Correspondence

Ivermectin for Crusted (Norwegian) Scabies

N Engl J Med 1995; 332:612March 2, 1995

Article

To the Editor:

Crusted (Norwegian) scabies is caused by an infestation with Sarcoptes scabiei var. hominis in which the mite population is enormous and may number in the millions. Crusted scabies is more difficult to treat than ordinary scabies and may require repeated treatments with scabicides and sometimes the sequential use of several agents. Recommended treatments for scabies include benzyl benzoate, sulfiram, malathion, lindane, and permethrin.

Ivermectin is an antiparasitic agent used in veterinary practice against a wide range of nematodes, insects, and acarine parasites. It is commonly used to treat onchocerciasis (river blindness) in humans. In pigs, a single oral dose heals lesions caused by S. scabiei var. suis and Hematopinus suis (sucking lice). Recent reports1,2 of the use of ivermectin for ordinary scabies prompted us to use the drug for crusted scabies. We describe two patients with crusted scabies that was successfully treated with a single oral dose of ivermectin.

A 48-year-old woman with Down's syndrome had extensive crusted scabies. She had been treated for ordinary scabies with benzyl benzoate six months previously. Generalized lymphadenopathy and eosinophilia (eosinophil count, 1800 per cubic millimeter) were observed. Examination of skin revealed multiple live mites with eggs. The patient was given a single oral dose (12 mg) of ivermectin (Mectizan, Merck), in addition to a 3 percent topical ointment of salicylic acid. Forty-eight hours later the itching and skin lesions had improved, and skin scraping did not reveal any mites. Definitive healing occurred on the fifth day after treatment. There were no recurrences or side effects during three months of follow-up.

An 82-year-old woman who had received systemic corticosteroids for 11 years for polymyalgia rheumatica was treated for scabies with benzyl benzoate. When the characteristic skin changes recurred, she was hospitalized, and crusted scabies was diagnosed. Superficial lymphadenopathy and eosinophilia (eosinophil count, 1100 per cubic millimeter) were present. The patient received a single oral dose of ivermectin (12 mg) in addition to a 3 percent salicylic acid ointment. The skin lesions improved within 48 hours and completely disappeared within six days. There were no recurrences or side effects during eight months of follow-up.

Our results suggest that oral ivermectin is a potential treatment for crusted scabies, as has been suggested previously.3 Further study is necessary to evaluate the effectiveness of this treatment, the risk of recurrence after treatment, and the incidence of side effects.4

François Aubin, M.D.
Philippe Humbert, M.D.
Centre Hospitalier Universitaire de Besançon, 25030 Besançon, France

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