27 Chapter 178 :: Scabies, Other Mites, and Pediculosis
:: Chikoti M. Wheat, Craig N. Burkhart,
Craig G. Burkhart, & Bernard A. Cohen
SCABIES
AT-A-GLANCE
Part 27
■ Human infestation caused by the Sarcoptes scabiei
var. hominis mite that lives its entire life cycle
within the epidermis.
::
■ Causes a diffuse, pruritic eruption after an
Infestations, Bites and Stings
incubation period of 4 to 6 weeks.
■ Is transmitted by close physical contact or
by fomites.
■ Topical therapy with permethrin 5% cream is
most effective topical therapy, but oral ivermectin,
although off-label, is also effective.
■ Because of the common occurrence of
asymptomatic mite carriers in the household, all
family members and close contacts should be
treated simultaneously.
EPIDEMIOLOGY
Scabies is a worldwide issue that affects all ages,
races, and socioeconomic levels. Prevalence var-
ies considerably with some underdeveloped coun-
tries having rates from 4% to 100% of the general
population.1 In the developing world the populations
affected include children, the elderly, and immuno-
suppressed individuals. An infested host usually
harbors between 3 and 50 oviparous female mites,2
but the number may vary considerably among indi-
viduals. For example, patients with crusted, formerly
“Norwegian,” scabies (Fig. 178-1) who have a defec-
tive immunologic or sensory response (ie, leprosy,
paraplegic, or HIV-infected patients) harbor millions
of mites on their skin surface, with minimal pruritus.
Infants and the elderly may not be effective scratch-
ers and harbor intermediate numbers between 50 and
250 mites.
It is well established that close personal contact is
a prime route of transmission. Although sometimes
considered a sexually transmitted disease, the equally
high prevalence in children attests that close nonsexual
contact among children and other family members is
also sufficient to transmit the infestation. Transmission
via inanimate objects has been best demonstrated with
crusted scabies but is much less likely to occur in nor-
mal hosts. Crusted scabies is notoriously contagious,
Kang_CH178_p3274-3286.indd 3274
and anyone roaming within the general vicinity of
these patients risks acquiring the infestation. Indeed,
6000 mites/g of debris from sheets, floor, screen-
ing curtains, and nearby chairs have been detected.3
Mites are also prevalent in the personal environment
of normal scabies patients.4,5 In one study, live mites
were recovered from dust samples taken from bed-
room floors, overstuffed chairs, and couches in every
patient’s dwelling.5
ETIOLOGY AND
PATHOGENESIS
Scabies is an infestation by the highly host-specific
mite, Sarcoptes scabiei var. homini, family Sarcoptidae,
class Arachnida. The mite is pearl-like, translucent,
white, eyeless, and oval in shape with 4 pairs of short
stubby legs. The adult female mite is 0.4 × 0.3 mm with
the male being slightly smaller—just slightly too small
to be seen by the naked eye. The scabies mite is able to
live for 3 days away from the host in a sterile test tube,
and for 7 days if placed in mineral oil mounts.4,6 Mites
cannot fly or jump.
The life cycle of mites is completed entirely on
human skin. The female mite, by a combination of
chewing and body motions, is able to excavate a slop-
ing burrow of 0.5 to 5 mm/day in the stratum cor-
neum to the boundary of the stratum granulosum.7,8
Along this path, which can be 1 cm long, she lays any-
where from 0 to 4 eggs a day, or up to 50 eggs during
her life span of 30 days. Eggs hatch in 10 to 12 days
and larvae leave the burrow to mature on the skin
surface. After the larvae molt, they become nymphs
which can only survive 2 to 5 days off host. The male
mite lives on the surface of the skin and enters bur-
rows to procreate.
CLINICAL FINDINGS
The diagnosis of scabies is suspected by pruritus
associated with a characteristic distribution of lesions
and epidemiologic history. Onset is typically insidi-
ous, with the patient complaining of intense noctur-
nal pruritus. Pruritus typically appears 4 to 6 weeks
after initial infestation, although many patients
may not develop symptoms for 3 months and some
patients are never sensitized. With subsequent rein-
festations, symptoms develop within 2 to 3 days.9
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Figure 178-1 Crusted scabies. Hyperkeratotic plaques
populated with thousands of mites.
Similar to the human response to other insects such
as fleas, yellow jackets, and mosquitoes, there is
a wide range of clinical responses to an infestation
with scabies and some individuals remain asymp-
tomatic despite being infested. These individuals are
considered “carriers.”
On physical examination, patients display excoria-
tions and eczematous dermatitis that favors the inter-
digital webs (see Fig. 178-1), sides of fingers, volar
aspects of the wrists and lateral palms (Fig. 178-2),
elbows, axillae, scrotum, penis (Fig. 178-3), labia,
and areolae in women. The head and neck are usu-
ally spared in healthy adults, but in infants, elderly,
and immunocompromised individuals, all skin sur-
faces are susceptible. Indurated, crusted nodules
can be seen in infants and young children on inter-
triginous areas as well as on the trunk. In crusted
Figure 178-2 Scabies. Several thread-like burrows are
present in the web spaces of the fingers and on the knuck-
les, a common location for these lesions in scabies. Longi-
tudinal scraping of a burrow will often reveal the mite or
mite products under microscopic examination.
Kang_CH178_p3274-3286.indd 3275
27
Chapter 178 :: Scabies, Other Mites, and Pediculosis
Figure 178-3 Scabies. Microscopic examination of a
mineral oil preparation after scraping a burrow reveals a
gravid female mite with oval, gray eggs and fecal pellets.
scabies (see Fig. 178-1), hyperkeratotic plaques
develop diffusely on the palmar and plantar regions,
with thickening and dystrophy of the toenails and
fingernails. Although, patients with crusted type
have an enormous mite burden they have few or no
symptoms.
The pathognomonic lesion is a burrow, which is a
thin, thread-like, linear, or often J-shaped structure
(see Figs. 178-2 and 178-4) 1 to 10 mm in length. It is
a tunnel caused by the movement of the mite in the
stratum corneum. When present, the burrow is best
seen in the interdigital webs and wrists; however, it
can be difficult to find in early stages of the condi-
tion, or after the patient has extensively excoriated
the lesions. In infants and young children who are
less-effective scratchers, burrows can be identified on
palms and soles as well as intertriginous areas and
the trunk. Identification of a burrow can be facili-
tated by rubbing a black felt-tip marker across an
affected area. After the excess ink is wiped away with
an alcohol pad, the burrow appears darker than the
surrounding skin because of ink accumulation in the
burrow.
Figure 178-4 A dermoscopic image of triangle or “delta-
wing jet” sign of dense scabies head parts (long red arrow),
relatively translucent scabies body (long black arrow), sca-
bies eggs (short red arrows), and classic S-shaped burrow.
Heine Delta 20× dermatoscope with Nikon Coolpix 4500
camera. (From Fox G. Diagnosis of scabies by dermoscopy.
BMJ Case Rep. 2009;2009. Reproduced by permission from 3275
BMJ Publishing Group Ltd.)
08/12/18 10:44 am
27 A definitive diagnosis is made by microscopic
identification of the scabies mites, eggs, or fecal pel-
lets (scybala). This is accomplished by placing a drop
of mineral oil over a burrow and then scraping lon-
gitudinally with a number 15 scalpel blade along the
length of the burrow or a suspicious skin area, being
careful not to cause bleeding. Scrapings are best
taken from a burrow, papule, or vesicle that is not
excoriated. The scrapings are then applied to a glass
slide and examined under low power (see Fig. 178-3).
Confocal microscopy and dermoscopy also can be
used to examine the mite in vivo.10,11 The classic
dermoscopic finding is the “delta-wing jet” sign of
dense scabies head parts and body, eggs, and a bur-
Part 27
row (see Fig. 178-4). A skin biopsy can be diagnostic,
if the mite happens to be transected in the stratum
corneum (Fig. 178-5).
An enzyme-linked immunosorbent assay has
::
been developed for serologic testing of other mite
Infestations, Bites, and Stings
infestations in animals; however, no serologic tests
for scabies exist for humans.12 Despite the possibil-
ity of confirming the presence of mites via multiple
methods of testing, the diagnosis usually is based
on clinical impression, and solidified by response to
treatment.
A
B ■ Bullous pemphigoid
Figure 178-5 A skin biopsy can be diagnostic, if the mite
happens to be transected in the stratum corneum. Images
3276 show (A) ×4 magnification and (B) ×10 magnification of
scabies mite within the stratum corneum.
Kang_CH178_p3274-3286.indd 3276
DIFFERENTIAL DIAGNOSIS
Table 178-1 outlines the differential diagnosis of
scabies.
COMPLICATIONS
Secondary impetiginization may occur and poststrep-
tococcal glomerulonephritis has resulted from scabies-
induced pyodermas caused by Streptococcus pyogenes.
Lymphangitis and septicemia also have been reported
in crusted scabies. Finally, scabies infestation can also
trigger bullous pemphigoid.13,14
TREATMENT
Scabies is treated by a combination of a scabicide and
fomite control. With all insecticidal therapies, a second
application, usually a week after the initial treatment,
is required to reduce the potential for reinfestation
from fomites as well as to kill any nymphs that may
have hatched after treatment as a result of a semipro-
tective environment within the egg. All household
and close contacts must be simultaneously treated to
prevent reinfestation from mildly symptomatic and
asymptomatic carriers.
Topical scabicides are applied overnight to the entire
skin surface with special attention to finger and toe
creases, cleft of the buttocks, belly button, and beneath
the fingernails and toenails. In adults, one can exclude
treating the scalp and face. Most treated individuals
experience relief from symptoms within 3 days, but
patients must be informed that even after adequate
scabicidal therapy, the rash and pruritus may persist for
up to 4 weeks. The itching experienced during this time
period is commonly referred to as “postscabetic itch.”
TABLE 178-1
Differential Diagnosis of Scabies
Most Likely
■ Atopic dermatitis
■ Dyshidrotic eczema
■ Pyoderma
■ Contact dermatitis
■ Insect bite reaction
■ Id reaction
■ Varicella
■ Miliaria
Consider
■ Dermatitis herpetiformis
■ Psoriasis
■ Linear immunoglobulin A bullous dermatosis
■ Drug eruption
■ Systemic causes of pruritus
■ Delusions of parasitosis
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 TABLE 178-2
Treatment of Scabies
DRUG DOSE
Permethrin 5% cream Apply to entire body (neck down) for 8 to
14 hours then wash off, repeat in 7 days;
if crusted scabies use daily for 7 days
then twice weekly until cured
Lindane 1% lotion Apply for 8 hours, repeat in 7 days
Crotamiton 10% cream Apply for 8 hours on days 1, 2, 3, and 8
Precipitated sulfur 5% to 10% Apply for 8 hours on days 1, 2, and 3
Benzyl benzoate 10% lotion Apply for 24 hours
Ivermectin 200 µg/kg Taken orally on days 1 and 8; if crusted
scabies take on days 1, 2, 8, 9, and 15
a
”Black box” warning warns against usage in premature infants and individuals with known uncontrolled seizure disorders, as well as cautious usage in
infants, children, and the elderly including people who weigh less than 50 kg (110 pounds) and over 65 years old may be at risk of serious neurotoxicity.
Patients should be educated that excessive washing of
the skin with harsh soaps will aggravate their skin irri-
tation. Instead, oral antihistamines and emollients can
be beneficial. Table 178-2 summarizes the treatments
for scabies, but a few comments are warranted:
■ Lindane has received a “black box” warning as
well as restrictive labeling changes from the U.S.
Food and Drug Administration (FDA) to greatly
restrict its usage.15,16 Moreover, it is banned in
California.17 A physician should write a prescrip-
tion for lindane only when cognizant of all the
caveats noted by the FDA (see the footnote to
Table 178-2).18
■ There are no documented cases of scabies resis-
tance to permethrin, but tolerance is beginning
to develop.19 Pregnant females, breastfeeding
mothers, and children younger than age 2 years
should limit their 2 applications (1 week apart) to
2 hours only when using permethrin.
■ Crotamiton is considerably less effective than all
■
other options offered.
Five percent to 10% sulfur is messy, malodorous,
tends to stain, and can produce irritant dermatitis,
but is inexpensive and may be the only choice in
areas of the world in which a lack of funds dictates
therapy.20 The efficacy and toxicity of sulfur has not
been critically evaluated in recent years, but many
believe that it is the safest choice for neonates and
pregnant females.21
Ivermectin is an anthelmintic agent derived from
a class of compounds known as avermectins. It has
been used in veterinary medicine since 1981, and
has excellent antiparasitic properties.22-24 Ivermec-
tin has been approved since 1996 by the FDA for
treatment of 2 diseases, namely onchocerciasis and
Kang_CH178_p3274-3286.indd 3277
27
COMMENTS
Most common treatment presently; pregnancy category B,
tolerance seems to be developing
U.S. Food and Drug Administration “black box” warning now in
effecta; banned in California
Has antipruritic qualities; effectiveness is marginal
Considered safe in neonates and during pregnancy; limited efficacy
data; inexpensive
Chapter 178 :: Scabies, Other Mites, and Pediculosis
Not available in United States
Highly effective with good safety profile; not recommended for
children who weigh less than 15 kg (33 lb) or for pregnant or
lactating women; wash sheets and clothing at 60°C (140°F) and
dry in a hot dryer; items that cannot be placed in a washer can be
placed in a sealed plastic bag in a warm area for 2 weeks
strongyloides. Clinical efficacy for scabies has been
impressive at a dosage of 200 µg/kg given twice
1 week apart.25,26 Given that millions of people have
been treated for onchocerciasis worldwide without
significant side effects including pregnant women, it
appears to be extremely safe. Nevertheless, because
the drug acts on nerve synpases that utilize glutamate
or γ-aminobutyric acid, and because the blood–brain
barrier is not fully developed in young children, it is
not recommended for use in children who weigh less
than 15 kg (33 lbs) or in pregnant or lactating women.
Success rates approach 100% in studies where entire
households and close contacts of infested individuals
are treated while maintaining strict fomite controls.24,27
In crusted scabies, the combination of oral ivermec-
tin and a topical scabicide is recommended as the oral
medication will not penetrate into the thickness of the
keratinous debris under the nails.
PREVENTION
Several measures should be considered to reduce
the potential of reinfestation by fomite transmission.
Because of the common occurrence of asymptomatic
mite carriers in the household, all family members and
close contacts should be treated simultaneously. After
treatment, treated individuals should wear clean cloth-
ing, and all clothing, pillow cases, towels and bedding
used during the previous week should be washed
in hot water and dried at high heat. Nonwashables
should be dry-cleaned, ironed, put in the clothes dryer
without washing, or stored in a sealed plastic bag in a
warm area for 2 weeks. Floors, carpets, upholstery (in 3277
both home and car) play areas, and furniture should
08/12/18 10:44 am
27 be carefully vacuumed. Fumigation of living spaces is
not recommended. Pets also do not need to be treated
because they do not harbor the human scabies mite.
OTHER MITES BESIDES
SCABIES
AT-A-GLANCE
■ Scabies and Demodex live in the skin, most other
Part 27
mites drop off human host after feeding.
■ Some species are vectors of human disease.
■ Chiggers can cause pruritic vesicular, papular, or
granulomatous lesions.
::
Infestations, Bites, and Stings
There are 45,000 described species of mites that belong
to the subclass Acarina and the class Arachnida.
Table 178-3 lists some of the mites that can affect
humans. Human infestation by these mites occurs only
accidentally (save for Demodex species).
Demodex folliculorum hominis and Demodex brevis
are the only mites that routinely live on humans; D.
folliculorum resides in the hair follicle and D. brevis
resides in the infundibulum of the sebaceous gland.
Their presence has been linked with rosacea, perioral
dermatitis, and suppurative folliculitis; however, a
causal role for mites in these diseases has not been
established.
Although animal and fowl mites are not primary
parasites of humans, Pyemotes sp. can cause straw
itch, oak leaf eruption, or itch mite eruptions. These
mites can cause epidemics of dermatitis with out-
breaks in the last decade occurring in several Mid-
western States. Pyemotes ventricosus and Pyemotes
tritici occur in animal handlers, farmers participating
in harvesting of grain, and those exposed to decora-
tive grain.28,29 Pyemotes herfsi’s normal host is the leaf
galls on oak trees, and therefore this eruption char-
acteristically occurs in people who spend time out-
doors in or near wooded areas. Typical bites appear
TABLE 178-3
Mites Other Than Scabies
TYPE OF MITE SCIENTIFIC NAME
Follicle Demodex folliculorum hominis and Demodex brevis
Fowl Dermanyssus gallinae and Demodex avium
Straw itch Pyemotes tritici, Pyemotes ventricosus, and Pyemotes herfsi
Harvest or red Genus Trombicula: Eurotrombicula alfreddugesi and
(chiggers) Eurotrombicula splendens
Animal Ornithonyssus bacoti, Liponyssoides sanguineus,
Cheyletiella sp. (Cheyletielosis)
3278 House dust Dermatophagoides sp.
Kang_CH178_p3274-3286.indd 3278
on exposed skin as red macules with a small blister
center 10 to 16 hours after contact.
Harvest mites (also called berry bugs, red bugs,
scrub-itch mites, and chiggers) are in the family
Trombiculidae and are distributed worldwide.30 In
the United States, they inhabit mostly the southeast,
south, and midwest, in areas of grasslands and forest,
and damp areas along lakes and streams. Humans are
susceptible to the larvae from April until the first frost.
The minute, reddish larvae of Trombicula are less than
0.5 mm long and feed on skin cells of animals, includ-
ing humans. Rather than sucking blood, these mites
inject digestive enzymes into the skin breaking down
cells, which can subsequently cause severe reactions
and swelling. Each bite has a characteristic red pap-
ule with a white, hard central area. After feeding, they
drop off their hosts and mature into adults, which are
harmless to humans. Rarely does a victim realize when
the bite is occurring, as itching from a chigger bite does
not develop until 1 to 2 days after the bite. Chiggers
prefer warm, covered areas of the body, and thus the
bites are often clustered behind the knees, or beneath
tight undergarments such as socks, underwear, and
brassieres.
The house dust mite is a cosmopolitan guest in
human habitation and feeds off flakes of shed human
skin. The mites are harmless, but their bodies and
excreta are believed to play a role in human disease.
They are a common precipitant of asthma, hay fever,
and allergic respiratory symptoms worldwide. In
addition, atopic dermatitis may be exacerbated in
some patients by dust mite allergens.31,32
PEDICULOSIS
Pediculosis, the infestation of humans by lice, has
been a human affliction since antiquity. Three species
of lice infest humans: (a) Pediculus humanus capitis, the
head louse, (b) Pediculus humanus humanus, the body
or clothing louse, and (c) Phthirus pubis, the pubic, or
crab, louse. Patients present with pruritus secondary
to a delayed hypersensitivity reaction. After the ini-
tial exposure, it may take 2 to 6 weeks for the pruritus
to occur. Subsequent exposure results in symptoms
within 1 to 2 days of exposure.33
CLINICAL FEATURES/DISEASE ASSOCIATION
Associated with rosacea, idiopathic facial burning
Pruritic papules, sometimes with a hemorrhagic center
Patchy dermatitis on trunk and arms during and after harvesting
Scrub typhus vector; papular to vesicular lesions found on ankles,
waist, or warm skinfolds; most common in United States
Endemic/murine typhus vector; rickettsialpox vector; nonspecific
pruritic eruption on body parts in close contact with infested pets
Atopic dermatitis, allergies
08/12/18 10:44 am
 PEDICULOSIS CAPITIS
and all ethnic groups; however, the incidence is low
among African Americans in the United States, possi-
27
(HEAD LICE) bly as a consequence of an anatomic inability of female
lice in America to deposit eggs on coarse curly hair.35
A recent study by Koch and associates showed an
increase in trend in the number of prescriptions sug-
gesting either an increase in the number of infestations
AT-A-GLANCE or increased failure rates of nonprescription home
regimens.36
■ Infestation occurs worldwide affecting hairs of the Transmission occurs primarily by means of direct
scalp most commonly in children between the ages head-to-head contact and less commonly by indirect
of 3 and 12 years. (fomite) transmission through combs, brushes, blow-
■ Presence of 0.8-mm eggs (nits) firmly attached to dryers, hair accessories, upholstery, pillows, bedding,
scalp hairs is most common sign of infestation. helmets, or other headgear.37-42 Lice can be dislodged
■

Chapter 178 :: Scabies, Other Mites, and Pediculosis

Spread by close physical contact and sharing of
headgear, combs, brushes, and pillows.
■ Resistance to traditional nonprescription
preparations is growing; topical malathion and
ivermectin should be considered in resistant cases.
EPIDEMIOLOGY
Head lice infestations occur worldwide and are
most common in children between the ages of 3 and
12 years.34 Based on pediculicide sales in the United
States, an estimated 10 to 12 million children are
infected each year. Head lice affect all levels of society,
by air movement, blow-dryers, combs, and towels,
and passively transferred to fabric, facilitating new
infestations.30-32,34,35
ETIOLOGY AND PATHOGENESIS
Head lice are blood-sucking, wingless, highly host-
specific insects belonging to the order Anoplura. They
are almost 2 mm long with 3 pairs of claw-like legs
that are well adapted for grasping hair. Their entire
life cycle is on the scalp (Fig. 178-6). More than 95% of
infested individuals have fewer than 100 adult lice in
their scalps. The female louse lays 5 to 10 eggs per day
during her 30-day life span. After 10 days, the eggs

Head louse life cycle

5 2

3
4

Figure 178-6 Head louse life cycle. During egg laying, the female louse secretes a proteinaceous cement that flows from
the genital opening to adhere the egg tightly onto the hair shaft (1 and 2). The hatch-ready louse uses its mouthparts to
cut a circular hole in the operculum and sucks in air, which is expelled from its posterior, causing it to be quickly ejected
from the egg, typically 5 to 10 days after the egg was first laid (3 and 4). The emerged instar requires a blood meal soon
after hatching, and completes 3 molts, taking a blood meal between each, before developing into an adult 9 to 12 days
after hatching (4, 5, and 6). (Adapted from Figure 1 in Koch E, Clark JM, Cohen B, et al. Management of head louse infesta-
tions in the United States—a literature review. Pediatr Dermatol. 2016;33:466-472, with permission. Copyright © 2016, 3279
John Wiley and Sons.)

Kang_CH178_p3274-3286.indd 3279 08/12/18 10:44 am

27 hatch producing larvae, which are referred to as
nymphs or “instars.” Instars look like miniature adult
louse and go through 3 stages of development that take
14 days for full maturation. The eggs are laid approxi-
mately 1 cm from the scalp surface, firmly attached to
individual hairs with a proteinaceous glue secreted by
the female louse and that closely resembles the amino
acid composition of the human hair shaft itself.43,44
Lice typically survive less than 2 days away from the
scalp, although under favorable conditions of heat and
humidity, survival has been reported at 4 days. Nits
can survive for 10 days away from the scalp.
CLINICAL FINDINGS
Part 27
Pediculosis capitis is confined to the scalp with nits
(Fig. 178-7) found most readily in the occipital and
retroauricular regions. Most patients experience pru-
::
ritus. The average incubation before symptoms is
Infestations, Bites, and Stings
4 to 6 weeks. Some individuals remain asymptomatic
despite infestation, and can be considered “carriers.”
Mite bites may produce 2-mm erythematous mac-
ules or papules, but usually an examiner only finds
excoriations, erythema, and scaling. Other findings
may include a low-grade fever, regional lymphade-
nopathy, and irritability.
Infestations are diagnosed by demonstrating egg
capsules (nits) and live lice. Nits are readily seen by
the naked eye and are an efficient marker of past or
present infestation. They can be differentiated from
dandruff, hair casts, and the like, as nits are not easily
removed from the hair shaft.45 The color of newly laid
or viable eggs is tan to brown; the remains of eggs that
have hatched are clear, white, or light in color. More-
over, newly laid eggs are usually identified within a
3280 Figure 178-7 Nit sheath. Microscopic view of an egg, con-
taining an unhatched louse, attached to a hair shaft.
Kang_CH178_p3274-3286.indd 3280
few millimeters of the scalp and lice embryos can be
seen on dermoscopy, while hatched nits are usually
further from the scalp. The presence of adult lice con-
firms active infestation. However, lice are fast, avoid
light, and blend in with the hair, making them difficult
to find. Finding live adult lice or immature nymphs
is best achieved with fine combing the hair with a nit
comb. Wet combing, in which water and conditioner
are applied to the hair prior to using the nit comb,
increases the yield by prying the adult lice from the
hair follicles.44,45
DIFFERENTIAL DIAGNOSIS
Table 178-4 outlines the differential diagnosis of head
lice.
COMPLICATIONS
Although head lice have never been identified as a
source of transmission of infection, secondary bacte-
rial infections can occur with pediculosis capitis. In
fact, head lice are thought to be the most common
cause of pyodermas of the scalp in the developed
world.46
Head lice and body lice are closely related, so it is not
surprising that head lice can serve as host for rickett-
siae and have the potential of transmitting diseases.47,48
Head lice in laboratory experiments have been read-
ily infected with Rickettsia prowazekii.49 Bartonella quin-
tana, which causes trench fever, also has been isolated
in head lice.50-53 Transmission of these infections to
humans by pediculosus capitis, however, has never
been described and it is highly unlikely to occur out-
side of experimental conditions.
TREATMENT
Standard treatment recommendations for pediculosis
capitis utilize a 2-step process of confirming active
infestation with live lice and then treating the infes-
tation with a nonprescription or prescription pedicu-
licidal therapy. Pediculicide choice is typically based
on local resistance patterns and access of patients to
a physician for prescription medications.54 However,
with increasing resistance to pediculicides, a mul-
timodal approach, similar to Staphylococcus aureus
TABLE 178-4
Differential Diagnosis of Head Lice
■ Seborrheic dermatitis (dandruff )
■ Insect bites
■ Eczema
■ Psoriasis
■ Hair gel hair spray
■ Piedra (a fungal infection)
■ Pseudonits (desquamated epithelial cells with sebaceous plugs
encircling the hair)
■ Delusions of parasitosis
08/12/18 10:44 am
 therapy, is warranted to prevent widespread resis-
tance to currently available products.55 This is espe-
cially important when treating with prescription
pediculicides.
Physical methods to treat infestations, including
shaving one’s head to avoid infestation, dates back
to the 6th century bc, when priests and wealthy
Egyptians removed scalp hair and wore wigs. The
routine of head shaving for military services today
was founded on the same principle. While a buzz
haircut may be a solution for boys, such an approach
would be traumatic psychologically for girls.
Another method is to comb the nits out after appli-
cation of a hair moisturizer such as Cetaphil. The
fomite reinfestation, it is recommended to repeat
treatment with all insecticidal treatments in 1 week.
27
Table 178-5 summarizes the array of treatments for
head lice. One of the leading factors for the increas-
ing number of infestations is resistance of lice to topi-
cal therapies.65-70 Since the introduction of insecticides
years ago, the louse has adapted by several genetic
alterations. The agents with the highest success rates,
namely malathion and ivermectin, are prescription
products. One trial has shown oral ivermectin given
twice at a 7-day interval to be more effective than topi-
cal malathion lotion.71 However, both pediculicides
are highly effective and treatment decisions should
be based on local resistance patterns and individual

Chapter 178 :: Scabies, Other Mites, and Pediculosis

moisturizer is applied, left in for 2 minutes, then all
the lotion is combed out. The hair is then dried with
a hair dryer. This can be done every few days, with
the best results showing cure rates of 95% if done
over a 24-day period.56 However, combing out nits
is difficult, tedious, time-consuming, and somewhat
painful. Although wet combing can be an adjuvant
to topical insecticidal therapy, it is not, by itself, suf-
ficient in most situations.47
Pediculicides remain the most effective treatment
for head lice.57-64 Given (a) variable ovicidal activity,
(b) possible lack of patient compliance, (c) growing
resistance to pediculicides, and (d) the potential of
patient characteristics.
There are a number of anecdotal and market-driven
reports with occlusive and suffocation methods
(such as with application of petrolatum, mayonnaise,
dimethicone, vegetable oil, mineral oil, hair pomade,
and olive oil).72,73 However, there are no studies estab-
lishing the safety and efficacy.36 To accurately evalu-
ate pediculicidal activity of any compound, one must
appreciate that head lice have the ability to “resurrect”
from a state of seeming death, in which respiratory and
motor function appear to have ceased.74,75 These insects
are less dependent than mammals for continuous ner-
vous control of respiration and circulation, and the

TABLE 178-5
Treatment of Head Lice and Crab Lice
ADMINISTRATION RISK FACTORS

Pyrethrins synergized (RID, Topically for 10 minutes b

Pronto, etc.)a
Permethrin 1%a lotion (Nix)
Permethrin 5% cream
Malathion 0.5% (Ovide) shampoo
Carbaryl 0.5%
Lindane 1%
Benzyl alcohol 5% lotion
Topical ivermectin 0.5% lotion
Ivermectin (Stromectol), oral
200 µg/kg
Spinosad 0.9% suspension
a
Available in nonprescription form.
b
Apply to dry scalp and hair followed by adequate washing out with nonmedicated shampoo (head lice).
c
See footnote to Table 178-2. “Black box” warning: Lindane is still available for patients weighing more than 50 kg (110 lbs) and younger than age 65 years,
but is cautioned against use because of neurotoxicity.
Topically to damp hair for 10 minutes,
rinse then repeat in 7 daysb
Topically overnightb
Topically to dry hair and leave on for
8 to 12 hours allowing to dry naturally;
then shampoo and use a lice comb
Topically overnight
Topically for 4 minutesb
Topically to dry hair for 10 minutes, rinse
then repeat in 7 days
Topically to hair once although most
experts recommend reapplication a
week later
Orally on days 1, 8, and 15
Topically to dry hair for 10 minutes then
rinse; repeat in 7 days
Allergy to chrysanthemums, ragweed, or related plants; increased
resistance with steep decline in effectiveness
First-choice treatment except in places with known resistance;
approved for patients older than age 2 months
None; if used for “resistant” head lice, no evidence that it is more
effective than permethrin 1% lotion
High flammability so avoid hair dryer or open flame while wet; burn-
ing/stinging at sites of eroded skin; approved for patients older
than age 6 years
Not available in United States
U.S. Food and Drug Administration (FDA) “black box” warning now in
effectc; banned in California
Dosed by hair length so can be costly; can be used in pregnant and
lactating women; approved for children older than age 6 months;
minor side effects
Approved for patients older than age 6 months
Very good efficacy on adult lice although inferior to permethrin; not
ovicidal, hence nits are safe until they hatch; not recommended
for pregnant females or children weighing less than 15 kg (33 lbs);
not FDA approved for pediculosis
Do not use in infants younger than age 6 months because of benzyl
alcohol content; minor side effects
3281

Kang_CH178_p3274-3286.indd 3281 08/12/18 10:44 am

27 exact point of death is not readily defined. Indeed, the
World Health Organization recommends pediculicidal
testing to be read 24 hours after application of insecti-
cide because doing otherwise results in overestimation
of mortality rates.52 Not following these guidelines has
led to overestimates of the efficacy of several alterna-
tive treatments with occlusive agents and essential oils
from health food stores. Such products slow the move-
ments of adult lice and may allow them to be more eas-
ily combed out of the scalp, but these substances are
usually not lethal to lice.
Patients should be counseled in at least some effec-
tive measures to prevent reinfestation by fomite
transmission. After treatment, treated individuals
Part 27
should wear clean clothing, and all clothing, hats, pil-
low cases, towels, and bedding used during the pre-
vious week should be washed in hot water and dried
at high heat. Nonwashables should be dry-cleaned,
::
ironed, put in the clothes dryer without washing,
Infestations, Bites, and Stings
or stored in a sealed plastic bag in a warm area for
2 weeks. Combs and brushes may be washed in very
hot water (65°C [149°F]) or may be coated with the
pediculicide for 15 minutes. Floors, carpets, uphol-
stery (in both home and car), play areas, and furni-
ture should be carefully vacuumed to remove any
hairs with viable eggs attached. Fumigation of liv-
ing spaces is not recommended and pets do not need
to be treated because they do not harbor the human
head louse. Despite treatment, nits can remain on the
hair for months. Therefore a strict “no nit” policy will
only result in significant absence from school.76 As a
result, the American Academy of Pediatrics does not
recommend a “no nit” policy.
PEDICULOSIS CORPORIS
(BODY LICE)
AT-A-GLANCE
■ Infestations most commonly found in homeless
individuals, refugees, and victims of war and
natural disasters.
■ Diagnosis made by presence of nits in lining of
clothing, particularly the seams.
■ Infections transmitted by body lice include
epidemic typhus, trench fever, and relapsing fever.
ETIOLOGY AND PATHOGENESIS
P. humanus humanus, body lice, have a very similar
morphology to head lice, except they are 30% larger.
The body louse’s life span is 20 days during which the
female may lay up to 300 eggs. The lice lay their eggs
in the seams of clothing, while obtaining their blood
3282 meals from the host. The body louse can survive with-
out a blood meal for up to 3 days.
Kang_CH178_p3274-3286.indd 3282
EPIDEMIOLOGY
Pediculosis corporis requires exposure to the louse
and favors an inability to wash and change clothing.
Consequently, it is most commonly found on homeless
individuals, refugees, victims of war and natural disas-
ters, or those forced into crowded living conditions
with poor hygiene. The infestation is usually transmit-
ted by contaminated clothing or bedding. After expo-
sure, the inability to wash or change clothes allows the
infestation to persist.
CLINICAL FINDINGS
Symptomatically, patients complain of pruritus. Most
commonly, the only sign of body lice is excoriations,
often linear and primarily on the back, neck, shoul-
ders, and waist. Postinflammatory pigmentation is
seen in chronic cases. Adult lice are not easily seen
except in heavy infestations. Diagnosis is made by
closely examining the lining of the clothing, particu-
larly at the seams, for the presence of nits. The cloth-
ing also may be shaken over a sheet of white paper,
at which time the lice may be seen moving about on
the paper.
DIFFERENTIAL DIAGNOSIS
Table 178-6 outlines the differential diagnosis of body lice.
COMPLICATIONS
Several important human diseases are transmitted
by the body louse. The major diseases include epi-
demic typhus (caused by a rickettsiae, R. prowazekii),
murine typhus (caused by Rickettsia typhi), trench
fever (caused by B. quintana), and relapsing fever
(caused by a spirochete, Borrelia recurrentis).77-81 Lice
obtain organisms, such as rickettsiae and spirochetes,
from ingestion of blood meals from infested hosts.
Transmission of microorganisms from body lice is
not from the louse bite, but rather by (a) contami-
nated fecal material being scratched into excoriated
skin of bite sites, (b) inhalation of dry, powdery louse
feces from handling typhus-contaminated bedding
or clothing, or (c) an infected louse having its gut
ruptured, allowing an infective blood meal to enter
TABLE 178-6
Differential Diagnosis of Body Lice
■ Scabies
■ Atopic dermatitis
■ Contact dermatitis
■ Drug reaction
■ Viral exanthem
■ Other animal parasites
■ Systemic causes of pruritus
■ Delusions of parasitosis
08/12/18 10:44 am
 excoriations on the skin. In addition, excoriation can
lead to secondary infection with S. aureus, S. pyogenes,
and other bacteria.
human hairs. The adult crab louse can survive for
36 hours off the human host, and the eggs are viable
27
for up to 10 days.

TREATMENT
The most important treatment for body lice is dis-
infestation of all clothing and bedding. Beds should
be burned or sprayed with lice sprays, because the
body louse may lay eggs on the seams of the mat-
tress or couch. Clothing is best treated like biohaz-
ardous waste, bagged, and tightly sealed in specially
marked, plastic, biohazard bags. The waste is handled
separately from other trash until it can be inciner-
EPIDEMIOLOGY
Crab lice can be found in all levels of society and all eth-
nic groups. Patients with crab lice often have another
concurrent sexually transmitted disease. Although
pediculosis pubis is considered a sexually transmitted
disease, transmission has been documented to occur
from contaminated clothing, towels, and bedding.
CLINICAL FINDINGS

Chapter 178 :: Scabies, Other Mites, and Pediculosis

ated, maintaining a temperature of 65°C (149°F) for
30 minutes. If this is not possible, clothing and bed-
In the case of crab lice, all hairy parts of the body should
ding should be fumigated, machine washed in hot
be examined, especially the eyelashes, eyebrows, and
water, and dried on high heat or dry-cleaned. Hot iron-
perianal area. Many individuals have 2 different hair-
ing of the seams of upholstered furniture should also
bearing sites infested.82 These lice can be mistaken for
be performed and exposure to infested items should
scabs or moles, or can blend in with skin color, mak-
be strictly avoided for 2 weeks. The patient should be
ing them difficult to detect. Infested patients have an
treated from head to toe with a topical insecticide or
average of 10 to 25 adult organisms on their body. Nits
given oral ivermectin.
also can be identified near the base of hairs (Fig. 178-8).
The diagnosis can be confirmed by microscopic exami-
nation of the plucked hair to identify the nits and/or
PEDICULOSIS PUBIS adult lice. Although rare, skin lesions named maculae
caerulea, representing hemorrhage, can be seen with
(CRAB LICE) pubic lice, with slate gray to bluish, irregular-shaped
macules approximately 1 cm in diameter. Pediculosis
palpebrarum, or phthiriasis palpebrarum, is the infes-
tation of the eyelashes with crab lice.
AT-A-GLANCE
■ Best to call “crab lice” (rather than “pubic lice”)
DIFFERENTIAL DIAGNOSIS
as infestations may involve other hair-bearing Table 178-7 outlines the differential diagnosis of crab lice.
sites such as mustache, beard, axillae, eyelashes,
eyebrows, and scalp hair.
■ Transmitted by sexual or close contact, as well
as via fomites (contaminated clothing, towels,
and bedding).
■ Topical therapy options similar to pediculosis
capitis, but oral ivermectin is the preferred
treatment for this infestation.

ETIOLOGY AND PATHOGENESIS

Pediculosis pubis is caused by infestation of the body
with P. pubis. Crab lice range from 0.8 to 1.2 mm in
length and have wide, short bodies resembling tiny
crabs. They have a serrated edge on their first claw,
which gives them traction on flat, hairless, surfaces;
thus, they can navigate across the entire body sur-
face. They most commonly are found in the pubic
and perianal region, but occasionally they also reside
in mustache, beard, axillae, eyelashes, eyebrows, and
scalp hair. In hirsute individuals, they are also found Figure 178-8 Pediculosis pubis. Several lice and their
on the short hairs of the thighs and trunk. The louse dot-like nits attached to the hair shafts can be seen in the
has a life span of less than 3 weeks, during which pubic area of this patient. (Used with permission from D.A. 3283
time the female will lay approximately 25 eggs on Burns, MD.)

Kang_CH178_p3274-3286.indd 3283 08/12/18 10:44 am

27 TABLE 178-7
Differential Diagnosis of Crab Lice
■ Excoriations
■ Scabies
■ Contact dermatitis
■ Piedra
■ Trichomycosis pubis
■ Hair casts
■ Nevi
TREATMENT
Part 27
Shaving is not curative as the louse will seek another
hairy area of the body to reside. Crab lice are treated
with the same topical therapy as that for pedicu-
::
losis capitis (see Table 178-5).83 In vitro and in vivo
resistance to pyrethrins have been shown.84 There is
Infestations, Bites, and Stings
a lack of appreciation for their tendency to inhabit
rectal hair.82 Unless the physician is certain that only
one body area is involved, all hairy areas of the body
should be treated because (a) it is not uncommon to
have other areas infested, and (b) lice can migrate away
from a treated areas to other hair-bearing locations. For
this reason, oral ivermectin is recommended for this
entity.52 However, as ivermectin treatment relies on
the insect obtaining a blood meal, so the nits are not
affected and the patient requires repeat oral ivermectin
on day 8 and day 15.
Phthiriasis palpebrarum (Fig. 178-9) has tradition-
ally been treated with petrolatum (Vaseline), but this
treatment is slow and needs to be applied at least
5 times a day for weeks. Ivermectin is the first-line
therapy for this condition.85
Fomite precautions mirror those discussed previ-
ously for pediculosis capitis. Treatment failure is usu-
ally a result of failure to treat all hairy areas (especially
perirectally) or reinfestation from neglecting to treat
sexual contacts. Other household members are also
infested occasionally and should be carefully ques-
tioned for symptoms and/or examined.
Figure 178-9 Pediculosis pubis. Eyelash infestation with
3284 Pthirus pubis. Nits can be seen attached to the eyelashes.
(Used with permission from D.A. Burns, MD.)
Kang_CH178_p3274-3286.indd 3284
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