JOURNAL OF DERMATOLOGICAL TREATMENT, 2016

VOL. 27, NO. 5, 473–479

http://dx.doi.org/10.3109/09546634.2016.1151855

ORIGINAL ARTICLE

Efficacy, acceptability and cost effectiveness of four therapeutic

agents for treatment of scabies
Talal A. Abdel-Raheema, Eman M. H. Meabedb, Ghada A. Nasefc, Wafaa Y. Abdel Wahedd and Rania M. A. Rohaime
a
Department of Dermatology, STDs and Andrology, Faculty of Medicine, Fayoum University, Fayoum, Egypt; bDepartment of Parasitology,
Faculty of Medicine, Fayoum University, Fayoum, Egypt; cDepartment of Dermatology, STDs and Andrology, Faculty of Medicine, El-Menia
University, El-Menia, Egypt; dDepartment of Community Medicine, Faculty of Medicine, Fayoum University, Fayoum, Egypt; eDepartment of
Dermatology, STDs and Andrology, Senors General Hospital, Ministry of Health and Population, Fayoum, Egypt

ABSTRACT ARTICLE HISTORY

The aim of this study is to evaluate four drug regimens for treatment of scabies as regard their efficacy, Received 12 July 2015
acceptability and cost effectiveness. Two hundred cases with ordinary scabies were randomized into four Revised 30 December 2015
groups. First group received ivermectin 200 lg/kg body weight single oral dose, repeated after one week. Accepted 30 December
2015 Published online 17
The second received benzyl benzoate 20% cream. The third received permethrin 2.5%–5% lotion, whereas
March 2016
the fourth group received 5–10% sulfur ointment. Topical treatments were applied for five consecutive
nights. Patients were followed up for two weeks for cure rate and adverse effects. At the end of the study, KEYWORDS
permethrin provided a significant efficacy of 88% and acceptability in 100% of cases, but had higher cost to scabies; ivermectin;
treat one case (20.25 LE). Ivermectin provided efficacy and acceptability rates of 84% and 96%, respect- permethrin; benzyl
ively, and had a cheaper cost (9.5 LE). Benzyl benzoate provided 80% for both rates and was the cheapest benzoate; sulfur
drug. Sulfur ointment provided the least rates, and it was the most expensive. Treatment choice will depend
on the age, the general condition of cases, patient compliance to topical treatment and his ability to stick to
its roles, and the economic condition of the patient.

Introduction action of the drug (10). There is no conclusive evidence

Scabies is an intensely itchy parasitic infection of the skin, caused
by Sarcoptes scabiei mites. It occurs throughout the world, but is
particularly problematic in areas with poor sanitation, overcrowd-ing
and social disruption (1,2). The number of infected cases worldwide
is estimated to be up to 300 million (3). Scabies usually spreads
from person to person via direct skin contact, including sexual
contact (4). Treatment is performed on patients definitely diagnosed
as having scabies on the basis of detection of the mite or patients
showing evident clinical symptoms of scabies. A num-ber of
medications are effective in treating scabies; however, treat-ment
must often involve the entire household or community to prevent re-
infection. A number of topical agents have been the mainstay of
therapy since ages and are still used as standard treat-ment (5).
Permethrin is the most widely used agent in developed countries
(6). Benzyl benzoate 10–25% is the most widely used topical agent
in developing countries. Sulfur preparations toxicity is low and can
be used in pregnant women and children (7). Although treatment
appears simple, the most difficult aspect of management is
adherence to proper use of medicines (8). Treatment failure, not
uncommon, is often due to dermatitis sec-ondary to the mite or
topical agent, incorrect application of the topical agent, poor
penetration of hyperkeratosis skin or nails, re-infestation from close
contact, and potential drug resistance (9).
Oral ivermectin targets primarily the glutamate-gated chloride
channels of many parasites (including mites), with c-aminobutyric
acid and other ligand gated chloride channels likely a secondary
target, resulting in paralysis and death of the parasite (3). A second
dose is necessary two weeks later due to the lack of ovicidal
indicating superiority of oral ivermectin for treating common
scabies than topical preparations (11,12), and there is a paucity
of high-quality studies conducted to compare and to evaluate
various therapies for scabies (5).
The aim of this study is at evaluating the efficacy, safety, cost
effectiveness of four drug regimens recommended by The
Egyptian Ministry of Health for treatment of scabies: oral
ivermec-tin, topical benzyl benzoate cream, permethrin lotion
and sulfur ointment.
Patients and methods
Subjects
This is a randomized controlled parallel multiple four arm clinical
trial with ratio (1:1:1:1) which was conducted on 200 patients
with scabies attending dermatology outpatient clinic at Fayoum
University Hospital during the period from November 2012 to
May 2013. The study was assessed and approved by the
Faculty of Medicine, Fayoum University, Ethics Committee.
This study has been registered at Pan African Clinical Trial
Registry (www.pactr.org) database, under a unique identification
number: PACTR201505001116484.
Exclusion criteria included pregnant or lactating women; chil-
dren lower than five years old and adults more than 50 years old;
cases with body weight less than 15 kg; participants with a sys-
temic condition such as abnormal liver and kidney functions, known
thyroid disease, cardiac disorders, nervous system disorders and
psychiatric illnesses; and participants with history of diabetes

CONTACT Eman M.H. Meabed, M.D emeabed@gmail.com, emm02@fayoum.edu.eg Associate Prof. of Parasitology, Faculty of Medicine, Fayoum
University,
Egypt
2016 Informa UK Limited, trading as Taylor & Francis Group
474 T. A. ABDEL-RAHEEM ET AL.
mellitus, hypertension, or chronic infectious diseases;
participants having any other associated skin disease which
could alter the pic-ture of scabies; immunocompromised
individuals; atypical presen-tations like crusted scabies; and
participants had taken any antiscabietic treatment in the
preceding month were also excluded.
Each case included in this study had a special file to keep
personal data, and items for diagnosis and investigations at the
time of primary diagnosis and each follow up visits.
1 A questionnaire interview Including name, age, sex, educa-
tion, socio-economic level, residence and contact with farm
animals, history of nocturnal itching, contact with a scabies
patient, involvement of family members, and determination of
body weight.
2 Clinical presentation of scabies; patients experiencing itching
and had characteristic lesions (i.e. burrows, vesicles, papules,
nodules or pustules) on anatomical sites of predilection for sca-
bies (i.e. the interdigital folds of the hands, the elbows, the
wrists, the buttocks, the axillary folds, the nipple areolas in
women and the male external genitalia) (13). A detailed phys-
ical and dermatological examination was done including
description of the lesions and their distribution on the body
and assessment of the degree of pruritus.
3 To confirm clinical diagnosis, parasitological examination of
lesions was performed by low-power microscopy for each
patient included in the trial. At least 4–6 scrapings per patient
from separate locations were obtained, placed in a drop of
10% potassium hydroxide solution on a glass slide and
exam-ined for the presence of living Sarcoptes scabiei (i.e.
adult forms), eggs or fecal pellets (12). Identification of a mite
was required for inclusion in the study.
Treatment
Participants were first treated from secondary bacterial infection,
if present, with azithromycin once daily for three days. Cases
were randomly allocated into four groups according to random
alloca-tion number generated though computer, each one
received treat-ment as follows: the first group received a single
oral dose of ivermectin 200 lg/kg body weight taken with meals,
repeated after one week. The second group received benzyl
benzoate 20% cream. The third group received permethrin 5%
lotion for adults and 2.5% for children below 10 years. Group 4
received sulfur 10% ointment for adults and 5% for children
below 10 years. Topical treatments were applied and left
overnight to the whole body below neck for five consecutive
nights. Repeated applications of topical treatments are indicated
to ensure controlling spread of the endemic disease.
Participants in group 2–4 were instructed to bath with warm
water before application of medication and on subsequent morn-
ing. Bed clothes and personal clothes had to be washed with hot
water. Members of the same family not enrolled in the study
were given the same drugs according to their age or any other
suitable regimen. Tablets were taken in the presence of the
physician, and topical agents were applied by the patient.
Follow up
Cases were followed up at day 7 and 14 after primary visit for
cure rate and adverse drug reaction monitoring. History,
examination and investigations were repeated on these visits.
Complete cure was defined as negative parasitological
examin-ation of the patient with complete absence of new
lesions at the time of follow up. Residual and all new lesions
were scrapped for detection of mites. If only one mite was
detected, this was consid-ered as treatment failure.
Cured participants were prescribed antihistaminic for
symptom-atic treatment of remaining pruritus and/or nodules,
and the uncured participants were prescribed repeated
intervention along with antihistaminic.
Statistical analysis
Sample size was calculated based on the following assumption;
difference in effectiveness between the treatment arms was
20%. The power of the study was 80%.
Collected data were computerized and analyzed using
Statistical Package for Social Science (SPSS) version 16
(Chicago, IL). Comparisons of quantitative variables between
groups was done using ANOVA test followed by post hoc tests
for intergroup comparison. Comparison of qualitative variables
was done using chi-square test, p values less than 0.05 were
considered statistically significant.
Cost effective analysis
On the basis of total expenditure incurred on medicines at the
end of two weeks in LE and cure rate in percentage, the cost
effectiveness was calculated and the four interventions were
com-pared on the basis of amount needed to treat one case
success-fully (14).
Results
For enrollment in this study, 500 cases with scabies were
assessed for eligibility, of them 284 cases were excluded, and
216 were ran-domly allocated into four intervention groups.
Finally, 200 cases completed the study. A flowchart diagram is
supplied to provide detailed information about the clinical trial
phases including (enrollment, intervention allocation, follow-up,
and data analysis) Figure 1.
There is no significant difference between the four groups
regarding their demographic characteristics (Table 1). Patients
belonged to both sexes with male/female ratio 84:116, and their
ages ranged from 7 to 50 years. Thirteen percent of cases were
below 10 years old, 55% of cases aged from 11 to 30 years, and
32% aged from 31 to 50 years. Seventy eight percent of cases had
previous history of scabies. About 67.5% of cases were categorized
as moderate in socioeconomic level according to the total daily
income of the family. Twenty-two percent had no or very low edu-
cation, 68% of the patients had moderate education level, and 10%
received higher education. About 72% of cases had residence in
rural areas and 52% of them had contact with farm animals.
At their primary diagnosis, precise laboratory and clinical inclu-
sion requirements were fulfilled by all cases, without any signifi-cant
difference between the four groups. There were no significant
differences between groups regarding severity of itching and its
mean duration, percent of patients with secondary bacterial infec-
tion, percent of patients presented with nodules and mean count of
lesions whether burrows, papules and nodules (Table 2).
Regarding anatomical distribution of lesions; trunk was
affected in all patients either alone or with other body parts, 93%
of cases presented with lesions on the upper limbs, 49% on the
buttocks, 10% had lesions on the external genitalia and 8% of
patients had lesions on the lower limbs.
 JOURNAL OF DERMATOLOGICAL TREATMENT 475

Enrollment Assessed for eligibility (n=500)

Excluded (n=284)
♦ Not meeting inclusion criteria (n=95 )
♦ Declined to participate (n=151 )
♦ Other reasons; big family size (n=38 )

Alloca on Randomized (n=216)

Follow
up at
day 7 BB group (n= 55) Ivermec n group Permethrin group Sulfur Group (n=54)
(n=53) (n=54)

Lost to
Lost to follow (n =3) Lost to follow Lost to follow (n=4)
follow n=5 n=4

Number remaining=50 Number remaining=50 Number remaining=50 Number remaining=50

Number cured=24 Number cured=22 Number cured=32 Number cured=12
Uncured =26 Uncured =28 Uncured=18 Uncured =38

Lost to follow Lost to follow Lost to follow Lost to follow

Follow
up (n=0) up (n=0) up (n=0) up (n=0)
up at
days
14

Number cured(n=16) Number cured=20 Number cured=12 Number cured=14

uncured (n= 10) Uncured (n=8) Uncured(n=6) Uncured (n= 24)

Figure 1. Flowchart describing the phases of parallel randomized clinical trial; comparing four drugs for treatment of scabies.

Table 1. The main demographic features of examined patients.

Ivermectin Benzyl benzoate Permethrin Sulfur Total
Parameters (n ¼ 50) (n ¼ 50) (n ¼ 50) (n ¼ 50) (n ¼ 200) p valuesa
Mean age (years) 27.84 69.46 22.52 6 12.77 25.28 613.73 28.40 613.42 25.33 6 12.84 0.072
Age range 14–49 7–50 8–50 8–50 7–50
Male/female ratio 26:24 24:26 14:36 20:30 84:116 0.37
Positive history 34 (68%) 38 (76%) 44 (88%) 40 (80%) 156 (78%) 0.109
Socioeconomic level (SEL) low:moderate 15:35 16:34 12:38 22:28 65:135 0.186
Education level low:moderate:high 6:38:6 10:38:2 14:32:4 14:28:8 44:136: 20 0.119
Residence, urban:rural 14:36 10:40 14:36 18:32 56:144 0.365
Contact with animals 26 (52.0%) 26 (52.0%) 24 (48%) 28 (56%) 104 (52%) 0.887
aChi-square test was used for comparing variables between the four groups except age was compared using ANOVA test.

At the two follow-up visits, there was a significant difference
between the four groups regarding percent of patients presented
with itching (p values ¼ 0.00, Table 3). Application of permethrin
decreased the percentage to 40%, 12% while application of
sulfur had the least effect, as 100% and 52% of cases
presented with itching at days 7 and 14, respectively.
The total number of cases with itching much exceeded the
number of positive cases (having residual lesions and were posi-tive
by microscopy) at both follow-up visits, in the second visits of follow
up, since 30% and 4% of cases presented with itching
despite being negative for lesions and microscopy, in the first
and second visits follow up, respectively.
Nodules did not show any response to any of the used drugs.
No significant difference between the four groups regarding
num-ber of patients presented with nodules throughout the
study period.
Regarding number of patients with lesions positive in micro-
scopic examination, permethrin significantly lowered the percen-
tages at day 7 and 14 (36% and 12%, respectively), while sulfur had
the least effect (76.0%, 48%), with no difference observed between
ivermectin and benzyl benzoate groups (p values < 0.05).
476 T. A. ABDEL-RAHEEM ET AL.

V
p

u
e
s
l

2
6
3

8
0
1
1
0
9
0
.

0.23
There was a significant difference between the four drugs

220.
0.084
0790.
b

b
a
a
a

b
b
regarding cure rate. Permethrin provided the highest rates (64%
and 88% at day 7 and 14), and sulfur provided the lowest rates
(24% and 52% at day 7 and 14), respectively (p values < 0.05).
To estimate drugs effect on decreasing lesion counts,
Residual and new lesions including burrows and papules were
6277. 2.53

68. 1.9844

6260. 0.77
625. 5.20 counted together at primary diagnosis then at follow up visits. All
40 (20%)
24 (12%)

88 (44%)
68 (34%)
56:54:90

10 (5%)

10 (5%)
14 (7%)
6 (3%)
4 (2%)
Residual and new lesions were scrapped for detection of mites,
Total

1:15

the percent decrease in the total counts of lesions in comparison

with the first visit was estimated (Table 4).
At day 7, many cases had residual lesions that were negative
for mites then disappeared spontaneously at day 14. New
lesions were usually positive for mites except in sulfur group at
623. 5.0784
6766. 1.98

6260. 0.75
68. 2.168

day 7 (1.6 60.67) and permethrin group at day 14 (0.023 60.15).

26 (52%)
18 (36%)
8 (16%)
6 (12%)
8:12:30

1 (2%)
0 (0%)
2 (4%)

1 (2%)
2 (4%)
Sulfur

At day 7, there was a significant difference between the four

1:10

groups regarding the mean count of residual lesions either posi-

tive or negative for mites. Sulfur group reported the highest
mean values (9.57 63.25, 5.3 6 1.15) and permethrin
significantly reported the lowest values (4.2 61, 3.1 61.15).
Permethrin

6646. 1.89

There was a significant difference between the four groups

625. 5.20
10 (20%)

18 (36%)
22 (44%)
68. 1.70

610. 0.5
18:14:18

0 (0%)

regarding appearance of new lesions. Sulfur group significantly

2 (4%)

0 (0%)
4 (8%)

2 (4%)
4 (8%)
3:10

reported the highest values (3.8 6 1.6), and permethrin group

reported the lowest values (0.8 60.6), with no significant differ-
ence between ivermectin and benzyl benzoate groups.
At the day 14, sulfur group had a significant higher mean
Benzyl benzoate

count of residual lesions, either positive or negative for mites, in

com-parison with the other three groups, with no significant
6527. 2.47

625. 5.422
68. 1.852

6280. 0.8

difference between them. Regarding new lesion counts; there

12 (24%)

24 (48%)
18 (36%)
16:12:22

6 (12%)

1 (2%)
1 (2%)
2 (4%)

3 (6%)
2 (4%)

was no signifi-cant difference between groups either positive or

3:14

negative for mites.

The mean percent decrease in lesion counts, either at day 7
and 14, was significantly higher in permethrin group (94 64 and
¼Acronymsforanatomicalsites:TTrunk,BButtocks,UUpperLimb,L Lower Limb, ¼Ex External Genitalia.

97.6 63.5) and the lowest values reported with sulfur group (73
610 and 86.7 6 8.9) respectively.
625. 5.0898
Ivermectin

68. 2.179

6420. 0.9
10 (20%)
10 (20%)

20 (40%)
10 (20%)
667. 2.9

Sensitivity and specificity of clinical cure (based on percent

14:16:20

6 (12%)
4 (8%)
3 (6%)
2 (4%)

4 (8%)

decrease in mean total counts of lesions) in relation to

3:15

microscopy was estimated; at day 7 they were (90.4% and

82.6%), at a cutoff point (91.5%), and at day 14 were (93.5%
and 89.6%) at a cutoff point (92.9%).
On comparing the four drugs as regard their cost effectiveness
(Table 5), Benzyl benzoate was more cost effective than ivermectin.
Permethrin and sulfur preparations were the most expensive.
Burrows
Table2.Clinicalandlaboratory data of patients at their primary diagnosis.

Discussion
Numberofcasesshowing certain anatomical dist. of lesions

Scabies is a common contagious parasitic dermatosis, its

control requires treatment of the affected individual and all
contact peo-ple (15). A number of medications are effective in
treating scabies; permethrin preparations are widely used and
Severityofitchingmild:moderate:severe (n of cases)
6Itchingdurationbeforediagnosis,Mean SD (days)

6Meancountoflesions/onecase SD

currently considered the treatment of choice in many countries,

having an excellent record for safety and low toxicity (16–18). In
Minimum:maximumdurationofitching (days)

a Cochrane review, it was concluded as the most effective

scabies treatment currently available (19), with excellent cure
rates ranging from 70% to 100%. (10,12,14,20–31).
Numberofpatientswith nodules

Failure with topical treatments including permethrin, resulting

in residual or new lesions, may be due to improper application,
T, B, U, L, Ex.
Parameters:

T, B, U, Ex.

missing some of lesions or may be a sort of reinfection or resist-

2rybacterialinfection

¼
Nodules
Papules

ance (9). In addition, permethrin efficacy as an ovicide remains

T, B, U
T,U, L

¼
T, U
T, B

unresolved, and therefore a more than one application to kill

¼
a
b

residual hatched eggs is prudent (32).

ANOVA test.

The drug is well tolerated, and safe in all cases ( 22). Rare
Chi-square

side effects of application of topical permethrin are erythema,

burning and muscle spasms, due to its effect on central nervous
test.

system especially in infants (33).

 JOURNAL OF DERMATOLOGICAL TREATMENT 477

Table 3. Parameters of efficacy of different drugs at days 7, 14 follow up.

Parameters of
efficacy Day Ivermectin Benzyl benzoate Permethrin Sulfur Total (n ¼ 200) p Valuesa
Number of patients D7 50 (100%) 50 (100%) 20 (40%) 50 (100%) 170 (85%) 0.000
presenting with D14 8 (16.0%) 16 (32.0%) 6 (12%) 26 (52.0%) 56 (28%) 0.000
Itching
Number of patients D7 10 (20%) 6 (12.0%) 2 (4.0%) 6 (12.0%) 24 (12%) 0.109
presenting with D14 10 (20%) 6 (12.0%) 2 (4.0%) 6 (12.0%) 24 (12%) 0.109
nodules
Number of patients D7 28 (56.0%) 26 (52.0%) 18 (36.0%) 38 (76.0%) 110 (55%) 0.004
presenting with D14 8 (16.0%) 10 (20.0%) 6 (12.0%) 24 (48.0%) 48 (24%) 0.000
lesions and having
positive microscopic
examination
Cure rate D7 22 (44.0%) 24 (48.0%) 32 (64.0%) 12 (24.0%) 90 (45%) 0.001
D14 42 (84.0%) 40 (80%) 44 (88.0%) 26 (52.0%) 152 (76%) 0.000
a
Chi-square test.

Table 4. Changes in lesion counts after treatment in relation with microscopic examination for mites, and percent decrease in the total counts of
lesions in comparison with the first visit.
Mean count of lesions Microscopic
(Burrows and papules)/one examination
case 6SD for mites Ivermectin Benzyl benzoate Permethrin Sulfur p Valuesa
D7b Residual Positive mite 7.5 6 1.6 5.53 61.45 4.2 61 9.57 63.25 0.00
Negative 4.68 6 2 4.09 61.68 3.1 61.15 5.3 61.15 0.00
New Positive mite 1.82 6 1.05 1.85 61.04 0.8 6 0.6 3.8 61.6 0.00
Negative 0 0 0 1.6 60.67 0.00
Total Positive mite 5.75 6 1.6 4.75 61.5 3.05 61.05 9.36 63.15 0.00
Negative 1.5 6 1.1 1.59 60.91 1.17 60.75 5.42 61.08 0.00
Mean % decrease in lesions 88.7 6 8 89.9 66 94 64 73 610 0.00
D14b Residual Positive mite 2.75 6 0.89 2 60.75 2 60.63 5.5 61.9 0.00
Negative 0.88 6 1.15 0.64 61.01 0.43 60.26 1.92 60.93 0.00
New Positive mite 1.25 6 1.04 1.37 60.52 0.83 60.41 1.25 60.61 0.48
Negative 0 0 0.023 60.15 0 0.47
Total Positive mite 4 6 0.92 3.37 60.74 2.8 60.98 6.79 62.2 0.00
Negative 0.88 6 1.15 0.64 61.07 0.46 60.66 1.92 60.93 0.00
Mean % decrease in lesions 95.9 6 4.9 96.8 64.1 97.6 63.5 86.7 68.9 0.00
aANOVA test.
bPost hoc analysis at days 7 and 14.

cPercent decrease equal (count at first visit – count of follow up visit) count of first visit 100.

The significantly higher cost of permethrin is a serious limita-
tion to increase its use (14). High costs can prevent patients
from completion of the treatment or prevent giving treatment for
con-tacts leading to reinfection.
Oral ivermectin has been introduced within the last decade
as an effective and cost-comparable alternative to the topical
agents in the treatment of scabies. It has been used extensively
and safely in the treatment of other parasitic infections. Some
studies con-cluded it is safe and effective in the treatment of
scabies (5,34–36) and comparable with permethrin. Its efficacy
rate ranges from (70% to 100%) for a single oral dose
(14,21,26,37–39). Treatment failure with ivermectin is due to
non-ovicidal action of the drug, leading to hatching of ova and
development of new generations of mites (10).
Several studies reported slower responses to ivermectin
com-pared with permethrin. Reasons for this could relate to the
rate of mite killing in vivo, the mechanism of action, or individual
differen-ces in the distribution and retention of ivermectin in skin
and tis-sues (40).
In the present study, only two cases in the ivermectin group
complained of nausea, which was not serious and did not affect
compliance. Safety of ivermectin has been documented in millions
of people with parasitic diseases with only transient and mild
adverse reactions included fever, headache, chills, arthralgia, rash,
eosinophilia, and anorexia. Ivermectin does not normally penetrate
the blood-brain barrier and consequently there is no risk of seiz-
ures; however, one recent report has indicated possible
neurotox-icity in the elderly. Because of limited safety data,
ivermectin should not be used in children younger than five
years of age or during pregnancy or lactation (38).
Beside its low cost, ivermectin has several clinical advantages
making it superior to topical treatment in developing countries. It is
safe, simple to administer, easily supervised and treats the entire
skin surface without neglected areas (35,41). Ivermectin is better
tolerated than topical treatment in those with excoriations or open
ulcerations. The drug has successfully been used for mass treat-
ment. It also has the additional benefit of reducing the prevalence of
other human parasitic infections common in the tropics, includ-ing
onchocerciasis, Ascaris infection, lymphatic filariasis, pediculosis,
cutaneous larva migrans and strongyloidiasis. Ivermectin is also
superior to topical agents in treating immunocompromised per-sons
with scabies (42,43).
The low cost, availability and the high cure rate induced by
benzyl benzoate, makes it quite a good alternative to permeth-
rin and ivermectin. It is a very popular treatment in Africa
including Egypt. There is a paucity of studies comparing differ-
ent treatment regimens for benzyl benzoate. One study con-
cluded superiority of topical benzyl benzoate for the treatment of
scabies than oral ivermectin (12). Other studies reported higher
efficacy of ivermectin in comparison with different
478 T. A. ABDEL-RAHEEM ET AL.

concentrations of benzyl benzoate at different weeks post treat-

Cost effectiveness to treat one case

ment (44,45). The main limitation of the drug is the immediate
local irritation (12,33). Otherwise, the drug is safe and is highly

Mean Cost for 100 case/number

recommended in diluted form for children, babies, and breast-

of treated cases (cure rate)

feeding mothers.
The low results of sulfur preparations as regard cure rate and

¼1782LE/88 20.25

¼1464LE/52 28.15
acceptability with higher cost exclude it from the list of drugs of

¼800LE/84 9.52
¼608LE/80 7.6
choice for scabies. The drug is still used in Africa and South
America (33), as it has low toxicity and its applicable to pregnant
women and children (7).
(LE)

Clinical trials reflect major differences in definition of cure. For

some, it is defined as absence of new lesions, whereas others
require complete disappearance of all lesions (32). In the present
study, microscopic examination was adopted to define cure, in
6Mean SD/1 case

conjunction with clinical examination, since the used drugs don’t

60.00
62.95
18217. 69.92

63.82
have any role in the resolution of lesions, they directly kill mites.
Once the mites are eradicated, signs and symptoms of scabies
gradually wane off (8). However, microscopy revealed low sensitiv-
8.00
6.08
(LE)

ity in comparison to clinical cure (3,46). The low sensitivity of

4

6
4
.

microscopy is explained by the low numbers of parasites in ordin-

ary scabies. Also, it depends on the number of sites sampled, the
in Egyptian

sampler’s experience, in addition to the clinical presentation since

10–32.408.
1.90–11.40

8.00–20.00
8.00–8.00
Min–Max
Cost Pounds

unscratched lesions are more valuable (46).

Relief of itching and nodules were not used in this study for
measurement of cure rate, as they may persist for long time due to
hypersensitivity to mite antigens including dead mites or excreta
Cost of a unit

which remained in the skin for long period even after complete cure
8.00
1.90
108.

(8,47,48). These cases need prescription of antihes-taminics or

2.
0
0

corticosteroids after killing mites by antiscabietic drugs for

completion of treatment (20,49). However, since itching forms a
major nuisance for patients, so the study was interested in show-ing
the efficacy of each drug on improvement of itching.
Acceptability(%)

Acknowledgements
100
96
80

This clinical has been registered at Pan African Clinical Trial

8
skin,burningsensation,stainingofclothes.

Registry (www.pactr.org) database, under a unique identification

number PACTR201505001116484.
Drug acceptability

Burning sensation

Dryness of

Disclosure statement
Table 5. Percent efficacy, acceptability versus cost effectiveness, of the four drugs.

Side effect
reported
Nausea

The authors report no conflicts of interest.

Null

Funding information
with side effects

This research was funded by authors themselves, and received

N of patients

support From Faculty of Medicine Fayoum University.

10 (20%)

46 (92%)
2 (4%)

0 (0%)

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