Parasites, bites, and stings

Examples of Parasites, Bites, and Stings

Parasites: Lice, Scabies

Bites: Ticks, Mosquitoes

Stings: Bees, Wasps, Hornets

Lice Presentation

Head Lice: Found on the hair of head, may also be present in the beard, eyelashes, etc.

Body Lice: Found on the clothing, lay eggs on or near seams of clothing, move to skin to feed

Public Lice: Found on the hair around the genitals

Lice Symptomology

Initially asymptomatic

As louse multiply, patient may experience tickling feeling from hair movement

Often progresses to severe itching

Severe infestations may be associated with the presence of pruritic lesions and macules

Lice Prevention

Do not share clothing (hats, coats) or hair accessories (combs, brushes, hair bows)

Avoid head to head contact during play and other acitivities

Do not lie on beds, couches, pillows, carpets, or stuffed animals that have recently been in contact with a person infested with head lice

Lice Nonpharmacologic treatment

Manual removal of lice/nits with fine-tooth comb - should be used in combination with all OTC and RX treatment options

No evidence that suffocating lice with mayo, olive oil, margarine, butter, or similar substances is an effective treatment form

Essential oils: Rosemary, citronella, peppermint, and eucalyptus oil have shown to be off putting and potentially toxic to lice

Several OTC brands that provide “natural” remedies for the prevention and treatment of lice infestations

Additional prevention/nonpharmacologic treatment of lice

Disinfect brushes and combs of infected person by soaking them in hot water (at least 130 F) for 5 to 10 minutes

Machine wash and dry clothing, towels, bed linens, and other items in hot water and high heat dry

Seal items that cannot be washed in a plastic bag or sealed container for two weeks

Vacuum the floor and furniture where infested person sat or lay

Fumigant sprays or fogs not necessary or helpful

Permethrin

Nix, OTC

Available as lotion (1%), cream (1%), and liquid rinse (1%)

1st line treatment option for lice

For children over 2 months

Drug choice in pregnancy

Only kills live lice, not nits, use on public lice is considered off label

Permethrin (Nix) dosing and safety

Used to kill live lice (OTC)

Head Lice:

• Wash hair with conditioner free shampoo prior to use and towel dry

• Apply enough to thoroughly coat all dry hair and scalp

• Leave for 10 minutes; rinse with warm water

• Remove nits with comb

• Repeat in 7 days

Public Lice:

• Apply to the affected area

• Leave for 10 minutes, rinse with warm water

ADEs: Topical irritation (burning sensation, skin rash)

Pyrethins + Puperonyl butoxide

RID, available as shampoo (0.33% / 4%), (OTC)

Made from chrysanthemum plants - avoid in allergy

For children over 2 years old

Only kills live lice, not nits

Pyrethins + Puperonyl butoxide (RID) dosing and safety

Used to kill live lice (OTC)

Head lice:

• Apply enough to thoroughly coat all dry hair and scalp

• Leave for 10 minutes

• Wash and dry hair

• Repeat in 7 days

ADEs: Topical irritation (burning sensation, skin rash)

Ivermectin

Sklice, available as lotion (0.5%) and cream (0.5%), (OTC)

For children > 6 months

Kills lice and nits

Ivermectin (Sklice) dosing and safety

Kills lice and nits (OTC)

Head lice:

• Apply enough thoroughly coat all dry hair and scalp

• Leave for 10 minutes

• Rinse hair with water only

• Wat 24 hours before using shampoo; single use only*

ADEs: Topical irritation (burning sensation, skin rash)

Spinosad

Used for lice (Rx)

Natroba, available as suspension (0.9%),

Can only be used in children greater than 6 months old

Spinosad (Natroba) dosing and safety

Head Lice (RX):

• Apply enough to thoroughly coat all dry hair and scalp

• Leave for 10 minutes; rinse with warm water

• If lice are seen within 7 days, re-apply

ADEs: Topical irritation (burning sensation, skin rash)

Malathion

Used for Lice (Rx)

Ovide, available as (0.5%) lotion

Can only be used in children over 2 years old, contains large amounts of alcohol

Do not use hairdryer on hair after use

Malathion (Ovide)

Head lice (Rx):

• Apply enough to thoroughly coat all dry hair and scalp

• Leave on 8-12 hours (typically overnight)

• Shampoo hair after completion

• Can be repeated in 7-9 days

ADEs: Topical irritation (burning sensation, skin rash)

Lindane

Used for lice (Rx)

Available as Lotion (1%) and shampoo (1%)

Reserved for last line treatment

Should only be used in patients who cannot tolerate or have failed first-line treatments

Lindane dose and safety

Head lice (Rx):

• Apply to dry hair and massage for 4 minutes

• Add small amount of water until later forms

• Rinse hair thoroughly

• Do not re-treat

ADEs: BBW - Neurotoxicity

CI: patients with seizure disorders

Use with caution in children, elderly, and patients with skin conditions

Ivermectin

Used for lice, scabies) (Rx)

Stromectol, available as tablets (3mg)

Used i n topical refractory cases, labeled for use in adults but not children

Round doses to nearest tablet size (no max dose)

Caution in children < 15 kg and in pregnancy

Not ovicidal

Topical ivermectin is not used in scabies treatment)

Ivermectin (Stromectol) dose and safety (Lice)

Head Lice:

• 200 mcg/kg/dose x2 doses given 7-14 days apart

Public Lice:

• Same as head lice

ADEs: Joint pain, tachycardia, diarrhea, elevated hepatic enzymes

CNS effects (neurotoxicity, confusion)

Scabies Presentation

Pruritic papules, vesicles, or burrow lesions found frequently between toes/fingers, palms, and genital areas.

Symptoms may take 3 to 6 weeks to appear if someone has never had scabies prior

Diagnosis: Skin scrapings evaluated on a wet mount

Scabies symptomology

Severe itching (often impacts sleep)

Excoriations in the interdigital spaces, wrists, elbows, buttocks, and groin

Burrows formed by the mite are visible to the naked eye

Scabies prevention

Avoid skin-to-skin contact - can be transmitted even when asymptomatic

Avoid sharing items like clothing and bedding

Wash all clothing, towels, bedding, and other items used by someone who has scabies in hot water.

Permethrin

Used for scabies (Rx)

Elimite, Available as cream (5%)

1st line treatment for scabies, labeled for children over 2 months

1 application is generally curative (need about 30 g per adult)

Limited data on ovicidal activity

Permethrin (Elimite) dosing and safety

Directions (for scabies, Rx):

• Scrub skin in warm water with soap using a soft brush to remove all scabs

• After bathing and drying off - apply lotion to the entire body

• Avoid mucous membranes, eyes, and the face

• Leave the application for 8-14 hours and then shower as normal

• Repeat the process in 2 weeks

ADEs: Topical irritation

Crotamiton

Used to treat scabies (Rx)

Eurax, available as cream (10%), lotion (10%)

1st line treatment if patient has a permethrin allergy

Not labeled for use in children but can be used in older than 2 months.

Crotamiton (Eurax) dosing and safety

Directions (for scabies, Rx):

• Apply a thin layer from neck to toes

• Repeat application in 24 hours

• Rinse off 48 hours after 2nd application

• May repeat in 2-4 weeks if new lesions appear or itching persists

ADEs: Topical irritation

Tick Bites Presentation

Bites are often not felt/painless

Evidence of envenomation may not appear for several days

Lyme disease typically manifests as a “target rash” or “bull’s-eye rash”

RMFS as petechial spots usually on wrists and ankles

Tick Bites Symptomology

Fever/chills

Aches/pains

Rash

Headache

Malaise

Tick Bites Prevention

Wear clothing that covers majority of skin when outdoors in wooded areas or areas with high grass

Treat clothing/gear with 0.5% permethrin

Use environmental protection agency (EPA) - registered insect repellants (i.e., DEET)

Check clothing and body for ticks after being outdoors

Rocky Mountain Spotted Fever

Most common tickborne disease in Oklahoma

Mosquito Bites Presentation

Small, raised bumps on the skin caused by a reaction to the saliva injected into the skin by the mosquito

Can also appear as hard blisters

Mosquito Bite Symptomology

Itching, swelling, erythema, fever, hives

Mosquito Bite Prevention

Wear clothing that covers majority of skin when outdoors in wooded areas or areas with high grass

Treat clothing/gear with 0.5% permethrin products

Use EPA-Registered insect repellants (i.e. DEET)

Avoid standing water

DEET

Topical insect repellant for ticks and mosquitos

Sprays, lotions, liquids, towelettes (5-99%)

DEET Protection time and Pearls

<10 hours (% DEET is related to protection time)

Avoid combined products with sunscreen

Products >50% DEET should be applied to clothing only

Max 30% DEET for Children

Can damage plastics

Picardin indication

Topical insect repellant used for ticks and mosquitos

Available as sprays, lotions (20%)

Picardin Protection time and pearls

Less than or equal to 14 hours

Alternative to DEET, less toxicity

Does not damage plastics

Avoid in children <2 years of age

IR 3535 Indication

Topical insect repellant for mosquitos

Available as spray, aerosol, towelette, lotion (7.5-20.5%)

IR 3535 Protection time and Pearls

<4-8 hours

Can cause eye irritation

Avoid combined products with sunscreen

Slightly less effective than DEET, but preferable because lacks strong odor

Oil of Citronella Indication

Topical insect repellant for mosquitos

Available as spray, lotion

Oil of Citronella Protection Time and Pearls

<2 hours

Avoid use in children <6 months of age

Less effective

Oil of Lemon Eucalyptus

Topical insect repellant for mosquitos

Available as spray (30%)

Oil of Lemon Eucalyptus Protection time and Pearls

<4-6 hours

Can cause allergic skin reactions

Can cause eye irritation

Avoid use in children < 3 years of age

Stings Presentation

Local: Pain erythema, edema, hives

Toxic: Results of multiple stings, anaphylactic-type reaction with nausea, vomiting, diarrhea

Anaphylaxis: Severe systemic reaction with hypotension and airway constriction, can be fatal

Delayed: Occurs 5-14 days after sting, general malaise

Stings Symptomology

Wheal-and-flare reaction

Edema

Erythema

Sharp pain

Itching

Stings prevention

Wear light-colored clothing that covers exposed areas of skin

Avoid sweet perfumes, shampoos, and deodorants

Cover open food and drinks when outside

Strings Treatment

1. Wash the area with soap and water

2. Remove stinger if able

3. Apply ice to help with swelling

4. NSAIDs if the patient is experiencing pain/swelling

Anaphylaxis Symptoms

Wheezing, diminished breath sounds, hives, angioedema, hypotension

Anaphylaxis Treatment

First Line: Epinephrine - Increased risk of poor outcomes when not given within 20 minutes of initial reaction, often underused and underdosed

MOA: Increases peripheral vascular resistance, increases cardiac contractility, stroke volume, output, reverses bronchoconstriction and mucosal edema

Additional therapies: Antihistamines (diphenhydramine) - Symptom management, always given after epinephrine adminstration

Steroids - Commonly given, however, limited data showing effectiveness

Epinephrine Options (outpatient)

Autoinjector:

Epi-pen (0.3 mg/0.3 mL)

Epi-pen Junior (0.15 mg/0.3 mL)

Auvi-Q (0.1mg/0.1 mL, 0.15mg/0.15mg, 0.30mg/0.30mL)

Nasal Spray: Neffy (1 mg, 2 mg)

Epinephrine Dosing and safety (outpatient)

Autoinjector:

• Patients greater than 30 kg: 0.3 mg IM injection

• Patients 15 to >30 kg: 0.15 mg IM injection

• Patients 7.5 to >15 kg: 0.1 mg IM injection

Nasal Spray:

• 15 to <30 kg: 1 mg

• >30 kg: 2 mg

Tachycardia, hypertension, arrhythmia, anxiety, restlessness

Nasal Spray: Headache, nasal congestion, rhinorrhea, sneezing

Epinephrine (outpatient) Pearls

Patients with severe allergic reactions should always have 2 Epi-Pens available for use

May repeat dose in 5 to 15 minutes

Can be injected through clothing

NO absolute contraindication to epinephrine use to anaphylaxis

Epinephrine options (Inpatient) and dosing

Vial (1 mg/mL)

Prefilled syringe (0.1 mg/ mL)

Adults: 0.3-0.5 mg IM every 15 minutes until resolution of symptoms

Pediatrics: 0.01 mg/kg every 15 minutes until resolution of symptoms

Epinephrine Safety and pearls (Inpatient)

ADEs: Tachycardia, hypertension, arrythmia, anxiety, restlessness

Pearls: May repeat every 5 minutes, no absolute CI in anaphylaxis,

Vesicant - extravasation may cause ischemic necrosis