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Treatment, prevention and public health management of impetigo, scabies, crusted scabies and fungal skin infections in endemic populations: a systematic review

  • Doherty Institute for Infection and Immunity


We conducted a systematic review of the treatment, prevention and public health control of skin infections including impetigo, scabies, crusted scabies and tinea in resource-limited settings where skin infections are endemic. The aim is to inform strategies, guidelines and research to improve skin health in populations that are inequitably affected by infections of the skin and the downstream consequences of these. The systematic review is reported according to the PRISMA statement. From 1759 titles identified, 81 full text studies were reviewed and key findings outlined for impetigo, scabies, crusted scabies and tinea. Improvements in primary care and public health management of skin infections will have broad and lasting impacts on overall quality of life including reductions in morbidity and mortality from sepsis, skeletal infections, kidney and heart disease. © 2018 The Authors. Tropical Medicine & International Health Published by John Wiley & Sons Ltd.
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Article Type: Systematic Review
Treatment, prevention and public health management of impetigo, scabies, crusted scabies and
fungal skin infections in endemic populations: a systematic review
Philippa J. May1, Steven Y.C. Tong2,3, Andrew C. Steer4,5, Bart J. Currie3,6 , Ross M. Andrews3,8,
Jonathan R. Carapetis8,9,10, Asha C. Bowen3,8,9,10,11
1. Northern Territory Centre for Disease Control, Rocklands Drive, Casuarina, Australia
2. Victorian Infectious Diseases Service, Royal Melbourne Hospital, and The University of
Melbourne, at the Peter Doherty Institute for Infection and Immunity, Grattan Street, Parkville,
3. Menzies School of Health Research, Charles Darwin University, Casuarina, Australia
4. Royal Childrens Hospital, Parkville, Australia
5. Murdoch Childrens Research Institute, University of Melbourne, Parkville, Australia
6. Royal Darwin Hospital, Casuarina, Australia
7. National Centre for Epidemiology & Population Health, Australian National University, Canberra,
8. Princess Margaret Hospital for Children, Subiaco, Australia
9. Wesfarmers Centre for Vaccines and Infectious Diseases,University of Western Australia,
Subiaco, Australia
10. School of Medicine, University of Western Australia, Nedlands, Australia
11. University of Notre Dame Australia, Fremantle, Australia
We conducted a systematic review of the treatment, prevention and public health control of skin
infections including impetigo, scabies, crusted scabies and tinea in resource limited settings where
skin infections are endemic. The aim is to inform strategies, guidelines and research to improve skin
health in populations that are inequitably affected by infections of the skin and the downstream
consequences of these. The systematic review is reported according to the PRISMA statement. From
1759 titles identified, 81 full text studies were reviewed, and key findings outlined for impetigo,
scabies, crusted scabies and tinea. Improvements in primary care and public health management of
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skin infections will have broad and lasting impacts on overall quality of life including reductions in
morbidity and mortality from sepsis, skeletal infections, kidney and heart disease.
Keywords: impetigo, scabies, crusted scabies, tinea
Children in developing countries and other resource-limited settings bear a disproportionate burden
of skin infections, owing to poverty, poorer living conditions, normalisation and limited access to
primary health care.1-4 More than 162 million children are estimated to have impetigo at any one
time5 and more than 110 million children with scabies.6 There are no estimates for the global burden
of tinea in children, although fungal skin infections were the leading skin disease and in the top 10
most prevalent diseases worldwide in 2010.7
Primary infection with impetigo and secondary bacterial infection of scabies, crusted scabies
and tinea with the bacteria Staphylococcus aureus and Streptococcus pyogenes (Group A
Streptococcus, GAS) lead to morbidity, mortality and socioeconomic costs via invasive infection.8,9
Invasive S. aureus has a global incidence estimate of 20 to 50 cases/100,000 population per year
with a case fatality rate of 530%.10,11 An estimated 163,000 people die from GAS bacteraemia each
year.8 Moreover, post streptococcal sequelae of acute rheumatic fever (ARF) and acute post
streptococcal glomerulonephritis (APSGN) can lead to long term consequences of chronic heart and
kidney disease.8,12,13 Due to differences in the social determinants of health, there exists a marked
disparity in the burden of skin infections and their sequelae between resource-rich and resource-
limited settings.14
Systematic reviews of skin infection treatments that have only included randomised clinical
trials (RCT),15-18 exclude a large body of available evidence from resource-limited settings where the
burden is highest.5-7 RCTs are often conducted in hospital outpatient departments (OPD) in high
income settings, and findings may not be directly applicable to resource-limited settings where
cultural practices, access, availability, cost and acceptability of treatments may differ. There remains
a lack of consensus on the best treatments and population health approaches for the prevention and
control of skin infections, both individual skin conditions and skin infections collectively, in these
resource-limited settings due to a lack of a review of the evidence that is externally valid to these
populations. We conducted a systematic review of studies from resource-limited and endemic
settings regarding the prevention, treatment and public health management of impetigo, scabies,
crusted scabies and tinea to inform the development of evidence-based guidelines and future
research priorities for skin infections in endemic populations.
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Search Strategy and Selection Criteria
This systematic review is reported according to the Preferred Reporting items for Systematic
Reviews and Meta-Analyses (PRISMA) statement.19 The methods and search strategy have been
described previously.20 Briefly peer reviewed and grey literature databases were searched. Studies
published in English since 1960 using any experimental study (RCTs, clinical controlled trials, before
and after studies and interrupted time series analyses) or observational study design (cohort and
ecological studies) were included. Eligible participant types included Indigenous peoples and
populations in resource-limited settings (low, low-middle and middle income countries and
resource-limited populations in Organisation for Economic Co-operation and Development (OECD)
countries) (see supplementary appendix for definitions) with a diagnosis of impetigo, scabies,
crusted scabies, tinea capitis, tinea corporis or tinea unguium (onychomycosis) in persons of any age
or sex. We reviewed any clinical or public health interventions aiming to reduce skin infections with
any type of comparator. Outcomes were categorised as primary (cure or decrease in prevalence for
population-based studies) or secondary (microbiological cure, symptom relief, recurrence,
adherence, acceptability, adverse events and spread to contacts). Two authors (AB and PM)
independently screened the titles and abstracts of all studies identified in the search process and
selected the studies for eligibility assessment. Full reports of these studies were obtained and
assessed by two independent reviewers (ten reviewers in total). Any discrepancies for inclusion were
resolved by consensus discussion.
Assessment of Methodological Quality and Data Extraction
Two reviewers independently scored for methodological quality of clinical trials using The Cochrane
Collaboration’s tool for assessing risk of bias.21 Observational studies were assessed for blinding,
completeness of outcome data, outcome reporting and other sources of bias including confounders.
All data were entered into data extraction forms using Covidence online software (Veritas Health
Innovation, Melbourne, VIC, Australia) by the two independent reviewers and discrepancies resolved
via discussion.
Statistical Analysis and Synthesis
The data are presented in a narrative synthesis. Meta-analysis was not performed due to the
heterogeneity of studies. Calculations were performed using STATA13 (Statacorp, Texas, USA). For
reading ease, results are presented in common theme groups in each area of clinical treatment or
public health prevention and control relevant to skin infections in resource-limited settings. As many
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population-based studies incorporate multiple strategies such as health education, treatment and
hygiene practices, it is recommended that all evidence is considered by the reader as a whole. We
used the GRADE approach to rate evidence across studies for specific clinical outcomes to link
evidence-quality evaluations to recommendations in clinical guidelines (Table 1).
The search strategy identified 1,759 titles and 455 abstracts for screening, of which 193 met the
inclusion criteria. 81 full text studies were included (Figure 1), representing >27,633 participants
over a 40-year period (1976 2015). The study size, type, location and condition under study are
summarised (Figure 2, Supplementary Table 1). The study details and characteristics are summarised
in Table 2. There were 44 (54%) RCTs, four (5%) cluster RCTs, three (4%) controlled clinical trials,
three (4%) controlled before and after studies and three (4%) controlled population studies
(Supplementary Table 2). There were two (3%) before and after studies, four (5%) ecological studies,
14 (17%) prospective cohort studies and four (5%) retrospective observational studies appraised
(Supplementary Table 3).
Summary of clinical treatment recommendations for resource limited settings (Supplementary File
1. Comprehensive community skin health programs
Moderate quality evidence that treatment combined with comprehensive skin control measures
(health promotion, environmental interventions and screening) add benefit in sustaining a reduction
in scabies prevalence alone (2B)22 and impetigo and scabies prevalence combined (2C).23-25 No
studies assessed the effect of a community skin health program on impetigo or tinea alone, whilst
one study described this for scabies,22 one for scabies and impetigo,23,24 and one for general skin
infections.25 High quality evidence from studies using control communities would be advantageous
in determining the measurable benefit over standard treatment (Table 3).
In Bangladesh, moderate quality evidence was provided from a study where permethrin MDA
was followed by randomisation of male boarding school students to a scabies control program
(repeat permethrin treatment for scabies, health promotion activities with a designated scabies class
monitor, daily bathing with soap, and bags for bedding and clothing storage) or control.22 At four
months, scabies prevalence was 5% (intervention) and 50% (control), p <0.001.22 In Australia, low
quality evidence was provided from a permethrin MDA that included a comprehensive skin control
program (annual treatment and community clean up days, health promotion and repeat treatment
with permethrin for scabies) in a remote Indigenous community.23,24 Scabies prevalence declined
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from 35% to 12%, p<0.0001 and impetigo from 11% to 2%, p=0.0005.23,24 In Kenya, ow quality
evidence was provided from a 5 year dermatology project within primary health care (training of
health care workers and school based treatments) that did not show a sustained reduction in
impetigo, scabies or tinea.25
2. Impetigo
I. Directed antimicrobial therapy
High quality evidence supports the use of oral co-trimoxazole or intramuscular (IM) benzathine
penicillin G (BPG) for the treatment of impetigo (1A).26,27 Oral amoxicillin or oral erythromycin are
suitable alternatives (2B).28 Oral penicillin G is not recommended for treatment of impetigo (2D).29
Although topical antibiotics are recommended as the preferred treatment for impetigo in
industrialised settings,16 there is no available evidence from resource limited contexts for topical
antibiotics or evidence to not treat impetigo.
High-quality evidence from two open label RCTs with Australian Indigenous children compared
oral co-trimoxazole versus IM BPG and found no difference in clinical or microbiological cure of
impetigo.26,27 Moderate quality RCT evidence reported clinical cure in 89% of patients in both groups
when oral amoxicillin and oral erythromycin for 7 days in Mali were compared.28 Low quality RCT
evidence in Canadian Indigenous children compared oral penicillin G for 10 days with IM BPG, with
treatment failure equivalent: 16% and 14% respectively.29 No studies assessed topical agents or used
a placebo controlled design for impetigo.
II. Mass Drug Administration (MDA)
No studies assessed MDA for impetigo alone. Impetigo was a secondary outcome in scabies MDAs
reported below
III. Complimentary/alternative therapies
No studies assessed complimentary therapies for impetigo.
IV. Handwashing and hygiene practices
High quality evidence supports daily handwashing with soap for the treatment and prevention of
impetigo, with no benefit found for antibacterial soap over regular soap (1A).30,31
In Pakistan, high quality evidence from two RCTs enrolling households with children assessed
handwashing with soap for impetigo and found a benefit for soap, but no difference between
antibacterial (triclocarbon 1.2%) and standard soap.30,31
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3. Scabies
All studies on scabies treatment used clinical cure or symptom relief as end points.
I. Directed anti-parasitic therapy
a. Topical treatment vs. topical treatment
Seven studies compared topical anti-parasitic agents for scabies,32-38 with low to moderate quality
evidence for either topical permethrin or topical ivermectin (2B).32,33 Permethrin is superior to
lindane (1A),34 topical crotamiton (2C)35 or Tenutex emulsion (disulphiram and benzyl benzoate[BB])
in those >4 years (2C).36 Topical ivermectin is superior to topical crotamiton in those >2 years (2C).37
Very low quality evidence from one study that topical BB or topical permethrin is safe in pregnant
women (2C).38 Without high-quality evidence to support modified applications of topical treatments
for scabies, the standard whole body application remains strongly recommended (1D).
High-quality RCT evidence from an Iranian hospital OPD found two applications of 5%
permethrin achieved a superior clinical cure (85%) compared to 1% lindane (49%), p<0.05.34 Clinical
cure was similar with topical ivermectin or topical permethrin in an Iranian dermatology OPD.33
When topical ivermectin 1% and topical permethrin 5% were compared with oral ivermectin, clinical
response at one week was superior with either topical treatment (69% and 75% v 30%, p<0.05)
whilst cure at 4 weeks was universal for all three agents.32 Topical permethrin35 and topical
ivermectin37 were superior to topical crotamiton at four weeks follow up. Topical permethrin was
superior to Tenutex emulsion.36 Very low quality evidence from a refugee camp on the Thai-Burmese
border assessed safety of permethrin and BB in pregnancy.38
b. Modified application of permethrin
Practice point Box: How is it best to apply topical scabicides?
Twenty-nine studies incorporated a topical scabicide/s, mostly permethrin. (Supplementary Table 4).
One study directly compared neck to toe application (head to toe in children) with application to
lesions only.39 Overall, head to toe or neck to toe was recommended in 26 studies, lesion only in four
(three of which were topical ivermectin and not specified in seven studies. Full body application of
topical scabicides is recommended (1D). The effective application of topical scabicides requires a
private setting where the clothes can be removed for application. This is not always practical or
achievable in overcrowded households and may limit the effect of topical therapy.
c. Oral treatment vs topical treatment
Moderate to high quality evidence supports the use of oral ivermectin or topical permethrin for the
treatment of scabies (1A).32,40-42
A comparison of topical 5% permethrin with oral ivermectin in a high quality RCT from India
found lesion count and pruritus significantly lower for permethrin at one week whilst clinical cure at
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four weeks was the same.40 Moderate quality evidence from India reached similar conclusions.32
From Iran, low quality evidence is provided from two studies that compared oral ivermectin with
topical permethrin and found superior symptom relief with permethrin at two weeks, whilst clinical
cure was the same.41,42 There is moderate-high quality evidence that oral ivermectin achieved
superior clinical cure than topical lindane43-45 or topical sulphur.46 Comparisons of oral ivermectin
with topical BB showed discrepant results: no difference in clinical cure based on high quality RCT
evidence from Vanuatu47 whilst oral ivermectin was superior for clinical cure in moderate quality
evidence from Senegal48 and Nigeria.49
II. Mass Drug Administration (MDA)
There is moderate quality evidence for MDA to control scabies in resource-limited communities
(1B),50-53 with high quality comparison studies needed to determine the best agent. Moderate
quality evidence for the population effect of MDA for scabies on scabies and impetigo prevalence
using either topical permethrin or oral ivermectin (1B).23,54-56 Oral ivermectin is superior to topical
permethrin and standard of care for community-wide use in children >5 years and non-pregnant
adults in isolated settings with high prevalence of scabies and impetigo (1B).57 High quality studies
conducted in mainland populations are required to determine the effectiveness of the MDA
approach in highly mobile populations.
a) Scabies only
Low to moderate quality evidence from four studies in Fiji,50 India52,53 and Tanzania51 assessed MDA
impact on scabies prevalence only. Two doses of oral ivermectin achieved a 95% reduction in scabies
in India52 whilst single dose ivermectin MDA was not superior to BB in Fiji.50 Ivermectin delivered in a
lymphatic filariasis MDA reported a 68-98% decline in scabies.51 When 25% BB was delivered in an
MDA to an Indian orphanage, cure was 100% at 6 weeks.53
b) Scabies and Impetigo
i. Permethrin MDA
Low quality evidence is provided from permethrin MDA’s, which were all ecological in design with
different populations reviewed at baseline and follow up. Four studies from Panama56 and remote
Australian Aboriginal communities23,54,55 showed a reduction in scabies and impetigo prevalence
following MDA with 5% permethrin. The first scabies MDA used permethrin in a remote Kuna Indian
population in Panama in 1986 and although interrupted by political tensions demonstrated a
sustained response.56 The permethrin MDAs were combined with impetigo treatment and broad-
based community skin programs including surveillance, health promotion, home cleaning and
retreatment of cases in Australia.23,54,55
ii. Ivermectin vs. Permethrin MDA
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Moderate quality evidence is provided from a cluster RCT where oral ivermectin and topical
permethrin MDAs were compared with standard case treatment with topical permethrin for scabies
in three Fijian island communities.57 Ivermectin was superior at 12 months for scabies and
iii. Ivermectin MDA
Low quality evidence is provided from two studies that assessed the effect of oral ivermectin
MDA on scabies prevalence.58,59 In the Solomon Islands, two doses of oral ivermectin reduced the
prevalence of scabies at three years59 and this was sustained at a further follow up 15 years later.60
In contrast, an oral ivermectin MDA delivered in a remote Australian Aboriginal community did not
show significant or sustained declines in scabies prevalence.58
iv. Azithromycin MDA
Very low quality evidence from an azithromycin MDA for trachoma in a remote Australian Aboriginal
population reported impetigo reduction at 2 3 weeks which returned to baseline at 6 months.61
Scabies prevalence was unchanged.61
III. Complimentary therapy
Moderate quality evidence that cold cream can be used as an adjunct to topical sulphur for scabies
In a Mexican orphanage RCT, topical 10% sulphur in pork fat was compared with topical 10% sulphur
in cold cream with high rates of cure.62
IV. Communicable disease control and prevention
There is low quality evidence for treatment of household contacts for the community control of
scabies (2C).63 Treatment of cases and contacts is recommended in scabies outbreaks (2C), however,
high quality studies comparing treatments during outbreaks are required.
Low quality evidence for the treatment of household contacts as the primary intervention for
scabies control from one cohort of Australian Aboriginal households where a 6-fold reduction in
scabies in compliant households was found.63 Fifteen other studies treated close contacts, family
members or the household as co-interventions for scabies, however without a comparison group,
the effect cannot be reliably assessed. Moderate quality evidence found oral ivermectin halted a
scabies outbreak amongst health care workers and patients in Peru,64 and topical BB for cases and
contacts with community education terminated an outbreak in Israel.65
V. Environmental co-interventions
Although washing and storage measures are unlikely to cause harm and should be encouraged, high
quality studies assessing the clinical effectiveness of washing clothing and bed linen, storage of items
in plastic bags, exposure to sunlight and household spraying are required before these measures can
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be strongly recommended as adjuncts in the control of scabies. No studies used a control group to
assess the effect of environmental interventions for scabies. Twelve studies included washing of
clothing and bed linen,34,39,40,43,47-50,53,62-64 two studies included storage of items in plastic bags,22,64
four studies included exposing items to direct sunlight39,47,49,53 and one study included household
spraying,65 as co-interventions (Table 2).
4. Crusted scabies
Moderate quality evidence supports oral ivermectin with topical keratolytics and topical
antiparasitics for crusted scabies (1B).66,67 Comparative trials are needed to explore more effective
treatments. Patients with crusted scabies require intensive supportive treatment (1B).66,67
Coordinated case management in the home may be of benefit (2C).68
I. Directed antimicrobial therapy
Moderate quality evidence from a prospective cohort study of Australian Aboriginal inpatients
receiving oral ivermectin at days 0, 14 and 28 and daily topical permethrin alternating with
keratolytic therapy (topical urea 10% and lactic acid 5%), found 40% achieved complete cure at four
II. Standard treatment protocols
Moderate-quality evidence from a retrospective study used a standard treatment protocol in
Australian Aboriginal inpatients with crusted scabies achieving 55% without recurrence at eight
III. Coordinated case management
Low-quality evidence supports topical BB, regular keratolytics, moisturiser and regular screening for
new lesions in home-based case management to prevent crusted scabies.68
5. Fungal skin infections
I. Directed antimicrobial therapy
a. Tinea capitis
Moderate quality evidence for griseofulvin, terbinafine and fluconazole having similar efficacy for
tinea capitis (1B).69-72 Tinea capitis is difficult to treat, takes several months and mycological cure is
High quality evidence of similar clinical and mycological cure was provided by a multicentre RCT
from Guatemala, Chile, Costa Rica, USA and India comparing daily oral fluconazole for 3 or 6 weeks
with daily griseofulvin.69 Low quality RCT evidence from Iran reported no difference between daily
fluconazole or daily griseofulvin at eight weeks.70 Low quality evidence from India found griseofulvin
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twice daily, fluconazole weekly and terbinafine daily all performed similarly.71 In addition, all used
Ketoconazole 2% shampoo and prednisolone prescribed for kerion.71 From China, low quality cluster
RCT evidence confirmed griseofulvin daily for four weeks or terbinafine daily for 2 4 weeks
performed similarly.72
b. Tinea corporis
Low to moderate quality evidence for topical sertaconazole, butenafine, miconazole or clotrimazole
over other agents for tinea corporis (2C).73-76 Low quality evidence that oral alternatives for tinea
corporis are terbinafine or fluconazole (2C).77 Although the systematic review on topical treatments
for tinea corporis recommends topical terbinafine as a first line agent,17 no high quality studies from
resource limited contexts were available to evaluate. Most included trials came from dermatology
outpatient clinics in India or Iran. Community setting, population level evidence is needed for tinea
corporis treatment.
Moderate quality RCT evidence from Iran confirmed similar clinical cure at eight weeks for
topical butenafine compared with topical clotrimazole75 and similar cure rates at four weeks for
topical miconazole and topical sertaconazole.73 Moderate quality RCT evidence from India found
sertaconazole outperformed miconazole with 62% and 45% cured at two weeks respectively,
p<0.05.74 Low quality evidence from India found topical clotrimazole and topical amorolfine were
comparable78 and that topical sertaconazole was superior to topical butenafine.76 Similarly, very low
quality pilot RCT evidence from India found superiority of topical sertaconazole over topical
terbinafine or topical luliconazole for clinical cure and symptom relief.79 Very low quality RCT
evidence also found no difference between topical sertaconazole and topical terbinafine80 and that
topical terbinafine and topical luliconazole could not be differentiated.81 Similarly, low quality RCT
evidence from India found daily oral terbinafine or weekly fluconazole achieved similar clinical
cures77 and topical butenafine was no better than weekly fluconazole combined with topical
Whitfield’s ointment (3% salicylic acid and 6% benzoic acid) at four weeks.82 Low quality evidence
from a prospective cohort of Australian Aboriginal people with tinea corporis and tinea unguium
found daily oral terbinafine cured 32%.83
c. Tinea unguium/onychomycosis
For tinea unguium, moderate to high quality evidence recommends oral terbinafine (1A),84-86 with no
added benefit of combination topical therapy in resource limited settings (1B).84,87 Surgical avulsion
prior to treatment of onychomycosis is not recommended (2D).87 High quality studies assessing
photo dynamic therapy (PDT) regimens for tinea unguium are required to determine the utility of
this therapy in resource-limited settings.
High quality RCT evidence from India trialled two different dosing regimens of terbinafine and
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showed no difference.84,85 Low quality RCT evidence from Brazil found monthly or second monthly
dosing of oral terbinafine had similar outcomes86 and photodynamic therapy (PDT) every 15 days for
6 months was superior to weekly oral fluconazole.88 No additional benefit of topical nail lacquer over
oral terbinafine alone was found in moderate quality evidence.84,87
II. Mass Drug Administration
No studies assessed the effect of antifungal MDAs on the prevalence of fungal skin infections.
III. Complimentary/alternative therapy
Further studies are needed to assess the role of aloe vera gel, as only very low quality evidence from
one study is available.89
IV. Communicable disease prevention and control
No studies assessed the effect of communicable disease control practices on fungal infections on
which to base relevant recommendations for resource-limited settings.
V. Hygiene practices
Daily soap use may be of benefit in the treatment of tinea capitis and tinea corporis. This is
recommended in combination with anti-fungal treatment (2C).90
From Tanzania, low quality RCT evidence found mycological cure at two months to be similar with
either daily washing with triclosan soap or placebo.90
6. Infrastructure including high quality water supply, swimming pools and housing improvement for
skin infections
I. Water provision
An adequate supply of water for washing and cleaning will reduce the burden of impetigo and
scabies (2C).91 From studies in remote Australian Indigenous communities, the installation of
community swimming pools may assist in the prevention of impetigo, along with other health
benefits (2C).92-94 No studies assessed the effect of quality water supply or swimming pools on
scabies or tinea on which to base recommendations for resource limited settings.
Low quality evidence from Panama found that when unlimited, high-quality water was
compared to a community with a limited water supply, declines in scabies and impetigo incidence
were reported.91 Low quality evidence from three studies in Australian Aboriginal communities
found a small benefit following the installation of swimming pools for impetigo and skin infections.92-
II. Housing improvement programs
Programs to improve housing may assist in the prevention and control of skin infections in resource-
limited populations (2C).95,96
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Low-quality evidence from a housing intervention evaluation of remote Australian Aboriginal
communities, found construction of new, standardised housing and the demolition of uninhabitable
dwellings did not change the prevalence of skin infections at 10 months.95 Low quality evidence from
a study that ran for 12 years showed reductions in skin infections following household
improvements based on health and safety priorities in a “survey and fix methodology.”96
This is the first systematic review to comprehensively inform treatment, public health control and
areas for future research in the control of skin infections using evidence generated in and from
settings where skin infection burden is the highest. High quality evidence for treatment of the
individual and community with scabies and for the individual with impetigo is synthesised for
inclusion into evidence-based guidelines. Similarly, high quality evidence for comprehensively
addressing scabies and impetigo concurrently is presented, with further studies needed to
determine the measurable benefit of additional interventions over treatment alone. The integration
of oral antibiotics for treatment of impetigo, use of oral ivermectin or topical permethrin MDA for
scabies in endemic or outbreak settings and community education and health promotion activities in
skin health programs are supported by the evidence and should form the basis of skin control
programs when needed. Evidence gaps include community control of dermatophyte infections and
targeted environmental health interventions to improve skin health.
Progress towards the streamlined integration of data collection on skin infections when
planning MDAs for other infections needs ongoing prioritisation. MDA for trachoma and yaws with
azithromycin97-99 may also reduce the burden of impetigo,61 whilst ivermectin MDA for lymphatic
filariasis100 and scabies57 will reduce scabies and impetigo prevalence61 as part of the roadmap
towards defeating neglected tropical diseases.101 This pragmatic, evidence-based strategy is now
being tested in larger populations with results awaited (ACTRN12618000461291p) to inform
whether community control of scabies will prevent severe skin infections.
For impetigo, duration of treatment, the role of topical therapy and added benefit of
comprehensive skin disease control programs over treatment alone are gaps in the literature. Whilst
three or five days of cotrimoxazole for impetigo treatment in resource limited settings is effective,26
more comparison studies are needed to optimise treatment duration and utility of cheap, widely
available, palatable alternative agents in high burden contexts. Cephalexin for up to 10 days remains
in guidelines for impetigo, yet this is lengthy, costly and may be impractical with no evidence
supporting its use for impetigo in high burden contexts. Unlike developed settings where topical
mupirocin and fusidic acid are recommended,16 there are currently no trials using topical antibiotics
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for impetigo inhigh burden settings. Results from New Zealand comparing topical antibiotics or
antiseptics with placebo are awaited [ACTRN1261000356460].
Patient preference for agent to treat scabies and the additional benefit of comprehensive
control programs for scabies above treatment alone are knowledge gaps. Topical permethrin has
more rapid reduction in symptoms40,42 but requires a private space in which to apply the cream to
the full body. Conversely, clinical response is slower, but ease of administration and overall
community efficacy in MDA support the use of ivermectin.57 Future studies should address the role
of a second dose of ivermectin in asymptomatic individuals as unhatched eggs are refractory to
ivermectin.102 Moxidectin shows promise for future human scabies trials as it has a longer half-life
and is ovicidal.103
Most studies assessing antifungal treatments were from dermatology OPD in middle income
country hospitals, which limits the external validity to other resource limited settings. Studies
assessing the effectiveness of topical and oral (for severe disease) treatments of tinea in a range of
resource-limited populations would be of benefit to make recommendations applicable to real life,
uncontrolled settings at the individual and population level. Future integration of treatment of tinea
into comprehensive skin disease control programs that address scabies and impetigo may be a way
Despite practical advantages, we found limited evidence for environmental interventions to
control skin infections. Although sound attempts to evaluate housing programs have been made,95,96
we remain unable to recommend small scale environmental interventions due to a lack of
comparative studies. For example, no studies compared household spraying with no intervention to
eradicate the scabies mite. Similarly, there was no evidence for hot washing of clothing compared to
not washing clothing. Although environmental measures are unlikely to cause harm in combination
with treatment of the skin infection, research is needed to determine any measurable benefit above
standard treatment to inform environmental health teams tasked with managing scabies outbreaks,
clinicians managing skin infections or governments and communities intending to include
environmental policy recommendations in comprehensive skin health programs in endemic areas.
Although 1759 non-duplicate studies were found for potential inclusion in this systematic
review, most were excluded prior to the final appraisal of 81 studies meeting the full inclusion
criteria (see Figure 1). This is the complete synthesis of available literature on these four skin
conditions. It is possible that restriction to English language publications or being unable to find the
full text publication has been a limitation in the scope of this, although <30 full-text studies were
excluded for this reason.
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A summary of the evidence-based recommendations for skin infections in high burden contexts also
highlights the need for further rigorous, experimental studies to fill the evidence gaps. Pragmatic,
practical, high quality, well-funded RCTs are essential in the settings where the findings will have
external validity if meaningful progress is to be made towards reducing the gap in skin health
outcomes between the rich and poor. Acknowledging that RCTs may present ethical issues for some
groups,104 robust observational studies of appropriately funded public health interventions can be
tested across large populations with designs that control for confounders and in meaningful
partnership with the communities under study using participatory research methods.
We wish to thank the following for assistance with the conduct of this review: Marianne Mullane
and Claudia Sampson for secretarial support; Aleisha Anderson, Ingrid Duff, Claire Ferguson, Myra
Hardy, Therese Kearns, Ella Meumann, Lauren Thomas, Georgia Walker and Daniel Yeoh for data
extraction contributions.
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Correspondence: Asha Bowen, Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon
Kids Institute, 100 Roberts Road, Subiaco WA 6008, Australia. Phone +61 412 608 003, email
Supporting Information Legends
Box: Definitions for Indigenous peoples and Income groupings used
Supplementary File 1: Evidence Summary and Recommendations for skin infection related research
to guide practice in resource limited settings.
Supplementary Table 1: List of studies included in the systematic review.
Supplementary Table 2: Risk of bias table with overall quality ratings using the GRADE approach for
included experimental and controlled studies
Supplementary Table 3: Risk of bias table with overall quality rating using the GRADE approach for
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included observational studies
Supplementary Table 4. Method of application of topical scabicides in 29 included studies
Supplementary Checklist: PRISMA Checklist
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Figure 1. PRISMA Flow Diagram for study selection in the systematic review
Records identified through database
searching (n = 3647)
Records after duplicates removed
(n = 1759)
Titles screened
(n = 1759)
Records excluded
(n = 262)
Full-text articles assessed
for eligibility (n = 193)
Full-text articles excluded
(n = 112)
No intervention/no assessment
of effect of exposure on the
outcome (n=31)
Wrong study design (n=27)
Not in English (n=19)
Unable to obtain full-text (n=8)
Wrong outcomes (n=8)
Wrong patient population (n=9)
Wrong setting (n=4)
Duplicate report of published
paper (n=3)
Wrong indication (n=1)
Studies included
(n = 81)
(n = 1893)
Abstracts screened
(n = 455)
Records excluded
(n = 1304)
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Figure 2. Selected summary characteristics of studies included in the systematic review.
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Table 1. Grading of Recommendations Assessment, Development and Evaluation Evidence Grades
and Strength of Recommendations
*1D and 2D recommendations are not routinely included by the GRADE approach as these are based
on expert consensus, rather than scientific evidence. These additional recommendation grades were
created due to lack of available supporting evidence but an identified need to make
recommendations to guide clinical and public health management.
Quality of Evidence
Further research is very unlikely to change the level of
confidence in the estimate of effect. i.e.
Several high-quality studies with consistent results
Further research is likely to have an impact in current
confidence in the estimate of effect and may change the
estimate. i.e.
One high quality study
Several studies with some limitations
Further research is very likely to have an important
impact on the level of confidence in the estimate of
effect and would likely change the estimate. i.e.
One or more studies with severe limitations
Very Low
Estimate of effect is very uncertain. i.e.
No direct research evidence
One of more studies with very severe limitations
Strength of
Implications when combined with evidence grade
1A: Strong recommendation, applies to most patients
without reservation. Clinicians should follow a strong
recommendation unless a clear and compelling rationale
for an alternative approach is present.
1B: Strong recommendation, applies to most patients.
Clinicians should follow a strong recommendation unless
a clear and compelling rationale for an alternative
approach is present.
1C: Strong recommendation, applies to most patients.
Some of the evidence base supporting the
recommendation is, however, of low quality.
1D: * Strong recommendation, applies to most patients.
However, the recommendation is based on expert
consensus only.
2A: Weak recommendation and best action may differ
depending on circumstances or patients or societal
2B: Weak recommendation and alternative approaches
likely to be better for some patients under some
2C: Very weak recommendation; other alternatives may
be equally reasonable.
2D: * Very weak recommendation based on expert
consensus. Further research is necessary.
Accepted Article
This article is protected by copyright. All rights reserved.
Table 2: Number of studies in each broad intervention group by skin condition. Gaps in the evidence
are shown as grey boxes.
*Communicable disease control activities= outbreak response or treatment of contacts. #Water
provision= swimming pools or clean water supply to homes. ~Hygiene practices= provision of soap
and hand washing education.
r of
Multiple skin
under study or
infections” that
were not
skin health
Mass Drug
ve therapy
le disease
Accepted Article
This article is protected by copyright. All rights reserved.
Table 3: Number of included studies with public health co-interventions for skin infections
*Total does not equate to 81 studies as some studies had more than one public health intervention.
Skin condition
Public health
Treatment of
Promotion of regular
bathing and/ or
Health education
Washing of clothing
and bed linen
Storage of items in
plastic bags
Exposing items to
direct sunlight
Household spraying
... There are 26 studies that recommend the full application of topical permethrin from the neck to the feet, but there are 4 studies suggesting its use is limited to lesions only. According to May et al. (2019), the overall use of topical permethrin is highly recommended, but there are some drawbacks, namely in terms of reduced patient comfort, the number of lotions to be used, the price, and the side effects that arise. According to Sungkar (2016), the disadvantages of permethrin include a sticky feeling that interferes with patient comfort, especially when sweating, and side effects in the form of burning, stinging, pain, and redness. ...
Background: Scabies is a contagious disease caused by Sarcoptes scabiei characterized by itching and lesions that affect quality of human life. Permethrin 5% as standard therapy for scabies has disadvantages in terms of price and side effects. Neem is a traditional plant that has a scabicide effect and could be an alternative treatment for scabies. Objective: to compare the quality of life of patients who were treated with 5% permethrin lotion and 10% neem leaf extract lotion using DLQI and Skindex-29 instruments. Methods: This study is an experimental design with a purposive sampling method. The sample was 42 male students in one of the Islamic boarding schools in Malang who were clinically diagnosed with scabies and met the research criteria. The research sample consisted of two groups: a group with 5% permethrin lotion therapy (21 students) and a group with 10% neem leaf extract lotion therapy (21 students). Data was collected with DLQI and Skindex-29 on day 0 before and day 14 after therapy. Data analysis used the Wilcoxon test and dependent t-test for comparison before and after therapy and independent t-test for comparison of quality of life between two therapies by using SPSS 25. Results: Statistic test to differentiate the two therapies showed p=0.670 (DLQI) and p=0.391 (Skindex-29). So, the two therapies did not differ significantly in reducing DLQI and Skindex-29 scores. Conclusion: 5% permethrin lotion and 10% neem leaf extract lotion are equally good in improving the quality of life of scabies patients.
... Scabies is a significant and common health problem, a highly contagious disease which can affect quality of life, work performance, sleep, and cause/influence psychosocial problems in patients and their family members. Therefore, additional measures in primary care and the public health management of scabies could impact overall patient quality of life and reduce this infectious disease in whole communities [72]. ...
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Reports from various countries have described increasing numbers of scabies cases, especially in the past two decades. The epidemiological data for various world regions showed prevalence estimates ranging from 0.2% to 71%, with the highest prevalence in the Pacific region and Latin America. Therefore, geographically, scabies occurs more commonly in the developing world, tropical climates, and in areas with a lack of access to water. According to results from specific regions of the world, the greatest burdens from scabies were recorded for East Asia, Southeast Asia, Oceania, tropical Latin America, and South Asia. Among countries with the highest rates, the top 10 were Indonesia, China, Timor-Leste, Vanuatu, Fiji, Cambodia, Laos, Myanmar, Vietnam, and the Seychelles. From Europe, available data shows an increasing trend in scabies infestation, particularly evident among populations with associated contributing factors, such as those who travel frequently , refugees, asylum seekers, those who regularly lack drinking water and appropriate hygiene and are of a younger age, etc. This increase in observed cases in the last 10-20 years has been evidenced by research conducted in Germany, France, Norway, and Croatia, among other countries. In addition, increased scabies transmission was also recorded during the COVID-19 pandemic and may have been the result of increased sexual intercourse during that time. Despite all the available treatment options, scabies commonly goes unrecognized and is therefore not treated accordingly. This trend calls for a prompt and synergistic reaction from all healthcare professionals, governmental institutions, and non-governmental organizations, especially in settings where population migration is common and where living standards are low. Furthermore, the proper education of whole populations and accessible healthcare are cornerstones of outbreak prevention. Accurate national data and proper disease reporting should be a goal for every country worldwide when developing strategic plans for preventing and controlling the community spread of scabies.
Sufficient, well-maintained housing infrastructure can support healthy living practices for hygiene, safety and nutrition. This article focuses on the relationship between housing and health through a case study in the remote Barkly region in the Northern Territory, Australia. A research partnership between Anyinginyi Health Aboriginal Corporation and academic researchers employed a mixed methodological approach, involving interviews with residents, clinical and outreach staff, and clinical database analysis. The results revealed much higher levels of crowding in remote communities and in Tennant Creek than officially recorded, with up to 22 residents in surveyed households. Interviews with clinicians and public health staff highlighted the impact of crowding on infection transmission, poor sleep and reduced personal safety, and damage to health hardware. The database analysis detailed the types of preventable, hygiene-related infectious diseases that dominated, with over half of the total infectious disease diagnoses being skin, respiratory and ear, nose and throat infections. Repeated infection likely contributes to increased rates of chronic kidney and rheumatic heart diseases. The combined overall findings highlight the parallel conditions of the prevalence of hygiene-related infectious diseases, crowding and environmental health issues (including health hardware). No objective evidence of direct causal relationships was obtained due to the small scale and methodological limitations of the study. More complex future research is outlined in order to understand how to further investigate the burden of disease that the affects morbidity and mortality of Aboriginal Australians, and underlies the urgency for housing policy reform and funding to upgrade housing.
Eye infections are one of the most common presenting problem in ophthalmology and prompted diagnosis and appropriate treatment is necessary to save sight. Identifying the causative organisms involved in the pathogenesis of the infection is important to ensure a good visual outcome. Clinical diagnosis of bacterial infections can be confirmed by several techniques such as clinical features, microbiological testing, serum analysis and ophthalmic imaging. A wide range of antibiotic treatments are available, however, treatment can still be challenging due to the diverse number of microorganisms.
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Objective We have produced a protocol for the comprehensive systematic review of the current literature around superficial group A Streptococcal infections in Australia. Methods MEDLINE, Scopus, EMBASE, Web of Science, Global Health, Cochrane, CINAHL databases and the gray literature will be methodically and thoroughly searched for studies relating to the epidemiology of superficial group A Streptococcal infections between the years 1970 and 2019. Data will be extracted to present in the follow up systematic review. Conclusion A rigorous and well-organised search of the current literature will be performed to determine the current and evolving epidemiology of superficial group A Streptococcal infections in Australia.
Resumen En la actualidad, las infecciones de piel y partes blandas forman parte de un alto porcentaje de las consultas en salud. Estas van desde infecciones leves, donde el manejo se realiza con tratamiento tópico, hasta aquellas con severo compromiso sistémico, requiriendo terapia antibiótica sistémica e incluso el desbridaje quirúrgico. En general, son producto de un desbalance entre los mecanismos de defensa de la barrera cutánea y los factores de virulencia y patogenicidad de los microorganismos que la afectan. Se pueden clasificar según distintos criterios, como por ejemplo, profundidad, gravedad, microorganismos involucrados y si estas son purulentas o no. El reconocer estas entidades clínicas es de suma importancia para llevar a cabo un adecuado tratamiento en los pacientes que presentan estas afecciones, ya que los diagnósticos erróneos llevan a las múltiples consultas con el consiguiente aumento de costos asociados en atención en salud.
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Introduction Scabies is recognised as a neglected tropical disease, disproportionately affecting the most vulnerable populations around the world. Impetigo often occurs secondarily to scabies. Several studies have explored mass drug administration (MDA) programmes, with some showing positive outcomes—but a systematic evaluation of such studies is yet to be reported. The main aim of this systematic review is to generate comprehensive evidence on the effect and feasibility of MDA programmes in reducing the burden of scabies and impetigo. Methods and analysis A systematic review and meta-analysis will be conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement. Electronic databases to be searched will include CINAHL EBSCOhost, Medline Ovid, ProQuest, Science Direct, PubMed and SCOPUS. In addition, grey literature will be explored via the Australian Institute of Health and Welfare, Australian Indigenous HealthInfoNet, Informit, OaIster database and WHO. No language restrictions will be applied. All treatment studies following an MDA protocol, including randomised/quasi-controlled trials, and prospective before–after interventional studies, will be considered. The main outcome is the change in prevalence of scabies and impetigo The Cochrane collaboration risk of bias assessment tool will be used for assessing the methodological quality of studies. A random-effect restricted maximum likelihood meta-analysis will be performed to generate pooled effect (OR) using STATA V.16. Appropriate statistical tests will be carried out to quantify heterogeneity between studies and publication bias. Ethics and dissemination Ethical approval is not required since data will be extracted from published works. The findings will be communicated to the scientific community through a peer-reviewed journal publication. This systematic review will present an evidence on the effect of MDA interventions on scabies and impetigo, which is instrumental to obtain a clear understanding of the treatments widely used in these programmes. PROSPERO registration number CRD42020169544
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Purpose Impetigo affects approximately 162 million children worldwide at any given time. Lack of consensus on the most effective treatment strategy for impetigo and increasing antibiotic resistance continue to drive research into newer and alternative treatment options. We conducted a systematic review to assess the effectiveness of new treatments for impetigo in endemic and nonendemic settings. Methods We searched PubMed, MEDLINE, CINAHL, Web of Science, and Embase via Scopus for studies that explored treatments for bullous, nonbullous, primary, and secondary impetigo published between August 1, 2011, and February 29, 2020. We also searched online trial registries and hand-searched the reference lists of the included studies. We used the revised Cochrane risk of bias (version 2.0) tool for randomized trials and the National Heart, Lung, and Blood Institute for nonrandomized uncontrolled studies to assess the risk of bias. Findings We included 10 studies that involved 6651 participants and reported on 9 treatments in the final analysis. Most clinical trials targeted nonbullous impetigo or did not specify this. The risk of bias varied among the studies. In nonendemic settings, ozenoxacin 1% cream appeared to have the strongest evidence base compared with retapamulin and a new minocycline formulation. In endemic settings, oral co-trimoxazole and benzathine benzylpenicillin G injection were equally effective in the treatment of severe impetigo. Mass drug administration intervention emerged as a promising public health strategy to reduce the prevalence of impetigo in endemic settings. Implications This review highlights the limited research into new drugs used for the treatment of impetigo in endemic and nonendemic settings. Limited recent evidence supports the use of topical ozenoxacin or retapamulin for impetigo treatment in nonendemic settings, whereas systemic antibiotics and the mass drug administration strategy have evidence for use in endemic settings. Given the troubling increase in resistance to existing treatments, there is a clear need to ensure the judicious use of antibiotics and to develop new treatments and alternative strategies; this is particularly important in endemic settings. PROSPERO identifier: CRD42020173042.
Scabies, impetigo, and other skin and soft tissue infections (SSTIs) are highly prevalent in many tropical, low-middle income settings, but information regarding their burden of disease is scarce. We conducted a surveillance of presentations of scabies and SSTIs, including impetigo, abscesses, cellulitis, and severe SSTI, to primary health facilities in Fiji. We established a monthly reporting system over the course of 50 weeks (July 2018–June 2019) for scabies and SSTIs at all 42 public primary health facilities in the Northern Division of Fiji (population, ≈131,914). For each case, information was collected regarding demographics, diagnosis, and treatment. There were 13,736 individual primary healthcare presentations with scabies, SSTI, or both (108.3 presentations per 1000 person-years; 95% confidence interval [CI], 106.6–110 presentations). The incidence was higher for males than for females (incidence rate ratio [IRR], 1.15; 95% CI, 1.11–1.19). Children younger than 5 years had the highest incidence among all age groups (339.1 per 1000 person-years). The incidence was higher among the iTaukei (indigenous) population (159.9 per 1000 person-years) compared with Fijians of Indian descent (30.1 per 1000 person-years; IRR, 5.32; 95% CI, 5.03–5.61). Abscesses had the highest incidence (63.5 per 1,000 person-years), followed by scabies (28.7 per 1,000 person-years) and impetigo (21.6 per 1,000 person-years). Scabies and SSTIs impose a substantial burden in Fiji and represent a high incidence of primary health presentations in this population. The incidence in low-middle income settings is up to 10-times higher than that in high-income settings. New public health strategies and further research are needed to address these conditions.
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Background Remarkable progress has been made in the fight against neglected tropical diseases, but new challenges have emerged. Innovative diagnostics, better drugs and new insecticides are often identified as the priority; however, access to these new tools may not be sufficient to achieve and sustain disease elimination, if certain challenges and priorities are not considered. Main body The authors summarise key operational challenges, and based on these, identify two major priorities: strengthening the capacity of the primary health care health system in correctly diagnosing and managing neglected tropical diseases; and establishing an effective disease surveillance process. Five steps are proposed as concrete actions to build an effective primary health care service for neglected tropical diseases, and a health management information system capable of accurately reporting these diseases. Community engagement and formalization of community health workers role are proposed as essential components of these steps. Shift of financial support from disease oriented programmes to disease integrated interventions, improved access to international guidelines for primary health care staff, and availability of donated drugs in health care structures are also suggested as key elements of the proposed process. Conclusion The authors conclude that failure to address these priorities now may lead to further challenges on the long path towards neglected tropical disease elimination and beyond. Electronic supplementary material The online version of this article (doi: 10.1186/s40249-017-0361-8) contains supplementary material, which is available to authorized users.
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Background: Complications of scabies and impetigo such as glomerulonephritis and invasive bacterial infection in Australian Aboriginal children remain significant problems and the overall global burden of disease attributable to these skin infections remains high despite the availability of effective treatment. We hypothesised that one factor contributing to this high burden is that skin infection is under-recognised and hence under-treated, in settings where prevalence is high. Methods: We conducted a prospective, cross-sectional study to assess the burden of scabies, impetigo, tinea and pediculosis in children admitted to two regional Australian hospitals from October 2015 to January 2016. A retrospective chart review of patients admitted in November 2014 (mid-point of the prospective data collection in the preceding year) was performed. Prevalence of documented skin infection was compared in the prospective and retrospective population to assess clinician recognition and treatment of skin infections. Results: 158 patients with median age 3.6 years, 74% Aboriginal, were prospectively recruited. 77 patient records were retrospectively reviewed. Scabies (8.2% vs 0.0%, OR N/A, p = 0.006) and impetigo (49.4% vs 19.5%, OR 4.0 (95% confidence interval [CI 2.1-7.7) were more prevalent in the prospective analysis. Skin examination was only documented in 45.5% of cases in the retrospective review. Patients in the prospective analysis were more likely to be prescribed specific treatment for skin infection compared with those in the retrospective review (31.6% vs 5.2%, OR 8.5 (95% CI 2.9-24.4). Conclusions: Scabies and impetigo infections are under-recognised and hence under-treated by clinicians. Improving the recognition and treatment of skin infections by clinicians is a priority to reduce the high burden of skin infection and subsequent sequelae in paediatric populations where scabies and impetigo are endemic.
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Background: Impetigo, scabies, and fungal skin infections disproportionately affect populations in resource-limited settings. Evidence for standard treatment of skin infections predominantly stem from hospital-based studies in high-income countries. The evidence for treatment in resource-limited settings is less clear, as studies in these populations may lack randomisation and control groups for cultural, ethical or economic reasons. Likewise, a synthesis of the evidence for public health control within endemic populations is also lacking. We propose a systematic review of the evidence for the prevention, treatment and public health management of skin infections in resource-limited settings, to inform the development of guidelines for the standardised and streamlined clinical and public health management of skin infections in endemic populations. Methods: The protocol has been designed in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols statement. All trial designs and analytical observational study designs will be eligible for inclusion. A systematic search of the peer-reviewed literature will include PubMed, Excertpa Medica and Global Health. Grey literature databases will also be systematically searched, and clinical trials registries scanned for future relevant studies. The primary outcome of interest will be the clinical cure or decrease in prevalence of impetigo, scabies, crusted scabies, tinea capitis, tinea corporis or tinea unguium. Two independent reviewers will perform eligibility assessment and data extraction using standardised electronic forms. Risk of bias assessment will be undertaken by two independent reviewers according to the Cochrane Risk of Bias tool. Data will be tabulated and narratively synthesised. We expect there will be insufficient data to conduct meta-analysis. The final body of evidence will be reported against the Grades of Recommendation, Assessment, Development and Evaluation grading system. Discussion: The evidence derived from the systematic review will be used to inform the development of guidelines for the management of skin infections in resource-limited settings. The evidence derived will be intended for use by clinicians, public health practitioners and policy makers in the treatment of skin infections and the development of skin infection control programmes. The review will identify any gaps in the current evidence to provide direction for future research. Systematic review registration: PROSPERO CRD42015029453.
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Background Scabies is an underrecognized cause of illness in many developing countries. It is associated with impetigo, which can lead to serious systemic complications. We conducted a trial of mass drug administration for scabies control in Fiji. Methods We randomly assigned three island communities to one of three different interventions for scabies control: standard care involving the administration of permethrin to affected persons and their contacts (standard-care group), mass administration of permethrin (permethrin group), or mass administration of ivermectin (ivermectin group). The primary outcome was the change in the prevalence of scabies and of impetigo from baseline to 12 months. Results A total of 2051 participants were enrolled; 803 were in the standard-care group, 532 in the permethrin group, and 716 in the ivermectin group. From baseline to 12 months, the prevalence of scabies declined significantly in all groups, with the greatest reduction seen in the ivermectin group. The prevalence declined from 36.6% to 18.8% in the standard-care group (relative reduction in prevalence, 49%; 95% confidence interval [CI], 37 to 60), from 41.7% to 15.8% in the permethrin group (relative reduction, 62%; 95% CI, 49 to 75), and from 32.1% to 1.9% in the ivermectin group (relative reduction, 94%; 95% CI, 83 to 100). The prevalence of impetigo also declined in all groups, with the greatest reduction seen in the ivermectin group. The prevalence declined from 21.4% to 14.6% in the standard-care group (relative reduction, 32%; 95% CI, 14 to 50), from 24.6% to 11.4% in the permethrin group (relative reduction, 54%; 95% CI, 35 to 73), and from 24.6% to 8.0% in the ivermectin group (relative reduction, 67%; 95% CI, 52 to 83). Adverse events were mild and were reported more frequently in the ivermectin group than in the permethrin group (15.6% vs. 6.8%). Conclusions Mass drug administration, particularly the administration of ivermectin, was efficacious for the control of scabies and impetigo. (Funded by the Australian National Health and Medical Research Council; Australian New Zealand Clinical Trials Registry number, ACTRN12613000474752.)
Importance Staphylococcus aureus bacteremia (SAB) in children causes significant morbidity and mortality, but the epidemiology in children is not well characterized. Objective To describe the epidemiology of SAB in children and adolescents younger than 18 years from Australia and New Zealand. Design, Setting, and Participants A prospective cohort study, using data from the Australian New Zealand Cooperative on Outcomes in Staphylococcal Sepsis cohort for 1153 children with SAB from birth to less than 18 years in pediatric and general hospitals across Australia and New Zealand, collected between January 1, 2007, and December 31, 2012. Multivariate analysis was performed to identify risk factors for mortality. Incidence calculations were calculated separately for Australasian children younger than 15 years using postcode population denominator data from Australian and New Zealand census data. Main Outcomes and Measures Demographic data, hospital length of stay, principal diagnosis, place of SAB onset (community or hospital), antibiotic susceptibility and principal antibiotic treatment, and 7- and 30-day mortality. Results Of the 1153 children with SAB, complete outcome data were available for 1073 children (93.1%); of these, males accounted for 684 episodes (63.7%) of SAB. The median age was 57 months (interquartile range, 2 months to 12 years). The annual incidence of SAB for Australian children was 8.3 per 100 000 population and was higher in indigenous children (incident rate ratio, 3.0 [95% CI, 2.4-3.7]), and the incidence for New Zealand children was 14.4 per 100 000 population and was higher in Māori children (incident rate ratio, 5.4 [95% CI, 4.1-7.0]). Community-onset SAB occurred in 761 cases (70.9%), and 142 cases (13.2%) of the infections were methicillin-resistant S aureus (MRSA). Bone or joint infection was most common with 348 cases (32.4%), and endocarditis was uncommon with 30 cases (2.8%). Seven- and 30-day mortality rates were 2.6% (n = 28) and 4.7% (n = 50), respectively. Risk factors for mortality were age younger than 1 year; Māori or Pacific ethnicity; endocarditis, pneumonia, or sepsis; and receiving no treatment or treatment with vancomycin. Mortality was 14.0% (6 of 43) in children with methicillin-susceptible S aureus (MSSA) treated with vancomycin compared with 2.6% (22 of 851) in children treated with alternative agents (OR, 6.1 [95% CI, 1.9-16.7]). MRSA infection was associated with increased length of stay but not mortality. Conclusions and Relevance In this large cohort study of the epidemiology of SAB in children, death was uncommon, but the incidence was higher for infants and varied by treatment, ethnicity, and clinical presentation. This study provides important information on the epidemiology of SAB in children and risk factors for mortality.
To the Editor: Romani et al. report the efficacy of mass treatment with oral ivermectin in an island community with hyperendemic scabies (Dec. 10 issue).(1) I would like to discuss a point that, unlike the authors, I found likely to be expected - that is, the persistent and major decline in scabies prevalence observed with that protocol. Indeed, although oral ivermectin appears slightly less efficacious in the treatment of individual cases of scabies than topical compounds such as permethrin or benzyl benzoate,(2) it is considered to bring a major advantage during mass treatment of epidemics in closed communities such as . . .