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Ectoparasitic Infections

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Sexually Transmitted Diseases Treatment Guidelines, 2010

Pediculosis Pubis

Persons who have pediculosis pubis (i.e., pubic lice) usually seek medical attention because of pruritus or because they notice lice or nits on their pubic hair. Pediculosis pubis is usually transmitted by sexual contact.

Recommended Regimens

Permethrin 1% cream rinse applied to affected areas and washed off after 10 minutes


Pyrethrins with piperonyl butoxide applied to the affected area and washed off after 10 minutes

Alternative Regimens

Malathion 0.5% lotion applied for 8–12 hours and washed off


Ivermectin 250 µg/kg orally, repeated in 2 weeks

Reported resistance to pediculicides has been increasing and is widespread (471-473). Malathion can be used when treatment failure is believed to have resulted from drug resistance. The odor and long duration of application for malathion make it a less attractive alternative than the recommended pediculcides. Ivermectin has been successfully used to treat lice, but it has only been evaluated in studies involving a limited number of participants.

Other Management Considerations

The recommended regimens should not be applied to the eyes. Pediculosis of the eyelashes should be treated by applying occlusive ophthalmic ointment to the eyelid margins twice a day for 10 days. Bedding and clothing should be decontaminated (i.e., either dry cleaned or machine-washed and dried using the heat cycle) or removed from body contact for at least 72 hours. Fumigation of living areas is not necessary.

Patients with pediculosis pubis should be evaluated for other STDs.


Patients should be evaluated after 1 week if symptoms persist. Retreatment might be necessary if lice are found or if eggs are observed at the hair-skin junction. Patients who do not respond to one of the recommended regimens should be retreated with an alternative regimen.

Management of Sex Partners

Sex partners that have had sexual contact with the patient within the previous month should be treated. Patients should abstain from sexual contact with their sex partner(s) until patients and partners have been treated and reevaluated to rule out persistent disease.

Special Considerations


Pregnant and lactating women should be treated with either permethrin or pyrethrins with piperonyl butoxide; lindane and ivermectin are contraindicated in pregnancy and lactating women.

HIV Infection

Patients who have pediculosis pubis and also are infected with HIV should receive the same treatment regimen as those who are HIV negative.


The predominant symptom of scabies is pruritus, but sensitization to Sarcoptes scabiei occurs before pruritus begins. The first time a person is infested with S. scabiei, sensitization can take several weeks to develop. However, pruritus might occur within 24 hours after a subsequent reinfestation. Scabies in adults frequently is sexually acquired, although scabies in children usually is not.

Recommended Regimens

Permethrin cream (5%) applied to all areas of the body from the neck down and washed off after 8–14 hours


Ivermectin 200µg/kg orally, repeated in 2 weeks

Alternative Regimen

Lindane (1%) 1 oz. of lotion (or 30 g of cream) applied in a thin layer to all areas of the body from the neck down and thoroughly washed off after 8 hours

Lindane is not recommended as first-line therapy because of toxicity (471). It should only be used as an alternative if the patient cannot tolerate other therapies or if other therapies have failed.

Lindane should not be used immediately after a bath or shower, and it should not be used by persons who have extensive dermatitis, women who are pregnant or lactating, or children aged <2 years. Lindane resistance has been reported in some areas of the world, including parts of the United States (474). Seizures have occurred when lindane was applied after a bath or used by patients who had extensive dermatitis. Aplastic anemia after lindane use also has been reported (471, 474).

Permethrin is effective and safe and less expensive than ivermectin (471, 474). One study demonstrated increased mortality among elderly, debilitated persons who received ivermectin, but this observation has not been confirmed in subsequent studies (475).

Other Management Considerations

Bedding and clothing should be decontaminated (i.e., either dry cleaned or machine-washed and dried using the hot cycle) or removed from body contact for at least 72 hours. Fumigation of living areas is unnecessary.

Crusted Scabies

Crusted scabies (i.e., Norwegian scabies) is an aggressive infestation that usually occurs in immunodeficient, debilitated, or malnourished persons (476). Patients who are receiving systemic or potent topical glucocorticoids, organ transplant recipients, mentally retarded or physically incapacitated persons, HIV-infected or human T-lymphotrophic virus-1-infected persons, and persons with various hematologic malignancies are at risk for developing crusted scabies. Crusted scabies is associated with greater transmissibility than scabies. No controlled therapeutic studies for crusted scabies have been conducted, and the appropriate treatment remains unclear. Substantial risk for treatment failure might exist with a single topical scabicide or with oral ivermectin treatment. Combined treatment with a topical scabicide and repeated treatment with oral ivermectin 200 µg/kg on days 1, 2, 8, 9, and 15 are suggested. Additional treatment on days 22 and 29 might be required for severe cases. Ivermectin should be combined with the application of either 5% topical benzyl benzoate or 5% topical permethrin (full body application to be repeated daily for 7 days then 2 times weekly until release from care or cure). Lindane should be avoided because of the risks for neurotoxicity associated with both heavy applications and denuded skin. Fingernails should be closely trimmed to reduce injury from excessive scratching.


Patients should be informed that the rash and pruritus of scabies might persist for up to 2 weeks after treatment. Symptoms or signs that persist for >2 weeks can be attributed to several factors. Treatment failure can be caused by resistance to medication, although faulty application of topical scabicides also can contribute to persistence — patients with crusted scabies might have poor penetration into thick scaly skin and harbor mites in these difficult-to-penetrate layers. Particular attention must be given to the fingernails of these patients. Reinfection from family members or fomites can occur in the absence of appropriate contact treatment and washing of bedding and clothing. Even when treatment is successful and reinfection is avoided, symptoms can persist or worsen as a result of allergic dermatitis. Finally, the presence of household mites can cause symptoms to persist as a result of cross reactivity between antigens. Retreatment can be considered after 1–2 weeks for patients who are still symptomatic or if live mites are present. Treatment with an alternative regimen is recommended for persons who do not respond to the recommended treatment.

Management of Sex Partners and Household Contacts

Sexual contacts and those that have had close personal or household contact with the patient within the preceding month should be examined and treated.

Management of Outbreaks in Communities, Nursing Homes, and Other Institutional Settings

Scabies outbreaks frequently occur in nursing homes, hospitals, residential facilities, and other communities. Control of an epidemic can only be achieved by treatment of the entire population at risk. Ivermectin can be considered in this setting, especially if treatment with topical scabicides fails. Epidemics should be managed in consultation with an infectious disease specialist.

Special Considerations

Infants, Young Children, and Pregnant or Lactating Women

Infants, young children, and pregnant or lactating women should not be treated with lindane; however, they can be treated with permethrin. Ivermectin is not recommended for pregnant or lactating patients, and the safety of ivermectin in children who weigh <15 kg has not been determined.

HIV Infection

Patients who have uncomplicated scabies and also are infected with HIV should receive the same treatment regimens as those who are HIV negative. HIV-infected patients and others who are immunosuppressed are at increased risk for crusted scabies, for which ivermectin has been reported to be effective in noncontrolled studies involving only a limited number of participants. HIV-infected patients with crusted scabies should be managed in consultation with an infectious disease specialist.