Scabies in Refugee Patients

Overview

Scabies is a skin infestation by the mite Sarcoptes scabiei, common in resource-limited settings and crowded conditions such as refugee camps. It is transmitted by prolonged skin-to-skin contact.

After a primary infestation, symptoms may take up to 8 weeks to appear.

Symptoms and Signs

*     Intense pruritus, worse at night. This is the hallmark symptom.

*     Multiple small erythematous papules

*     Mite burrows (small, grey, serpentine lines). Look between fingers, wrists, and elbows.

*     The head is usually spared in adults but not in young children

Common locations: fingers, web spaces, wrists, elbows, axillae, areolae, groin, genitalia, buttocks, feet.

Diagnosis

Definitive diagnosis: microscopy of skin scrapings from high-yield areas.

In practice: do not wait for results. Treat based on clinical presentation. Typical pruritus with the above distribution is sufficient to initiate treatment.

Treatment

First-line: Topical permethrin 5% cream (30g per adult application)

Application instructions:

1.   Apply from the neck down to the soles of the feet, including under fingernails

2.   In young children, also apply to the scalp and face (avoid eyes and mouth)

3.   Leave on for at least 8 hours (overnight)

4.   Wash off in the morning

5.   Repeat the application 1-2 weeks later

Treat all close contacts simultaneously, even if asymptomatic.

Permethrin is safe in pregnant and lactating women and in infants 2 months and older.

When to Use Oral Ivermectin

Oral ivermectin (200 mcg/kg, repeated 1-2 weeks later) is an alternative for patients who have failed permethrin or cannot comply with topical application.

Contraindication: Do not use ivermectin in patients from loa loa endemic countries (central Africa) unless loiasis has been excluded. See Strongyloides page for details.

Follow-Up

Pruritus and lesions should resolve within 1 week of successful treatment. Post-scabetic itch can persist up to 4 weeks. This does not indicate treatment failure.