Scabies Lice & Bedbugs !

Scabies
Lice &
Bedbugs !
Tor Shwayder, MD
Director, Pediatric Dermatology
Henry Ford Hospital
Detroit, MI 48202

No conflict of interest
Please turn cell phones to stun

Scabies are species specific
Species specific
– “var. Hominis” = Humans
– Can’t blame the dog
– Scabies from other animals only transient
infections in humans
– One of the causes of “mange” in animals

Scabies, When do you itch?
10 - 30 days after infection
Probably need critical mass of mites to
trigger immune response
Nota Bene:
– Can be a month between infection and itch

10 - 30 Days Until Itch Begins
“Is anyone else itching at home?”
This question does not always help you!

Scabies Facts of Life
Females 0.4mm x 0.3 mm
Burrows 2 mm a day in upper epidermis
Lays 2-3 eggs/day
Lives about a month, then dies
Males die after copulation
How was it for you, Dear? ….. AHHHHHhhhhhhhhhhh

Scabies - Clinical Signs
“Classic” signs
Papules burrows in
– Web spaces
– Palms
– Wrists

Scabies -
Clinical Signs
Can involve FACE
– Old literature says it
does not. This is
simply not true
Common
presentation: The
vague “all overs”

Scabies -
Clinical Signs
Classic picture
Nodules in Axillae
Nodules on Penis
Scabies until proven
otherwise!

Scabies - Clinical Pictures

More Scabies Pix

Still More Scabies Pix
6 month Guatemalan Child

Clinical Distribution Percentages
D Taplin & T Meinking Pediatric Derm 7:1, March 1990

Nipple Scabies
Women
– Palms
– Nipples

Male Scabies
Men
– Penis
– Glans
– Scrotum
Burrows on the
glans a sure sign of
scabies

Scabies - A Caveat
Clean people - Hard to fine scabies
– Physical act of scrubbing removes the mite
– Total population 11-12 mites/human

The Scabies Prep - Easy to Do!
Apply oil
Gently scrape 15 blade
Center on a glass slide
Observe at low power

The Scabies Prep - Microscopic
Newborn scabies!
Scabetic Feces and One Egg

Scabies Microscopic Continued

Scabies, Oil Prep, Low Power

Treatment Options - Main Ones
Lindane
Permethrin

Lindane
1% solution or cream
Safe if used as directed
Apply once to cool dry skin bedtime
Wash off in a.m.
Do not repeat

Lindane Caveats
It is a toxin
Almost all adverse cases reported were:
– Misuse
– Repeated use
– Oral use!
– Agricultural concentration (>1%)
I do not use it on premie babies
I no longer use it less than 90 lbs children
– Because of AAP edicts
I do not use it on erythrodermic pts
It is my SECOND line drug now

Permethrins My First Line Drug
Pyrethroids a flower
derivative. Usually
“synergized” w/ PBO
Permethrins
synthetic derivative
– Much more effective
than the natural
extract

Permethrins (Elimite®)
5% cream
No toxicity reported
Stinging sensation common
Safety tested down to 2 months age
– I use it from zero on up

Treatment options - Old Ones
Sulfur
– Been around for thousand years
– No one will sue you over it
– Stinks!
– Have to leave it on for three days
– I use it on pregnant lawyers

Sulfur - Balsam of Peru
Concoction
Sulfur ppt. 12 %
Balsam of peru 8%
Castor oil 4%
Petrolatum Alb qsad 100
Balsam has benzoyl compounds
Castor oil prevents “blackening” of balsam

Benzyl Benzoate Solution
Benzyl Benzoate
– Works, cheap, Rest of world uses it

Benzyl Benzoate in Bangladesh
Entire villages
Bathed and
scrubbed
Worked great!
20-35% emulsion if
applied as a topical
Tropical Doctor Jan 1984 14:41

Treatment Options - Old Ones
Crotamiton (Eurax®)
– Does not work
– Don’t bother using it.

Treatment Options - New One
Ivermectin
– Oral
– Topical (near future)

Ivermectin - New treatment
Used for River
Blindness
Now used orally for
scabies in AIDS pts
Used orally for
Norwegian scabies
Used topically
outside the USA
1% solution

Oral Ivermectin for
Norwegian Scabies
11 year old
Columbian girl
Treated single dose
200 micrograms/Kg
orally
Arch Derm Feb 1998 Ivermectin for Crusted Norwegian Scabies

Norwegian Scabies

Treating Scabies- The Right Way
Make sure of your diagnosis
– Not all itchy people have scabies
– Not all scabies cases itch
– Do not guess, do a scraping

Treating Scabies- The Right Way
-2-
Treat the index case head to toe
Do not forget to treat:
– Scalp (use shampoo based Rx)
– Face and neck
– Under nails
– In all folds
– In the groin recesses

Treating Scabies- The Right Way
Apply before bed
-3-
Rinse off medicine in the morning
Treat all skin to skin contacts at same
time
Repeat index case in one week
(optional)
No need to retreat contacts

Treating Scabies- The Right Way
-4-
Treat everyone in the same household
at the same time
Only way to make sure not missing a
carrier who is not itching

Treating Scabies- The Right Way
Post Scabetic Eczema
Most cases continue to itch
Itching can last 2-4 more weeks
This is post scabetic eczema
Treat with 1% or 2 1/2% Hydrocortisone
cream BID
Tell patient not to panic
Tell patient not to retreat with scabecide
on their own

Treating Scabies: What do I
Mean by Skin-to-Skin Contacts?
Scabies spreads by skin to skin contact
One caveat: can spread if sleep in same
bed as index case without skin to skin
contact

Skin-to-Skin Contacts
Primary:
– Spouses
– Siblings
– Baby sitters
– People who hug, fondle, hold index case
Secondary
– Kids in same classroom, party
– Grandparents
Depends on “Cool” vs “Warm” personality

Lindane Caveats -2-
Will probably become THIRD line
After Permethrins & Ivermectin
When topical Ivermectin arrives

Nursing Homes
Make sure of diagnosis
Must treat entire cutaneous
surface
Treat all skin-to-skin
contacts
– Can be difficult to ascertain
People usually “forgotten”
– DOCTORS!

Scabies -
Treating the Environment
Wash all clothing that was worn before
treatment
Wash all bedding
If can’t wash it:
– Put it someplace hot & dry for a week
– Or
– Put it in the dryer on high for 20 minutes

Scabies -
Treating the Environment -2-
NO need to spray “bomb” home
NO need to spray furniture
Scabies cannot live off of humans for
more than a few hours

Scabies - ?Resistance?
NO well documented cases of scabies
resistant to our chemicals
NO outbreaks in defined geographical
areas unresponsive to a given chemical
Literature on this very bad
– Poorly written
– Poorly documented (i.e. no microscopic)
– Incompletely treated primary cases
– Contacts not treated

Scabies - Final Words
Be prepared
All parents FREAK
OUT!
Hands outs needed
Be flexible to see
possible contacts
No one sleeps until
they are checked

One Last word
Please do not
Treat first without doing a scabies prep
– Like the joke about the surgeon going duck
hunting
It shows bad thought process to treat for
unproven scabies, then see the patient
back and ask if the itching went away
– Let the non-thinking docs do this

Head Lice
True insect
Order: Anoplura
Three body parts
Six legs
Sucks blood for a
living

Pediculosis Capitis
Suck blood q 4-6 hrs
Copulate
Lay 5-10 eggs/day
Live about a month
Schachner & Hansen 2nd Ed 1998
Fomite transmission in head lice. Burkhart CN, &
father. JAAD 2007 v56 n6 June pp1044 - 1047

Can’t live without us!
Lice rarely live more
than 36 hours
without a blood meal
Nits can survive up
to 10 days in right
conditions
– 28 - 32 C
– 70 - 90% humidity

Nits
Laid close to scalp
for warmth
Usu w/i 1 cm
Warm climates
viable nits up to
15cm away
Esp nape of neck

Nits, Inc.

Pubic louse
Has serrated edge on
tarsal claw of first leg
Adapted to movement
of host skin rather than
hair
Also adapted to coarser
hairs more widely
spaced
Allows migration trunk,
legs, armpits, beard,
scalp, eyelashes and
eyebrows.

Pediculosis Capitis - Diagnosis
Observing the louse
Seeing nits
Tips
– Itchy scalp (esp. occiput)
– Excoriations nape of neck
– Recurrent impetigo nape of neck
– Lymphadenopathy around occiput

Seeing the nit move
Very difficult. Live move quickly away
from any disturbance
Wetting hair first slows them down
Same color as hair usually

Lice can FLY!
Airborne with
hairdryers!
Static electricity
– can eject an adult
– louse up to a meter!
-Takano-Lee M, et al. Int J Dermatol 2005;44:811-6-
Burgess IF. Human lice and their management. Adv
Parasitol 1995; 36:271-342

Lice Transmission
Direct head-to-head contact
Fomite
– Combs
– Brushes
– Blow-dryers
– Hair accessories
– Bedding
– Helmets and other head gear
Burkhart & Burkhart JAAD June 2007

Lice on a helmet…
Lice can survive up to 3 days
– In right circumstances
Nits can survive up to 10 days
Remember this next time they offer you
a hair net to go under your rental helmet
:-)

Watch when you comb out the
lice…
Vigorous combing of
child’s hair leaves
lice on you too!!
Hunting for head lice
Ter Borch. Muritshuis Hague

Lice Transmission
Lice remain on towel after drying hair
27% of lice transferred from hair
wristlets to adjacent fabric w/i 5 min
– Hand held vacuum failed to remove lice
– Carpet vacuum was able to.
Takano-Lee, M et al. Transmission potential of
human head louse. Int J Derm 2005;44:811-6

Head Lice -
Rx Treatment Options
Permethrins
Pyrethroids + PBO
Malathion
Lindane
Near future
– Ivermectin

Head Lice - NON-RX
Treatment Options
Frequent combing
– “Bug Busting”
Occlusives
Oral Bactrim ®

Comparative Efficacy
Update 2000
Tropical field station in Panama
– Niadup Island, Kuna Indians
Same group: Terri Meinking et al.
Re-evaluation of same pediculocides
plus NIX
Arch Derm 137:287, March 2001

Comparative Efficacy
Update 2000 -2-
Rx used a lot in the past had poor performance:
– Lindane
Rx never used had great performance:
– NIX and Malathion
T. Meinking et al. Arch Derm Mar 2001

Comparative Efficacy
Update 2000 -3-
Resurrection Effect!
RID (synergized natural pyrethrin)
– At 30 min 75% lice appeared dead
– At 3 hours 53% were dead
RID was reformulated in between 1986
and 2000
T. Meinking et al. Arch Derm Mar 2001

Comparative Efficacy-Nits
Lindane only 24% ovicidal activity
T. Meinking et al. Arch Derm Mar 2001

Comparative 1984-2000
T. Meinking et al. Arch Derm Mar 2001

Malathion
Organophosphate
pesticide.
Irreversible
cholinesterase
inhibitor
Works great
because not been
available here in
USA

Head Lice Treatment -1-
Make the correct diagnosis
Use the medicine as directed
Repeat in one week - definitely
– Because of residual nit hatch rate
Remove all nits
Treat all positives in the home

Head Lice Treatment -2-
Check playmates
Wash contact clothing
Vacuum beds
Vacuum areas of scalp contact
– Backs of chairs
Clean or dispose of combs & brushes

Head Lice Resistance
A Real Problem
Anytime insecticide used in given area
Resistance develops
Happens all over world
The chemical most used in one area
selects for resistant clones
Most recently in USA:
Permethrin resistance

Oral treatments?
Septra/Bactrim in otitis media doses
Theory
– Lice swallow bactrim with the blood
– Kills gut bacteria in the lice
– Lice need gut bacteria to live
Anecdotal reports

Nit Combs
16th century 20th century

Other Lice Treatments
Shrink wrapping them
Dehydrating them

Dehydrating Lice
Dehydrates lice
– Not a toxin
– 80% isopropyl
myristate
Launched Britain
2005
– “Full Marks Solution”
Canada Fall 2006
– “Resultz”

Suffocating Lice

“Drowning” Lice
Ulesfia Lotion
5% benzyl alcohol
Two treatments @
10 minutes
One week apart
Claim 100% cure
rate
Meinking T. Clinical Trials. Poster
SPD Summer 2009

Ulesfia Lotion
(5%Benzyl Alcohol)
Lice 7 pairs
breathing spiracles
These close in water
– Permit lice to survive
many hours
Benzyl alcohol
“stuns” spiracles
open
Allows mineral oil
vehicle to
asphyxiate the lice

Reasons for Lice Treatment
Failures
Make the correct diagnosis?
Repeated Rx in one week?
Avoided cream rinses?
Removed all nits?
Checked all contacts?
Washed contact clothing/linens that may have hairs
on them?
Discarded combs/brushes

Not Head Lice
Pediculosis Pubis
Groin
Also:
– Axillae
– Eyelashes
– ANY hairy area!

Treating Eyelash Lice
Petrolatum occlusion
Physostigmine ophthalmic ointment
Yellow oxide of mercury ophthal. oint.
Manual removal

Pubic Lice
Usually groin
Can live elsewhere
MUST check all other hairy areas!

Three
Blind
Lice

Bed Bugs!
Thanks to Susan C Jones, PhD. Assoc Professor
OSU Extension Entomology Department

Cimex Lectularius
External parasite
Blood feeder
Usu at night
Prefer humans
Did you spot the nymph yet?

Bed Bugs
Alternate hosts
– Rodents
– Bats
– Birds
– Pets (cats, dogs)

Bed Bugs Good Hitchhikers
Can be moved /hide
via:
– Luggage
– Furniture
– Bedding
– Backpacks
– Purses
– Clothing

Hotels, Dorms, Shelters, Apts,
Planes, Buses, Trains, Ships…

Dayton Daily News July 2009

How to spot a bed bug
Oval shaped
Flattened body
– Swells with blood
Beaked shaped
mouth
Adults 1/4-3/8 inch
Young nymphs are
tiny (

How to spot a bed bug -2-
Very young nymphs
– Almost colorless
(unfed)
– Crimson w. blood
Older nymphs/adults
– Various shades
brown (unfed)
– Red-brown w blood

Developmental Stages
Eggs
– 1-12/day/female
– Glued in place
– Hatch in 6-17 days
Nymphs (immature)
– 5 nymphal stages
– Require blood meal
to grow

Developmental Stages -3-
Adult Bedbugs
– Can live 12-18 mon
– Can survive months
without a blood meal!

Bedbug Developmental Cycle
Total developmental
time egg to adult
21 days @86 F
120 days @ 65 F

Bedbug Comparative Size

Bedbug Bite
Bite is painless
Some - no reaction
Some - allergic
– Swelling, welts, itch
Scratching -
– Secondary infection
No evidence
disease spread
From a 4 star Copenhagen Hotel!

Bed Bug Bite
Sometimes in
groups or in a row
On exposed skin
Resemble other
insect bites
Confirm by finding
evidence of bedbug
infestation

“Injury” from Bed Bugs
Sleepless nights
Agitation
Anxiety

Bed Bug Movements
Cannot fly, Can walk very fast
Can cling tightly to surfaces

Bed Bug Hiding Places
Hide in the day
Like to hide in dark, protected sites
– Esp cracks and crevices
Prefer fabric, wood and paper surfaces

Bed Bug Hiding Places -2-
Matress, box
springs
Bed frame
Furniture in room
– Bed Side Desk
– Dresser Drawers
Carpet tack strips
Baseboards

Bed Bug Hiding Places -3-
Widow frames and door frames
Electrical outlets and switch plates
Wall hangings
Drapery pleats
Peeling wallpaper
Ceiling moldings
etc

How to Prevent Bed Bugs
Recognize them
Don’t bring them home!

Recognize Bed Bugs
Black fecal spots
Shed skins
Eggshells
Live bugs
Blood stains
Welts/bites on
human skin

Don’t bring them home!
Inspect secondhand
– Beds
– Furniture
– Clothing
– Mattresses
Inspect clothing and luggage of
travelers visiting your home

Prevention for Travelers -1-
Check hotel rooms for bedbug signs:
– Pull back bedding, mattress, box springs
– Carefully examine underside of bed skirt
– Look for signs along bed frame
– Open night stand drawers look along
inner/outer edges
– Look along baseboards

Prevention for travelers -2-
Keep clothes in your zipped suitcase
Do not keep them in hotel chest of
drawers
O.K. to hang in closet
Keep your suitcase on luggage rack
Do not store suitcase on floor, bed, or
upholstered furniture

Ridding your home of Bed Bugs
Correctly identify the pest
Use sanitation measures
Apply insecticides to correct areas

Step 1
Remove clutter
Clutter provide hiding places
Clutter makes finding the bugs difficult
Clutter makes treating the bugs difficult

Step 2
Launder bedding, clothing
Wash hot water (>120 F)
Drier on hot setting (>15 min)
Dry clean other items
Bag items after they are inspected and
laundered, and seal the bags

Step 3
Vacuum Thoroughly
Use high efficiency particulate air
filtered vacuum
Heavy duty vacuum for cracks and
crevices
Vacuum prior to chemical treatment
Throw out bag immediately
Don’t share your vacuum

Step 4
Encase mattresses and box springs
Use specialized plastic encasements
This traps the bugs to starve them out
May take a year!
Restricts bug activity to outside of
mattress easier to spot
Keep zipper closed, check for tears

Step 5 -
Insecticides for Mattresses
Steri-Fab ®
– Phenothrin w isopropyl alcohol & synergist
– Kills on contact
Bedlam®
– Active Ingredient: 3-Phenoxybenzyl-2, 2-dimethyl-
3-cyclopropanecar boxylate- 0.40%, N-Octyl
bicycloheptene dicarboximide- 1.60%
BenzaRid® Spray
– Benzalkonium chloride

What about DEET?
DEET has not been shown to repel bed
bugs
Susan C Jones PhD - OSU Extension Entomology

Step 6 - The Furniture
Infected furniture can be treated
Do not throw away furniture
– If bed bugs still around, they simply climb
back inside new furniture

Of Note
Do not apply insecticide to
– Human skin
– Clothing
– Bed linens
– Bedding
These are all treated by washing

What about bug bombs?
Bug bombs do not
work
Only those bugs out
in the open will be
killed
Those hiding will
simply scatter to
other rooms
Worsens problem!

What about grocery store sprays?
Would need to spray
bugs directly
Most bugs are
hiding
Have little to no
residual activity

The End
Good Night, Sleep Tight, and
don’t let the bed bugs bite!