Chapter 3Infectious Diseases Related To Travel
Scabies (Sarcoptic Itch, Sarcoptic Acariasis)
Scabies is caused by the microscopic human itch mite (Sarcoptes scabiei var. hominis).
MODE OF TRANSMISSION
Transmission occurs directly via prolonged skin-to-skin contact with a person with conventional scabies or via brief skin-to-skin contact with a person with crusted (Norwegian) scabies. Indirect transmission occurs via contact with objects (such as bedding, clothing, or furniture) contaminated by a person with crusted (Norwegian) scabies, but rarely via contact with fomites used by a person with conventional scabies. Human scabies is not spread by pets or other animals.
Scabies occurs worldwide; it is epidemic in much of the developing world and common in the tropics. Outbreaks are reported most commonly in nursing-care facilities, prisons, and schools. Infection occurs in all races and social classes, and all ages are at risk. Household members and sexual partners of infested people are at high risk.
Exposure to crusted (Norwegian) scabies is more likely in institutions that care for elderly, immunocompromised, or mentally or physically disabled people. Crowded living conditions and settings where close body and skin contact are common (such as refugee settings, schools, and childcare facilities) increase the risk of scabies, as does close day-to-day contact with local populations in areas where the prevalence is high.
Symptom onset occurs 2–8 weeks after first exposure and 1–4 days after subsequent exposures. A patient is contagious from the time of exposure, even while asymptomatic, until successfully treated and all mites and eggs are killed. Head, neck, palms, and soles are usually not affected in older children and adults in temperate climates.
Conventional scabies is characterized by intense pruritus, particularly at night, and papular or papulovesicular, pruritic (itchy), erythematous rash; common sites are wrists, elbows, axillae, groin/genitals, breasts/ nipples, beltline, buttocks, between fingers/shoulder blades; itching can be generalized; papules are often excoriated; secondary bacterial infection can occur. Tiny, raised, grayish or skin-colored, serpiginous lines on skin surface represent mite burrows; they are most commonly seen on the wrist, penis, and between fingers. Burrows are often few and difficult to find. Crusted (Norwegian) scabies is characterized by often mild or absent pruritus and exfoliating hyperkeratotic scales or crusts that contain large numbers of mites.
Scabies is generally diagnosed by identifying burrows in a patient with pruritus and characteristic rash. Diagnosis can be confirmed by microscopically identifying mites, mite eggs, or scybala (mite feces) in skin scrapings of fresh lesions (intact papules/burrows). Placing a drop of mineral oil on the skin can facilitate scraping and subsequent microscopic examination. Excoriated lesions rarely contain mites.
Permethrin (5%) cream is considered by many to be the drug of choice; it is not Food and Drug Administration (FDA)-approved for use in children aged <2 months. Ivermectin, an oral antiparasitic agent, is reported safe and effective to treat scabies, including crusted (Norwegian) scabies. Two or more doses may be necessary to eliminate infestation. It is not FDA-approved but should be considered for patients in whom treatment has failed or who cannot tolerate other approved medications.
Crotamiton (10%) lotion or cream is associated with frequent treatment failure and is not FDA-approved for use in children. Lindane (1%) lotion is not recommended as first-line therapy because of neurotoxicity. Its use is restricted to patients in whom treatment has failed or who cannot tolerate other medications that pose less risk. It should not be used to treat premature infants, people with a seizure disorder, women who are pregnant or breastfeeding, people who have very irritated skin or sores where lindane will be applied, infants, children, the elderly, and people who weigh <110 pounds (50 kg). Other medications that are used in some areas include topical precipitated sulfur in petrolatum and benzyl benzoate solution or emulsion.
All household members and intimate contacts should be treated at the same time. To prevent reinfestation, exposed clothing and bed linen should be washed in hot water (≥122°F [50°C]) or be dry-cleaned at the same time as treatment.
PREVENTIVE MEASURES FOR TRAVELERS
No vaccine is available. Preventive measures are aimed at reducing skin-to-skin contact with affected people and with items such as clothing and bed linen used by an affected person.
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- Strother MS, Colven R. Ectoparasites, cutaneous parasites, and cnidarian envenomation. In: Jong EC, McMullen WR, editors. The Travel and Tropical Medicine Manual. 3rd ed. Philadelphia: Saunders; 2003. p. 459–70.
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