Question: In children or adults with a clinical or parasitological (microscopic) diagnosis of scabies, what is the evidence for effectiveness of available topical and systemic therapies? Design: Systematic review and meta-analysis. Data Sources: Data were obtained from the Cochrane Infectious Disease Group Specialized Register (to February 2007), Cochrane Central Register of Controlled Trials, MEDLINE (1966 to February 2007), EMBASE (1974 to February 2007), LILACS (1982 to February 2007), INDMED (February 2007), and the Gray literature and sources for registered trials in March 2007. Reference lists of all retrieved trials were checked for additional trials. Study Selection: The selection criteria for studies included randomized controlled trials that examined therapies used in children or adults with a clinical or parasitological diagnosis of scabies. Outcomes: The primary outcome measures included treatment failure in a clinically or parasitologically confirmed case; treatment failure was defined as the persistence of original lesions, appearance of new lesions, or confirmation of a live mite. The secondary outcome measure was the persistence of patient-reported itch. Results:Theauthorsanalyzed20randomizedcontrolledtrials thatmettheir inclusioncriteria, involvingatotalof2392participants.Seventeenofthe20includedstudieswereconducted in resource-poor countries. Of the other 3 trials, 1 was carried out in the United States and 2 in Italy. Altogether, the effectivenessof the followingdrugswas tested: topicalbenzylbenzoate,crotamiton,decamethrin, lindane,permethrin, synergized natural pyrethrins, sulfur, and oral ivermectin. Sixteen trials compared 1 drug with at least 1 other drug; 1 trialcomparedivermectinagainstplacebo;2trialscompared different drug treatment regimens; and 1 trial compared 2 different vehicles for the same drug. No randomized controlledtrials investigatingmalathionwereidentified,andthe only 3 trials of herbal remedies did not meet inclusion criteria. Although the treatment of family members and close contactssimultaneouslywithcasesisgenerallyrecommended, none of the trials tested this hypothesis. The authors extracted data to allow intention-totreat analysis. All included trials reported dichotomous outcomes. Results were presented as relative risks (RRs) of treatment failure with 95% confidence intervals (CIs) around these estimates. Therefore, RRs less than 1 favor the intervention of interest. Where significant heterogeneity was detected and it was appropriate to combine the trials in a meta-analysis, the authors used a random effects model; otherwise, a fixed-effect model was used. One potential source of heterogeneity was explored by stratifying the analyses into 2 groups on the basis of whether the diagnosis was clinical or microscopic. Microscopic confirmation of the diagnosis was thought to be more accurate than clinical assessment alone. The results (Table) indicated that among trial participants with clinically diagnosed scabies, oral ivermectin was less effective than topical permethrin. Topical permethrin was more effective than topical crotamiton and topical lindane. Significant study heterogeneity was detected in the 5 trials comparing permethrin and lindane in clinically diagnosed patients. The comparison of permethrin and lindane in trial participants with microscopically diagnosed scabies had a combined RR of 0.31 (3 trials), but the difference was not statistically significant (95% CI, 0.09-1.09). Permethrin also appeared to be more effective in reducing itch persistence than either crotamiton (RR, 0.26; 95% CI, 0.11-0.65) or lindane (combined estimate of 2 trials: RR, 0.62; 95% CI, 0.44-0.87). In 1 small trial, permethrin was less effective than synergized pyrethrin (a topical preparation of natural pyrethrins synergized with piperonyl butoxide, used as an alterative to permethrin in some countries), but the difference did not reach statistical significance (Table). Ivermectin was more effective than placebo and topical
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