Nov 29, 2016

By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy

"How's it going Mr. Peterson?" "It's a dog eat dog world, Woody and I'm wearing Milk Bone underwear." If you knew that quote was from Norm at Cheers, you are an intelligent, worldly, urbane and probably exceedingly good looking person. If you just asked "Who is Norm?" or "What is Cheers?", what is wrong with you? Okay, that might be a little harsh. It might be that you are too young to have seen Cheers on TV. Or that I'm getting old. Last week, Randy Daley came to the pharmacy to teach the Dauphin Clinic Pharmacy staff a customer service seminar. It was very well done, and I loved his example of giving Cheers level service. Cheers is where everyone knows your name. Whether it is a bar, restaurant, bank or pharmacy, customers love it when you take the time to learn their name. It might not always be easy, but learning people's names is something to strive for. However, while I thought Randy nailed the idea with his Cheers level service example, it seemed like over half the people in my group had no idea what Cheers was. The youth of today has wandered off the path, again…

The path to an itch free evening can take you through scabies country. Scabies is a contagious infestation of the skin caused by the human mite called Sarcoptes scabiei. The scabies mite is almost too small to be seen with the naked eye. The mites also burrow under the skin so they are almost never seen. Over 300 million people worldwide have scabies, and it is most common in people living or working in very crowded conditions. Schools are not usually crowded enough to promote transmission. Scabies is most commonly transmitted by close personal contact (i.e. usually by skin to skin contact). The pregnant female mite burrows 0.5 to 5 mm per day through the top layer of skin and lays two to three eggs per day. Three or four days later, the eggs hatch and the larvae travel to the skin surface and mature into adult mites in 14 to 17 days. The smaller male mite lives on the skin surface and dies shortly after mating. The female mite lives about 30 days.

What are the main symptoms of scabies? The most common symptom of scabies is itching. It can be quite severe and worse at night. If this is the first infestation a person has with scabies, the itchiness may not occur until weeks after the infestation. The itchiness is due to sensitization to the mites, eggs and feces. If a person has had scabies before, the itchiness can happen as early as 24 hours after infestation. As the female digs through the skin, she leaves behind a burrow. The burrows look like tiny lines or waves in the skin 2-5 mm long. The burrow lines don't appear on every patient, but if you can see the wavy lines it is easier for the doctor to confirm the itch is from scabies. In adults, the itch and rash don't appear on the face or scalp, but in young children they can. Excessive scratching can lead to secondary infections like impetigo.

What do you do if someone in your house is very itchy, especially at night? See the doctor to find out what the itch is for certain. After the diagnosis of scabies is confirmed, we should treat the infested person and their close physical contacts at the same time, whether or not symptoms are present. Remember some people can have scabies for weeks before they start itching, and they are still contagious during that time. Permethrin 5% cream is the preferred agent for anyone over 2 months old. We usually tell people to use the permethrin cream before bed. We then tell the person take a warm (not hot) bath or shower, and dry off. They should massage the cream into the skin from their neck down to the soles of their feet. They should pay special attention to areas between fingers and toes, under fingernails, wrists, armpits, buttocks, and external genitalia. After applying the cream they should put on clean clothing, put clean sheets on the bed and climb in. The cream should be washed off in the shower or bath after 12 to 14 hours. Usually one treatment will kill off the scabies, but a second treatment in 7-10 days is now becoming a standard recommendation. The itchiness will take 1-2 weeks to go away, and is not a sign that the scabies treatment isn't working. A child is safe to go to school the day after using the first dose of permethrin cream. Even after the permethrin 5% cream is applied, itching is often still a problem. Steroid creams like betamethasone and oral antihistamines like diphenhydramine or Benadryl are often prescribed with the permethrin 5% cream.

There are less commonly used alternatives to 5% permethrin cream. We have compounded a sulfur cream under the direction of a physician in the past. It also works, but it is messier and smellier than permethrin. It is less convenient as it has to be applied for 3 days in a row. But the sulfur ointment is an effective alternative to permethrin. Another commercially available alternative to permethrin 5% cream is crotamition or Eurax cream. It is considered less effective than permethrin 5% cream and it has to be applied daily for 2 days so it is less convenient.

What about cleaning the house, bed linens and yourself? Start by trimming finger and toe nails to make sure there aren't mites hiding there. Then wash clothes and linens in soap and hot (60 C) water. Items that can't be washed should be dry cleaned, or put in a plastic bag for a week. The mite doesn't survive for more than two days off of people. All surfaces, rugs, and furniture should be vacuumed. There is some controversy about how likely it is to get scabies from inanimate objects like bed sheets. The easiest way to get scabies is from skin to skin contact with a person who has scabies. Although there are documented cases of people getting scabies only through touching bed sheets, it is apparently much more difficult than through contact with a person.

Back at Cheers, a bartender asked, "Hey Norm, how's the world been treating you?" to which Norm replied "Like a baby treats a diaper." If you and your family have scabies, it does kinda feel like the world is treating you unfairly. But with a week or two of treatment, we should be able to get everyone back to normal. In the meantime, may I suggest you take up an artistic pursuit? I think I know how Norm would react if I suggested that. "Can I draw you a beer, Mr. Peterson?" "I know what they look like, Woody. Just pour me one."

The information in this article is intended as a helpful guide only. It is not intended to be used as a substitute for professional advice. If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.

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As always if you have any questions or concerns about these or other products, ask your pharmacist.


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