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Insect bite infestations

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 Chapter 21

Insect Bite Infestations

Rama Jayaraj, PhD* • Shelley F. Walton, PhD† •
Deborah C. Holt, PhD‡ • Kabir Sardana, MD, DNB, MNAMS§

SCABIES by direct, close contact with an infected person,

although transmission by fomites is possible.
Scabies is an ectoparasitic skin disease caused by the
burrowing itch mite Sarcoptes scabiei var hominis. CLINICAL FEATURES Patients of all ages may
be afflicted. However, children are commonly
affected. It occurs equally in both sexes. The clinical
AETIOLOGY The major factors that contrib-
features are as follows:
ute to the spread of scabies are poverty and over-
crowded living conditions. In developed countries, • Generalised pruritis occurs which is often more severe
outbreaks of scabies commonly occur in hospitals, at night.
kindergartens and old age facilities. • Papular or vesicular lesions are seen in the vicinity of
The female Sarcoptes mites burrow into the burrows which in some cases become pustular or bul-
stratum corneum and lay two to three eggs per lous (Fig. 21.1).
day, for up to 6 weeks at a time, resulting in raised
papules on the skin surface. The female mite does
not penetrate deeper than the S. granulosum. The
developmental stages of the mite include egg, larva,
protonymph and tritonymph. Adult mites emerge
after approximately 2 weeks. The average burden
on a normal host is 10–12 mites.
Some authors have reported fluctuations of
scabies every 7 years (scabies is also termed ‘7-year
itch’). Some studies have suggested that there is a
higher incidence during the winter months as colder
weather encourages overcrowding in human beings.
The mites might also be sensitive to antimicrobial
peptides in human sweat, leading to reduced infes-
tation in summer.
Crusted scabies is a more severe form of infes-
tation and is also known as Norwegian scabies. It
occurs in the immunocompromised patients (HIV Figure 21.1 The interdigital area is dominated by linear
infected, especially), those with decreased sensory papules and burrows and because of
function (e.g. people with leprosy), and institu- constant scratching, the classic burrow is
tionalised patients. Transmission of scabies occurs rarely seen.

* Lecturer, Tropical and Emerging Infectious Disease Division, Menzies School of Health Research and School of Environmental and Life
Sciences, Charles Darwin University, Darwin, Australia.
†Associate Professor, School of Health and Sport Sciences, University of the Sunshine Coast, Sippy Downs, Queensland, Australia.
‡Senior Research Officer, Skin Pathogens Research Laboratory, Menzies School of Health Research, Institute of Advanced Studies,

Charles Darwin University, Darwin, Australia.

§Associate Professor, Department of Dermatology and Nodal Officer STD (Regional STD Centre), Maulana Azad Medical College and

Lok Nayak Hospital, New Delhi, India.

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Figure 21.4
Figure 21.2 Urticarial lesions on the abdomen.
• Generalised itchy papular eruption/skin rash is com-
monly seen around the axillae, the peri-areolar regions,
abdomen, buttocks and thighs (Fig. 21.2).
• Symptoms in children follow a pattern similar to that
in adults. However, the face, neck, scalp, palm/soles
(Fig. 21.3) and the post-auricular folds are more often
involved in children.
Clinical Types
1. Ordinary scabies
• Ordinary lesions of scabies are seen in the webs
of the fingers, the volar aspects of the wrists and
2. Norwegian or crusted scabies
arms, the extensor aspect of the elbow, periumbili-
cal skin, pelvic girdle including buttocks, ankles
Figure 21.3 Papules on the palm.
M21_WK_XXXXX_C21.indd 501
Insect Bite Infestations „ 501
Secondary infection and eczematisation
superimposed on the classic findings of
scabies.
and the penis in males and the peri-areolar region
in females (Figs 21.1–21.3).
• Chronic excoriation and eczematisation
(Fig. 21.4) of the skin is frequently observed in
patients with long-standing infestations.
• The majority of the patients complain of an
intense itch, especially at night and after a hot
shower. This has been associated with a hypersen-
sitivity reaction to the excreta that the mite depos-
its within the burrow.
• This can be attributed to immunosuppression
(such as topical or systemic glucocorticoid ther-
apy, HIV, human T-lymphotropic virus 1 (HTLV-
1) infection, organ transplant patients), mentally
retarded and physically incapacitated patients.
• Hyperkeratotic skin crusts are either loose, scaly
and flaky, or thick and adherent.
• The lesions of this severe form (Fig. 21.5)
can either be distributed all over the body or
(Fig. 21.5) localised in the neck, scalp, face, eye-
lids, legs, feet and the area under the nails.
• Mites are commonly found beneath the nails of
affected patients, and in crusted scabies, this can
result in thickened dystrophic nails. In ordinary
scabies, the distal ends of nails may harbor scabies
mites, where they are protected from topical treat-
ment. However, in crusted scabies, larger popula-
tions of mites may cause subungual hyperkeratosis
and longitudinal splitting of the nail. Untreated
nails can act as a reservoir of infection, resulting
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 502 „ Insect Bite Infestations

Figure 21.5 A case of Norweigian scabies with

erythroderma and involvement of the web
space of the hand. (Courtesy: Dr. Chander
Grover Kubba )

in treatment failure with recurrence of symptoms Figure 21.6 Scabeitic nodules on the scrotum.
months later.
• Generalised adenopathy and eosinophilia are
present in some cases.
DIAGNOSIS
• Due to an altered immune response in immuno- Laboratory and Special Examination Microscopic
compromised subjects, the itching is less intense identification of mites, mite parts, eggs, egg shell
or absent in these subset of patients. This occurs fragments or faecal pellets of mites from skin
also because they have physical limitations, lack of scrapings, is confirmatory for diagnosis (Fig. 21.9);
control or unawareness of the defensive scratch- however, the sensitivity of this test is less than 50%.
ing movements, as in neuropsychiatric disorders,
The diagnosis becomes difficult in patients who have
osteoarticular deformities, muscular atrophy or
other neuromuscular problems. Sometimes, it is
associated with loss of sensation and hypoesthe-
sia. These patients are highly infested with mites.
3. Nodular scabies
• Violaceous, pruritic, nodules are seen on the
glans, scrotum, thighs, buttocks and axilla
(Figs 21.6 and 21.7). Mites cannot be recovered
from these nodules.
• It is believed that this represents a form of hyper-
sensitivity reaction to mite antigens.
4. Vesicular–bullous scabies
• It is commonly seen in elderly patients and is located
on the extremities or on the trunk (Fig. 21.8).
• It clinically and histologically mimics bullous
pemphigoid.
• It may result from super infection with Staphylo-
coccus aureus, with a mechanism similar to the
development of blisters in bullous impetigo.
• This condition is mainly due to the penetration
of the mite in the dermo-epidermal junction, or
a cross-reaction with bullous pemphigoid antigen
or lytic secretions produced by the mite at the der-
moepidermal junction. Figure 21.7 Multiple nodules with eczematisation on the
5. Other minor variants: These are discussed in Table 21.1. scrotum.

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 Insect Bite Infestations „ 503

Figure 21.9 Examination of skin scrapings from patients

Figure 21.8 Bullous lesions with crusted papules. of scabies and the observation of mites
under the microscope (40×).

severe hypersensitivity reactions that result in the
development of multiple excoriations or plaques.
In this situation, a biopsy or the examination of
scrapings obtained from the papules–vesicles may
be helpful. The burrows may be demonstrated in
these cases with the help of stains such as India ink
or gentian violet.
Epiluminescence microscopy and high-
resolution video dermatoscopy allow comprehensive
examination of the patient’s skin, from the surface
to the superficial papillary dermis. This equipment
is expensive and is available only in well-resourced
hospitals or clinics.
The latest test is the detection of the DNA of
S. scabiei from cutaneous scales based on ampli-
fication by polymerase chain reaction (PCR)
or detection by enzyme-linked immunosorbent
assay.

Table 21.1 Minor Variants of Scabies

Types Clinical features Comments

Scabies incognito • This is consequent to topical application of
corticosteroids. It is less itchy
Scabies in infants and • Vesicles, pustules and nodules
young children • Sites: hands, feet and body folds
Scabies in elderly • Senile itch or bullous lesione
Scabies of the scalp • Seen in elderly, children, infants,
immunosuppressed patients and patients with
crusted scabies
Subungual scabies • Persistent nail plate dystrophy. The nails may have
a thickened, whitened appearance with or without
nail plate deformity and/or subungual horny debris
Canine scabies • Site: Forearms, thighs, chest and abdomen
• Onset: Within 24–96 h after contact with the
infected pet
• Course: Self-limited, lasting an average of 5–13 wk
• Hypereosinophilia in the presence of
mild reduction of immunity
• A dense Langerhans cell infiltrate may
be present in histological sections
• Frequently misdiagnosed
• Cutting of the nails prevents both the
condition and the relapse
• The pet is easily recognised because
it presents with patches of hair loss
and/or scratching. Treatment of the
dog is required

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 504 „ Insect Bite Infestations
TREATMENT The treatment options can be
classified according to the evidence-based approach
as follows:
1. Randomised controlled trials: These are available for
comparison between the effects of the following drugs:
• Ivermectin versus benzyl benzoate
• Ivermectin versus permethrin
• Ivermectin versus benzyl benzoate
• Permethrin versus crotamiton
2. Case series: These are available for the following
therapies:
• Benzyl benzoate
• Permethrin
• Ivermectin
• Permethrin versus lindane
3. Case reports: These are available for the following
therapies:
• Pimecrolimus
• Monosulfiram
General Measures Washing bed linens and cloth-
ing is highly recommended. This can be performed
by machine washing at 60°C followed by heat dry-
ing. Unwashed clothes can be stored in a bag for a
minimum of 3 days as mites do not survive for more
than a few days after isolation from human host.
Exposing mattresses to direct sunlight can also be a
useful technique. Vacuuming is also beneficial.
Drugs Used in the Treatment of Scabies The
major factors that determine the suitability of dif-
ferent scabicidal drugs for patients are the age of the
patient, presence of pregnancy and lactative stage of
women, efficacy of the drugs, degree of eczematisa-
tion and the cost involved.
1. Benzyl benzoate: The treatment of thousands of
cases of scabies with topical benzyl benzoate was
documented in Denmark during the 1930s; 10–25%
benzyl benzoate applied in the form of a cream or
lotion is highly efficient. Benzyl benzoate requires fre-
quent applications such as twice daily for 2–3 days
and needs to be repeated after 10 days. Benzyl ben-
zoate is very effective when used correctly. If not, it
may cause skin irritation and or a burning sensation
particularly with the 25% lotion. If the skin irritation
is severe, the benzyl benzoate should be washed off.
It may cause irritant dermatitis on the face and scro-
tum. The use of analgesia and antihistamines is often
advisable before the application. A trial found that
48% patients treated with topical benzyl benzoate
were cured as compared with 70% of patients treated
with oral ivermectin.
M21_WK_XXXXX_C21.indd 504
2. Permethrin: This is a pyrethroid component and is a
highly efficacious topical scabicide. Five per cent per-
methrin is applied overnight once a week for 2 weeks,
over the entire body from neck downwards. Although
permethrin is the most expensive of all the topical
applications, it has almost no allergic side effects. The
recommended period of contact with permethrin is
about 8 hours. A case report of the treatment of 467
patients in an outbreak of scabies cited that a single
application of 5% permethrin was as effective as 1%
lindane. A second application is necessary 1 week
later only if there is clear evidence of treatment fail-
ure. However, Walton and colleagues (1999, 2004)
have demonstrated growing concerns about resis-
tance to permethrin in Australia. It is often used in
pregnant women, and the application time is short-
ened to 2 hours and it is also widely used in young
children (greater than 2 months). At present, despite
the limitations of small trials, a dearth of placebo-
controlled trials, and some conflicting information;
the first-line treatment for uncomplicated scabies
continues to be 5% permethrin.
3. Lindane (γ-hexachlorcyclohexane): It is available
as 1% cream or lotion, and its application time is
approximately 6 hours. It is also recommended that
the application be repeated after 1 week. A single,
6-hour application is effective in the treatment of sca-
bies. Although it is a cost-effective topical scabicide,
it can cause severe skin irritation, allergic contact der-
matitis and neurological symptoms such as insomnia,
irritability, vertigo, convulsions, vomiting, diarrhoea,
restlessness and collapse. As a result, the use of this
drug has been prohibited in the European Union since
2001. It is banned in children younger than 3 years
due its toxicity and increasing resistance.
4. Crotamiton: It is widely prescribed for newborn
babies. For the treatment of scabies in children
between 2 months and 5 years of age, 5% perme-
thrin was compared with 10% crotamiton cream in a
randomised trial. Two weeks after a single overnight
treatment, 30% and 13% of children were cured with
permethrin and crotamiton respectively, and 4 weeks
after treatment, 89% and 60% of patients respectively,
were cured. This indicates that crotamiton may not be
as efficacious as permethrin. It should be applied twice
a day for five consecutive days, and the contact period
has to be 48 hours. It has an additional antipruritic
effect but may cause erythema and conjunctivitis.
5. Sulphur: Sulphur can be used as an ointment in a
concentration between 2% and 10%, and most
commonly, the 6% formulation is used. Sulphur is
highly recommended in that subset of patients who
cannot tolerate lindane, permethrin or ivermectin,
though it is substandard to all these agents in efficacy.
The ointment is applied to the entire surface of the
12/18/11 12:06 PM

body on two to three consecutive nights. It is cheap
and is a safe choice for the treatment of scabies in
infants, children and pregnant women. Sulphur has
an unpleasant smell and can cause staining of clothes.
In addition, in some cases it may have irritant effects
and variable absorption may result in side effects in
the kidney.
6. Monosulfiram: It is used in an emulsion form which
is applied all over the body after a bath. It is recom-
mended that this should be applied once a day on two
or three consecutive days. The use of alcohol should
be strictly avoided during treatment to avoid severe
reactions.
7. Malathion: This is an organophosphate insecticide
which is not currently recommended for the treat-
ment of scabies due to its severe adverse effects.
8. Pimecrolimus: It is a class of immunomodulatory
drugs and a recent report suggests that it appears to
be effective in the treatment of eczema on keratinised
skin. A case report highlights that nodular scabies
treated with topical pimecrolimus showed a marked
improvement after therapy.
9. Ivermectin (systemic): It is used as a treatment of
choice for a large number of endoparasites (nema-
todes) and ectoparasites (insects, Sarcoptes scabiei
[0.2 mg/kg in a single dose], Pediculus humanus,
Demodex folliculorum and Cheyletiella spp.). Mul-
tiple doses are used repeatedly for the treatment of
Norwegian scabies (200 μg/kg along with kerato-
lytics), and in immunocompromised patients. More
than 98% of the oral dose of ivermectin is excreted
in the faeces and it is also metabolised in the liver.
A study conducted on 1153 scabies infested prison-
ers revealed that a single dose of ivermectin cured
88% of recipients after 4 weeks and showed 95.5%
efficacy after 8 weeks. Some trials highlighted that a
single dose of 200 μg/kg of oral ivermectin is as effec-
tive as traditional topical applications such as benzyl
benzoate, lindane and permethrin for the treatment
of ordinary scabies. It is likely a second dose after 1
week may be required in many patients. The adverse
effects may include anorexia, asthenia, headache,
arthralgia, myalgias, fever, eosinophilia and macu-
lopapular rashes. Due to the limited data on safety,
ivermectin should not be used in children weighing
<15kg or during pregnancy or lactation. One study
suggested a possible neurotoxicity in the elderly. The
resistance of scabies mites to ivermectin has been
reported in two cases.
10. Ivermectin (Topical): It has been tested in a few open
label studies; in the most recent one, two applications
of 1% ivermectin (400 μg/kg per dose) in a solution
of propylene glycol, spaced 1 week apart, had 100%
success in treating scabies in adults and children
as young as 1 year old with no side effects. Again,
M21_WK_XXXXX_C21.indd 505
Insect Bite Infestations „ 505
further studies need to be performed to prove both
the efficacy and safety.
Drug Resistance Resistance to lindane, permeth-
rin and crotamiton treatment has been observed.
In El Salvador, Peru, Panama, New Zealand, Egypt
and United States, resistance to lindane has been
recorded. In vitro evidence of resistance to permeth-
rin was reported in recurrent crusted scabies. A recent
study highlighted the in vitro tolerance of Sarcoptes
scabiei mites to ivermectin in scabies-endemic com-
munities. In such circumstances, a cocktail of lindane
and benzyl benzoate or permethrin can be used.
Type-Specific Treatment The basic principles of
treatment of scabies include the establishment of a
diagnosis of scabies and the decision regarding a
suitable medication. If the treatment is topical, the
whole body should be treated, from the neck to the
toes in adults and including the head and face in
babies. It is also necessary to treat all the direct
contacts of the case. Follow-up of treated cases
should be carried out at 1 and 4 weeks after scabi-
cidal treatment. In addition to scabicidal treatment,
antipruritic agents such as antihistamines may be
necessary to alleviate itching. Furthermore, suitable
antibiotics can be used if secondary bacterial infec-
tion is present.
1. Crusted scabies: Most cases of Norwegian scabies
need to be admitted to the hospital for treatment.
Multiple doses of oral ivermectin may be required in
addition to topical agents which should be applied all
over the body. A cure is generally attained after three
consecutive treatments with topical applications.
However, in some cases, additional treatments such
as keratolytics (5–10% salicylic acid in petrolatum)
will be required to increase the penetration of scabi-
cides. Decayed nails should be trimmed and brushed
with a scabicidal agent. Ten per cent precipitated sul-
phur in petrolatum is more reliable than permethrin
in this setting. Oral ivermectin can be used alone, but
is more effective when used in combination with topi-
cal treatment.
2. Scabies in children: A total of 2–10% sulphur in pet-
rolatum can be used in infants and 5% permethrin
cream can be used in infants older than 2 months.
Crotamiton is also recommended for use in babies
and toddlers. In infants, the use of ivermectin and lin-
dane are not advisable. A case report demonstrated
that when oral ivermectin was used in combination
with lindane and keratolytics, an 11-year-old girl
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 506 „ Insect Bite Infestations

with crusted scabies was cured without any side
effects. A 12.5% benzyl benzoate emulsion can also
be used in children.
3. Scabies in pregnant and lactating women: Six per cent
sulphur precipitate/crotamiton are the drugs of choice
in pregnant women and lactating women. Use of iver-
mectin, permethrin (category B) and lindane should
be avoided.
4. Nodular scabies: The use of a scabicide followed by
intra-lesional steroids is recommended for the treat-
ment of nodular scabies. Corticosteroids can be rec-
ommended if the nodules persist after repeated treat-
ment. A recent report demonstrated that nodular
scabies was cured by topical pimecrolimus.
are because of reinfection from untreated con-
tacts. It has also been suggested that pruritus can
temporarily worsen after treatment secondary to
the massive death of mites and the release of their
toxic products.
SUMMARY OF THERAPY IN SCABIES The
summary of evidence-based treatment is given in
Figure 21.10. Some general treatment tips are given
in Box 21.1.

Treatment of Persistent Symptoms It is normal PEDICULOSIS

for patients to experience persistence of symptoms
for 2–6 weeks after successful treatment because
of the immune response against the mite antigens.
If the symptoms persist beyond 2 weeks, it could
be because of an incorrect initial diagnosis, incor-
rect application of treatment and poor penetra-
tion of treatment through thick scales, reinfection
or drug-resistant mites. Most cases of recurrence
There are two species of lice that can infect
humans—P. humanus humanus and P. humanus
capitis. Only the body louse is capable of trans-
mitting the disease-endemic typhus (Rickettsia
prowazekii), trench fever (Bartonella quintana) and
relapsing fever (Borrelia recurrentis, Borrelia dut-
toni). P. capitis is not a known vector for disease.

First line

Topical antiscabietic agents

• Permethrin$
Oral antiscabetic agent
• Benzyl benzoate$
• Ivermectin^
• Lindane$
• Sulphur$
• Crotamiton$
• Monosulfiram+

Second line
Pimecrolimus+ (nodular scabies)

Supportive therapy
• Keratolytics
• Antipruritics
• Antibiotics (infection)

Figure 21.10 Evidence-based treatment of scabies.

^Randomised controlled trials.

$Case series/retrospective studies.
+Case reports/small case series.

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 Insect Bite Infestations „ 507

BOX 21.1 Treatment Tips

• Ensure that the cream is applied to the whole body,

specifically on the scalp (children) and under the free
edges of nails.
• As fomites can play a role, the laundering of sheets and
clothing also helps.
• Close physical contact with the infested patients
spreads the disease. It is estimated that 15–20 minutes
of close contact with an infected patient is enough to
transfer the mites from one person to another.
• People that are reinfected are at risk of cumulative
drug toxicity.
• Clothes and bed linens can be machine washed at 60°C
followed by heat drying. If washing is not possible,
they should be isolated in a bag for at least 3 days.
• In the setting of crusted scabies, the use of insecticidal
powders or aerosols may be considered for materials
that cannot be washed.

Figure 21.11 Multiple nits are seen on the scalp.

Extreme pruritus is the primary character- CLINICAL FEATURES

istic of pediculosis. This is a manifestation of the
immune response and it takes 4–6 weeks for the
pruritus to develop in a non-sensitised individual
and only 24–48 hours in case of repeat exposure.
Rarely, children may be totally asymptomatic.
PEDICULOSIS CAPITIS
The head louse is responsible for spreading the
disease and can be a cause of social stigma, and
be embarrassing and uncomfortable. Head lice,
paradoxically, prefer to infest a clean healthy
head and will leave a host if the conditions are
not optimal. Straight hair is more vulnerable than
curly hair.
Symptoms One of the first indications of infesta-
tion is intense itching. Pruritus indicates an infesta-
tion of about 2 months’ duration.
Examination The lice are difficult to be seen in
clean individuals. Yet, they can be abundant and
are easily seen in malnourished individuals and in
those with poor hygiene (Fig. 21.11). Head lice
can be identified with the naked eye or with a
hand lens but are difficult to find. The majority
of patients have a population of 10 head lice. Nits
are firmly cemented to the hairs; vary in number
from only a few to thousands. Nits are deposited
by the head lice on the hair shaft as it emerges
from the follicle.

LIFE CYCLE DIFFERENTIAL DIAGNOSIS Nits can be con-

• The incubation period from the time of exposure to
the development of pruritus is approximately 30 days.
• The ova (nits), hatch in approximately 7–9 days and
mature in another week.
• The ova are laid very close to the scalp and hatch
before the hair grows more than 1/4 inch. Thus, if no
nits are found within 1/2 inch of the scalp and no lice
are seen, treatment is not necessary.
• As nits can live for 10 days, and nymph and adult
lice for 3 days away from human host, head lice may
be transmitted by both direct contact and by fomites
(combs, brushes, hats, helmets).
fused with dandruff. The flakes of dandruff fall eas-
ily from the hair whereas nits are firmly attached
to it. Pseudonits are bits of desquamated epithe-
lium which encircle the hair but are more readily
removed than true nits.
COMPLICATIONS
1. Eczema and lichen simplex chronicus: These occur
on the occipital part of the scalp and over the
neck secondary to chronic scratching and rubbing
(Fig. 21.12).

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 508 „ Insect Bite Infestations
Figure 21.12 Secondary infection with crusting on the
scalp with eczematisation on the neck
(plica polonica).
2. Excoriations, crusts and secondarily impetiginisation
(Figs 21.12 and 21.13): These lesions are seen com-
monly on the neck, forehead, face and ears. In the
extreme cases, the hair over the entire scalp becomes
a confluent, purulent mass of matted hair, lice, nits,
crusts and purulent discharge, so-called plica polon-
ica. This can result in alopecia (Fig. 21.13)
Figure 21.13 Scalp shows areas of hair loss due to
secondary infection.
M21_WK_XXXXX_C21.indd 508
DIAGNOSIS The gold standard for diagnosis is
direct identification of a live louse (nits are within
1 cm of head). In tropical countries like India,
viable nits may be located greater than 1 cm from
the scalp. A microscopic examination of the nit is
necessary to see whether the egg case is empty or
viable. Areas that provide a higher yield for screen-
ing include the nape of the neck and that behind
the ears.
In a recent study it was found that the louse
comb method was found to be four times more effi-
cient and twice as fast, as direct visual examination,
in the diagnosis of P. capitis infestations.
TREATMENT
Topical Therapy Permethrin and malathion are
effective in the treatment of head lice, whereas syn-
ergised pyrethrins are slightly less effective. A recent
study found that out of five head lice treatments
used in vitro against lice that had previous exposure
to permethrin and pyrethrins, 0.5% malathion was
the most effective pediculicide and ovicide, killing
all the lice and eggs within 10 minutes. Also effec-
tive was 1% permethrin, which killed all lice in
about an hour. The ovicidal activity of permethrin
was 73% in its diluted form and 90% in its non-
diluted form, demonstrating that permethrin should
be used on dry hair. One per cent lindane was found
to be the slowest-acting pediculicide and the least
effective ovicide.
Systemic Therapy
Ivermectin The drug is pediculicidal, but only
when the lice takes a blood meal. Apart from the
standard dose (Table 21.2) of ivermectin, three
doses of 12 mg given every 7 days, has also been
used to eradicate body lice in the homeless adult
population in France. It is not approved by FDA for
patients with a weight under 15 kg.
A recent study (Chosidow et al., 2010) has
found that for difficult-to-treat cases of infestation
with head-lice infestation, oral ivermectin, given
twice at a 7-day interval, had superior efficacy as
compared with topical 0.5% malathion lotion, a
finding that suggests that it could be an alternative
treatment.
Trimethoprim-Sulfamethoxazole It works by
killing bacterial flora necessary for the synthesis of
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 Insect Bite Infestations „ 509

Table 21.2 Therapy of Louse Infestation*

Agent Application Comments

• Permethrin cream, 1% (age • Applied for 10 min and then rinsed off • It has low toxicity, is cosmetically
>2 mo; pregnancy B) well. One single application is sufficient acceptable
although it can be repeated in 10 days
to treat the viable ova that may have
hatched since the initial application
• Lindane 1% (pregnancy C) • Applied to dry hair, left on for 4 min • Excessive application induces resistance
and rinsed. No re-treatment needed and/or toxicity, especially if it is applied
after a warm bath which favours its
absorption. Toxicity may include local
irritation
• Malathion 0.5% lotion (age • Apply to dry hair, leave on 8–12 h, rinse; • Not available in India
>6 yr; pregnancy B) repeat in 7–9 d
Ivermectin • 200 μg/kg/dose; repeat in 7–10 d —
• Off-label for scabies, head lice
• Prescription (pregnancy C)
*Dimethicone has been launched in India.

B vitamins in the louse. There are two combinations
proposed for the use of this oral drug.
• Combination of 1% permethrin cream and oral TMP
(10 mg/kg/d based on TMP for 10 days in two divided
doses)
• Combination of 1% lindane shampoo plus oral TMP
(8 mg/kg/d based on TMP for 12 days in two divided
doses)
Further studies need to be performed to fully evalu-
ate the role of oral TMP as an adjunctive treatment.
Use of louse repellants is another approach to
minimise infestation. Piperonal is twice as effec-
tive as DEET (N,N-diethyl-m-toluamide) in a body
louse model. Slow-release citronella has some effect
but may cause scalp irritation.
The search for newer drugs has focused on
newer, non-toxic methods of intervention such as
5% benzyl alcohol, 4% dimethicone lotion and suf-
focants. Recently spinosad has been approval for
use in patients greater than 4 years of age.
Future Therapies The newer therapies target
components of the nit sheath, which is an insolu-
ble polymer that acts as a glue to attach the egg
case to the hair shaft. Potential therapeutic agents,
including proteases, denaturants, β-sheet breaker
proteins and small protein inhibitors of sheath
formation.
CONCLUSION The best treatment depends on
local patterns of resistance. Due to the absence
of these data in India, we rely on western data.
Resistance can increase if the same formulation
has been used for an extended period of time.
Resistance has been reported to occur with per-
methrin, synergised pyrethrins and lindane. Most
treatment failures can be attributed to poor tech-
nique, non-compliance or reinfection. As there is
no product that kills 100% of the eggs; all patients
should be retreated in 1 week’s time to eradicate
the mature eggs.
Although the American Academy of Pediat-
rics prefers malathion, a European study favours
the use of oral ivermectin over malathion. In India,
in the absence of malathion, ivermectin is a good
option; though it is not FDA approved less than
15 kg. Although transmission from fomites has not
been proven, it is still recommended to wash, dry
clean, vacuum or isolate (in a sealed plastic bag for
2 weeks) items such as hats, combs, brushes and
linens.
In Table 21.2, we have excluded pyrethrins as
they are not available in India. The current recom-
mendations for treatment in order of decreasing
efficacy include (i) permethrin 1% cream followed
by (ii) lindane 1%, (iii) pyrethrins with piperonyl
butoxide and (iv) malathion 0.5%. Dimethicone is
a safer but probably less efficacious options.

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 510 „ Insect Bite Infestations

• As with pediculosis capitis, the symptoms begin only

First line after several weeks of infestation or sooner, in cases of
reinfestation.
• Pruritis is the main symptom, although in cases with
• Malathion 0.5%*,^ secondary infection, there may also be pain, fever, mal-
• Permethrin 1%†,^ aise and lymphadenopathy.
• Carbaryl 0.5%$
TREATMENT Body lice are treated by the
improvement of hygiene and laundering (heat to a
Second line temperature of 65ºC for 15–30 minutes), discard-
ing, or applying insecticides to clothing. In severe
infestations, topical pediculicides can also be used.
• Crotomiton 10%$
It should be emphasised that though there is no evi-
• Occlusive therapy (dimethicone^, dence for the use of topical agents for body louse,
cetaphil cleanser$, petroleum most clinicians prescribe pediculicides (Fig. 21.15)
jelly+) Box 21.2.
• Home remedies (vinegar, olive
oil, melted butter)+
PEDICULOSIS PUBIS (PUBIC LICE)
The crab or pubic louse (P. pubis), which usually
Third line inhabits the genital region, is short (1–2 mm) and
broad, and the first pair of legs is shorter than
the claw-like second and third pairs. Infestation
• Lindane 1%^ may occur in other areas including the moustache,
• Oral ivermectin$ beard, axillae, chest and even scalp hair. They are
• TMP/SMX, Levamisole$
seen in STD patients and more commonly in homo-
• Head shaving+
sexual men.
Figure 21.14 Evidence-based management of P. capitis.
LIFE CYCLE/TRANSMISSION Crab lice usually
^ Randomised controlled trials.
lay only three eggs per day. Adult lice can live off
$ Retrospective study/large case series. the host for up to 36 hours and the viable eggs, for
+ Small case series/case reports. 10 days. Eggs continue to hatch for 1 week after
* It is the preferred first line as it is shown to reduce the resistance.
treatment. The chances of acquiring pediculosis
† In India in the absence of malathion, permethrin is the preferred

line of therapy.

General measures
An evidence-based management of P. capitis is • Laundering (>60°C—10 min)
depicted in Figure 21.14. • Seal mattress for 3 wk
Insecticidal agents
PEDICULOSIS CORPORIS Topical agents
The adult body louse (Pediculosis humanis) lives on • Malathion 0.5%, carbaryl 0.5%, permethrin 5%+
and lay eggs in clothing and not directly on the human Systemic agents
skin. Body lice are most often found in the homeless, • Oral ivermectin+
refugees, beggars and in people staying in generally
unsanitary and/or crowded living conditions.

CLINICAL FEATURES Figure 21.15 Evidence-based management of P. corporis.

• Papular lesions, scabs, urticaria and excoriations are
usually seen. + Small case series/case reports.

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BOX 21.2 General Measures for Treatment of Pediculosis
1. The presence of dead organisms on the scalp/body
is an issue that is rarely addressed. The only certain
way to remove dead nits is with a fine-toothed comb
or a forceps. Pediculicides have varying ovicidal
activity, and eggs attached to hair shafts require
7–10 d to hatch. Thus, a second application is
needed after this interval only if the living lice can be
demonstrated or eggs are observed. Combs and
brushes should be soaked in 2% Lysol or a
pediculicidal shampoo for approximately 1 h or
heated in water for 5–10 min.
2. For treatment of pediculosis corporis, the patient
needs to wash with soap and water and apply topical
antipruritic lotions. If lice are present on the body,
pediculicides should be used. Lice residing in clothing
may be killed by washing the clothes and/or dried by
machine (hot cycle in each); by boiling, followed by
ironing the seams; by dry-cleaning; or by the
application of dry heat at 60ºC for 20 min.
3. Products with an oil base (vaseline, olive oil,
mayonnaise and margarine) may smother the adult
lice, but have no effect on the nits. Vinegar or
formic acid has been reported to remove the glue
that holds the nit firmly to the hair shaft. Alcohol,
kerosene and paint thinners have also been used
but carry extreme risks.
pubis from one sexual exposure with an infected
person are approximately 95%. The transmission
of crab lice can occur without body contact, espe-
cially in warm environments.
CLINICAL FEATURES Pubic lice cause severe
pruritus that is difficult to ignore. Examination of
the patient reveals the presence of black powder-
like louse faeces as well as lice firmly adherent to
hair in the pubic and abdominal areas. Small blue-
black dots caused by the irritating secretion of the
lice’s bite (macula cerulea) are characteristically
seen on the lower abdomen and thighs.
COMPLICATIONS These include secondary bac-
terial infections and lymphadenopathy.
DIFFERENTIAL DIAGNOSIS The yellow-grey
adult louse may be difficult to find and are usually
located at the base of the hairs, resembling small
freckles, scabs or moles.
M21_WK_XXXXX_C21.indd 511
Insect Bite Infestations „ 511
First line
• Malathion 0.5%+
• Permethrin 1%$
• Carbaryl 0.5%+
Second line
• Lindane 1%$
• Oral ivermectin+
• TMP/SMX, Levamisole+
Figure 21.16 Evidence-based management of P. pubis.
$ Retrospective
study/large case series.
+ Small case series/case reports.
TREATMENT The body and axillary hair as well
as the eyelashes and beard should also be examined
for nits; the scalp may rarely be involved. Shaving
of the pubic area should be discouraged because fol-
liculitis and irritation may develop.
The treatment recommended for pediculosis
pubis includes (i) permethrin 1% cream applied for
10 minutes and then washed off; (ii) lindane 1%
applied for 4 minutes and then washed; and (iii)
pyrethrins with piperonyl butoxide applied for 10
minutes and then washed off.
Lindane should not be used in pregnant
women or children younger than 2 years of age, In
addition, bedding and clothing should be decon-
taminated (machine washed/dried with high heat);
sexual partners in the last month should be treated;
and patients should be examined for the presence
of other STDs.
Summary of treatment for P. pubis is depicted
in Figure 21.16.
PHTHIRIASIS PALPEBRARUM
Most therapies for this disease are based on case
reports. No clinical trials have been performed to
help delineate the best treatment for phthiriasis
palpebrarum (Fig. 21.17). The various treatments
include mechanical removal; maximal trimming of
the eyelashes; or topical applications of occlusive
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 512 „ Insect Bite Infestations

4. After a further period of exposure, the delayed reac-

First line tion no longer occurs, and eventually there is no reac-
tion at all. The patient is then said to be immune.

• Petroleum jelly+
• Mechanical removal+ AETIOLOGY Fleas (dog or cat), mosquitoes,
• Physostigmine 0.25%/1%+ bedbugs, lice, scabies or mites (fowl, grain, grass)
can be implicated in most cases. In India, the most
common cause is mosquito bite. While cimicosis
Second line (bed bugs) is discussed later in the chapter the other
causes are enumerated in Table 21.3.

• Cryotherapy+ CLINICAL FEATURES Papular urticaria is

• Yellow oxide of mercury+
• Oral TMP/SMX, teracycline+
Figure 21.17 Evidence-based management
of P. palpebrarum.
+ Small
case series/case reports.
ointments (e.g., petrolatum or precipitated sulfur-
based ointments) used twice daily for 7–10 days,
4% pilocarpine nitrate twice daily for 4 days, anti-
cholinesterase eye ointments, 1% yellow oxide of
mercury (applied for a few minutes before washing
off) twice daily for 14 days, permethrin cream, or
20% fluorescein.
described as an urticarial wheal reaction followed
by the development of a firm pruritic papule, which
usually persists for several days. The wheal and
papule may show a central haemorrhagic punctum,
and the papule may be surmounted by a tiny vesicle.
Lesions are often grouped in clusters, and develop
in crops at irregular intervals (Fig. 21.18).
The number and distribution of skin lesions
produced by the bites depends upon the type of
exposure and the feeding habits of the arthropod
involved. New bites by an arthropod of the same
species often cause recrudescence of activity in
existing lesions.
Bullous reactions (Fig. 21.19) are common on
the lower legs but may occur at other sites, especially
in children. In cases with venous hypertension in the

INSECT BITES HYPERSENSITIVITY

REACTION (PAPULAR URTICARIA)
Papular urticaria is a common sequelae which
occurs because of injection of pharmacologically
active substances, and partly because of sensitisa-
tion to injected antigens. The type of reaction in an
individual patient provoked by an arthropod bite
or sting largely depends on previous exposure to
the same or related species. The sequence of events
which determine this was described initially by Mel-
lanby (1944, 1946) and is as follows:
1. In the first instance of exposure, there is commonly
no reaction.
2. After repeated bites, sensitivity begins to develop,
which manifests as an itchy papule that develops
about 24 hours after each bite and persists for several
days. Figure 21.18 Urticarial wheal with a central vesicle and
3. With prolonged exposure, there is an immediate wheal a crusted lesions which corresponds to the
reaction followed by the delayed papular reaction. morphology of popular urticaria.

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Table 21.3 Other Common Insect Bite/Infestations
Species Example
Hymenoptera • Bees, wasps and ants
Diptera (flies) • Botfly (Dermatobia hominis) can cause myiasis
• Simulium or black fly (Onchocercosis)
• Sand fly carries Leishmaniasis
Siphonaptera (fleas) • Human flea (Pulex irritans)
• Oriental rat flea (Xenopsylla cheopis) which
carries Yersinia pestis (plague) and Rickettsia
typhi (endemic typhus)
Mites • Cheyletiella mites (walking dandruff )
• House mouse mite
• Scabies mite (Sarcoptes scabei)
• The red mite (Chigger or Trombiculidae)
• Demodex folliculorum
Ticks • They are found in trees, grass, bushes or on
animals (dogs, cattle). After attaching itself
to the human skin, the female tick feeds,
becomes engorged after 7–14 d, and then
drops off
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Insect Bite Infestations „ 513
Clinical features
• Mild: Mild wheal and flare reactions with
variable oedema persisting <24 h
• Systemic reactions: Vomiting, diarrhoea,
generalised oedema, dyspnoea,
hypotension and collapse. Rarely, it can be
life-threatening
• Delayed allergic reactions: They occur within
hours to 2 wk following the sting and
have symptoms similar to those of serum
sickness with urticaria accompanied by
lymphadenopathy and polyarthritis
• Most commonly there is immediate pruritic
wheals followed by itchy, red papules
• Myiasis: There is a painful furuncle that
occurs when a fly deposits parasitic larvae on
human skin
• Onchocerciasis: Facial oedema, subcutaneous
nodules and iritis
• These bites are typically evident as grouped
urticaria papules, some with a central
punctum
• They cause pruritic dermatitis in humans
who handle pets
• It can cause an extremely pruritic papular
bites
• Already discussed
• Chiggers can transmit scrub typhus
(Rickettsia tsutsugamushi), leaving a black
eschar at the bite site, pneumonitis and
constitutional symptoms
• Tick bites are painless and are recognised
later on when there is itching or when
the engorged tick is found. Other features
that can be seen include urticaria, eschar
formation and granulomatous reaction to
insect bites
• Minor or major constitutional symptoms
can be associated with early stages of
Lyme disease. Multiple symptoms can
accompany both the early-disseminated
disease and late-stage disease, depending
on which system is involved (CNS, cardiac or
musculoskeletal). Very rarely, children can
develop a reversible flaccid paralysis that
starts after the tick has been attached for
several days
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 514 „ Insect Bite Infestations

tion is severe, there may be fever and malaise.

Secondary infection is a common complication, and
may manifest as impetigo, folliculitis, cellulitis or
lymphangitis. A mnemonic ‘SCRATCH’, has been
used to describe the clinical features (Table 21.4).

Major Clinical Points

1. Children aged 18 months to 10 years are typically
affected
2. One child in the family may be the only person bitten
3. Common in spring or summer
4. May occur anywhere on the body, but typically on
exposed skin

5. Erythematous pruritic papule

6. May be grouped in clusters; where the insect has bit-
ten the patient several times, it looks like ‘breakfast,
lunch and dinner’ (Fig. 21.21)
7. Occasional vesicles or bullae, especially in young
children
8. Some immunosuppressed children or those with HIV
infections can have severe exaggerated reactions
9. Recurrent crops are common
Figure 21.19 Bullous eruption due to insect bite reaction.
COURSE The lesions tend to start after infancy,
and an affected child usually ‘grows out’ of the
lower limbs, haemorrhagic or ulcerated lesions may
problem in a few years, even if the source of the
develop. Severe local changes are sometimes found,
bites is not dealt with. Individual lesions last for 1
with the development of cellulitis and lymphangitis
or 2 weeks and recur in distinct crops, especially in
in the apparent absence of secondary infection.
the summer and hence the lay term ‘heat bumps’.
Irritation is an almost inevitable symptom, and
The lesions disappear with any change of environ-
rubbing and scratching may increase the inflamma-
ment, for example, by going on a holiday. Surpris-
tory changes and induce eczematisation (Fig. 21.20).
ingly, often only one member of a family is affected,
When there are numerous bites, or if the local reac-
perhaps because the others have developed immu-
nological tolerance after repeated bites.

MOSQUITO BITES
Allergic reactions to mosquito bites occur due to sen-
sitisation to mosquito salivary proteins. Mosquito
saliva-specific immunoglobulin IgE, IgG antibodies
and T-cell-mediated delayed type hypersensitivity
reaction appear to be involved in the pathogenesis.
Culex quinquefasciatus, Aedes aegypti and Aedes
vexans are the three most important species of mos-
quitoes worldwide.
A recent study found that mosquito bites were
more commonly seen in females and 50% of cases
had a personal history of atopy. The average age of
Figure 21.20 Eczematous reaction which in Indian onset of this reaction was 5.7 years (range 2–58)
skin causes post-inflammatory and the patients were desensitised by an average of
hyperpigmentation. 9.5 years of age.

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 Insect Bite Infestations „ 515

Table 21.4 Clinical Features of Papular Urticaria (SCRATCH)

Abbreviation Description Comments

S • Symmetrical distribution (scalp, neck,
face, torso, extremities)
C • Crops/clusters of different colouration
(Fig. 21.22) (erythema, hypo-/hyper-
pigmentation)
R • Rover not required: pets are not
necessary criteria for diagnosis. In fact,
a history of exposure to pets often
cannot be elicited from the patient
A • Age specific (usually occurring between
2 and 10 yr of age)
T • Target lesions and time (may take weeks
to years to resolve). It is a chronic
condition and takes time to resolve
C • Confused paediatrician/parent: ‘We
don’t have fleas!’
H • Household with single family member
affected
• Diaper area is spared
• Trunk is rarely involved with bites along the socks line,
waistline or other sites where clothing is occlusive.
• Lesions usually appear in a ‘meal cluster’, sometimes
described as ‘breakfast, lunch and dinner’. These linear
or triangular groupings of lesions are characteristic of
bedbug bites; however, they may also be seen in flea bites
• There is a remote history of exposure to cat fleas,
mosquitoes, bedbugs and any stay in hotels which has to
be elicited
• Tolerance develops in most children by 10 years of age
• Prevention of secondary infection with appropriate
hygiene of the nails and hands and the use of moisturisers
is perhaps the BEST intervention
• It is important but difficult to make the parents appreciate
that the condition is because of insect bites and it requires
observation and patience for resolution
• Since this condition is due to hypersensitivity, some
individuals, by definition, will react while others will not

CLINICAL FEATURES The reaction to mosquito Other uncommon reaction include anaphy-
bites is determined by previous exposure, and the lactic reactions, serum sickness-like illness, bullae,
sequence of events following multiple bites was elu-
cidated by Mellanby (1944, 1946)
• Stage 1 (induction of hypersensitivity): In an individual
not previously exposed, the bites produce no response.
• Stage 2 (delayed skin reactions): With subsequent
bites, a delayed reaction occurs (pruritic wheals) which
develop approximately 24 hours after the bites and
persist for several days.
• Stage 3 (immediate skin reactions and delayed reactions):
After repeated bites for several weeks, the response
changes, with the appearance of an immediate wheal at
the bite site. This resolves after about 12 hours, to be
replaced by the delayed reaction. (papule).
• Stage 4 (immediate reactions): Further exposure provokes
the immediate reaction, but not the delayed response.
• Stage 5 (no reaction): Eventually, tolerance is acquired,
and no reaction occurs.

Thus, with time there is no response to the bite. This

sequence of events explains the lack of symptoms in
adults and elder sibling of the affected child. Also,
it gives an idea of the acquisition of immunological Figure 21.21 Clustered papules the so-called ‘breakfast,
tolerance in the child with age. lunch and dinner’.

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 516 „ Insect Bite Infestations
Figure 21.22 Polymorphic presentation on the limbs
with papules, central punctum, excoriated
lesions and pigmentation. The associated
hyper/hypopigmentation makes it a
cosmetically inelegant presentation.
cellulitis, ecchymosis, urticaria, angioedema and
eczematisation. Exaggerated hypersensitivity
responses to mosquito bites have been seen in cases
of chronic lymphatic leukaemia and HIV infection.
There have been reports of development of
malignant histiocytosis, but this has only been
observed in Japan. The triad is constituted by
hypersensitivity to mosquito bites, chronic Epstein–
Barr virus infection and natural killer cell leukae-
mia/lymphoma.
MANAGEMENT OF INSECT BITE REACTIONS
AND IBIH (PAPULAR URTICARIA)
PREVENTION It is a useful measure to explain
the importance of this as it is easier to prevent than
to treat insect bite reactions especially insect bite-
induced hypersensitivity (IBIH). This includes wear-
ing of protective clothing for outdoor play with the
judicious use of insect repellents. Families with pets
should participate in aggressive measures for flea-
control (flea collars, flea medication, frequent bath-
ing of the dog/cat and frequent washing of personal
bedding in hot water). Patients should be asked to
avoid attractants such as perfumes, scented prepa-
rations; brightly coloured clothing or jewellery;
and wool, suede or leather apparel. Factors that
attract mosquitoes to skin include warmth, sweat,
moisture, carbon dioxide and other body secretions
found in the convective air currents above or down-
wind of humans. Mosquito repellents do not mask
these attractive stimuli but form a barrier against
penetration that extends to a distance of less than
4 cm away from the skin. DEET blocks the ability
M21_WK_XXXXX_C21.indd 516
of the mosquito to track the vapour trail of carbon
dioxide exhaled by a human. Nets and clothing
treated with repellents not only prevent mosquitoes
from biting through clothes but also from biting the
adjacent areas. Repellents may remain effective for
several days on fabric.
If bedbugs exist in the home, measures such as
laundering the bedding and mattress pads every 2–4
weeks in combination with applying double-sided
tape to the legs of the bed have been shown to pre-
vent bedbugs from becoming long-term residents in
their common dwelling places.
USE OF INSECT REPELLENTS Although DEET
is recommended (diethyltoluamide [DEET]) as it
works against mosquitoes, flies, fleas, mites and
ticks, it is not widely available in India. It should
be noted that the OTC products in the Indian mar-
ket contain N,N-diethyl benzamide and not DEET.
However, permethrin is a good alternative and
works as an insecticide and repellent against lice,
ticks, fleas, mites, mosquitoes and black flies. The
other agents that have been recommended include
ethyl hexanediol, dimethyl phthalate and dimethyl
carbate butopyronoxyl. It should be noted that
sweating reduces the effect of all repellents. The
following repellents are safe for application on the
skin: DEET, picaridin, MGK-326, MGK-264, IR
3535 and botanical oils (citronella, lemon oil, euca-
lyptus, geranium).
Insect repellents containing DEET in a concen-
tration of 10% or less may be applied to clothing or
skin (caution should be exercised as it can be neuro-
toxic). Special fabrics impregnated with acaricides
are available. No product will protect against spi-
ders, wasps or bees.
TREATMENT
General Measures Parents should be advised of
the frustrating, persistent, recurrent nature of IBIH
and reassured by the eventual development of toler-
ance and resolution of symptoms. They should be
made to understand the natural history of IBIH in
order to prevent multiple consultations and inva-
sive, unnecessary investigative studies.
Active Therapy (IBIH/Mosquito Bites) Pruritic
lesions can be individually treated with a topi-
cal steroid (low to medium strength) two to three
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 Insect Bite Infestations „ 517

times a day. Oral antihistamines (diphenhydramine,

First line
hydroxyzine) may help reduce itching. Topical cro-
tamiton is a useful adjunct to therapy. Although it
does not have evidence topical benzoyl peroxide is
• Elimination+
effective in resolution of mosquito bite reactions • Antihistaminics
(personal experience). A summary of the evidence- • Topical steroids, topical
based therapy for IBIH (papular urticaria) is given (calamine, camphor/menthol)+
in Figure 21.23. • Crotomiton+

Active Therapy (Other Insect Bites) Insects

should be flicked or brushed (not squeezed) off the Second line
skin in a way that the venom sac is also removed.
The removal of the stinger with a forceps is not
recommended as it may squeeze the attached
• I/L steroids, oral steroids+
venom sac. • Insect repellants+
The administration of cold packs, systemic
antihistamines and a topical steroid may be useful
for the control of pruritus and inflammation associ-
ated with local reactions. Third line
A summary of the evidence-based therapy for
insect bites is provided in Figure 21.24.
• Phototherapy, cyclosporin+
Treatment of Anaphylaxis
1. A total of 0.3–0.5 mg epinephrine HCl (0.3–0.5
mL of a 1:1000 dilution) should be injected IM and Figure 21.23 Evidence-based approach to papular
repeated after15–30 minutes, as needed. Lower doses urticaria (IBIH).
should be used in the elderly and in patients with car-
diovascular problems. + Small case series/case reports.

• Elimination of insects
• Use of repellants (DEET, permethrin)
• Botanicals oils+
Prevention • Fleas (lufenuron, fipronil, Imidacloprid)^

• Topical steroids, camphor, menthol, lidocane

Active
therapy+

Figure 21.24 Summary of preventive and therapeutic measures for insect bites.

^ Randomised controlled trials.

+ Small case series/case reports.

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 518 „ Insect Bite Infestations

2. In severe anaphylaxis with hypotension and poor
peripheral circulation, epinephrine should be admin-
istered intravenously in a dilution of 1:10,000 (1 mg =
10 mL) in a bolus dose of 0.1 mg until symptoms
improve. An intravenous line should be started. If the
patient does not respond to initial measures, critical
care referral is essential. These measures include the
administration of oxygen, intravenous aminophylline
and inhaled bronchodilators.
3. Antihistamines should be administered as an adjunct
to epinephrine because their effect is not immediate.
4. Steroids have a delayed onset of action and are not
the first-line drugs for treating a severe systemic reac-
tion. However, unless medically contraindicated,
they should be used to prevent continued reaction in
all but the mildest allergic reactions. The treatment
should begin with 100 mg of hydrocortisone given IV
every 6 hours and the patient should be discharged on
a dose of 30 mg of prednisone per day, tapering over
3–7 days as symptoms dictate.
5. Immunotherapy with insect venom is effective and
should be considered mandatory for patients who
have had an immediate systemic reaction to an insect
sting. Commercial venoms and fire ant extract can be
used for diagnosis (skin testing) and desensitisation.
Adults with a previous systemic reaction to a sting
and a positive venom test will have a similar reaction
in approximately 50% of instances if stung again.
After immunotherapy, a re-sting will elicit a systemic
reaction in less than 5% of patients.
parasite in the faeces of the host. On humid soil or
sand, they hatch giving rise to rhabditiform larva
which form filariform larva which penetrate unpro-
tected skin. Through the circulatory system, the lar-
vae lodge in the small intestine. Eggs, as well as the
larvae, can be transported by flies, increasing their
dissemination. The human skin can be penetrated
by mud, dirt or, especially, sand. They are capable
of invading the skin through follicular pores or
sweat glands where they could remain for a long
time and lead to folliculitis. Usually, they migrate
through the epidermis at speeds that vary from a
few millimetres to centimetres per day. Rarely, they
may also penetrate the dermis.
CLINICAL FEATURES
1. Larva migrans caused by Uncinaria: Skin penetration
is usually asymptomatic. The infestation presents
with the formation of a pruritic papule associated
with an erythematous track that follows an erratic
course. This lesion is usually intensely pruritic,
and it can cause burning or pain (Fig. 21.25). The
most commonly involved areas are the soles, hands,
gluteus and back.
2. Larva migrans caused by Gnathostoma (Gnathostomi-
asis): The clinical manifestations vary depending on the
organ involved; the digestive and genitourinary tract,
kidney, lungs, brain, eyes and ears may be affected.
Skin is the most frequently involved organ and the easi-
est to detect and present in the following forms:

MISCELLANEOUS CONDITIONS
LARVA MIGRANS
(LARVA MIGRANS SYNDROME)
Larva migrans or creeping eruption is an infestation
of the skin by the nematode larvae. These worms
normally parasitise the intestine of other animal
species. The nematode cannot complete its life cycle
in man. As the worm migrates in the epidermis, it
produces a characteristic lesion.

AETIOLOGY/LIFE CYCLE The following types

of worms can cause cutaneous larva migrans:
Uncinaria, Gnathostoma and Necator. Some fly lar-
vae of the varieties Gasterophylus and Hypoderma
bovis also cause similar clinical pictures. Most cases
are caused by Uncinaria. The principal agents are
Ancylostoma braziliensis and A. caninum. Their
life cycle begins with the expulsion of eggs of the Figure 21.25 Serpiginous track associated with vesiculation.

M21_WK_XXXXX_C21.indd 518 12/18/11 12:06 PM


• The inflammatory form or migratory panniculitis
is of variable intensity. It is characterised by the
formation of erythematous, oedematous, circular
or irregular, elevated plaques. The surface is
warm, and may be associated with pain or a
burning sensation and the rate of migration of the
larvae is about 1–5 cm/d.
• The superficial or serpiginous form presents as an
irregular, sinuous track with a mild inflammatory
reaction.
3. Larva migrans caused by Strongyloides (anguilluli-
dos): The systemic phase is manifested by Larva cur-
rens, characterised by rapidly developing (5–15 cm/h)
serpentine skin lesions that may spontaneously disap-
pear in a few hours. They frequently present around
the anus and in the gluteal area and can affect the
lumbar, pelvic and thoracic regions. The cutaneous
lesions are accompanied by intense pruritus and
sometimes, by a papular, pseudourticarial eruption.
4. Larva migrans caused by fly larvae: This is also known
as rampant or migratory myasis. The species of gen-
der Gasterophylus are the main aetiological agents,
and the species G. intestinalis, G. haemorrhoidalis and
G. precorum are, among others, the most frequently
involved. These are habitual parasites of the stomach
and rectum of horses. In humans, the larvae tunnel into
the epidermis and form linear tracks that progress by
1–2 cm daily. Vesicles and blisters form along the track.
Larval activity and pruritis are more intense at night.
COURSE This is a self-limited disease and humans
are ‘dead-end’ hosts. Most larvae die and the lesions
resolve within 4–6 weeks.
MANAGEMENT The best way to prevent cuta-
neous larva migrans (CLM) is to ban dogs from
beaches or wear shoes while walking on the beach
and to lie on the sand only on tide-washed areas or
on a mattress (a towel does not give enough protec-
tion). Symptomatic relief can be provided by topical
application of a corticosteroid preparation under
occlusion.
Although the human host is a ‘dead end’ in the
life cycle and this disease is self limiting, spontane-
ous remission takes up to 12 weeks and intervention
is essential. This includes administration of topical
or oral antihelminthics (albendazole, thiabendazole
and ivermectin). The regimens include:
• Topical thiabendazole 10–15% cream, applied twice
to thrice daily, for 5–10 days
• Oral albendazole in a dose of 400 mg daily for 3–5 days
• A single dose of 12 mg of oral ivermectin
M21_WK_XXXXX_C21.indd 519
Insect Bite Infestations „ 519
CUTANEOUS AMEBIASIS
This is a parasitosis caused by the protozoan,
Entamoeba hystolytica, which may be found in
the digestive tract. Through different ways, it may
invade the skin and cause painful, rapidly growing
necrotic ulcers.
CLINICAL FEATURES The cutaneous form of
amebiasis is rare and is characterised by rapidly
growing, necrotic ulcers associated with severe
pain, regional adenopathy, fever and malaise. The
ulcers have a central zone of granulation covered by
purulent exudates or fibrin with necrotic tissues and
an intensely erythematous halo and well-defined
margins. Rarely, multiple ulcers and other clinical
variants including vegetative, verrucous or hyperk-
eratotic tumours may be present. The lesions do not
usually heal spontaneously. They grow rapidly and
can lead to extensive destruction of genital areas.
INVESTIGATIONS Amoeba are usually found
microscopically from fresh material taken from
the base of the ulcer and placed on a glass slide to
which warm saline solution is added to stimulate
movement. On biopsy of the edge of the lesion, tro-
phozoites may be seen.
TREATMENT Emetine and dehydroemetine are
the drugs of choice. Emetine is given in a dose of
1 mg/kg/d for 10 days. Dehydroemetine is given IM
and its dose should not exceed 60 mg/d, because of
cardiac effects.
Metronidazole may be given orally, in a dose
of 30–40 mg/kg/d, for 21 days. Iodochlorohydroxy-
quinolein 0.25 g can be given 3 times a day for 2–3
weeks along with emetine and dehydroemetine.
MYIASIS
Myiasis is an infestation of tissues by the larval form
of non-biting dipterous insects (flies). Species of flies
involved in myiasis include the genera Dermatobia
(human botfly), Cochliomyia (screw worm), Cordy-
lobia, Chrysomya, Cuterebra (rodent or rabbit bot-
fly), Oestrus (sheep botfly), Gasterophilus (horse
botfly), Hypoderma (warble fly), Phaenicia (also
known as Lucilia) (blowfly) and Wohlfahrtia (flesh
fly), among others. In Asia, the common causes are
Chrysomya and Wohlfahrtia and in Africa, Cordy-
lobia and Chrysomya.
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 520 „ Insect Bite Infestations
MODE OF TRANSMISSION The mode of trans-
mission is different for different species. The human
botfly deposits its eggs on a mosquito or other
blood-feeding insect, which then transfers them to
the host. Cordylobia species deposit their eggs onto
moist clothing, blankets or sand. The larvae pen-
etrate the skin after contact with the host.
Other organisms deposit their eggs directly on
open wounds or orifices. In some cases, the larvae
move about in the subcutis (migratory myiasis),
mimicking the pattern of cutaneous larva migrans.
This is caused by Hypoderma bovis (warble fly),
whose normal hosts are cattle, or Gasterophilus intes-
tinalis (horse botfly), which normally infects horses.
In wound myiasis (Cochliomyia hominivorax—
New World screw worm), the larvae initially consume
necrotic debris but may proceed to feed on normal
tissue. Furuncular myiasis occurs following the
penetration of normal skin by the larvae. A pruritic
papule develops at the site. This slowly enlarges over
several weeks into a domed nodule (resembles a
furuncle). The lesion has a central pore through which
the posterior end of the larva protrudes intermittently.
The larva can be induced to exit the lesion by covering
this exit with pork fat or petrolatum.
TREATMENT
General Measures To prevent infestation by
Cordylobia spp., people should avoid wearing
damp clothing or resting in sandy areas and cloth-
ing can be sun- or heat-dried and/or pressed Insect
repellents can be used to keep mosquitoes carrying
larval eggs away.
Specific Treatment Most treatment recommenda-
tions are based on in vitro experiments or case studies.
1. Furuncular myiasis: The various options include sur-
gical debridement; occlusion/suffocation (i.e. with
petrolatum, liquid paraffin, beeswax, nail polish,
heavy oils); ethyl chloride sprays; lidocaine injections;
cryotherapy; chloroform in vegetable oil or ivermec-
tin. Treatment consists of the following measures:
• Mechanical removal with a haemostat
• Compression with a pair of wooden spatula on
either side of the nodule so that the larva emerges
vertically out of the skin, like a ‘grain of rice’
• Mechanical removal with forceps—in some cases
under anaesthesia—after applying a small amount
of commercially available mineral turpentine)
2. Wound myiasis can be cured by surgical debridement
or surgical removal. An effective treatment for the
M21_WK_XXXXX_C21.indd 520
removal of the human botfly from pregnant women
involves surgical removal using a cruciform incision.
The three-step process is as follows:
• Aesthetising the area around the aperture (which
effectively paralyses the larva) with an injection of
1% lidocaine.
• Covering the breathing hole with a sterile occlu-
sive ointment (polymyxin B in this case) to suf-
focate the larva.
• Placement of a cruciform incision slightly off centre
from the breathing hole to extract the whole larva.
Miscellaneous Agents Camphor (in a concentra-
tion of 1:0 and 1:1) demonstrated a 100% mortal-
ity rate of the Oestrus ovis (sheep nasal botfly) lar-
vae. Essential oil of betel in a concentration of 3%
and 4% was effective in killing 100% of the larvae
(Chrysomya).
BEDBUGS (HEMIPTERA)
This small blood-sucking insect was largely eradi-
cated in developing countries around the 1950s sec-
ondary to the widespread use of DDT. Within the
past 3 years, 500% increase in the number of cases
of bedbug infestations have been reported from the
United States and Europe.
The factors for this increase include, the fre-
quency and ease of international travel, their non-
dependence on the surrounding environment for
reproduction, survival time of up to 1 year without
a blood meal and the ideal environment prevalent
in urban cities. The sites of transfer include shelters,
hotels and apartment units.
Insect: Flattened dorsolaterally, with an ovoid body.
The light to red brown bedbug is wingless, and the adult
is typically about 6 mm in length.
LIFE CYCLE/MODE OF INFECTION The life
cycle has five stages and it completes in about 6–8
weeks. The adult bedbug can typically live for 6–12
months. A female lays 200–500 eggs which remain
cemented and hatch within 6–10 days at room tem-
perature. They are extremely robust creatures and
remain alive in temperatures as low as 7°C, and as
high as 45°C. At homes, bedbugs hide in the dark
crevices of walls, furniture, picture frames, and peel-
ing wall-paper, the folds of clothing and linens or in
the corners of suitcases. There are two separate species
of bedbug, Cimex adjunctus and Cimex pilosellus.
12/18/11 12:06 PM

Figure 21.26 Although the classic clustering is seen it is
by no way specific of bedbugs and can be
seen due to other insect bites also.
CLINICAL FEATURES Typically, bedbug bites
occur at night, and the patient awakes with new
lesions. Bite reactions occur on exposed sites such
as the face, neck, arms and hands, with two to three
lesions in a row (‘breakfast, lunch, dinner’; Fig. 21.26).
The typical reaction to the bite of is the development
of an erythematous wheal, followed by a firm, reddish
papule. Occasionally a small central haemorrhagic
punctum may be visualised. In unexposed individu-
als, the bite appears as erythematous, pruritic mac-
ules while in sensitised individuals, intensely pruritic
papules, papular urticaria or vesicles/bullae may occur.
Changes secondary to scratching include exco-
riations, eczematous dermatitis and secondary
infections.
ACKNOWLEDGEMENTS
The first three authors have contributed to the section on scabies. The images are of Indian patients.
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