SUPPLEMENT ARTICLE

Scabies and Pediculosis Pubis: An Update

of Treatment Regimens and General Review
Peter A. Leone
Department of Medicine, University of North Carolina and North Carolina STD/HIV Prevention and Care Branch, Chapel Hill

Ectoparasites continue to be a common cause of skin disease throughout the world. The present article dissects
the epidemiological profile and treatment of both Sarcoptes scabiei variant hominis and pediculosis pubis.

Introduction and methods. Scabies is caused by the

mite Sarcoptes scabiei var. hominis. It is estimated that
300 million cases of scabies occur worldwide each year
[1], and scabies continues to be a major public health
problem in resource-poor areas. A nuisance infection,
scabies can cause significant morbidity resulting from
secondary bacterial infections. The present article updates previously published treatment-guideline recommendations and will provide a brief overview of the
characteristics of the mite, the epidemiological profile
of infestation, and the manifestations of disease. To
update current approaches to diagnosis and treatment,
a search was conducted of the English-language literature published between 1 June 2000 and 1 January
2006. A Medline search was conducted using the terms
scabies, Sarcoptes scabiei, Norwegian scabies,
crusted scabies, ivermectin, benzyl benzoate,
malathion, lindane, and permethrin. AIDSLine
was searched, excluding Medline listings, for the terms
scabies, Sarcoptes scabiei, Norwegian scabies, and
crusted scabies. For each study identified, the study
population, treatment, outcome measures, findings,
and potential biases in study design and analysis were
evaluated. This article is an update of an article by
Wendel and Rompalo [2] published after the publication of the Centers for Disease Control and Preventions

Reprints or correspondence: Dr. Peter A. Leone, North Carolina STD/HIV

Prevention and Care Branch, CB #7030, 130 Mason Farm Rd., University of North
Carolina, Chapel Hill, North Carolina 27599-7030 (Peter_Leone@med.unc.edu).
Clinical Infectious Diseases 2007; 44:S1539
 2007 by the Infectious Diseases Society of America. All rights reserved.
1058-4838/2007/4407S3-0009$15.00
DOI: 10.1086/511428

sexually transmitted diseases treatment guidelines in

2002.
Etiologic and epidemiological profiles. Sarcoptes
scabiei was first identified in the early 1600s but was
not recognized as the etiology of the skin disorder scabies until the 1700s [3]. The mite is an obligate human
parasite that lives in burrowed tunnels in the stratum
corneum of the epidermis. It completes its entire life
cycle on humans. Pregnant female mites lay 1025 eggs
in burrows that can be up to 1 cm long and can reach
to the boundary of the stratum granulosum [4]. In 3
4 days, the eggs hatch, and the larvae mature on the
skin surface. The total length of the life cycle is 3060
days. On average, 1015 female mites live on an infected host, but the number of mites can reach millions
in humans with crusted scabies.
The burden of disease is highest in tropical countries
where scabies is endemic. In regions other than tropical
countries, there is limited evidence of a cyclic prevalence of disease. Epidemiological studies involving Israeli soldiers and regional studies in England and Denmark suggest a 2028-year pattern of disease in these
groups [58]. A higher burden of disease appears to be
related to crowded living conditions. Some studies suggest higher rates of disease in urban areas and an increased incidence of disease during winter months [6
8]. Scabies disproportionately affects women and children [6, 8].
Such institutions as hospitals, nursing homes, and
long-term care facilities are sites of epidemic scabies
infestations. In 1992, a study evaluating 130 Canadian
long-term health care facilities found that scabies infestations had occurred in 20% of such facilities during
a 1-year period [9]. Facilities that are older in age, larger
Scabies and Pediculosis Pubis CID 2007:44 (Suppl 3) S153

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SCABIES

S154 CID 2007:44 (Suppl 3) Leone

in 2 years, with only 1 death occurring and with complete

resolution of glomerulonephritis occurring in 97% of cases.
Diagnosis. A presumptive diagnosis of scabies is based on
the clinical presentation of pruritus with skin lesions and identification of a characteristic burrow. Burrows can be best identified by mineral oil or ink enhancement or by tetracycline
fluorescence tests [4]. Definitive diagnosis requires microscopic
identification of mites or their eggs or feces. This is usually
achieved by obtaining skin scrapings at the site of a burrow or
under the fingernails. Other possible strategies for diagnosis
include skin biopsy, videodermatoscopy, and epiluminescence
microscopy. Videodermatoscopy is performed using a video
microscope system [20]. In one study, this technique was evaluated and compared with regular skin scraping. Both procedures were performed twice by 2 independent observers. This
test can be performed at a magnification of 1000, and it takes
5 min to perform. The results of scraping and videodermatoscopy were similar, but 2 cases were only evident on scraping.
Thirty-eight patients were evaluated, and 16 had demonstrable
microscopic proof of infection [20]. Epiluminescence microscopy allows examination of the skin to the level of the superficial papillary dermis [21]. For 65 of 70 cases of scabies, this
technique showed dark triangular structures at the sites of infection. The technique requires 5 min and has a low falsepositive rate [21]. However, the special diagnostic equipment
required for videodermatoscopy and epiluminescence microscopy is unlikely to be available at most sites performing primary
evaluation, and these methods have not been shown to be more
sensitive than routine skin scraping.
Transmission. Transmission is by direct skin-to-skin contact. The average host has only 510 mites. A patient with
crusted scabies can be infected with millions of mites and is
therefore far more contagious than a patient with normal scabies [3]. Live mites have been documented in dust samples
obtained from patients with normal scabies and have been
found on floors, furniture, and bedding [22]. For this reason,
fomite transmission of disease is considered to be possible.
Some studies have documented survival of mites for 13 days
[2225]. After initial infection, symptoms can take several
weeks to develop. In recurrences, symptoms of pruritus may
arise within 24 h [11].
Treatment. Regimens for the treatment of scabies are presented in table 1. Although not studied in randomized controlled trials, treatment of all close contacts and housemates of
persons with scabies and washing bedding, towels, and clothing
in warm to hot water are generally recommended. Items that
cannot be washed should be isolated from use for 3 days.
Since 1996, 5 randomized, controlled clinical trials of scabies
treatment have been reported in the English-language literature
[3134]. Usha et al. [31] performed an important study addressing the relative efficacy of topical permethrin and oral

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in size, and have a low ratio of beds to health care workers

have a higher risk of scabies infestations [9].
Certain populations are at particularly high risk of developing severe, or crusted scabies. This form of hyperkeratotic
scabies infection was first described in Norway in patients with
leprosy [10]. Patients receiving systemic or potent topical glucocorticoids, organ transplant recipients, mentally retarded or
physically incapacitated individuals, HIV-infected or human Tlymphotropic virus 1infected individuals, and individuals with
various hematologic malignancies are at risk of developing
crusted scabies [11]. Of interest, crusted scabies is also seen in
Aborigines of rural Australia without identifiable immunocompromise [12]. Compared with normal scabies, crusted scabies
is highly infectious and is characterized by a much higher burden of mites in the infested individual.
Clinical manifestations. Patients with scabies usually complain of pruritus that is most severe at night. Occasionally,
patients are asymptomatic. Skin lesions most commonly involve the interdigital spaces and the flexor surfaces of the wrist,
axillae, waist, feet, and ankles [4]. In women, the area around
the nipple of the breast may be affected, as can the scrotum
and penis in men [4]. The initial infection is asymptomatic,
with symptoms developing after 36 weeks in association with
the development of an immune response to mites and their
excrement. Reinfestation is associated with a brisk immune
response and a rapid onset of symptoms within 2472 h [13].
The most characteristic lesion of scabies infestation is the
burrow, the excavated tunnel in which the mite lives. These
burrows are usually thin, curvy, elevated tracts that measure
110 mm [4]. Other skin manifestations include papules, blisters, eczematous changes, and nodules [8, 14]. In patients with
crusted scabies, the lesions are psoriasiform or warty and can
be accompanied by nail hyperkeratosis. The head and neck can
be involved, and there may be only mild pruritus. On occasion,
there is accompanying eosinophilia and lymphadenopathy [11].
Complications. Scabies is a common dermatosis that usually results in a mild-to-moderate rash with pruritus. However,
significant morbidity occasionally is associated with scabies infestation. The extensive lesions of crusted or bullous scabies
can be debilitating, with pain occurring on movement and a
significant breakdown in skin integrity developing. In northern
Australia, a mortality rate of up to 50% over 5 years was reported, with deaths primarily resulting from secondary sepsis
[15]. Secondary bacterial infection is most commonly due to
Staphylococcus aureus, group A b-hemolytic streptococci, or
peptostreptococci [16]. Several case reports have documented
leukocytoclastic vasculitis complicating scabies, and one report
also noted the presence of lupus anticoagulant [17, 18]. Glomerulonephritis has also been reported to complicate scabies
[19]. A pediatric service in Dakar, Senegal, observed 114 cases

Table 1. Scabies treatment options.

Average
wholesale price, US$

Treatment
Permethrin 5% (60 g) cream
Lindane 1% (60 mL)

15.9940.79a

Instructions for use

Apply to whole body from the neck down; wash off after 814 h
No longer recommended as first-line or alternative therapy because
of toxicity; should only be used in clinical situations in which there
is an inability to tolerate other therapies; apply thinly to the whole
body from the neck down; wash off completely after 8 h

2.7514.37b

Lotion
Shampoo
c

Crotamiton

Benzyl benzoate (500 mL)e

85.99125.97a
d

62.79

Not an FDA-approved indication; apply to the whole body from the

neck down; leave on for 24 h and apply for 2 consecutive days
b

12.7026.62

Not an FDA-approved indication

a

109.55143.99
6.7527.52b

Not an FDA-approved indication

Not an FDA-approved indication; apply thinly to the whole body;
leave on 24 h before washing and reapplying for a total of 3
applications

Ivermectin (3 mg)g

103.99116.99a

Not an FDA-approved indication; 200250 mg/kg given as a single oral

dose or 2 doses separated by an interval of 12 weeks

NOTE. FDA, Food and Drug Administration.

a
b
c
d
e
f
g

Data (from 2006) are from Drugstore.com [26], CVS.com [27], and Kerr Drug (North Carolina) [28].
Data from 1999 Drug Topics Red Book [29].
10% cream (croton oil [5 g]) or 10% lotion.
Data (from 2006) are from GetCanadianDrugs.com [30].
Not commercially available in the United States.
Sulfur 6% or precipitated sulfur powder (500 g).
Twenty tablets.

ivermectin. They found that a single topical dose of permethrin

produced a clinical cure rate for scabies (97.8%) that was superior to that produced by a single dose of ivermectin (70%).
However, 2 doses of ivermectin administered at a 2-week interval were as effective as a single dose of topical permethrin.
In a comparison of topical lindane and oral ivermectin, 53
patients were enrolled in the study and were randomized to
follow a blinded treatment regimen [32]. Only 43 patients completed the study, and final results were determined by as-treated
analysis. This study suggested treatment equivalency between
these medications after administration of 2 courses of therapy
separated by 2 weeks. On clinical evaluation, the rate of cure
of signs and symptoms of scabies was 95% for ivermectin and
96% for lindane. This study was limited by low statistical power.
Madan et al. [33] compared ivermectin (200 mg/kg as a single
dose) with 1% lindane lotion, with 180% of patients who were
given ivermectin demonstrating a marked clinical improvement
at 4 weeks of therapy, compared with 44% of patients given
lindane lotion. Their study suggests that ivermectin may be a
better treatment choice than lindane, because of the good clinical response, lower toxicity, and improved adherence associated with ivermectin. A study conducted in Vanuatu compared
benzyl benzoate with a single dose of oral ivermectin (200 mg/
kg) [35]. There was no statistically significant difference between the findings in the 2 arms in the study. The reported
cure rate was low, with a cure rate slightly better than 50%
noted 3 weeks after treatment initiation. The study was limited

by a 27% rate of failure to return for follow-up, by the single

dose of ivermectin administered, and by the short-term followup.
Several other clinical studies have been conducted. One retrospective comparative study analyzed the outcomes of 39 HIVinfected inpatients with 60 episodes of scabies treated with
benzyl benzoate, ivermectin, or a combination of benzyl benzoate and ivermectin [10]. Benzyl benzoate achieved a cure in
9 (47.4%) of 19 patients; ivermectin, in 10 (62.5%) of 16 patients; and combination treatment, in 4 (100%) of 4 patients.
Of interest, a cure was not achieved for any of the 4 patients
with crusted scabies who received either treatment alone. All
the patients who received combination treatment had been
given a diagnosis of crusted scabies, and, for all these patients,
a cure was achieved using a combination of topical benzyl
benzoate and oral ivermectin. This study provides some preliminary evidence for the use of combination treatment for
severe scabies in HIV-infected patients.
Several open-label studies of ivermectin for the treatment of
patients with uncomplicated scabies have been published since
1996 [3639]. The studies evaluated 12 doses of ivermectin
(200 mg/kg separated by 7 days). In the largest study, which
included 120 patients, the clinical response rate, as determined
by as-treated analysis, was 88% after administration of 1 dose
of ivermectin. After 4 weeks and administration of 2 doses of
ivermectin, the cure rate increased to 100% [38]. There have
been reports of several other open-label studies that involved
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Malathion 0.5% lotion (60 mL)

f
Sulfur

S156 CID 2007:44 (Suppl 3) Leone

used only as an alternative therapy if other treatments are not

tolerated or if other approved therapies have failed. It is thought
that warm baths and extensive dermatitis may increase systemic
absorption of lindane. Lindane is not recommended for pregnant or lactating women, for children !2 years of age, or for
patients with extensive dermatitis. Given the warnings and concerns about toxicities, lindane is not recommended as a firstline or alternative therapy for scabies. The use of lindane would
best be reserved for patients for whom the inability to tolerate
other therapies leaves this as a last option.
In a randomized controlled trial of lindane versus ivermectin
treatment, all reported adverse effects were mild and transient
[32]. Patients treated with lindane more frequently complained
of headache, but some patients treated with ivermectin noted
abdominal pain and vomiting. One patient treated with lindane
developed hypotension. Ivermectin has been well tolerated in
all but one study. This study described an outbreak of scabies
in a long-term care facility for elderly individuals; in the study,
patients received multiple applications of topical scabicides before finally receiving treatment with a single dose of ivermectin
[50]. Over the following 6 months, there was an increased
incidence of death among these 47 patients, compared with
age- and sex-matched control subjects. These patients experienced lethargy and anorexia before death. Other investigators
argue with the outcomes of the study, pointing out that patients
were not matched for comorbidities, such as severity of dementia [51]. No other studies have demonstrated increased
mortality occurring in association with a history of ivermectin
therapy. In another study, involving 220 patients in a psychogeriatric nursing home who were treated with ivermectin
for a scabies outbreak, the mortality rate in the 6 months after
treatment was compared with that occurring in the 30 months
before treatment; no significant difference was found [46]. Of
note, a rash and a transient increase in pruritus have been
reported in the first 3 days after scabietic patients receive ivermectin [37].
Persistent symptoms. All patients should be informed that
the rash and pruritus associated with scabies may persist for
up to 2 weeks after treatment completion [11]. When symptoms and signs persist for 12 weeks, there are several possible
explanations, including treatment resistance, treatment failure,
reinfection from family members or fomites, drug allergy, or
worsening rash due to cross-reactivity with antigens from other
household mites [12, 52].
Poor response and presumed resistance to lindane have been
reported elsewhere [48, 5357]. Treatment failure not related
to resistance can be due to faulty application of topical scabicides. Patients with crusted scabies may have poor penetration of scabicides into thick scaly skin and may harbor mites
in these difficult-to-penetrate layers. Particular attention must
be given to the hyperkeratotic fingernails of such infested pa-

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smaller patient cohorts treated with ivermectin (200 mg/kg)

given in 12 doses, with cure rates of 76%100% noted [36,
37, 39]. These studies included few cases of crusted scabies. In
a cohort study, 20 patients with crusted scabies were treated
with 13 doses of ivermectin (200 mg/kg) combined with a
topical scabicide and a keratolytic agent. Eight of 20 patients
had an initial complete response, and 8 of 10 patients had a
response to 3 doses of ivermectin [40]. Finally, in a study of
10 patients with uncomplicated scabies, a complete response
was seen in all 10 patients after receipt of 34 treatments with
topical 1.8% ivermectin cream [41]. In vitro testing of 6 different scabicides (neem, permethrin, benzyl benzoate, ivermectin, lindane, and tea tree oil) showed that all reduced mite
survival, with the exception of neem [42]. However, of the 5
treatments that reduced mite survival, the duration of survival
was found to be longest with permethrin exposure.
A clear challenge facing scabies treatment in the future is the
optimal management of populations with high rates of endemic
scabies. In one recent study, community-wide permethrin treatment was followed by treatment of patients with newly diagnosed scabies at all follow-up visits [43]. At 25 months of
follow-up, the prevalence of scabies had decreased from 28%
to 7% (P p .002). In Papua, New Guinea, inhabitants of 2
villages were evaluated for filariasis and scabies [44]. The inhabitants of one village were selected to receive ivermectin (400
mg/kg) as a single dose. The inhabitants of the treated village
experienced a decrease in the prevalence of scabies (from 87%
to 26%) at 5 months of follow-up. These studies suggest a role
for community-wide treatment in controlling disease in communities where scabies is endemic; however, additional studies
will be needed to clarify the long-term influence of these treatments and their economic feasibility.
Scabies epidemics in long-term care facilities were the focus
of several additional cohort studies, which demonstrated good
control of the epidemic with the use of 12 doses of ivermectin
[45, 46]. One of these studies reported that ivermectin treatment was successful after treatment with several different topical scabicides failed [46].
Treatment toxicity. Topical agents have been the most extensively used type of scabies treatment, and, therefore, their
toxicity profiles are fairly well defined. Both permethrin and
benzyl benzoate have been reported to cause rash and diarrhea
[47]. More worrisome are the reports of convulsions and aplastic anemia occurring in association with benzyl benzoate and
lindane [48, 49]. According to the World Health Organization
1998 Collaborating Centre for International Drug Monitoring,
convulsions have been associated with the use of benzyl benzoate, crotamiton, lindane, malathion, and permethrin. Deaths
were reported to occur in association with crotamiton, lindane,
and permethrin treatment [49]. In 2003, the US Food and Drug
Administration issued a health advisory that lindane should be

Table 2. Treatment regimens for pediculosis pubis.

Treatment
Permethrin 1% cre`me rinse (2 oz)
Lindane 1% shampoo

Average
wholesale price, US$
7.67a
3.0014.72b

Pyrethrins with piperonyl butoxide

1.67c

5.5 oz (mousse)

9.20

b
c

No longer recommended as first-line therapy

because of toxicity; should only be used as
alternative therapy because of an inability to
tolerate other therapies; apply to affected areas
and wash off thoroughly after 4 min
Apply to affected area and wash off after 10 min

2 oz (shampoo)

Instructions for use

Apply to affected areas and wash off after 10 min

Warner-Lambert product information.

Data from [29].
Bayer product information.

PEDICULOSIS PUBIS
Introduction and methods. Lice are blood-sucking insects
that have no free-living stage in their life cycle [58]. Lice primarily infest the head (Pediculus humanus var. capitis), the body
(Pediculus humanus var. corporis), or the pubic region (Phthirus
pubis). Head lice are the most common lice. In the present
article, we will summarize key characteristics of pediculosis
pubis and update the current approaches to diagnosis and treatment. A search was conducted of the English-language literature
published between 1 June 2000 and 1 January 2006. A Medline
search was conducted using the terms pubic lice, Phthirus
pubis, pediculosis, pediculosis pubis, permethrin, and
lindane. AIDSline was searched, omitting Medline listings,
by use of the terms Phthirus pubis, pediculosis, and pediculosis pubis. Abstracts from meetings of the Infectious Diseases Society of America and the International Society of Sexually Transmitted Diseases Research, as well as from the joint
meetings of the American Sexually Transmitted Diseases Association and the Medical Society of Venereal Diseases, were
reviewed for contributory work. For each study, the following
characteristics were defined: study dosing, study population,

treatment, outcome measures, findings, and potential biases in

study design and analysis. Head lice treatment trials were included in our findings.
Characteristics of lice. P. pubis is 13 mm long and has 3
pairs of legs [11]. The life cycle of the female insect is 13
months. The adult female lays up to 300 eggs adhering to the
hairs at the skin-hair junction. Eggs or nits hatch in 610 days.
These nymphs then mature to adults within 10 days.
P. pubis infests hairs in the pubic area and, occasionally, in
areas heavily covered with body hair. They rarely infest eyebrows and eyelashes [59]. The most common symptom of infection is pruritus that is thought to be due to hypersensitivity
to feeding lice. Physical findings include visible opalescent nits
or live lice and blue macules (maculae ceruleae) at feeding sites.
Diagnosis and transmission. Pediculosis pubis is diagnosed by the identification of live lice and/or viable nits. All
patients with pediculosis pubis should be thoroughly investigated for other sexually transmitted diseases. Transmission occurs through direct intimate contact [11]. Fomite transmission
is unlikely to play a significant role. Condoms do not prevent
transmission of P. pubis.
Treatment. Recommended treatment regimens are listed in
table 2. In addition, all bedding, towels, and clothing should
be washed. Patients should be instructed to avoid contact with
their sex partner until they have been treated and both individuals have been seen in follow-up. Some patients may require
a second application of topical therapy 37 days after the initial
treatment application [59]. Infestation of the eyelashes should
be treated by application of an occlusive ointment, such as
petroleum jelly, twice daily for 10 days. Other agents that may
be effective in the treatment of P. pubis are 0.5% malathion,
0.5%1% carbaryl, and 0.2% phenothrin [59].
Since 2000, to our knowledge, there have been no new treatment trials published concerning the treatment of pediculosis
pubis. There were, however, 3 randomized clinical treatment
trials assessing the treatment of head lice. In one comparative
Scabies and Pediculosis Pubis CID 2007:44 (Suppl 3) S157

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tients. Certainly, to avoid reinfection, it is recommended that

all close contacts of patients with scabies be empirically treated.
All linens, bedding, and clothing should be washed, if possible,
during the time of application of the topical scabicide. Even
when treatment is successful and reinfection is avoided, symptoms may worsen secondary to allergic dermatitis. This complication has been seen with several of the topical scabicides.
Finally, ordinary household mites may drive persistent symptoms resulting from cross-reactivity between antigens. In a
study of 25 patients, scabietic patients had higher skin-prick
test results, as determined by the extent of wheal development
in response to extracts of mice antigen, and higher levels of
IgE to house dust mite and storage mite antigen than did control subjects [52].

DISCUSSION
Ectoparasites continue to be a common cause of skin disease
throughout the world. Topical agents are generally effective in
the management of extoparasites but are accompanied by
sometimes-serious adverse effects, and resistance to several
agents has been documented. Ivermectin is a new oral mode
of treatment for scabies and may hold particular promise in
the treatment of epidemic or severe scabies. Lindane is no
S158 CID 2007:44 (Suppl 3) Leone

longer recommended as a first-line or alternative treatment for

scabies. Combination treatment with ivermectin and topical
scabicides may prove to be the best treatment for crusted scabies, but this requires further study. Pediculosis pubis is usually
effectively treated with topical agents, but increasing rates of
resistance among head lice warrant concern regarding future
efficacy of current topical agents in the treatment of pediculosis
pubis.
Acknowledgments
Supplement sponsorship. This article was published as part of a supplement entitled Sexually Transmitted Diseases Treatment Guidelines,
sponsored by the Centers for Disease Control and Prevention.
Potential conflicts of interest. P.A.L.: no conflicts.

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trial conducted in Florida, comparison of 0.5% malathion and

1% permethrin demonstrated a clearance rate of 98% with
malathion, compared with 55% with permethrin [60]. Permethrin coupled with oral trimethoprim-sulfamethoxazole enhanced the efficacy of therapy with permethrin [61]. Combing
did not improve clearance in response to therapy with permethrin [62]. One study assessed both the in vitro susceptibility
of lice and the in vivo response to topical treatment of lice in
children in Bath and Bristol, England. Both cohorts of children
had lice that demonstrated a decreased mortality rate in response to permethrin and malathion [63]. Children in Bath
were treated with malathion, with a cure rate of 36% noted at
4872 h. Children in Bristol were treated with permethrin, with
a cure rate of 13% noted at 4872 h. The sample size of this
study was only 30 children, but it suggests the presence of dual
resistance to permethrin and malathion in these cohorts.
Additional in vitro evaluations were performed by Pollack
et al. [64], who sampled head lice from children in Massachusetts, Idaho, and Malaysian Borneo. They found that, among
lice in the United States, the mortality rate was 50% in response to treatment with permethrin. The mortality rate was
unaltered by increasing concentrations of drug. Conversely, the
mortality rate for lice from Malaysia was 37% when the lowest
concentrations of permethrin were used. Their mortality rate
increased linearly with increasing permethrin concentrations,
to a maximum mortality rate of 95%. This study used different evaluation times for the US and Malaysian lice, because
of baseline differences in survival times. Regardless, this study
suggests the possible emergence of drug resistance in head lice
in the United States. The concerns raised by these results are
amplified by another in vitro analysis demonstrating that lice
with resistance to permethrin also have resistance to sumithrin
and a newer agent for treatment, deltamethrin [65]. The emergence of drug resistance in head lice throughout the world is
of concern, but the implications for treatment of pediculosis
pubis are unclear. A case of pubic lice resistant to pyrethrins
in vitro was reported, but the patient demonstrated clinical
clearance with 5% permethrin [66]. The current recommendations for treatment of pediculosis pubis are listed in table 2.
Since 1996, there have not been any English-language studies
documenting significant treatment failure in the management
of pediculosis pubis.

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51.
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53.
54.
55.

56.

57.

58.
59.

60.

61.

62.

63.

64.

65.

66.

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