 8e12 h, usually overnight. Patients
should be informed that resolution of the irritation and skin lesions

Figure 4 Material from skin lesions is obtained by scraping, curettage or

Figure 2 The pathognomonic lesion of scabies is the burrow. shave biopsy.

MEDICINE 38:6 307 2010 Elsevier Ltd. All rights reserved.

 GENITAL SKIN CONDITIONS
associated with scabies may take several weeks and that reap-
plication of the scabicide is not routinely necessary. Treatment
failure is suggested by the persistence of original skin lesions for
more than 3 weeks after treatment, the development of new lesions
or finding a live mite on microscopy. Worsening of itching may
occur with some topical therapies because of allergic dermatitis.
Bedlinen and clothing
After treatment patients should be advised to decontaminate
bedlinen, towels and clothing by machine-washing.
Contacts
Both pediculosis and scabies are transmitted only by intimate
physical contact. It is important to treat sexual partners and, in
the case of scabies, close household contacts, to prevent re-
infestation. A C
REFERENCES
1 Morse SA, Ballard RC, Holmes KK, et al. In: Atlas of sexually
transmitted diseases and AIDS. 3rd edn. Oxford: Elsevier Science,
2003.
MEDICINE 38:6
2 Leone PA. Scabies and pediculosis pubis: an update of treatment regi-
mens and general review. Clin Infect Dis 2007; 44 (suppl. 3): S153e9.
3 Walton SF, Currie BJ. Problems in diagnosing scabies, a global disease
in human and animal populations. Clin Microbiol Rev 2007; 20:
268e79.
4 Chosidow O. Scabies and pediculosis. Lancet 2000; 355: 819e26.
5 Strong M, Johnstone P. Interventions for treating scabies. Cochrane
Database Syst Rev 2007; (3): Art. No.:CD000320.
Practice points
C Young adults with pediculosis or scabies should be screened
for other STIs
C The itch of scabies is characteristically most intense at night
The diagnosis of scabies should be considered in debilitated
patients with crusted psoriasiform rash
C Adequate coverage of the whole body is achieved with 60 g of
permethrin 5% cream
C Patients should be warned that the genital lesions and itch in
scabies may take several weeks to resolve after treatment
308 2010 Elsevier Ltd. All rights reserved.