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CPS Position Statement

Anna Banerji; Canadian Paediatric Society, First Nations, Inuit and Métis Health Committee

Français en page 399

A Banerji; Canadian Paediatric Society, First Nations, Inuit and La gale

Métis Health Committee. Scabies. Paediatr Child Health
2015;20(7):395-402. La gale est une infestation cutanée contagieuse causée par un acarien.
Elle est responsable d’une morbidité importante dans le monde,
Scabies is a contagious skin infestation caused by a mite. It causes sig- puisqu’environ 300 millions de nouveaux cas se déclarent chaque année.
nificant global morbidity, with an estimated 300 million cases annu- Même si elle touche des individus de tous les milieux socioéconomiques,
ally. Although it can affect individuals at any socioeconomic level, les personnes qui vivent dans la pauvreté ou qui habitent dans des
individuals who live in poverty or in overcrowded conditions are at logements surpeuplés y sont beaucoup plus vulnérables. À cause de
much higher risk for scabies. Lack of local expertise can result in fail- l’absence de compétences locales, la gale risque de passer inaperçue, ce
ure to recognize scabies, leading to delayed diagnosis and inadequate qui peut entraîner un retard de diagnostic et un traitement inadéquat des
treatment of cases and contacts. Scabies disproportionately affects cas et des contacts. La gale est présente dans un nombre disproportionné
many Indigenous (First Nations, Inuit, Métis) communities where risk de communautés autochtones (Premières nations, Inuits, Métis) où
factors are present. Scabies risk is also higher in young children, the interviennent des facteurs de risque. Le risque de gale est également plus
elderly and immunocompromised individuals. Institutional outbreaks élevé chez les jeunes enfants, les personnes âgées et les personnes
of scabies have also been reported. Apart from a very itchy rash, sca- immunodéprimées. Des éclosions de gale se produisent également dans
bies can lead to secondary bacterial infections and related complica- des établissements fermés. À part un prurit intense, la gale peut susciter
tions, as well as to stigmatization, depression, insomnia and significant des infections bactériennes secondaires et des complications connexes,
financial costs. Topical antiscabies lotions are still the mainstay of de même que des préjugés, une dépression, de l’insomnie et des coûts
treatment, but oral ivermectin has also proven effective under certain financiers importants. Les lotions topiques contre la gale demeurent le
circumstances. Asymptomatic and symptomatic household members pilier du traitement, mais l’ivermectine par voie orale s’est révélée
should all be treated at the same time. In Canada and globally, the efficace dans certaines situations. Les membres asymptomatiques et
presence of scabies is usually a symptom of poor living conditions and symptomatiques du ménage doivent tous être traités en même temps. Au
a sign that basic necessities need improvement. Clinicians who work Canada et dans le monde, la gale est généralement révélatrice de
with Indigenous communities can improve their ability to diagnose pauvreté et de manque d’accès aux besoins de première nécessité. Les
and treat scabies, and should advocate for better living conditions cliniciens qui travaillent auprès des communautés autochtones peuvent
where scabies is prevalent. améliorer leur capacité de diagnostiquer et de traiter la gale et doivent
préconiser de meilleures conditions de vie dans les milieux où la gale est
Key Words: Crusted scabies; Indigenous communities; Infestations; répandue.
Norwegian scabies; Oral; Poverty; Pruritus

S cabies is a contagious skin infestation that affects an estimated

300 million people around the world every year.(1) While
scabies can affect people at all socioeconomic levels, individuals
scabies, delays in diagnosis and inadequate treatment of cases and
their contacts. A lack of clean running water may contribute to
secondary skin infections and related complications. Improving
who are young, elderly, immunocompromised or developmentally living conditions and enhancing local health expertise will help
delayed are at significantly higher risk for scabies and related com- reduce the burden of scabies in Indigenous communities.
plications.(2,3) Community-wide and institutional outbreaks(2,4)
have occurred in child care settings, long-term care facilities and Transmission and disease
prisons. Because scabies is associated with poverty, overcrowding, Scabies is the result of an infestation with a mite, Sarcoptes scabiei,
malnutrition and reduced access to health care,(3) some Indigenous that is transmitted by direct skin-to-skin contact.(2) Because the
and resource-poor communities are disproportionately impacted. mite can only live away from human skin for a brief time (typically
(5,6) In some remote Australian Indigenous communities, the 24 h to 36 h),(8) only limited transmission occurs through fomites,
point prevalence of scabies approached 50%.(7) such as clothing and bed linen. The female adult mite burrows into
Because scabies is not a reportable disease in Canada, the epi- the epidermis, depositing eggs over several days. The larvae hatch
demiology and real prevalence of this condition among Indigenous in approximately two to four days and take approximately 10 to 14
populations is not known. However, in the experience of health days to mature into adult mites.(3,8) The infected individual
professionals working with Indigenous communities, scabies results develops a hypersensitive reaction to the mite, its eggs or its feces,
in significant and under-recognized morbidity. Poverty, overcrowd- which usually occurs approximately three weeks after the first
ing, bed-sharing and families with many children are all factors exposure. With reinfestations, the immune response can be brisk,
that increase the risk of scabies spreading in some Indigenous com- even as soon as the day after reinfection.(8) The average adult
munities. A lack of local expertise can lead to failure to recognize infestation is approximately 10 to 15 adult female mites.(3)

Correspondence: Canadian Paediatric Society, 2305 St Laurent Boulevard, Ottawa, Ontario K1G 4J8. E-mail info@cps.ca, website www.cps.ca

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CPS Position Statement

The classic presentation of scabies includes burrows, erythema- due to hypersensitivity, itching may persist or even increase over
tous papules and generalized pruritus that is typically worse at several weeks despite killing the mites and is not by itself evidence
night. Burrows are usually located between the fingers, in the of persistent infection. However, the appearance of new lesions
flexure of the wrist, elbows or armpits, or on the genitals or breasts; should be considered as a sign of persistent infection and a signal
however, they can sometimes be difficult to find.(3) In infants and to retreat. Patients and their families should be warned of the pos-
elderly individuals, burrows may be found on the head and neck, sibility of persistent itching and an antihistamine or steroid may
and can manifest as vesicles, pustules or nodules. be considered as an adjunct to help relieve pruritus.(17) Secondary
Scabies is often confused with other pruritic rashes such as bacterial infections need to be treated with topical or oral anti-
eczema, impetigo, tinea corporis (ringworm) and psoriasis.(3) For biotics, depending on severity.
example, according to one study from Brazil,(9) 18% to 43% of Topical creams or lotions with 5% permethrin have low tox-
children diagnosed with eczema actually had scabies. Scratching icity and excellent results but are relatively expensive compared
frequently leads to secondary bacterial infections such as impetigo, with other treatments. A second treatment is usually given one
pyoderma with Staphylococcus aureus and group A streptococcus. week later to eliminate recently hatched eggs. Benzyl benzoate
Complications of bacterial infections include poststreptococcal (28% for adults, and 10% to 12.5% for children) has high efficacy
glomerulonephritis(10) and cardiac disease.(11) Furthermore, and a lower cost and is widely used outside of North America; it
scabies can lead to stigmatization, depression, insomnia, and sig- sometimes causes immediate skin irritation. Lindane (gamma ben-
nificant direct and indirect financial costs.(5,8,12) zene hexacholoride), an organochloride that has been withdrawn
Crusted scabies (Norwegian scabies) is a rare condition caused from the market in many parts of the world because of neurotox-
by the host response to control the mite, resulting in hyperinfesta- icity concerns,(18) is only considered when other therapies have
tion with millions of mites, severe inflammation and hyperkera- failed. Sulphur precipitated in petroleum jelly has been used safely
totic reaction.(13) Approximately one-half of patients with in young children and pregnant women, although its odour and
crusted scabies do not report itching. Crusted scabies can occur in messy application can compromise adherence to treatment.
immunologically normal hosts,(13) although it is more often asso- While oral ivermectin has been shown to be effective in circum-
ciated with immunodeficiencies such as individuals with HIV, stances described below, this medication is not available in Canada
human T-lymphotropic virus 1, leukemia, T-cell lymphoma or except through Health Canada’s Special Access Programme.
autoimmune disease, as well as developmental delay and malnutri- Ivermectin is a synthetic drug, which was discovered incidentally to
tion.(13) Crusted scabies is commonly misdiagnosed as psoriasis or have an impact on scabies during mass treatments for strongyloides
eczema, especially when a topical steroid has already been and filiariasis. Although 5% permethrin continues to have higher
used,(14) and is more difficult to treat than classic scabies. Because efficacy according to studies,(19) ivermectin has the advantage of
of the burden of mites (potentially millions),(15) crusted scabies is being administered orally as a single dose, making treatment easier
also more contagious than classic scabies and can cause significant in some settings. Oral ivermectin has proven effective in managing
outbreaks.(16) institutional or community outbreaks, with rapid reduction of sca-
bies symptoms.(20) It has also been used very effectively in manag-
Diagnosis ing crusted scabies, especially with recurrent disease, and often in
The clinical diagnosis of scabies is usually based on a history of combination with keratolytics (to break down the keratin in the
pruritic rash that is typically worse at night and present in charac- scales) or with topical 5% permethrin.(21) Ivermectin’s use for sca-
teristic locations, especially with similar symptoms occurring in bies remains off-label but can be requested under Health Canada’s
other household members. Although the presence of burrows Special Access Programme (www.hc-sc.gc.ca/dhp-mps/acces/drugs-
often helps to establish the diagnosis, these are infrequently seen. drogues/index-eng.php) for controlling outbreaks and crusted sca-
Other ways to make a definitive diagnosis for scabies include: bies therapy. Ivermectin is not approved for use in children weighing
• skin scraping (scraping an oil-covered scalpel blade across a <15 kg, or in women who are pregnant or breastfeeding. Topical
burrow and examining the sample microscopically), ivermectin may become a future treatment option but is not
• a burrow ink test (covering a lesion with ink and removing it licensed for scabies management at this time.
with alcohol leaves ink tracking in the burrows),
• dermatoscopy (direct visualization of magnified skin). This Scabies control measures
option is not practical in many locations, especially remote • Treat all symptomatic and asymptomatic household members and
communities.(3) close contacts with one of the therapies described in Table 1.
Treatment • To prevent reinfection, treat all household members and close
All household contacts, even those without symptoms, must be contacts at the same time as the known case.
treated simultaneously to avoid reinfestation and transmission. • All bed linen (sheets, pillowcases, blankets) and clothing worn
The main reason for treatment of household contacts is that sca- next to the skin (underwear, T-shirts, socks, pants) should be
bies symptoms can take several weeks to appear, especially in new laundered using a hot cycle wash and a hot drying cycle.
cases. In community-wide or institutional outbreaks, mass treat-
• If hot water is not available, put all linen and clothing into
ment should be considered. Typical treatment options for scabies
sealed plastic bags and store them away from household
are outlined in Table 1. Topical lotions are the mainstay of scabies
members and close contacts for five to seven days. The mite
treatment, although oral ivermectin has been used more recently
cannot survive beyond four days without contact with
in special circumstances.(17) First-line treatment continues to be
human skin.
5% permethrin cream or lotion, which is applied to the skin from
neck to toes, usually for several hours – often overnight – then • Children may return to child care or school the day after
washed off. For infants, apply lotion to the face as well. Some completing their initial treatment series.
products need to be reapplied after an interval of one to two weeks • By improving living conditions and building local expertise in
because they do not kill the mites’ eggs.(17) In general, a retreat- Indigenous communities, individual morbidity and the risk of
ment in seven days improves efficacy. It is important to note that scabies spread can be reduced.

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CPS Position Statement

Table 1
Scabies management in Canada
Treatment Application period Repeat Age restrictions Caution(s) Other comments
5% permethrin cream Leave on for 12–14 h, 7 days >3 months of age Consider as first-line
(Nix Dermal Cream*, followed by bathing treatment
Kwellada-P Lotion†)
10% crotamiton lotion/ 24 h May be repeated in 24 h; Skin irritation and contact Consider as second-line
cream (Eurax Cream) wash off 48 h after last dermatitis treatment
Sulphur (8%–10%) Daily for 3 No Safe in pregnancy Effective but not commonly
precipitated in petroleum consecutive days and for infants used due to messy
jelly (compounded) application and odour
Benzyl benzoate 28% 24 h May be repeated Caution in pregnancy Not available in North
in adults, 10%–12.5% 1 day apart America but widely
in children available elsewhere
1% Lindane cream Apply 8–12 h for adults, Only if new mites or Use with caution Associated with neurotoxicity, Consider as second-line
6–8 h for children, papules after 7 days in small children ataxia, tremors and bone treatment only
followed by bathing of treatment marrow suppression
Ivermectin (oral) for Single dose oral May need to be Safety not established Not licensed in Canada§
outbreak (Stromectol, 200 mcg/kg repeated in 2 weeks in infants <15 kg,
Mectizan‡) pregnant or lactating
Ivermectin (oral) for Single dose oral Multiple repeat doses Safety not established Not licensed in Canada§
crusted scabies 200 mcg/kg with keratolytics¶ and in infants <15 kg,
(Stromectol, Mectizan‡) consider combination pregnant or
with 5% permethrin lactating women
Read the product monographs before prescribing or applying any of these products. For information on coverage under Non-Insured Health Benefits Program, see
<http://www.drugcoverage.ca/en-ca/Federal-Plans/non-insured-health-benefits>. *GlaxoSmithKline, USA. †MedTech Products, USA. ‡Merck and Co, USA. §Need to
request through Health Canada’s Special Access Programme <www.hc-sc.gc.ca/dhp-mps/acces/drugs-drogues/index-eng.php>. ¶Keratolytics help remove keratin
to allow better penetration of topical medications

Other considerations see the Canadian Paediatric Society position statement

Scabies management must be clearly discussed with patients, their “Housing need in Canada: Healthy lives start at home”.
family and close contacts, as appropriate. Written instructions can • Help to lower infection rates through advocacy and education,
be helpful, especially when provided in a family’s native language. because scabies should be a relatively infrequent health
Be sure to inform the family that even with appropriate treatment, problem in a country such as Canada.
symptoms may persist for several weeks. For an asymptomatic con-
tact, explain that there may be a delay of three weeks between Acknowledgements: The present position statement has
infestation and the appearance of symptoms, making whole- been reviewed by the Infectious Diseases and Immunization,
family/household treatment necessary to prevent further infection Community Paediatrics, and Drug Therapy and Hazardous Substances
and spread. Committees of the Canadian Paediatric Society.

Future measures
The WHO considers scabies to be a neglected tropical disease
with considerable disease burden worldwide.(3,11) This designa- References
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• Engage in advocacy efforts to raise awareness of the link communities. Med J Aust 1994;161(10):636-7.
between scabies and substandard living conditions, and press for 8. Heukelbach J, Feldmeier H. Scabies. Lancet
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Members: Anna Banerji MD (past member); Roxanne Goldade MD (Board Representative); James Irvine MD; Radha Jetty MD;
Keith Menard MD; Sam Wong MD (Chair)
Liaisons: Halina Cyr, First Nations and Inuit Health Branch, Health Canada; James Jarvis MD, Committee on Native American Child Health;
American Academy of Pediatrics; Lisa Monkman MD, Indigenous Physicians Association of Canada; Melanie Morningstar, Assembly of First Nations;
Anna Claire Ryan, Inuit Tapiriit Kanatami; Eduardo Vides, Métis National Council; Cathy Winters, First Nations and Inuit Health Branch, Health
Principal author: Anna Banerji MD

The recommendations in this statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account indi-
vidual circumstances, may be appropriate. All Canadian Paediatric Society position statements and practice points are reviewed on a regular basis. Retired
statements are removed from the website. Please consult the Position Statements section of the CPS website (www.cps.ca) for the full-text, current version.

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