Novel use of wraps for patients with crusted scabies in a resource limited setting
Dear Editor, Crusted scabies is a severe variant of scabies caused by the hyperinfestation with the mite Sarcoptes scabiei var hominis. Conventional therapies for scabies are less successful in treating this condition. Ivermectin in combination with topicals is more effective than topicals alone and is the drug of choice in outbreaks as it allows quick control of lesions and hence decreases spread. Unfortunately, ivermectin is not easily accessible in Sub Saharan Africa and where it is available the cost is exhaustive, precluding public sector patients from benefitting from it. Wet wraps are a well established therapy in atopic eczema and have been successfully adapted for use in psoriasis, pityriasis rubra pilaris, mycosis fungoides, dermatomyositis, urticaria pigmentosa, and erythroderma. The mechanism of actions includes repair of the epidermis, decreased water loss, increase absorption of corticosteroids, and protection from allergens and scratching. To our knowledge wet wraps have not been used in patients with crusted scabies. Seven adult patients who presented consecutively with crusted scabies to our outpatient dermatology clinic over a 1 year period were treated with wet wraps (Table 1) Patients with typical scabies did not receive this regimen. On examination they had hyperkeratotic plaques on the trunk, limbs, hands, and feet with a mean body surface area of 30% involvement (Figures 1 and 2) Fissuring was noted on the hands of four patients. Three patients had concomitant secondary bacterial infection and were treated with flucloxacillin orally prior to wraps. A mixture of 40% salicylic acid 500 g and 100 mL benzyl benzoate was applied to the hands and feet and a mixture of 20% salicylic acid 500 g and 100 mL benzyl benzoate was applied to the trunk and extensors. The lesions were then covered with a double layer of bandages; a moist inner and a dry outer layer (Figure 3B) This was repeated for three consecutive days. Benzyl benzoate was then applied for a further 3 days, administered as outpatient therapy. Patients were followed up a week after the initiation of therapy. A
Dermatologic therapy