CASE 4

3. Differentiate the drugs in the regimen based on their mechanisms of action,

benefits and major toxicities anticipated.

RECOMMENDED REGIMEN
MECHANISM OF ACTION BENEFITS MAJOR TOXICITES
1. Permethrin Acts on the nerve cell  Drug of choice for  No known toxic effects
5% cream membrane to disrupt the scabies, Preg Cat B. to human
sodium channel current by  More effective than  Tolerance seems to be
which the polarization of Crotamiton in developing
the membrane is treating symptoms
regulated. Delayed and reducing chances
repolarization and of secondary
paralysis of pests are bacterial infection
consequences of this  Safer choice
disturbance
2. Lindane 1% Stimulates nervous system  Second line drug if  Unsafe for children
of parasites causing Permethrin is not and neonates, because
seizures and death effective of increased
transcutaneous
absorption leading to
possible neurotoxicity
 Black box warning
now in effect
 Neurotoxicity

ALTERNATIVE REGIMEN
MECHANISM OF BENEFITS MAJOR TOXICITIES
ACTION
1. Crotamiton 10% Unknown; has good  Has antipruritic  Effectiveness
Cream acaricidal action in qualities marginal and
vitro associated with
frequent treatment
failures
2. Precipitated sulfur Elicits antiseptic,  Safe in neonates and  Limited efficacy data
5%-10% antiseborrheic and during pregnancy  Messy, malodorous,
keratolytic and  Inexpensive stains clothes,
antiparasitic effects  Used in mass therapy requires repeat
but not approved by in resource poor application, reduced
FDA for scabies economies compliance
 Irritant dermatitis
3. Benzyl benzoate Unclear but acts as  High efficacy, no  Significant immediate
10% lotion acaricide in vitro resistance, low cost skin irritation
4. Ivermectin 200 Binds selectively with  Highly effective with  Not recommended
mcg/kg glutamate-gated good safety profile for children less than
chloride ion channels  For crusted scabies 15kg or for pregnant
in invertebrates nerve  Good compliance or lactating women
and muscle cells because oral  CNS Toxicity
causing cell death
4. What additional measures will you advise the mother aside from pharmacologic
treatment?

Several measures should be considered to reduce the potential of re-infestation by fomite

transmission. Because the common occurrence of asymptomatic mite carriers in the
household, all the family members and close contact should be treated simultaneously. After
treated individual should wear clothing and all clothing, pillowcases, towels and bedding
used during the previous week should be washed in hot water and dried high heat. Non-
washable 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. Cutting fingernails, and clean under them
thoroughly to remove any mites or eggs that may be present. Floors, carpets, upholstery
play areas, and furniture should be carefully vacuumed. Avoid scratching and keeping any
open sores clean. Topical measures to reduce itching such as cool baths or calamine lotion
should not be given while the prescription cream is being used because it will wash the
cream off or prevent it from getting into the skin. Regular washing of hair with shampoo
should also be done. Fumigation of living spaces is not recommended. Pet also does not
need to be treated because they do not harbor the human scabies mite.