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Use of oral ivermectin in permethrin‐resistant scabies: A pilot study

Editor, According to the European guidelines for the management of scabies, permethrin 5% cream and oral ivermectin (OI) are the first line treatments of Sarcoptes scabiei var. hominis. However, in Italy permethrin is almost the exclusive treatment used, since OI has only very recently become available on the national market. As previously reported by our group and others, scabies is clearly becoming less sensitive to permethrin therapy. As a consequence, we treated a series of patients who failed topical treatments with OI, achieving an optimal outcome. Following this observation, we started an explorative observational study on the use of OI in non-responder patients to permethrin. From March 31, 2021 to February 10, 2022, we registered all the confirmed scabies (as defined by the Consensus Criteria) evaluated at the sexually transmitted infections clinic of Trento, Italy, who were treated with OI, after the failure of a single cycle of permethrin. Although the topical treatment protocol we adopt is more aggressive than that suggested by the European Guidelines, we follow exactly the dosage indicated for OI: 200 μg/kg as two doses 1 week apart. Moreover, we encourage environmental disinfection and patients are informed via leaflets. All cases are followed up 7– 14 days after the treatment completion. We collected 14 consecutive index cases with 21 affected cohabitants, totaling 35 patients (Group A). The population was compared to the previously reported case series consisting of 33 patients (12 index cases and 21 cohabitants) who failed multiple topical treatments cycles (i.e., permethrin and benzyl benzoate 25% cream) and received OI (Group B; Table 1). Clearance of the disease was achieved in all cases except one, namely one patient of Group B lost at followup after the second OI cycle. A recent Cochrane systematic review found that there was no difference detected in the efficacy of permethrin compared to OI, despite the major limitation of a poor reporting. Moreover, nearly all studies have been conducted in South Asia or North Africa, where the disease is more common. However, in Europe there is a rising consensus concerning the resistance of Sarcoptes scabiei var. hominis to permethrin. The development of acaricide resistance, especially in ticks infesting cattle,