疥瘡

中國醫藥大學附設醫院
内科部感染科
何茂旺 醫師
 Outline

疥瘡的寄生蟲學

臨床圖片

治療

群突發的控制
 Scabies

Sarcoptis scabiei var. hominis

8 legs

female:0.4×0.3mm,
male:0.22×0.18mm

Two to three eggs daily and total
10-25 egg are laid by fertilized
female in burrows; after 72-84
hours larvae emerge and after 3
molts (8-10 days), leave the burrow
for surface and became adult mite
 Scabies

Fertelized female burrows
into epidermis to the level of
stratum granulosum

Feed by ingesting
intracellular fluids within
epidermis

Male die shortly but the
gravid female live for 4-6
weeks

Can only live 2-3 days away
from a human host
 Transmission

Spread under crowded
conditions such as in
hospitals, institutions,
child-care facilities and
nursing homes or
mother to infant

Direct, prolonged, skin
to skin contact
 Signs and symptoms of Scabies

Incubation period: 3-4 weeks vs. 1-4 days

Pimple-like irritations, burrows or rash of the skin,
especially the webbing of fingers, skin folds, penis,
breast.

Intense itching, esp. at night

A background eczematous eruption may be present and
is probably related to hypersensitivity.

Few than one hundred mites in healthy host.
 Norwegian Scabies

Scabies crustosa

Malodorous

Nail frequently involved

Tens of thousands of mites

Highly contagious

Risk factor (impaired cellular
immunity): AIDS, leprosy,
or lymphoma

Secondary staphylococcus
infections may cause sepsis
and death
Area of distribution
Hand and wrist: 63%
Elbow: 11%
Feet 9%
Genitalia 9%
Buttocks 4%
Axilla 2%
All the rest 2%
 Histopathology

Female mite may be identified within her tunnel in the
stratum corneum.

Simply a lymphocytic perivascular infiltrate, often rich
in eosinophils and often associated with an excoriation.

Nodular scabies show a deep and dense perivascular
infiltrate of lymphocytes, plasma cells, eosinophils and
atypical mononuclear cells.
Diagnosis

Discovery of burrows and
microscopic examination

Typical lesions on the penis
& nipples, the presence of
tunnel even without a mite
and interdigital lesions

Severe pruritus, esp. at night,
of short onset or in multiple
members of a living unit
 Scabies test

Look for a nonexcoriated papule

Place two to three drops of ink over the papules

Wipe the area with an alcohol prep

Place a drop of mineral oil on the skin

Scrape the area or pinch the area and superficially shave
the top layer of skin

Place the specimen on a glass slide, apply coverslip and
examine at 10x magnification

Female adult (0.4mm long), male (0.2mm long)
Clinical Picture
Abdominal scabies
Abdominal scabies
Hand Scabies
Trunk Scabies
Scabies Burrow
Scabies Burrow
Scabies Burrow
Web Scabies
Scabies at Glans
Scrotal Scabies
Hand Scabies
 Treatment

1% gamma benzene hexachloride (Lindane, Scabi cream), for
8-12 hours; not for young children, pregnant women, nursing
women due to neurological diseases and not shortly after a bath

Sulfur

Permethrin (5% dermal cream): for 8-12 hours, more effective
but more expensive

25% Benzyl benzoate emulsion for 24 hours

Crotamiton (10%): less effective

Ivermectin in single dose (200ug/kg); for crusted scabies: q2w
xII
 Lindane
(gamma benzyl hexachloride)

Mechanism of action/Effect:

A central nervous system (CNS) stimulant when absorbed
systemically.

stimulate the nervous system, resulting in convulsions and
death.

Dry the skin well before applying it.

Apply enough lindane to cover the entire skin surface
from the neck down, including the soles of your feet,
and rub in well.

Leave lindane on for 8 to 12 hours, then remove by
washing thoroughly
 Sulfur 6% in petrolatum

Precipitated sulfur 6% in petrolatum

The oldest known treatment of scabies.

Safe and effective and the treatment of choice in
infants <2 mo and pregnant or lactating women.

Sulfur is less acceptable to patients secondary to
its odor and messy application.

Apply topically to entire trunk and extremities
hs for 3 consecutive nights
 Permethrin

A neurotoxin that causes paralysis and death in ectoparasites.

It is the most common treatment used today for scabies.

Drug of choice (DOC), particularly for infants, young children,
and pregnant or breastfeeding women.

The lotion should be applied over the entire body, including the
face and scalp in infants.

Left on for 8-12 hours and then rinsed.

Reapplication one week later is advised; however, no controlled
studies exist that show that 2 applications are better than one.

No cases of scabies resistant to permethrin have been
documented.
 Benzyl benzoate (BB)

Action of mechanism: Unknown, may act on the nervous system of the
parasite, resulting in its death

Washing, rinsing, and drying skin well before using benzyl benzoate

Drying skin well if bath or shower is taken before use of benzyl benzoate

Cover entire skin surface from neck down, including soles of feet; rubbing in
well

Leaving benzyl benzoate on skin for 24 hours

Removing BB by washing thoroughly with soap and warm water

Rinsing thoroughly; drying with clean towel

Washing hands immediately after using to remove any BB that may be on
them

Repeating treatment for severe infestation
 Crotamiton 10% (Eurax)

Mechanism of action is unknown.

Associated with frequent treatment failures

Wash thoroughly and scrub away any loose
scales, apply thin layer topically from neck to
toes, gently massage into skin and leave on; a
second application should be applied after 24 h;
bathe 48 h after the last application
 Ivermectin

Veterinary anthelmintic and formerly restricted in
human medicine to tx onchoceriasis (nematodes)

Interruption of gamma-aminobutyric acid-induced
neurotransmission and invertebrates are selectively
paralyzed by the drug.

Half life: 16 hours

Currently use in tx of cutaneous parasitosis such as
cutaneous larva currens, cutaneous larva migrans and
human ecotparasitosis, mainly head lice and scabies
 Short-coming of permethrin and
lindane in an institutional setting

Understaffed

Difficulty in applying cream

Treatment-related dermatitis can be difficult to
distinguish from persistent scabies
Therapeutic Efficacy and safety of Ivermectin
and Lindane in the Tx of Human Scabies
Chouela EN et al. Arch Dermatol 1999;135:651-5

Design: randomized, prospective, controlled,

double-blind, double-dummy, and parallel
clinical study.

Patients: outpatients, hospitalized patients, and
thosed referred patients.

Intervention: Single oral dose of ivermectin
(150-200 ug/kg) or topical application of 1%
lindane solution. Repeated 15 days later if
clinically not cured
Therapeutic Efficacy and safety of Ivermectin
and Lindane in the Tx of Human Scabies
Chouela EN et al. Arch Dermatol 1999;135:651-5

Results:

43(19 vs. 24) /53 (81%) completed the study

At day 15, 14(74%) in ivermectin tx group were
healed, 13(54%) in lindane tx group were healed.

At day 29, 18 (95%) in ivermectin tx group and
23(95%) in lindane tx group were healed

Conclusion: Ivermectin is as effective as lindane
for the tx of scabies
Nosocomial Scabies in an extended
care Veterans Affairs Medical Center

Four nurse reported pruritic skin rash to IC officer

Index case: 76 y/o with CLL, Norwegian scabies

112 persons were affected during 3 subsequent outbreak

Control measures:

1% lindane or 10% crotamiton use qw x II

Contact isolation

Contacts, including household member and staff member undergo similar
treatment

Launder clothing and bedding in hot water after scabicide application

Active surveillance program for early detection

Am J Infect Control 1995; 23:44-9

 Eradication of Nosocomial Scabies
Category Cases Exposed Attack Control measures
rate (%)
Outbreak Staff 42 160 26.3 Lindane (1%) or
1 (Feb ’91) crotamiton (10%) t/u
Patients 22 255 8.6
x 2; close to new
admission; launder
clothing and bedding
in hot water scabicide
application
Outbreak Staff 10 67 14.9
2 (July ’91)
Patients 7 89 7.9
Outbreak Staff 7 110 6.4 Rotation of nurses was
3 (Nov ’91) suspended
Patients 8 163 4.9
Investigation: Identify index case; Determine personnel contacts; Dx of scabies
was made clinically by the presence of typical pruritic rash.

Jimenez-Lucho et al. AJIC 1995;23:44-9

 Scabies in Chronic Health Care
Institutions

Scabies in institution---Residents: 10/59; Staff: 16/34; Staff
relative: 7/15

Control measures: All residents, residents’ family members who
visited them and their families and staff and staff members’
families were treated.

Bath then 1% lindane from neck down for 12 hours then
another bath and the linen and clothing was changed again

All formites were changed prior to treatment

10% precipitated sulfur ointment was applied to Norwegian
cases for two 24-hour-applications 1 week apart.

Arch Dermatol 1992;128:1257-60

 Randomized Trials Assessing the
Effectiveness of Specific Drugs
Walker et al, Arch Dermtol 2000;136:387-9

Study No. D C DRR (95% CI) NNT (95%CI)

Schultuz, 1990 467 P L 0.01(-0.06~0.09) 73 (-16~11)
Amer & El-Gharib, 1992 150 P L 0.24(0.11~0.37) 5 (3~9)
Hansen, 1986 99 P L 0.02(-0.12~0.15) 55 (-9~7)
Taplin, 1986 52 P L 0.29(0.07~0.50) 4 (2~14)
Amer & El-Gharib, 1992 150 P C 0.10(-0.02~0.22) 10 (-56~5)
Taplin, 1990 94 P C 0.30(0.13~0.46) 4 (3~8)
Amer & El-Gharib, 1992 150 C L 0.14(-0.01~0.29) 8 (-89~4)
Macotela-Ruiz & Pena- 55 I P 0.64(0.44~0.84) 2 (2~3)
Gonzalez, 1993
Glaziou, 1993 44 I BB 0.22(-0.07~0.50) 5 (-16~2)
Chouela, 1999 53 I L -0.16(-0.38~0.16) -7 (-3~16)
P: permethrin; L: lindane; C: crotamiton; BB: Benzyl benzoate; P: placebo; C: comparison
 呼叫照護病房疥瘡群突發

民國92年10月24日感控小組接獲呼吸照護病房專
科護理師通報該單位有4名病患於手腳指縫出現皮
膚病變

10月底病患數增加至9位，且有5位護理人員有皮
膚疹且會劇癢，經診斷為疑似疥瘡感染

11月4日經感染科全面篩檢住院病患，共發現25位
病患疑似感染，其中一位經皮膚刮削確定為疥瘡
感染。

診斷主要依臨床症狀，接觸史，皮疹特性及所在
位置為診斷依據
受感染病患分佈圖
呼吸照護病房醫護人員與病患感染
疥瘡分析表
職業別 人數 感染個案 感染率(%)
住院醫師 1 0 0
護理人員(含護佐) 41 5 12.2
專科護理師 3 0 0
清潔人員 1 0 0
住院病患 40 25 62.5
呼吸治療人員 2 0 0
總人數 88 30 34.1
 感控過程

11月4日感染科醫師予以全面篩檢所有住院病患

於調查同時，即建議該單位採取各項防治措施，
包括工作人員照護感染病患時應採接觸隔離措
施，即穿上拋棄式隔離衣並戴手套，照顧病患前
後須徹底洗手，照顧另一位病患應更換隔離衣及
戴手套。

被感染之工作人員，接受治療24小時內不直接照
顧病患，治療後不可照顧未受感染之病患；若排
班困難，照顧病患時應穿上拋棄式隔離衣並戴手
套。
 感控過程

11月3日起至11月17日止所有工作人員不得輪值至
其他單位。

同時並限制訪客，家屬及訪客探視感染病患應穿
上拋棄式隔離衣並戴手套。

11月3日起至11月17日止被感染病患的衣物及被單
更換時，須以傳染性布單處理，即送高溫高壓滅
菌或密封靜置一週，另不可清洗之床墊建議擦拭
稀釋之漂白水或密封靜置一週。

被感染之工作人員衣服床單應與家人分開處理，
衣物與被單應使用50℃以上熱水清洗10分鐘或密
封靜置一週。
 感控過程

11月3日起至11月17日止每日由感染科醫師、感控
人員及單位護理長一起篩檢所有住院病患，觀察
有無新增個案。

本院治療藥膏有二種抗疥要膏，受感染之病患及
護理人員頸部以下予以Scabies (Lindane)
cream，懷孕之人員則投與Eurax藥膏治療。於11
月1日、5日、12日同時予以全面性投藥(包括：病
患及照顧家屬、醫師、護理人員、呼吸治療師、
專科護理師、洗腎人員)，建議投藥前應先幫病患
沐浴或擦澡。

予以全面性投藥同時，環境以稀釋漂白水噴灑消
毒並更換病患之衣物、床單、被褥及隔廉。
 所 全
有 面 疑似疥瘡個案追蹤結果分析
病 篩
患 檢
25

20 第 第 第
一 二 三
次 次 次
個 15
投 投 投
案 藥 藥
藥
數 10

0
1028 1031 1101 1104 1105 1106 1107 1110 1111 1112 1113 1114 1117 1118 日 期
RCW疑似個案追蹤(11月17日)結果
RCW疑似個案分析
20%

皮膚診未消失
已緩解個案
80%
皮膚診已消失
個案
 Control Measure

Use medication as directed.

Notify and treat all partners and household members.

Abstain from intimate or sexual contact until treatment
is completed successfully.

Wash infested clothing and linen on the hot cycle
setting. Dry on hot cycle for at least 20’.

Infested articles that cannot be laundered may be dry-
cleaned or placed in a bag for 2 weeks.
 感染管制：
感染管制：病患方面

應採接觸隔離(contact isolation)。

單獨房間：當病患衛生習慣不好時，則需要
單獨房間。

隔離衣：與病患密切接觸時，則需要穿上隔
離衣。

手套：與病患密切接觸時，則需要戴上手
套。

隔離期間：有效治療後二十四小時內。
感染管制：
感染管制：工作人員或其他人員

工作人員照護病患時，應採接觸隔離，集中護理，以減少接觸
疥瘡病患機會。

工作人員照顧病患前後須徹底洗手。

被感染之工作人員在接受治療24小時內不宜照護病患；若排班
困難，照護病患時應穿戴隔離衣及手套。

住宿之工作人員，請勿接觸他人之衣物與床單。

工作人員之家裡或宿舍，其衣物與被單類應以熱水消毒或用袋
子密封靜置二星期。

流行期間應限制家屬及訪客探視時間。

家屬與訪客探視病患時，應穿上隔離衣及戴手套。

流行期間曾接觸疥瘡病患之工作人員(含醫生、護理人員、行
政助理、護佐、家屬)應預防性用藥。

在職教育，包括醫護工作人員、病患家屬等。
 感染管制：
感染管制：用物之處理

病患的衣物及被單更換後，應將衣物及被單
以傳染性布類處理。

衣服及被單應用攝氏50度以上熱水清洗十分
鐘或高壓蒸氣滅菌。

病患之床墊、毛毯等可密封靜置二星期。

傢俱、環境可用消毒劑清潔。
敬請指教