10.5826/dpc.1304a307
Introduction: Scabies is a common disease affecting the pediatric population. Treatment failure and relapses are frequent.
Objectives: We aimed to define factors affecting topical treatment success in pediatric scabies patients.
Methods: This multicenter cross-sectional study was performed between April and December 2022. Pediatric scabies cases were classified as treatment failure (TF) versus treatment success (TS).
Results: We enrolled 170 patients in the study. In the TF group, the presence of symptomatic household members and referral from physicians other than dermatologists were more common (both p&lt;0,001) and relapse rates and total symptom duration were higher (p=0,007, p&lt;0,001 respectively). Permethrin 5% was more commonly used in the TF group (71.1% versus 25%) (p&lt;0,001); however, the ratio of patients treated with sulfur preparations was significantly higher in the TS group (60.7% vs 16.9%) (p&lt;0,001). Misapplication of topical therapy was significantly more common in the TF group (p&lt;0,001), statistically significant errors being: (i) lack of treatment of close contacts (p&lt;0,001); (ii) single application (p&lt;0,001); and (iii) local application (p=0,027). In a multivariate analysis, treatment success was mainly associated with (i) presence of atopy (O.R.: 5,29, 95% CI:  1,22-25,57) ;(ii) absence of symptomatic household members (O.R.: 5,29, 95% CI:  1,72-16,27);  (iii) presentation to dermatologists rather than other specialties (O.R.: 6,08, 95% CI: 1,9-19,51); whereas use of permethrin negatively affected treatment success (O.R: 0,22, 95% CI: 0,07-0,71).
Conclusions: Pediatric scabies patients should be treated before other family members get affected and with topicals other than permethrin. Awareness of scabies disease needs to be increased among non-dermatologists.
text/xml
2160-9381
3717
en
Beril Kara Esen
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
treatment
Factors Affecting Topical Treatment Success in Pediatric Scabies Cases: A Cross-Sectional Study
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2023-10-31
2023-07-24
2023-10-31
2024-01-16
e2023307
Dermatol Pract Concept
Introduction: Scabies is a common disease affecting the pediatric population. Treatment failure and relapses are frequent.
Objectives: We aimed to define factors affecting topical treatment success in pediatric scabies patients.
Methods: This multicenter cross-sectional study was performed between April and December 2022. Pediatric scabies cases were classified as treatment failure (TF) versus treatment success (TS).
Results: We enrolled 170 patients in the study. In the TF group, the presence of symptomatic household members and referral from physicians other than dermatologists were more common (both p&lt;0,001) and relapse rates and total symptom duration were higher (p=0,007, p&lt;0,001 respectively). Permethrin 5% was more commonly used in the TF group (71.1% versus 25%) (p&lt;0,001); however, the ratio of patients treated with sulfur preparations was significantly higher in the TS group (60.7% vs 16.9%) (p&lt;0,001). Misapplication of topical therapy was significantly more common in the TF group (p&lt;0,001), statistically significant errors being: (i) lack of treatment of close contacts (p&lt;0,001); (ii) single application (p&lt;0,001); and (iii) local application (p=0,027). In a multivariate analysis, treatment success was mainly associated with (i) presence of atopy (O.R.: 5,29, 95% CI:  1,22-25,57) ;(ii) absence of symptomatic household members (O.R.: 5,29, 95% CI:  1,72-16,27);  (iii) presentation to dermatologists rather than other specialties (O.R.: 6,08, 95% CI: 1,9-19,51); whereas use of permethrin negatively affected treatment success (O.R: 0,22, 95% CI: 0,07-0,71).
Conclusions: Pediatric scabies patients should be treated before other family members get affected and with topicals other than permethrin. Awareness of scabies disease needs to be increased among non-dermatologists.
Beril Kara Esen
2023/10/31
10.5826/dpc.1304a307
e2023307
Esenler District Health Directorate, Republic of Türkiye Ministry of Health, Istanbul, Turkey
2160-9381
treatment
en
e2023307
De Sainte Marie B, Mallet S, Gaudy-Marqueste C, et al. Gales en échec de traitement : étude observationnelle [Therapeutic failure in scabies: An observational study]. Ann Dermatol Venereol. 201;143(1):9-15. DOI: 10.1016/j.annder.2015.10.588. PMID: 26651923.
Factors Affecting Topical Treatment Success in Pediatric Scabies Cases: A Cross-Sectional Study
https://dpcj.org/index.php/dpc/article/download/3717/2368
     Factors Affecting Topical Treatment Success
 in Pediatric Scabies Cases: A Cross-Sectional Study
       Muazzez Cigdem Oba1, Defne Ozkoca2, Rana Basara Sahin3, Didem Senses Kazan4,
                            Gaye Guldiken5, Beril Kara Esen6


1 Department of Dermatology, Health Sciences University, Sancaktepe Sehit Prof. Dr. Ilhan Varank Research and Training Hospital,
  Istanbul, Turkey
2 Department of Dermatology, Zonguldak Atatürk State Hospital, Zonguldak, Turkey
3 Department of Dermatology, Menemen District State Hospital, Izmir, Turkey
4 Department of Dermatology, Kutahya Evliya Celebi Research and Training Hospital, Kutahya, Turkey
5 Department of Dermatology, Artvin Hopa State Hospital, Artvin, Turkey
6 Esenler District Health Directorate, Republic of Türkiye Ministry of Health, Istanbul, Turkey



Key words: children, permethrin, scabies, sulfur, treatment
Citation: Oba MC, Ozkoca D, Basara Sahin R, Senses Kazan D, Guldiken G, Kara Esen B. Factors Affecting Topical Treatment
Success In Pediatric Scabies Cases: A Cross-Sectional Study. Dermatol Pract Concept. 2023;13(4):e2023307. DOI: https://
doi.org/10.5826/dpc.1304a307
Accepted: September 20, 2023; Published: October 2023
Copyright: ©2023 Oba et al. This is an open-access article distributed under the terms of the Creative Commons
Attribution-NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted
noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Muazzez Cigdem Oba, MD, Department of Dermatology, Health Sciences University, Sancaktepe Sehit
Prof. Dr. Ilhan Varank Research and Training Hospital, Istanbul, Turkey. Email: muazzez.oba@istanbul.edu.tr
Patient Consent Statement: All patients legal representants gave written consent to participate in the study.




  ABSTRACT              Introduction: Scabies is a common disease that affects the pediatric population. Treatment failure and
                        relapse occur frequently in children.
                        Objectives: We aimed to identify the factors that affect topical treatment success in pediatric scabies
                        patients.
                        Methods: A multicenter cross-sectional study was conducted from April 2022 to December 2022.
                        Pediatric scabies cases were classified as belonging to either the treatment failure (TF) group or the
                        treatment success (TS) group.
                        Results: We enrolled 170 patients for the study. In the TF group, the presence of symptomatic house-
                        hold members and referrals from physicians other than dermatologists were more common (both
                        P < 0.001), and relapse rates and total symptom duration were higher (P = 0.007, P < 0.001, respec-
                        tively). Regarding treatment agents, 5% permethrin was more commonly used in the TF group (71.1%
                        versus 25%; P < 0.001). The proportion of patients treated with sulfur preparations was significantly




Original Article | Dermatol Pract Concept. 2023;13(4):e2023307                                                                     1
                      higher in the TS group (60.7% versus 16.9%; P < 0.001). Misapplication of topical therapy was sig-
                      nificantly more common in the TF group (P < 0.001), with statistically significant errors being (i) lack
                      of treatment of close contacts (p<0,001), (ii) single application (P < 0.001), and (iii) local application
                      (P = 0.027). A multivariate analysis revealed that TS was mainly associated with (i) the presence of at-
                      opy (odds ratio [OR] 6.12, 95% CI: 1.39–27.04), (ii) the absence of symptomatic household members
                      (OR 6.31, 95% CI: 2.14–18.63), and (iii) presentation to a dermatologist rather than another spe-
                      cialist (OR 6.51, 95% CI: 2.11–20.13). The use of permethrin negatively affected treatment success
                      (OR 0.22, 95% CI: 0.07–0.71).
                      Conclusions: Pediatric scabies patients should be treated before other family members become infest-
                      ed and with topicals other than permethrin. In addition, awareness of scabies needs to be increased
                      among non-dermatologists.




Introduction                                                       Patient Population
                                                                   All consecutive pediatric scabies cases were prospectively en-
Scabies is a significant global healthcare issue, with a rising    rolled to the study at the time of the outpatient dermatology
incidence and reported outbreaks [1,2]. Treatment failure          visit. Patients were classified as belonging to either the treat-
occurs in approximately one third of the cases of scabies,         ment failure (TF) group or the treatment success (TS) group.
which possibly contributes to the increasing incidence of the      Treatment failure cases were diagnosed both clinically and
disease in developed countries [3].                                dermatoscopically by the presence of burrows despite topical
    Epidemiologic data shows that the most common age              therapies that had persisted for at least one month. The diag-
range of scabies cases is 10–29 years [4]. Children represent      nosis of the treatment success group was made according to
a special population, as there are delays in their diagnosis,      previous patient medical records along with patient history
and they are frequently insufficiently treated [1]. Thus, treat-   (eg, previous involvement of predilection sites and presence
ment failure and relapse are frequent in children.                 of postinflammatory changes).
    In clinical practice, authors have observed a growing
number of pediatric scabies cases presenting to dermatology        Data Collection
outpatient clinics. To improve treatment outcomes, risk fac-       During the dermatology outpatient visit, the following pa-
tors for treatment failure should be identified and addressed.     rameters were recorded for each enrolled patient: age, sex,
                                                                   presence of atopic diathesis, travel history, presence of pruri-
Objectives                                                         tus, duration of symptoms, number of household members,
                                                                   number of children in the household, presence of symptom-
In this study, we aimed to identify the factors that affect top-   atic household members, prescribed treatment, referring
ical treatment success in pediatric scabies patients presenting    physician, number of relapses, and application errors. The
to dermatology outpatient clinics.                                 latter included lack of treatment of close contacts, lack of
                                                                   reapplication, local application of topical products, inap-

Methods                                                            propriate concentration of topical products, inappropriate
                                                                   quantity of topical products, and lack of head and neck
Study Design                                                       treatment of infants.
A multicenter cross-sectional national study was performed
from May 2022 to December 2022 on pediatric scabies cases          Statistical Analysis
presenting to dermatology outpatient clinics in five different     We used SPSS version 21 for the statistical analyses. Median
cities. The study was approved by the ethics committee of          and interquantile range (IQR) values were noted in descrip-
Sancaktepe Sehit Prof.Dr.Ilhan Varank Research and Train-          tive analyses for continuous variables, and percentages were
ing Hospital (no. 38 12-04-2022) and performed in accor-           noted for categorical variables. A Mann–Whitney U test was
dance with the principles of the Declaration of Helsinki.          performed to compare continuous variables between the two
Written informed consent was obtained from the legal repre-        groups, whereas categorical variables were compared with
sentatives of the pediatric patients.                              the chi-square test and Fischer exact test when appropriate.




2                                                                      Original Article | Dermatol Pract Concept. 2023;13(4):e2023307
Using variables with P values < 0.25 in univariate analy-                was also more common in the TF group (85.9%) than the TS
ses, factors affecting TS were analyzed with logistic regres-            group (39.3%; P < 0.001). Sociodemographic factors, includ-
sion analysis. A P value of less than 0.05 was considered                ing number of household members and number of children
significant.                                                             in the household and duration of symptoms before the first
                                                                         therapy, did not seem to affect treatment results (Table 1).
                                                                         The TF group had significantly higher relapse rates and to-
Results
                                                                         tal symptom duration (P = 0.007 and 0.001, respectively;
We enrolled 170 pediatric patients for the study, which in-              Table 1). Patients were also classified according to the spe-
cluded the TF group (N = 142, 83.5%) and the TS group                    cialty of the referring physicians. The proportion of patients
(N = 28, 16.5%). All patients in the TF group had associ-                treated solely by dermatologists was greater in the TS group
ated pruritus at referral, and severe pruritus was significantly         than the TF group (71.4% versus 20.4%; P < 0.001; Table 2).
more commonly present in the TF group (P < 0.001) than                         Regarding errors in application of topical therapy,
in the TS group. The TS group (25%) included significantly               96,5% of the patients in the TF group had made at least
more patients with atopic diathesis than the TF group (9.2%;             one error, whereas all except one patient in the TS group
P = 0.026). The presence of symptomatic household members                had applied the prescription correctly (P < 0.01). A list of



                                               Table 1. Patient characteristics.
                                                          Treatment failure               Treatment success
                                                               N = 142                         N = 28                      P
 Sex N (%)
 Female                                                            71(50)                      17(60.7)                   0.3
 Male                                                              71(50)                      11(39.3)
 Pruritus N (%)
 None                                                                0                         19(67.9)                 <0.001
 Mild                                                             33(23.2)                       7(25)
 Severe                                                          109(76.8)                       2(7.1)
 Travel history N (%)
 Yes                                                             130(91.5)                     25(89.3)                   0.716
 No                                                               12(8.5)                       3(10.7)
 Atopy N (%)
 No                                                              129(90.8)                      21(75)                    0.026
 Yes                                                              13(9.2)                        7(25)
 Symptomatic household members N (%)
 Present                                                          20(14.1)                     17(60.7)                 <0.001
 Absent                                                          122(85.9)                     11(39.3)
 Age (year) median (IQR)                                         7 (3.75-12)                 6 (3.25-13.25)               0.784
 Number of household members
 Median (IQR)                                                      5(4-5)                       4 (4-4)                   0.081
 Number of children in the household
 Median (IQR)                                                      2 (2-3)                       2(2-2)                  0.141
 Duration of symptoms before first therapy
 Median (IQR)                                                    30 (15-30)                   20 (11-30)                 0.083
 Total symptom duration
 Median (IQR)                                               60 (56.25-120)                   60 (32.5-60)                0.007
 Number of relapses
 Median (IQR)                                                      1 (1-2)                      0 (0-0)                 <0.001

IQR = interquartile range




Original Article | Dermatol Pract Concept. 2023;13(4):e2023307                                                                       3
                     Table 2. Specialty distribution of pediatric patients treated for scabies.
                                                                     Treatment failure         Treatment success
                                                                          N = 142                   N = 28
                                                                           N (%)                     N (%)                   P
 Referring specialist before presentation to dermatology
 Emergency physician                                                      24(16.9)                      1(3.6)             0.082
 General practitioner                                                     53(37.3)                    4(14.3)              0.018
 Pediatrician                                                             42(29.6)                    4(14.3)              0.096
 Dermatologist alone                                                      29(20.4)                   20(71.4)            <0.001




                                   Table 3. Application errors of topical therapy.
                                                             Treatment Failure            Treatment Success
                                                                  N = 142                       N = 28
                                                                   N (%)                        N (%)                       P
 Application error
 Present                                                          137(96.5)                       1(3.6)                <0.001
 Application errors
 Close contacts not treated                                        73(51.4)                       0(0.0)                <0.001
 Lack of reapplication                                             57(40.1)                       0(0.0)                <0.001
 Local application                                                 21(14.8)                       0(0.0)                  0.027
 Inappropriate dosage                                              16(11.3)                       1(3.6)                  0.312
 Inappropriate quantity                                             14(9.9)                       0(0.0)                  0.130
 Lack of head-neck treatment of infants                              6(4.2)                       0(0.0)                  0.591




application errors can be found in Table 3. In the TF group,      95% CI: 2.14–18.63), and (iii) presentation to a dermatolo-
statistically significant errors were the following: (i) close    gist rather than another specialist (OR 6.51, 95% CI: 2.11–
contacts were not treated (P < 0.001), (ii) reapplication         20.13). The use of permethrin lotion negatively affected
in the first week was not performed (P < 0.001), and (iii)        treatment success (OR 0.22, 95% CI: 0.07–0.71).
treatment was not applied to the whole body (P = 0.027).
Regarding the referring physician, patients treated solely by
                                                                  Conclusions
dermatologists made significantly fewer application errors
(Table 4). Patients without atopic diathesis (83.3%) were         The present study focuses on factors affecting treatment suc-
more prone to make errors in the application of topicals than     cess of anti-scabietic topical treatments in pediatric popula-
atopic patients (65%), with a borderline statistical difference   tion. We identified presence of atopy, absence of symptomatic
(P = 0.066).                                                      household members and presentation to dermatologists
    Regarding treatment agents (Table 5), 5% permethrin           rather than other specialties as predictors of treatment suc-
lotion was more commonly used in the TF group than in             cess whereas use of permethrin lotion negatively affected
the TS group (71.1% versus 25%; P < 0.001). However,              treatment success. Several studies have previously investi-
the ratio of patients treated with sulfur preparations was        gated risk factors of treatment failure in scabies, focusing
significantly higher in the TS group (60.7% versus 16.9%;         on different treatment methods and clinical features. In a
P < 0.001).                                                       multicenter study conducted in France, monotherapy with
                                                                  topical benzyl benzoate and a single intake of oral ivermec-
Univariate and Multivariate Analyses                              tin were identified as predictors of treatment failure in mul-
Univariate and multivariate analyses were performed to iden-      tivariate analyses [3]. Lee et al reported that limited mobility
tify the factors associated with treatment success ­(Table 6).    and topical steroid use before diagnosis were associated with
The predictors of treatment success were (i) the presence         treatment failure in topical permethrin treatment [5].
of atopy (odds ratio [OR] 6.12, 95% CI: 1.39–27.04), (ii)             Boralevi et al studied the clinical characteristics of pe-
the absence of symptomatic household members (OR 6.31,            diatric scabies according to age. They reported a history of



4                                                                     Original Article | Dermatol Pract Concept. 2023;13(4):e2023307
        Table 4. Specialty distribution of pediatric patients treated for scabies according to presence
                                             of application errors.
                                                                                              Application error
                                                                                Absent                Present
                                                                                N = 32                N = 138
                                                                                N (%)                  N (%)                 P
 Referring specialist before presentation to dermatology
 Emergency physician                                                            1(3.1)                  24(17.4)             0.05
 General practitioner                                                        5(15.6)                    52(37.7)             0.017
 Pediatrician                                                                6(18.8)                     40(29)              0.226
 Dermatologist alone                                                        21(65.6)                    28(20.3)            <0.001



            Table 5. Topical therapy agents used in treatment failure and treatment success groups.
                                                                   Treatment failure             Treatment success
                                                                        N = 142                       N = 28
                                                                         N (%)                         N (%)                     P
 Topical therapy agent
 Permethrin 5% lotion                                                 101(71.1)                          7(25)               <0.001
 Permethrin 5% cream                                                      9(6.3)                         0(0.0)               0.358
 Wilkinson ointment (sulfur 12.5%., tar 12.5%))                         26(18.3)                        5(17.9)               0.955
 Sulfur in vaseline                                                     24(16.9)                     17(60.7)                <0.001
 Other (benzyl benzoate, balsam of Peru)                                  4(2.8)                         1(3.6)               1.000



         Table 6. Factors associated with treatment success in univariate and multivariate analyses.
                                                                   Univariate                                Multivariate
                                                            OR       %95CI                P        OR             %95CI          P
 Sex (ref. Female)
 Male                                                       0.65    0.28-1.48            0.302    0.37        0.12-1.20       0.098
 Age (year)                                                 1.02    0.94-1.10            0.683    1.05        0.95-1.16       0.364
 Atopy (ref. Present)
 Absent                                                     3.31    1.18-9.25            0.023    6.12       1.39-27.04       0.017
 Symptomatic household members (ref. Present)
 Absent                                                     9.43   3.86-23.04        <0.001       6.31       2.14-18.63       0.001
 Presentation to dermatologist alone (ref. No)
 Evet                                                       9.74    3.9-24.34        <0.001       6.51       2.11-20.13       0.001
 Use of permethrin lotion (ref. No)
 Yes                                                        0.14    0.53-0.34        <0.001       0.22        0.07-0.71       0.011

CI = 95% confidence Interval; OR = odds ratio;, ref. = reference category.Nagelkerke R2:0,491, Hosmer and Lemeshow:0,689


atopic dermatitis in 12.8% of 323 pediatric patients, mainly            Our study showed that the presence of symptomatic
in patients under 15 years of age. A very similar proportion        household members decreased treatment success. In ad-
of pediatric patients in our cohort (11.8%) had atopy. These        dition, total symptom duration was significantly longer in
children with atopic diathesis were found to respond better         the TF group. We can conclude that the identification and
to therapies. We hypothesized that parents of atopic children       treatment of the disease before its propagation is associated
would have better compliance with topical therapies. In fact,       with better treatment outcomes. In this regard, prompt and
in our series, patients with atopic diathesis made fewer er-        correct recognition of the disease by all specialists is im-
rors in the application of topical therapies than non-atopic        portant, as scabies patients also present to general practi-
patients.                                                           tioners, pediatricians, and emergency departments [6,7]. In



Original Article | Dermatol Pract Concept. 2023;13(4):e2023307                                                                        5
our cohort, the majority of patients (71.8%) were referred to            The limitations of our study include a lack of longitu-
dermatology outpatient clinics by non-dermatologists. How-         dinal follow-up with the patients and a relatively small TS
ever, patients treated solely by dermatologists had better         group, as patients typically present to dermatology outpa-
treatment outcomes than those referred by other specialists.       tient clinics with persistent infection.
Treatment application errors were also less common in pa-                In conclusion, in line with previous reports of perme-
tients treated solely by dermatologists. We stress that aware-     thrin resistance, pediatric scabies cases should be prescribed
ness of the proper treatment of scabies needs to be increased      with topicals other than permethrin, preferably sulfur con-
among general practitioners, pediatricians, and emergency          taining preparations. Pediatric patients should be treated
physicians.                                                        promptly before other family members are affected. Special
    At the time of the study, oral ivermectin was unavail-         care should be taken in topical treatment of scabies patients
able in our country; thus, all patients in our study cohort        without atopic diathesis as they are more prone to make ap-
were only treated with topical therapies. Topical permetrin        plication errors. In addition, awareness of scabies treatment
is the first-line therapy for scabies in children [8]. Although    needs to be increased among non-dermatologists.
in vitro results prove its effectiveness [9], longer exposure
times are required for its effectiveness, and widespread clin-     References
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