Review Article

Journal of Cutaneous Medicine and Surgery

Scabies: Diagnostic and 00(0) 1–7

© The Author(s) 2020
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​DOI: ​10.​1177/​1203​4754​20960446
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Robert N. Richards1 ‍ ‍

Abstract
Background:  Scabies is globally ubiquitous and is a significant health issue for institutions, the economically disenfranchised,
resource-­poor areas, and for those with weakened immune systems. Topicals are usually effective, but are cumbersome and
expensive to use in large populations and for those nonadherent to topicals. Oral ivermectin became available in Canada for
the off-­label treatment of scabies in the fall 2018.
Objectives:  To review the diagnosis and management of scabies. Dose schedules and concomitant management measures
are outlined for scabies simplex and for crusted scabies. Ivermectin use is outlined.
Methods:  Medline, colleague discussions, practice review, and experience from managing scabies in institutions.
Results:  Oral ivermectin is safe, easier to use, cheaper, more effective, and more economical than topicals in widespread
institutional scabies, for those nonadherent to topicals, and in crusted scabies.
Conclusions:  Oral ivermectin is the treatment of choice in large populations, the nonadherent, and for crusted scabies.
Oral ivermectin is produced by Merck Canada as Stromectol 3 mg. The treatment dose for noncrusted scabies is 200 µg/kg,
taken in a single dose with food. For example, 15 mg (5 tablets) for a 70 kg person. Retreat in 10-14 days to enhance effec-
tiveness, and perhaps to reduce scabicide resistance.

Keywords
scabies, crusted scabies, institutional scabies, ivermectin, permethrin, population outbreaks

Scabies occurs globally, and is caused by the species-­specific
ectoparasitic mite: Sarcoptes scabiei (var. hominis).1-5 In the
fall of 2018, oral ivermectin became available in Canada for
the off-­label treatment of scabies. The use of ivermectin in
other jurisdictions has been a huge therapeutic advance for
mass populations, institutional outbreaks, crusted scabies,
resistant scabies, and those nonadherent to topicals.6,7
Common scabies (scabies simplex) and crusted scabies differ
in their morphology, degree of contagion, severity, complica-
tions, and treatment.
Sarcoptes scabiei (var. hominis) measures about 0.35 mm
and lives in linear burrows dug in the stratum corneum. It can
be visible to the naked eye as a speck, and may be visible to
expert dermoscopists.8 Female mites burrow into the skin
and lay eggs, which take 10-14 days to produce new mites.
Adult males live on the skin and may enter the burrows for
food and mating.1-5 The average scabies simplex case carries
about 10-20 mites, but infants and the elderly may harbor
between 50 and 250 mites.2 Patients with crusted scabies
carry thousands to millions of mites.1–5
Transmission of scabies simplex is most frequently by
skin-­to-­skin contact, usually prolonged skin contact. Some
individuals are more susceptible.1-5,9 Those affected can be
of any age or social strata, and good personal hygiene does
not always prevent infestation. Large outbreaks are more
common in institutions, the economically disadvantaged,
crowded tropical areas, and in crowded resource-­poor areas
such as those found in some indigenous areas in Northern
Canada and Australia. Transmission is facilitated by skin-­to-­
skin contact, sleeping with or sex with an infested person, the
sharing of living quarters, and close continuous contact.
Transfer by casual contact such as shaking hands is rare. The
risk of transmission by fomites is negligible except in severe
crusted scabies.1-3 Mites cannot jump or fly and die outside
their human host within 24-48 (72 maximum) hours.5,9 An
infested person is contagious, even when symptom free, but
there is no risk of spread in scabies simplex after appropriate
treatment. Healthcare workers may find gloves reassuring,
but scabies simplex is often present but undiagnosed before
gloves are considered, and statistics regarding their
1
Departments of Medicine, North York General Hospital and Baycrest
Health Sciences, Courtesy Staff Dermatology, Toronto, ON, Canada
Corresponding Author:
Robert N. Richards, Suite 507, 3018 Yonge Street, Toronto, ON
M4N0A2, Canada.
Email: ​revrichards@​hotmail.​com
2 Journal of Cutaneous Medicine and Surgery 00(0)
effectiveness are not available. Hand washing after examina-
tions is logically recommended but there is no factual evi-
dence of its effectiveness.
Animals carry mite-­specific species such as Sarcoptes
canis in dogs, which may produce a temporary eruption in
humans, but not scabies, because canine mites do not survive
on humans.4
Epidemiology
Scabies is a global disease and there is great variation in its
prevalence and health burden. The scabies burden is greatest
in tropical regions, in areas of overcrowding, in times of war
and social disruption, and in economically disadvantaged
populations such as indigenous Australians.10 The most com-
monly affected age groups are children, adolescents, and
elderly people. In some areas over 50% of the population is
affected and scabies continues to be a significant health prob-
lem. Worldwide estimates of current cases vary from 200 to
300 million.5,9 Hay et al noted that scabies is endemic in
tropical areas and estimated an average prevalence of
5%-10% in children, commonly with total family involve-
ment.11 In low-­frequency countries such as North America
and Europe, the occurrence of scabies is more evenly distrib-
uted among all age groups. Institutional outbreaks are always
of concern.12 Except for institutional outbreaks, scabies is
not a reportable disease in western countries; therefore, its
epidemiology and true prevalence remain unknown.6 Studies
are not available. We know that scabies is ubiquitous and
every family doctor, dermatologist, and institution with
whom I have spoken has seen cases in the past year. Scabicide
sales are not helpful in establishing scabies incidence because
these products are used widely for lice, and commonly for
trial treatments or misdiagnoses. The occurrence of scabies
is cyclical and it is more easily transmitted in some years or
decades than others. This periodicity is often less obvious in
poor communities. There is always an increase during times
of war and social disruption.11,13 There are no North American
data but all colleagues with whom I consulted have anecdot-
ally noticed a cyclical pattern in the frequency of scabies.
Clinical presentation of scabies simplex
Itch and/or rash begin 4-6 weeks after contact, but a person
experiencing scabies reinfestation within 6 months of this
initial infection will develop itch in hours to days.5 Scabies
itch results from the mechanical effect of mite burrowing,
and from an allergic reaction to the mite and its products.1,3,5
In severe cases we see disseminated erythematous papules,
excoriations, hemorrhagic crusts, linear scratch marks,
eczema (dermatitis), vesicles (even bullae), often pustules
and impetigo from secondary bacterial infection, and, if
intact, the mites’ linear burrows, which appear as 3-10 mm
linear lines, most easily seen around the hands and wrists.
Scabetic nodules may result from an exaggerated hypersen-
sitivity reaction and from rubbing and scratching, and may
be skin-­colored, red-­brown, or violaceous. Bruising, second-
ary to rubbing and scratching, is not uncommon. Itch occurs
all over (below the neck), not just at rash sites, and is usually
nocturnal. Severity of itch and the number of lesions vary
from person to person, and asymptomatic carriers are not
rare.3 Elderly patients may have less itch and fewer typical
lesions.1-5 The use of topical steroids reduces visible inflam-
matory reactions, but may permit the mites to flourish.
Scabies Simplex Distribution
Lesions are usually symmetrical, and are seen on the finger
webs, anterior wrists, palms, thenar eminences, elbows, ante-
rior axillae, lower buttocks, inner thighs, waist, umbilicus,
knees, margins and soles of the feet, and vulva; and almost
diagnostically the female areola, breasts, glans penis, shaft,
and scrotum. The neck and above are usually spared, except
in infants, the elderly, the immunocompromised, and in
crusted scabies. Infants are often affected on the face, scalp,
palms, and soles. Symptoms and morphology can vary
greatly, and most experienced clinicians (author included)
have missed the diagnosis.1-5
Diagnosis of Scabies Simplex
Classic morphology is diagnostic, but there is often confus-
ing secondary eczema (dermatitis) produced by scratching
and/or by excessive washing. Normal soap washing may
alter scabies morphology by reducing the number of active
lesions. I have, not infrequently, seen patients itch all over,
whose only visible lesions were on the genitals or female
areolae. A history of itchy family, friends, or intimate con-
tacts is helpful. A definitive office diagnosis is made by
retrieving (by needle or scrapings) the mite, its eggs, or its
fecal pellets (scybala),1-5,9 but this requires a microscope,
time, and skill, so its office use is limited. The mite is located
at the end of the burrow and may attach to a carefully inserted
pin or needle. Scrapings obtained by a scalpel or similar
instrument may be placed on a glass slide, covered with clear
tape and examined under a microscope. An alternative is to
send a sample to the laboratory, by placing scrapings on
black laboratory paper but the yield is less with these meth-
ods. Skin biopsy (also time consuming and expensive) is
helpful if taken from a burrow showing the mite or its prod-
ucts, but if the burrow is missed, the report will return show-
ing dermatitis.14 Inks or oils may help outline burrows, as
does good lighting and magnification. Diagnosis, however, is
often established by a positive response to empiric treatment.
Clinical and epidemiological scabies research has been lim-
ited by a lack of diagnostic standardization. International
groups have tried to establish diagnostic criteria that can be
implemented in a variety of settings and they note that Level
Richards
A evidence requires direct visualization of the mite or its
products.15,16 Dermoscopy is heavily operator dependent, but
in expert hands can identify the mite but not its eggs or fecal
pellets. Mite identification is more difficult in darker skin
types and in hairy areas. The expense of dermatoscopes and
the requirements for training limit its widespread use.16 An
Italian group has recommended the use of a low-­cost video
dermoscopy but more studies are required.17
There are no blood tests to diagnose scabies or vaccines to
prevent scabies.1
Complications of Scabies Simplex
In resource-­ rich areas, mild impetigo, not infrequently,
develops from scratching, as it does in eczema and similar
conditions, but precise data about its incidence are not avail-
able. It is usually mild and easily controlled with topical or
oral antibiotics. However, in tropical resource-­poor areas
(and in crusted scabies), significant impetigo, secondary
staphylococcal or streptococcal bacteraemias, and toxin-­
mediated diseases such as scarlet fever, streptococcal toxic
shock syndrome, rheumatic fever, and glomerulonephritis
are major health issues.1,5,7,10 The common organisms are
Streptococcus pyogenes and Staphylococcus aureus.5 The
“SHIFT” trial studied the effects of mass drug administration
for scabies control in a Fijian population with endemic dis-
ease. On 1 island the incidence of scabies was 32.1% and that
of impetigo was 24.6%. Oral ivermectin treatment reduced
the incidence of scabies to 1.9% and of impetigo to 8%.18
Similar results were obtained in the “AIM” study in which
over 26 000 Solomon Islanders were treated with a combina-
tion of ivermectin and azithromycin. Scabies prevalence was
reduced from 19.5% to 1.3% and that of impetigo from
22.4% to 5.1%.19 Fortunately, scabies is not a known vector
for other diseases.3
Treatment of Scabies Simplex
Underclothes and linen should be changed and hot washed at
degrees 50 °C or 122 °F, but sterilization is not required.1,4
Alternatively, linens, clothing, and similar items may be
sealed in a plastic bag for 72 hours.5 All persons living in the
household, and all intimate or prolonged contacts, must be
treated simultaneously, even if they do not have symptoms.
If not treated, they may be a source of reinfestation for oth-
ers. Matthewman et al20 compared the effectiveness of indi-
vidual versus household treatment for scabies. Participants in
the household treatment group had about twice the odds of
being cured.
In resource-­rich areas, most patients use 5% permethrin
cream or lotion, which kills both mites and eggs. Both are
effective and pleasant to use, and most insurers pay for pre-
scribed permethrin. Permethrin produces neurotoxicity by
inhibiting sodium channels, which culminates in paralysis
3
and death of the mite.21 Permethrin is available without pre-
scription in Canada, Great Britain, and Europe, but requires
a prescription in the United States. Permethrin is applied
overnight to ALL the skin from the neck down. No area of
skin can be missed so application may require assistance.
One night’s application is theoretically adequate, but the
vagaries of human behavior and compliance dictate that an
important standard of practice is to repeat the treatment in
7-10 days as this is more effective. Additionally, the second
treatment will kill newly hatched mites as the initial treat-
ment may not always be ovicidal to all eggs.1-5,9,22 Most
authors consider permethrin to be safe for pregnant or lactat-
ing women,1,4,5 and for children over 2 months of age.1,4,5,9
The usual amount of product required for a single night’s
treatment for persons over 12 is approximately one 30 g tube
or 1 container of 100 mL of lotion. For children 5-12 years of
age, the usual amount is ½ of the above, and ¼ for children
2-4 years. Prices vary from vendor to vendor. Average prices
in Toronto in August 2020 for 1 night’s treatment for 1 adult
were $25 for Nix dermal cream (30 g) and $80 for Kwellada-­P
lotion (100 mL). Presently, neither Nix lotion nor generic
permetherin lotions are available in Canada.
For infants under 2 months, the American Center for
Disease Control and Prevention recommends 5%-10% sulfur
ointment (sulfur in vaseline) applied all over for 3 days.4,5
Sulfur ointment is messy and has an unpleasant smell, but is
effective and safe.1,4 Ointment-­induced secondary irritation
is managed by topical steroids and soap avoidance. Infants,
and occasionally the elderly and infirm, may require topical
applications to the face and scalp.5,9 We have observed that
many patients (and their contacts) require reassurance that
their acquisition of scabies does not necessarily reflect issues
of hygiene or sexual behavior, as this concern is often para-
mount for them. Pets do not require treatment.3
Other topical applications are used in permethrin-­
resistant cases, and in countries where economics dictate the
use of cheaper 25% benzoyl benzoate, which is effective but
irritating. Lindane lotion (1% gamma benzene hexachloride)
is applied in the same manner as permethrin, and can be used
for treatment failures. It is safe if used properly for a short
period.7 Lindane is available in Canada and most states, but
is banned in California and many countries because of over-
use and accidental swallowing, which can produce nervous
system damage. Although used for decades, it is no longer
considered safe for children under 10 years, pregnant or
nursing women, or those under 110 lb. Topical 0.5% mala-
thion aqueous lotion and ivermectin 1% lotion are used in
some countries.4 Ivermectin is not ovicidal so it is important
to retreat in 1 week. Sulfur 5%-10% cream, ointment, or
lotion is effective when used for 3 consecutive days and is
considered safe in pregnancy and infants.5
Post scabetic itch may persist for days/weeks. Treatment
is midstrength to strong cortisone creams and soap avoid-
ance. Soaps dry the skin and should be used only for
4 Journal of Cutaneous Medicine and Surgery 00(0)
essential areas such as underarms, genitals, hands, and face.
First- and second-­ generation antihistamines assist some
patients, but must be used with caution in the elderly. Post
scabetic localized nodules respond to intralesional triamcin-
alone acetonide suspension at 2.5-5 mg/cc., but clinicians
must be certain they are not missing persistent infestation.23
Oral ivermectin is indicated for topical failures, those
nonadherent to topicals, those unable to apply topicals (phys-
ically or mentally disabled, refugees, the homeless), wide-
spread institutional outbreaks, mass populations, and crusted
scabies.1,5
Oral ivermectin was introduced in 1981 and has been
used extensively to treat strongyloides, onchocerciasis, trich-
uriasis, and scabies. Veterinarians and farmers use it for
heartworm and other helminths in pets and farm animals.
Ivermectin was approved in France for the treatment of insti-
tutional scabies in 2001.1 In the fall of 2018, Health Canada
approved ivermectin for oral use in strongyloides, onchoce-
criasis, and lymphatic filariasis suspected to be caused by
Wucheria bancrofti.24,25 Previously, the drug could be
obtained by special access from Health Canada, but this was
prohibitively onerous. Similar approval was given by the
Food and Drug Administration in the United States in 1997.
The decades delay in Canadian availability is presumed to be
due to our small market and regulatory issues. Another fac-
tor, perhaps, was the 1997 Lancet report of an increased
death rate among elderly patients treated with ivermectin for
scabies in an Ontario nursing home,26 but this has never been
confirmed by any other study, and is no longer considered
relevant.3,6,27 The World Health Organization lists ivermectin
as one of the most effective and safe medicines needed in a
health system.28 Ivermectin is marketed by Merck Canada as
Stromectol 3 mg tablets25 and is readily available for off-­
label use.
Ivermectin is not ovicidal so a second dose is given 2
weeks after the initial dose3 to ensure that the newly hatched
mites are killed,1,7 even though some studies found single
dosing effective.5,7 The oral dose, taken with food at one
time, is 200 µg/kg. The dosage per kg weight is (1) 15-24
kg—1 tablet, (2) 25-35 kg—2 tablets, (3) 36-60 kg—3 tab-
lets, (4) 51-65 kg—4 tablets, (5) 66-79 kg—5 tablets, (6) >80
kg—200 mcg/kg.24 The usual adult dose range is 9-15 mg.
Some studies combined oral ivermectin with topical scabi-
cides, but this has no consensus, other than in the treatment
of crusted scabies.5,7
Ivermectin is remarkably safe and dosing can err above the
exact body weight without concern. Side effects in these
doses are uncommon and difficult to distinguish from the dis-
ease and anxiety, but can include headache, nausea, dizziness,
and gastrointestinal upset. Many side effects are thought to
result from mite deaths rather than from the drug itself.6,7
There were no side effect withdrawals in the Cochrane review
of 15 studies with 1896 participants.6 Significant drug inter-
actions have not been a problem.6,7 Currie7 noted that by
2010, over 400 million doses of ivermectin have been given
in Africa for the treatment of onchocerciasis with minimal
adverse events.
Ivermectin is not approved for use in pregnancy or nursing,
or for children weighing less than 33 lb (15 kg)4 but the drug
has been used in these groups without reports of adverse out-
comes.1,7 The product monograph notes that less than 2% of
the standard dose appears in the breast milk, but safety in new-
borns has not been established.25 The product monograph sug-
gests taking it on an empty stomach, but many scabies experts
believe it is more effective if taken with food, and Currie7 noted
that food increases the viability of ivermectin by a factor of 2.29
There is no parenteral ivermectin available for human adminis-
tration but subcutaneous ivermectin is used regularly in veteri-
nary medicine and has been used in a case of human
strongyloidiasis.30 Ivermectin cost per tablet ranges from $20
to $9 depending on the number purchased. Therefore, it is
cheaper to use than topical therapies for widespread outbreaks
and institutional outbreaks.
Institutional scabies7,31,32 can occur in crowded living
conditions such as hospitals, nursing homes, residential
schools, college dormitories, camps, custodial facilities, and
the military. Hard data are not available on transmission rates
as they vary hugely from institution to institution. I have seen
scabies involve most residents of a nursing home, as well as
staff members, visitors, and visitors’ families. But in another
facility, I observed single resident involvement with no
spread to others. There are clearly unknown factors that
influence the spread of scabies. In extensive outbreaks, it is
usually cheaper and easier to administer oral ivermectin than
topical therapies. Adherence to a single drug protocol is not
essential, and some persons, such as pregnant women, may
prefer topicals. Depending on the circumstances, infestation
control measures must include residents, staff, visitors, and
their family contacts. Treatment must be coordinated. Severe
outbreaks may require short-­term isolation, gowns, contact
tracing, and public health assistance. Institutional scabies is a
reportable disease in many North American jurisdictions. A
dermatologist may be required to assist with diagnosis.
Bedding, linens, and clothing should be hot water laundered
but sterilization is not required. General cleaning and thor-
ough vacuuming is recommended, including soft and uphol-
stered furniture, but there is no need for fumigation or special
treatment of wood furniture, mattresses, or rugs. A scabies
outbreak produces anxiety. Residents, staff, their families,
and visitors require reassurance and open communication.
Educational materials are important. Pregnant women must
be reassured that scabies does not affect unborn children.
Most institutions already have established protocols to deal
with individuals who refuse necessary treatment,such as
those that exist now for vaccinations, flu shots, head lice, and
similar problems.33
Richards
Mass populations
Oral ivermectin, where available, is often cheaper than topi-
cals and easier to administer;therefore, it is useful in large
populations.4–7,18,31 A Cochrane review6 considered 15
papers from South Asia and North Africa, which studied
1896 participants. They compared topical permethrin, topi-
cal ivermectin, and oral ivermectin. Many studies were
incomplete, but nevertheless they concluded: “For the most
part, there was no difference in the efficacy of permethrin
compared to systemic or topical ivermectin.” However, other
authors18 have found oral ivermectin to be more effective.
Mass treatment of the population (infants to elderly) was
used in Fiji island communities who had an incidence of sca-
bies over 20%.6,7 There were 3 treatment groups: (1) Topical
permethrin to scabies patients and contacts. (2) Mass popula-
tion administration of topical permethrin. (3) Mass popula-
tion administration of oral ivermectin. A single dose was
given to all participants but patients with scabies received a
second dose 7 days later. After 2 years the prevalence of sca-
bies in group A was 15.2%, group B was 13.5% and the iver-
mectin group C 3.6%
Nearly all studies, regardless of their protocol, repeated
the treatment in 7-14 days and emphasized the importance of
follow-­ up and surveillance. Emerging drug resistance to
scabicides is of concern1,4,7 and it is theoretically possible
that repeat treatment may assist in preventing drug resis-
tance. New drugs, topical and oral, are under study.5
Crusted scabies previously called Norwegian scabies4,7,10
can occur in those with a weakened immune system as found
in immune diseases, AIDS, malignancy, lymphoreticular dis-
eases, those on immunosuppressant drugs, the elderly, the
immunocompromised, those with Down’s syndrome, and so
on.1-5,14 It also occurs in indigenous Australians,10 even in
those without immune defects. It is uncommon in the general
community, and experienced dermatologists working outside
a hospital or institution may never see a case. Patients with
crusted scabies may have millions of mites, which induce an
inflammatory and hyperkeratotic reaction, which in many
patients is not itchy. Patients may present with thick crusted,
often fissured, hyperkeratotic plaques, which typically
involve the palms and soles, and may be scattered on the
trunk, limbs, and scalp. The trunk is often very xerotic.
Fingernails and toenails may be thick and dystrophic and
have subungual involvement. The presentation can be con-
fused with psoriasis or eczema and especially so by nonder-
matologists.1-5,7,10,14 The highly contagious crusts are loaded
with mites and eggs. Severe cases may have lymphadenopa-
thy, odiferous secondary infection, and eosinophilia.34
Precise figures on mortality are yet to be elucidated but the
most common cause of death is staphylococcal bacteremia,
with estimates in indigenous Australians suggesting that
1%-2% of cases end in death from this cause.35 In North
America and Europe, the contribution of crusted scabies to
mortality will remain obscure because nearly all patients
5
with crusted scabies have serious comorbidities and prob-
lems with immunity. Nevertheless, crusted scabies is a risk
factor for sepsis.1,5,10 Grading scales for crusted scabies have
been developed based on body surface areas, depth of skin
crusting, previous episodes, hospitalizations, degree of skin
cracking, and pyoderma. Each domain is scored between a
mild 1 and a severe 3 and combined to produce an overall
score: grade 1 (4-6), grade 2 (7-9), grade 3 (10-12).1,10 There
are no specific studies, but examination gloves are logically
important, because crusted scabies can carry millions of
mites.7,10 Crusted scabies can be very contagious. Some of
my unprotected dermatological colleagues in Toronto
acquired scabies when they examined a patient with crusted
scabies.
Management of Crusted Scabies
The physical and social circumstances that predisposed the
patient to crusted scabies require identification and correc-
tion. Social workers and public health may assist in monitor-
ing and contact tracing.1,10 Many studies on crusted scabies
emanate from Australia as this problem occurs in indigenous
Australians.7,10 A topical scabicide is applied daily for 1
week and then 2 times weekly until cured. Keratolytic creams
such as urea 10% plus lactic acid 5% or 5%-10% salicylic
acid ointments assist in removing scale and facilitate scabi-
cide penetration. Oral ivermectin at 200 µg/kg is given with
the treatment duration depending on the severity: Grade 1:
days 1, 2, 7. Grade 2: days 1, 2, 7, 8, 14. Grade 3: days 1, 2,
7, 8, 14, 21, 28.10 Antibiotics are often required for second-
ary bacterial sepsis and some clinicians use them routinely in
severe cases, which may not have clinically evident infec-
tion, but are often infected with S. pyogenes and S. aureus.
Severe cases may require hospitalization with single room
isolation and contact precautions. It is recommended that
attending staff be protected by protective garments such as
gloves, gowns, and shoe covers. After patient discharge, the
room needs to be thoroughly cleaned and vacuumed. The
patient’s household members and other close contacts require
simultaneous topical treatment. The patient’s house requires
a thorough cleaning as rugs, furniture, and other fomites may
be contaminated with mites shed from skin scales and crusts.
Bedding, clothing, and similar items require hot laundering
or storage in plastic sealed bags for 10 days. In scabies sim-
plex, mites can live up to 3 days after separation from their
host, but in crusted scabies, mites may survive for up to 7
days by feeding on sloughed skin.3
Conclusions
Scabies continues to occur globally and has done so far as
long as recorded history. We are fortunate that new treatment
modalities such as ivermectin enable us to treat problem
cases and large populations more satisfactorily.
6 Journal of Cutaneous Medicine and Surgery 00(0)
Acknowledgments
Thank you to Drs Yuanshen Huang, Mary McKenzie, and
pharmacist Dr Nina Lathia for manuscript review.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iD
Robert N. Richards ‍ ‍ https://​orcid.​org/​0000-​0003-​3830-​8978
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