Permethrin 5% cream

BackgroundOral ivermectin is commonly used as a second-line treatment for classic scabies, particularly in cases of treatment failure or poor adherence to topical permethrin, the standard of care. However, the comparative efficacy and safety of oral ivermectin, alone or in combination with permethrin, remains unclear. This systematic review and network meta-analysis evaluated the efficacy and safety of these treatments to guide clinicians and policymakers.MethodsOn April 17, 2022, we conducted a comprehensive search of databases, including MEDLINE and CENTRAL, as well as secondary sources for randomized controlled trials comparing oral ivermectin, alone or in combination with topical permethrin, and topical permethrin, or any of the three with other scabicides or placebo/vehicle/no treatment among patients with classic scabies. The primary outcomes were clinical cure and serious adverse events. We assessed the risk of bias using the Cochrane Risk of Bias 2.0 and evaluated the certainty of evidence using the GRADE approach. Network meta-analyses were performed using available case analysis and a random-effects model. Sensitivity and subgroup analyses explored the impact of methodologic decisions and known effect modifiers. Effect estimates and certainty of evidence ratings were presented in the Summary of Findings tables.ResultsWe included 38 RCTs (N = 4879), most of which had moderate or high overall risk of bias. Oral ivermectin, given in varying dosing regimens (single dose, two-dose, or flexible dosing) showed little or no difference in clinical cure rates compared to permethrin, which was also administered in different dosing schedules, at one to two weeks post-treatment (network RR 0.95, 95% CI [0.89, 1.02]; 30 RCTs, N = 3469; global inconsistency P = 0.42; low certainty evidence). Serious adverse events were rare (1/3212; 0.03%, 95% CI [0.000079, 0.17]; 29 RCTs; very low certainty evidence). One child who received oral ivermectin was hospitalized for cellulitis but eventually recovered. Limited data (1 RCT; n = 100) suggested that combination oral ivermectin/permethrin may be as effective or more effective than permethrin for clinical cure at one to two weeks (network RR 1.21, 95% CI [0.94, 1.56]; low certainty evidence).ConclusionThere may be little or no difference between oral ivermectin and permethrin in clinical cure. However, combination therapy with oral ivermectin and permethrin may be as good as or better than permethrin alone. The rate of serious adverse events is uncertain. Further well-designed RCTs should be conducted to confirm the findings and inform clinical practice and public health policy on scabies control.Study registrationUPM RGAO-2021-1058; PHRR230322-005013; PROSPERO CRD42022278007.

Abstract licence: CC BY-NC-ND

ObjectiveTo investigate whether oral ivermectin or topical 5% permethrin can clinically cure scabies in index cases and in members of their households.DesignMulticentre, assessor blinded, cluster randomised clinical trial.Setting28 French hospitals, 19 January 2016 to 16 December 2021.ParticipantsIndex cases; adults and children weighing >15 kg with scabies, confirmed by dermoscopy.InterventionsIndex cases were randomly assigned to the ivermectin group or permethrin group (1:1 ratio). Each member of the cluster, defined as the household of each index case, received the same treatment as the index case, except for children weighing Main outcome measuresThe primary outcome was clinical cure of the cluster on day 28 (ie, disappearance of clinical signs and symptoms of scabies for all cluster members). Secondary outcomes were index case and individual level analyses and safety. Dermatologists were used as assessors and were masked to the treatment.Results507 participants in 142 households (clusters) were treated with ivermectin and 568 participants in 147 households received permethrin. Cluster level cure rates were 71.8% versus 88.5% (-16.7 percentage point difference, 95% confidence interval (CI) -26.3 to -7.1) for ivermectin versus permethrin. Secondary outcome percentage point differences also showed the inferiority of ivermectin compared with 5% permethrin for index cases (76.6% v 91.5%; percentage point difference -14.9, 95% CI -23.6 to -6.2) and participants (85.3% v 94.2%; -9.2 percentage point difference, -14.9 to -3.5). Intraclass correlation coefficients were higher for permethrin than ivermectin for all clusters (0.68, 95% CI 0.61 to 0.75 v 0.46, 0.37 to 0.56) and for cluster size >1 (0.67, 0.60 to 0.74 v 0.47, 0.37 to 0.56). Cutaneous adverse events were found in 11.9% and 15.6% of participants treated with ivermectin and permethrin, respectively.ConclusionsThe results of this cluster randomised trial of classic scabies, confirmed by dermoscopy, did not show the non-inferiority of oral ivermectin compared with 5% permethrin cream, given on days 0 and 10, in achieving clinical cure of scabies on day 28 in index cases and their household members. Conversely, the trial showed the statistical superiority of 5% permethrin cream.Trial registrationNCT02407782.

Abstract licence: CC BY-NC