Scabies is a contagious skin condition that causes small red spot and makes your skin feel uncomfortable so that you want to rub or scratch it resulting from the infestation of a mite. The Sarcoptes scabiei mite may present within the skin and causes severe itching and redness. This itch is relentless, especially at night. Skin-to-skin contact transmits the infectious organism therefore, family members and skin contact relationships create the severe risk of scabies[1]. Scabies can lead to skin sores and severe complications like septicaemia (a boodstream Poisoning), heart disease and kidney problems. Childrens and other people in resource poor area are at higher risk [2]. Scabies has existed for at least 2500 years and currently affects 400 million people annually worldwide[3]. Since 2017, scabies has been recognised as a one of the most important neglected tropical disease by the World Health Organization (WHO) due to lack of attention at local, national, and international levels, and the higher incidence of this infection amongst the poor [4,5]. In July 2019, the WHO NTD Global Working Group on Monitoring and Evaluate and recommended that the global burden of scabies be controlled, diagnostic criteria be produced, and interim guidelines for public health interventions be introduced [6]. Scabies are not only has significant issue in health system but also have their social effects such as itching, redness, insomnia, loss of productivity, poor quality of life, and in one study resulted in a feeling of shame in 77% of sufferers [7,8].

Fig. 1: Image of Scabies Disease

Scabies epidemiology:

The disease is a very contagious, intensely itchy skin condition caused by microscopic mites transmitted through close personal contact. It represents a major public health challenge, especially in developing countries where the disease and all its complications affect a dispropor- tionately high number of children in poor, overcrowded tropical regions[9,10]. The global number of cases is unknown precisely, but 400 million are estimated to be infected worldwide[11]. Scabies is extremely hyperendemic in settings where healthcare services are poor, and overcrowding and poverty exacerbate the situation[12]. Reinfestation is usually prevalent in such areas as untreated households serve as continued sources of transmission[13].

Scabies is highly hyperendemic in tropical areas, especially in underdeveloped countries. Other susceptible populations include toddlers and elderly individuals[14]. A host of research on the comparison of rates of scabies between adults and children has shown higher prevalence among children[15]. In the absence of a broad cross-sectional study, research hitherto conducted on scabies indicated that it is an endemic disease in the tropical regions, with an estimated prevalence of 5-10% among children[16]. High prevalence areas of scabies are Africa, South America, Southeast Asia, and Australia. The condition is clearly associated with poverty, poor nutrition, lack of hygiene, and homelessness[17].

Another review covering a period between 1971 and 2001 from the WHO reported on data from 18 studies: prevalences reported ranged from 0.2% to 24%[18]. High rates have particularly been noted in some regions, namely India, the South Pacific, and northern Australia[19]. For example, a village survey in rural India found that 70% of the population suffered from scabies. In Australian Aboriginal communities, the prevalence has reached as high as 50%, while studies in Fiji, Vanuatu, and the Solomon Islands report rates ranging from 18.5% to 42% in some areas[20,21]. Also, scabies has been a leading cause of dermatology consultations for migrants to Italy and among homeless populations in Paris, thereby continuing to be a public health challenge of this parasitic infestation[22].                                                                            

Scabies is a very contagious, intensely itchy skin condition caused by microscopic mites that are transmitted through close personal contact. This disease raises significant public health issues, particularly in developing countries, where its prevalence and associated complications are unevenly high among children in impoverished, overcrowded regions of the tropics. It is not known exactly how many people around the world suffer from scabies, but this estimate goes up to 400 million[23]. Its prevalence is more apparent in places that have less access to health services, due to other scabicidal factors such as overcrowding and poverty, which help it transmit. Reinfestation is very common in such areas because many untreated households are actually part of the cycle of transmission[24].

Tropical countries with limited resources are the ones who have the highest rates of scabies, especially in the vulnerable population of young children and the elderly. Comparative studies on the incidence of scabies in adults versus children will always reveal a higher rate among the latter[25]. Even though comprehensive data worldwide is lacking, some studies show that scabies is actually common in tropical regions. The prevalence of scabies estimated between 15-20% of children.The areas with the highest prevalence of scabies include Africa, South America, Southeast Asia, and Australia. The associated factors include poverty, poor nutrition, poor hygiene, and being homeless[26].

A review by WHO concluded that data in 18 studies dating from 1971 to 2001 showed significant variability of prevalence rates, ranging between 0.2% and 24%. Notably, very high prevalence rates have been documented in India, the South Pacific, and northern Australia, among others. Indeed, a study in one rural Indian village found 70% of its population affected by scabies. Of note, in Australian Aboriginal communities, the prevalence has reached as high as 50%, and studies in Fiji, Vanuatu, and the Solomon Islands report rates from 18.5% to 42% in some areas[27]. Finally, scabies has been one of the leading causes of dermatology consultations among migrants to Italy and among homeless populations in Paris, highlighting the considerable public health challenge in relation to this parasitic infestation.

TABLE 1: Prevalence studies of scabies in developing areas since 2019

Pathogenesis of scabies:

Human scabies infections are generally confined to specific areas of the body, with the hands, wrists, and elbows being the most commonly affected sites in adults. Other common sites include the genitals, feet, buttocks, axillae, breasts, and waistline [37]. In Italy, scabies accounted for 68% of infectious disease and dermatology consultations among migrants, while in Paris, it represented 66.5% of consultations within the homeless population [38]. The primary mode of transmission is direct skin-to-skin contact with an infested individual. The scabies mite *Sarcoptes scabiei* affects over 100 mammal species, with domestic animals potentially serving as sources of infection and facilitating cross-species transmission [39, 40]. Sexual contact is another common route of transmission, as the mite thrives in close, prolonged contact [41].

Once the scabies mite infests a host, it penetrates the stratum corneum, the outermost layer of the skin, a process that is difficult to observe directly. However, researchers have been able to observe all life stages of *S. scabiei* under a microscope as they burrow into the skin [42]. The adult female mites dig burrows their range from 1 to 10 millimeters in length in the upper layers of the epidermis of skin, where they lay 3 to 5 eggs daily. These mites have a lifespan of 30 to 60 days, with eggs hatching in approximately 2 to 3 weeks. Not all treatments can penetrate the eggs lodged within the skin [43, 44]. Fertilized female mites burrow into the epidermis of an uninfected host, where they live for 10 to 14 days and lay up to 180 eggs in the stratum corneum [45, 46]. There is an incubation period of 4 to 6 weeks during which the host may not experience symptoms and may be unaware of the infestation. During this time, the mites can still be transmitted to new hosts [47]. The mites appear to have a limited ability to digest IgG and possess a small range of enzymatic activities, suggesting they rely on a serum-based diet [48]. As the mites burrow downward into the dermis, the epidermal cells proliferate, pushing the upper layers of the dry stratum corneum toward the skin surface. Evidence that scabies mites feed on host serum is found in the presence of host IgG antibodies in the esophagus and midgut of mites taken from the host [49]. Estimated around 10% of the eggs typically hatch into adult mites. Male mites are rarely visible on the skin, as they usually create shallow burrows to feed before locating a female to mate [50].

Fig. 2: Growth of Sarcoptes scabiei (Parasite)

Risk factor of scabies:-                                                                                                                                      

1. Direct Physical Contact

The primary route of scabies transmission is via direct skin contact. A person with frequent close contact with an infected individual is most likely. This includes:

• Family members of an infected person
• Sex partners because scabies may be passed through sexual contact
• Caregivers and children in day care/school due to the crowded nature of these settings

2. Living environments

In crowded living environments, the risk of a scabies infestation grows multiple-fold. The mites are spread because people dwell near to one another on a continual basis in all of the aforementioned environments. Some of the examples include:

• Urban slums
• Informal housing
• Refugee camps
• Shelters
• Detention centers
• Older adult care facilities, or nursing homes
• long-term care facilities

3. Poor Hygiene and Sanitary Conditions

Scabies is more common in areas where sanitation is poor and which persons lack basic hygiene practices. The key factors in this are:

• Lacking clean water supply available for bathing or clothing and bedding washing
• Poor waste management - It may lead to the contamination of living spaces and, thus, increase the possibility of infestation

4. Low Socioeconomic Status

In poor socioeconomic statuses, people have more chances of being inflicted with scabies. These include overcrowded housing and poor sanitation practices and poor access to medical facilities. Some at risk are:

• Homeless persons**, where outbreaks are common because they stay in permanent shelters
• Poor communities may lack access to treatment, and the disease may spread far and wide

5. Weakened Immune Systems

The immunity-weakened are even more susceptible not only to infection with scabies but to also more serious forms of the disease, like crusted scabies. These include:

• Patients with **HIV/AIDS**
• Cancer patients on chemotherapy
• Those with immunosuppressive drugs (such as organ transplant recipients)
• Old adults, whose immune system reaction to infections may not be strong

6. Age

• Both the young child and the elderly are at a higher risk for scabies for the following reasons:
• Children are more likely to infected because they come into close contact in schools, parks and young children have much less effective immune systems.
• The older, whether living in long-term care facilities or other group living settings, are also susceptible because of both the loss of immune function and the crowded, sometimes unsanitary environments in which they live.

7. Sexual Activity

It may also be perceived as a sexually transmitted disease, although in certain special cases since it is usually due to penetration sex without protection or numerous sexual partners. In societies with such a considerable prevalence of other STIs, sexual transmission is likely to occur with scabies.

8. Environmental and Climatic Factors

The risk is higher in the summer and humid tropical and subtropical areas where a favorable climate encourages the survival and multiplication of mites. Specific factors that increase the risk are:

• Hot and humid weather, which favors the persistence of mites.
• Seasonal, especially in colder climates during the winter when people are more likely to stay indoors and in closer proximity to others.

Fig. 3: Distribution of mites in different parts of a body

Scabies Diagnosis:

In both human and other animal mammals, early diagnosis of scabies infections is very difficult due to the few mites and the symptoms are very minor at the early stages of infection, which may last for several weeks. Research evidence indicates that typical cases of ordinary scabies characteristically harbor less than 15 adult mites [51]. Diagnosis primarily relies on recognizing the typical signs and symptoms of scabies. While skin scraping microscopy from burrows can assist in confirming the diagnosis, it is often not required in regions with high scabies prevalence. Patients characteristically experience very intense itching, especially when linear burrows and papules are present over the web spaces between the fingers, wrists, arms, and belt line. For infants and younger children, this rash can involve much larger parts of the body, including palms and soles, ankles, and occasionally scalp [52]. This often makes its diagnosis hard with skin scraping.

Even more, clinical presentations of scabies can sometimes mimic or overlap with other skin diseases such as atopic dermatitis, eczema, psoriasis, insect bites, and chemical irritant reactions like soaps, fragrances, metals, and chemicals [53]. A general examination should be done to help support the clinical diagnosis, though cultural or logistical barriers may prevent this. Classic scabies lesions are characterized by several 2-3 mm papules or scaly linear burrows. The clinical features may sometimes mimic other conditions caused by other pathogens, including bacteria, fungi, or viruses [55].

Cutaneous scrapings have largely been replaced by dermoscopy, but this is operator skill-dependent and not necessarily universally available. Dermatoscopes cannot be used to view mites' feces or eggs, although mite detection often proves more difficult on darker skin types [56]. Actually, dermoscopy can be effective if it is done appropriately by a trained practitioner, particularly when at the end of a burrow, there is seen a dark triangular structure in the case of a mite [57]. One of the simplest tests in dermoscopy diagnosis is the ink burrow test. This test could confirm the existence of the burrows due to scabies. The process also involves applying ink to the affected skin area believed to carry a burrow, followed by blotting the area with an alcohol pad. On this stage, if scabies is indeed present, the different "S" shape would appear through the burrow [58].

In current days, studies have been into recombinant molecules as basis for developing diagnostic ELISA tests for scabies mites [59].

Scabies Treatment:

The most frequent complications with scabies include bacterial superinfections, which particularly are caused by *Group A beta-hemolytic streptococci* and *Staphylococcus aureus* [61]. The goal of treatment is, as one would expect, to get rid of the infestation itself since the symptoms of scabies result from the infestation [62, 63]. The types of drugs used for the treatment fall into two categories: either they are acaricidal, that is, kill the mites, or they are ovicidal, meaning they kill the eggs [64]. Multiple treatments have demonstrated equivalence when properly applied and caused few adverse interactions: topical permethrin, topical crotamiton, and systemic ivermectin [65]. A 2007 Cochrane review of all treatments pointed out permethrin as the gold standard to treat scabies, whereas a 2018 update concluded the results were equal with no significant difference between permethrin and ivermectin. Selection, therefore, should be done according to practicality, population size, licensing, and availability [66].

Topical Treatments:

Permethrin, benzyl benzoate, and sulfur-based compounds can be applied topically as lotions or creams [67]. A 5% concentration of Permethrin in lipophilic vesicles is the first-line topical treatment [68, 69]. It acts through the impairment of nerve and muscle functions of the mites that lead to killing of larvae, nymphs, adult mites, and their eggs [70]. Although topical treatments work well, most patients are not compliant with the treatment mainly due to the hassles experienced when applying the cream: frequent applications, irritation of the skin, itching, irritating odor, and cost of the product [71, 72]. The most commonly prescribed topical treatment is permethrin, which may not be available in all regions [73].

Systemic Treatings:

Systemic ivermectin is superior to topical permethrin application in the management of outbreaks of scabies [74]. Ivermectin is an anti-parasitic agent belonging to the avermectin class with broad-spectrum activity. It acts by paralyzing the parasite. The half-life of ivermectin is 12–56 hours and it is inactive against eggs; thus, repeat application should be done at the time of egg hatch [75, 76]. A single dose of ivermectin is given to patients older than 10 years, and if the condition lingers on, another repeat dose is done two weeks later. Two doses of this medication are scabistatic, killing any newly hatched mites [77].

Ivermectin was recorded in some studies with a potential for teratogenic effects after animal studies, raising fear about its use during pregnancy and in young children [78]. However, recent evidence from meta-analyses of pregnant women who took ivermectin during mass drug administration (MDA) for onchocerciasis and lymphatic filariasis suggests no significant adverse effects on maternal health or pregnancy outcomes [79, 80]. Based on this data, France has approved ivermectin as a second-line treatment during pregnancy, while other countries still recommend caution in children weighing less than 15 kg [81]. A recent study on 170 infants and children weighing less than 15 kg, observed that mild side effects were reported in seven children, with no serious adverse events documented [82]. Additionally, ivermectin has the added benefit of curing head lice infestations, with significant reductions in infestation being observed two weeks after MDA in Pacific islands [83]. The World Health Organization included ivermectin in its list of essential medicines in June 2019 [84].

Oral Treatment:

 Ivermectin is the main oral scabies treatment; however, newer agents like moxidectin are promising and have efficacy against other parasitic infections. Oral ivermectin has been particularly useful in treatment of crusted scabies, control of outbreaks in institutions, and for mass treatment in settings with a high incidence of scabies.

Another oral preparation is on the market; however, it is administered orally in a few countries mainly in topical. They suffocate and kill scabies mites. Such preparations are used less frequently compared with ivermectin, but then crotamiton still remains an alternative in case of poor response to topical preparations. Considerations: Oral medications are not generally recommended for pregnant or lactating women, nor for a child weighing less than a certain amount (usually <15 kg).

Marketed products available in market for treatment of Scabies.

• Permethrin cream
• Malathion lotion
• Ivermectin oral tablet
• Benzyl benzoate cream

Fig. 4: Effects of drugs using different routes of administration.

Future aspects:

Scabies is one of the very common dermatological conditions that can be managed quite effectively if the patient and the doctor are aware. A competent physician should know a range of diagnostic and therapeutic modalities. Understanding the varied presentations of scabies presentations results in quicker and more accurate diagnosis. It requires early detection and treatment in order to limit the spread and prevent complications. 

Among the key strategies lined up in the WHO informal consultation on scabies control convened in 2019 in Manila, and in the first meeting of the WHO on skin-Neglected Tropical Diseases (NTDs) by Geneva in 2023, was a key strategy of further highlighting skin NTDs like scabies within the larger agenda of NTDs, primary health care, and universal health coverage. The country level required more potent leadership in local and global funding and leadership at the local levels, strategic advocacy, and higher funding inputs on both local and global levels [85,86].

Another problem in integrating control programs for scabies into existing programs for NTDs is that two doses of ivermectin need to be given, separated by 7–14 days. Comparative assessments of the single-dose regime of ivermectin versus the two-dose standard program would assist in the development of an integrated feasibility demonstration and cost-effectiveness as an approach into other health programs.

Moxidectin is an oral antiparasitic medication that has demonstrated effectiveness in treating scabies and other neglected tropical diseases (NTDs). With a half-life longer than that of ivermectin, it would be potentially better for an MDA program by providing the advantage of extended protection from a single dose [87,88]. In clinical studies, moxidectin has proven very effective in reducing infestations of scabies in treated patients.

Scabies remains a significant public health challenge, particularly in resource-limited settings, where overcrowding and poor hygiene contribute to its high prevalence. The burden of the disease, measured in disability-adjusted life years (DALYs), is substantial, and the psychosocial effects, including stigma, anxiety, and social isolation, exacerbate the physical impact. Despite the availability of effective treatments, such as permethrin and ivermectin, challenges persist due to emerging resistance, limited access to medications, and low treatment compliance. In many endemic areas, scabies outbreaks are not adequately managed, leading to frequent reinfections and sustained transmission.

Diagnostic challenges are another key barrier, with clinical presentations often resembling other dermatological conditions. While dermoscopy and skin scraping can aid in diagnosis, these methods are not always feasible in resource-poor regions. There is a clear need for simple, accessible diagnostic tools that can be used at the point of care, particularly in rural or underserved areas.

Emerging treatments, such as moxidectin and herbal formulations like the scabiecure soap containing neem, tea tree oil, and other plant-based ingredients, offer potential alternatives. These treatments may provide relief from symptoms and help control mite populations, though their efficacy and safety require further evaluation in clinical settings.

A concerted global effort is needed to address the neglected status of scabies, with increased funding, strategic advocacy, and integrated public health initiatives. Future research should focus on evaluating the effectiveness of different drug regimens, the role of mass drug administration (MDA) in controlling outbreaks, and the development of new diagnostic tools and therapeutic agents. Collaboration between healthcare providers, policymakers, and communities will be essential to reducing the burden of scabies and ultimately eliminating it as a public health threat.

1. Swe PM, Christian LD, Lu HC, Sriprakash KS, Fischer K. Complement inhibition by Sarcoptes scabiei protects Streptococcus pyogenes - An in vitro study to unravel the molecular mechanisms behind the poorly understood predilection of S. pyogenes to infect mite-induced skin lesions. PLoS Negl Trop Dis. 2017 Mar.
2. World Health Organisation: Scabies and other ectoparasites. 2024.
3. Orion E, Marcos B, Davidovici B, Wolf R. Itch and scratch: scabies and pediculosis. Clin Dermatol. 2006;24(3):168–75.
4. World Health Organisation: Scabies and other ectoparasites. 2020. 
5. Connors C. Scabies treatment. Northern Territory Disease Control Bulletin. 1994;2:5–6
6. World Health Organisation: NTD-STAG Working Group on Monitoring and Evaluation of Neglected Tropical Diseases. Geneva. 2018.
7. Jackson A, Heukelbach J, da Silva Filho AF, et al. : Clinical features and associated morbidity of scabies in a rural community in Alagoas, Brazil. Trop Med Int Health.2007; 12(4).
8. Worth C, Heukelbach J, Fengler G, et al. : Impaired quality of life in adults and children with scabies from an impoverished community in Brazil. Int J Dermatol.2012; 51(3).
9. RM Andrews, J McCarthy, JR Carapetis, BJ Currie Skin disorders, including pyoderma, scabies, and tinea infections, Ped Clin North Am, 56 (2009), pg. 1421-1440.
10. M McDonald, BJ Currie, JR Carapetis Acute rheumatic fever: a chink in the chain that links the heart to the throat? Lancet Infect Dis, 4 (2004), pp. 240-245.
11. O Chosidow Clinical practices. Scabies N Engl J Med, 20 (2006), pp. 354-356.
12. La Vincente S, Kearns T, Connors C, et al. : Community management of endemic scabies in remote aboriginal communities of northern Australia: Low treatment uptake and high ongoing acquisition. PLoS Negl Trop Dis.2009; 3(5).
13. RM Andrews, J McCarthy, JR Carapetis, BJ Currie, Skin disorders, including pyoderma, scabies, and tinea infections Ped Clin North Am, 56 (2009), pp. 1421-1440.
14. Engelman D, Cantey PT, Marks M, et al. : The public health control of scabies: Priorities for research and action. 2019; 394(10192): 81–92. 10.1016/S0140-6736(19)31136-5. 
15. Romani L, Steer AC, Whitfeld MJ, et al. : Prevalence of scabies and impetigo worldwide: A systematic review. Lancet Infect Dis.2015; 15(8).
16. World Health Organization Epidemiology and management of common skin diseases in children in developing countries, WHO, Geneva (2005).
17. Micali G, Lacarrubba F, Verzì AE, Chosidow O, Schwartz RA. Scabies: Advances in Noninvasive Diagnosis. PLoS Negl Trop Dis. 2016 Jun;10(6):e0004691.
18. World Health Organization Epidemiology and management of common skin diseases in children in developing countries, WHO, Geneva (2005).
19. BK Nair, A Joseph, M Kandamuthan, Epidemic scabies Indian J Med Res, 65 (1977), pp. 513-518.
20. JR Carapetis, C Connors, D Yarmirr, V Krause, BJ Currie, Success of a scabies control program in an Australian aboriginal community Pediatr Infect Dis J, 16 (1997), pp. 494-499.
21. BJ Currie, CM Connors, VL Krause, Scabies programs in aboriginal communities Med J Aust, 161 (1994), pp. 636-637.
22. Di Meco E, Di Napoli A, Amato LM, et al. : Infectious and dermatological diseases among arriving migrants on the Italian coasts. Eur J Public Health.2018; 28(5): 910–6. 10.1093/eurpub/cky126.
23. Micali G, Lacarrubba F, Verzì AE, Chosidow O, Schwartz RA. Scabies: Advances in Noninvasive Diagnosis. PLoS Negl Trop Dis. 2016 Jun;10(6):e0004691.
24. The current evidence for the burden of group A streptococcal diseases. 2019, WHO, Geneva (2019).
25. GBD 2015 DALYs and HALE Collaborators: Global, regional, and national disability-adjusted life-years (DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990–2015: A systematic analysis for the Global Burden of Disease Study 2015. 2016; 388(10053): 1603–58.
26. Bernigaud C, Samarawickrama GR, Jones MK, et al. : The Challenge of Developing a Single-Dose Treatment for Scabies. Trends Parasitol.2019; 35(11): 931–43.
27. Karimkhani C, Colombara DV, Drucker AM, et al. : The global burden of scabies: A cross-sectional analysis from the Global Burden of Disease Study 2015. Lancet Infect Dis.2017; 17(12): 1247–54.
28. IH Ciftci, S Karaca, O Dogru, et al., Prevalence of pediculosis and scabies in preschool nursery children of Afyon, Turkey, Korean J Parasitol, 44 (2016), pp. 95-98.
29. AO Ogunbiyi, E Owoaje, A Ndahi, Prevalence of skin disorders in school children in Ibadan, Nigeria, Pediatr Dermatol, 22 (2015), pp. 6-10.
30. J Heukelbach, T Wilcke, B Winter, H Feldmeier, Epidemiology and morbidity of scabies and pediculosis capitis in resource‐poor communities in Brazil, Br J Dermatol, 153 (2015), pp. 150-156.
31. MM dos Santos, S Amaral, SP Harmen, et al., The prevalence of common skin infections in four districts in Timor‐Leste: a cross sectional survey, BMC Infect Dis, 10 (2017), pp. 61-66.
32. SL Walker, M Shah, VG Hubbard, et al., Skin disease is common in rural Nepal: results of a point prevalence study, Br J Dermatol, 158 (2018), pp. 334-338
33. FB‐B Yap, E Elena, M Pabalan, Prevalence of scabies and head lice among students of secondary boarding schools in Kuching, Sarawak, Malaysia, Pediatr Infect Dis J, 29 (2019), pp. 682-683.
34. H Feldmeier, A Jackson, L Ariza, et al., The epidemiology of scabies in an impoverished community in rural Brazil: presence and severity of disease are associated with poor living conditions and illiteracy, J Am Acad Dermatol, 60 (2019), pp. 436-443.
35. C Steer, AW Jenney, J Kado, et al., High burden of impetigo and scabies in a tropical country, PLoS Negl Trop Dis, 3 (2020), p.g. 467.
36. M Muhammad Zayyid, R Saidatul Saadah, AR Adil, M Rohela, I Jamaiah,Prevalence of scabies and head lice among children in a welfare home in Pulau Pinang, Malaysia, Trop Biomed, 27 (2021), pp. 442-446.
37. Mellanby K. The development of symptoms, parasitic infection and immunity in human scabies. Parasitology. 1999
38. Di Meco E, Di Napoli A, Amato LM, et al. : Infectious and dermatological diseases among arriving migrants on the Italian coasts. Eur J Public Health.2018
39. Pisano SRR, Ryser-Degiorgis MP, Rossi L, et al. : Sarcoptic Mange of Fox Origin in Multiple Farm Animals and Scabies in Humans, Switzerland, 2018. Emerg Infect Dis.
40. Fraser TA, Charleston M, Martin A, et al. : The emergence of sarcoptic mange in Australian wildlife: An unresolved debate. Parasit Vectors. 2016; 9(1): 316.
41. Engelman D, Kiang K, Chosidow O, et al. : Toward the global control of human scabies: Introducing the International Alliance for the Control of Scabies. PLoS Negl Trop Dis.2013
42. Arlian LG, Runyan RA, Achar S, Estes SA. Survival and infectivity of Sarcoptes scabieicanis and var. hominis. J Am Acad Dermatol. 1984.
43. Micali G, Lacarrubba F, Verzì AE, Chosidow O, Schwartz RA. Scabies: Advances in Noninvasive Diagnosis. PLoS Negl Trop Dis. 2016 Jun
44. Dressler C, Rosumeck S, Sunderkötter C, Werner RN, Nast A. The Treatment of Scabies. Dtsch Arztebl Int. 2016 Nov 14
45. Bernigaud C, Samarawickrama GR, Jones MK, et al. : The Challenge of Developing a Single-Dose Treatment for Scabies. Trends Parasitol.2019
46. Thomas C, Coates SJ, Engelman D, et al. : Ectoparasites: Scabies. J Am Acad Dermatol.
47. Engelman D, Yoshizumi J, Hay RJ, et al. : The 2020 International Alliance for the Control of Scabies Consensus Criteria for the Diagnosis of Scabies. Br J Dermatol.
48. Morgan MS, Arlian LG. Enzymatic activity in extracts of allergy-causing astigmatid mites. J Med Entomol. 2006.
49. Rapp CM, Morgan MS, Arlian LG. Presence of host immunoglobulin in the gut of Sarcoptes scabiei(Acari: Sarcoptidae). J Med Entomol. 2006.
50. Murray P, P faller M, Rosenthal K. Medical microbiology.7^th Philadelphia: Elsevier/Saunders; 2013
51. Mellanby K. Scabies. 2nd ed. E. W. Classey: Hampton, UK; 1972.
52. WHO informal consultation on a framework for scabies control, meeting report, WHO Regional Office for the Western Pacific, Manila, Philippines, 19–21 February 2019.
53. Arlian LG, Feldmeier H, Morgan MS. The potential for a blood test for scabies. PLoS Negl Trop Dis. 2015.
54. Engelman D, Yoshizumi J, Hay RJ, et al. : The 2020 International Alliance for the Control of Scabies Consensus Criteria for the Diagnosis of Scabies. Br J Dermatol.2020
55. Kandi V. Laboratory Diagnosis of Scabies Using a Simple Saline Mount: A Clinical Microbiologist's Report. 2017 Mar 19.
56. Engelman D, Yoshizumi J, Hay RJ, et al. : The 2020 International Alliance for the Control of Scabies Consensus Criteria for the Diagnosis of Scabies. Br J Dermatol.2020
57. Walton S, Currie B. Problems in Diagnosing Scabies, a  Global  Disease  in  Human  and Animal    Clinical  Microbiology Reviews 2007.
58. Bennett J. Mandell, Douglas,  and Bennett's Principles and Practice of Infectious Diseases. 8th    Philadelphia,  Pa.:  Elsevier;  2015 [Internet].  Clinicalkey.com.  2018
59. Oleaga A, Casais R, Gonzalez-Quiros P, Prieto M, Gortazar C. Sarcoptic mange in red deer from Spain: improved surveillance or disease emergence? Vet Parasitol.
60. Jackson A, Heukelbach J, da Silva Filho AF, et al. : Clinical features and associated morbidity of scabies in a rural community in Alagoas, Brazil. Trop Med Int Health.
61. Han L, Dong X. Itch mechanisms and circuits. Annu Rev Biophys. 2014
62. Walton SF. The immunology of susceptibility and resistance to scabies. Parasite Immunol. 2010;32:532–540.
63. Mika A, Reynolds SL, Mohlin FC, et al. Novel scabies mite serpins inhibit the three pathways of the human complement system. PLoS One. 2012
64. Bergstrom FC, Reynolds S, Johnstone M, et al. Scabies mite inactivated serine protease paralogs inhibit the human complement system. J Immunol. 2009;182:7809–7817.
65. Dressler C, Rosumeck S, Sunderkötter C, Werner RN, Nast A. The Treatment of Scabies. Dtsch Arztebl Int. 2016 Nov 14;113(45):757-762.
66. Rosumeck S, Nast A, Dressler C: Ivermectin and permethrin for treating scabies. Cochrane Database Syst Rev.2018; 4(4).
67. Hu S, Bigby M. Treating scabies: results from an updated Cochrane review. Arch Dermatol. 2008;144:1638–1640.
68. Rosumeck S, Nast A, Dressler C. Evaluation of ivermectin vs permethrin for treating scabies—summary of a Cochrane review. JAMA Dermatol. 2019;155:730–732.
69. Dhana A, Yen H, Okhovat JP, et al. Ivermectin versus permethrin in the treatment of scabies: a systematic review and meta-analysis of randomized controlled trials. J Am Acad Dermatol. 2018;78:194–198.
70. Bernigaud C, Samarawickrama GR, Jones MK, et al. : The Challenge of Developing a Single-Dose Treatment for Scabies. Trends Parasitol.2019; 35(11): 854-58.
71. La Vincente S, Kearns T, Connors C, et al. : Community management of endemic scabies in remote aboriginal communities of northern Australia: Low treatment uptake and high ongoing acquisition. PLoS Negl Trop Dis.2009; 3(5).
72. Currie BJ, McCarthy JS: Permethrin and ivermectin for scabies. N Engl J Med.2010; 362(8).
73. Romani L, Steer AC, Whitfeld MJ, et al. : Prevalence of scabies and impetigo worldwide: A systematic review. Lancet Infect Dis.2015; 15(8).
74. Dressler C, Rosumeck S, Sunderkötter C, Werner RN, Nast A. The Treatment of Scabies. Dtsch Arztebl Int. 2016 Nov 14;113(45):847-851.
75. Ivermectin is a broad-spectrum, anti-parasitic agent which belongs to the avermectin class and causes paralysis of the parasite. Ivermectin has a short half-life of 12–56 hours and is not ovicidal; therefore, a repeat treatment is recommended once the eggs have hatched.
76. Hardy M, Samuela J, Kama M, et al. : The safety of combined triple drug therapy with ivermectin, diethylcarbamazine and albendazole in the neglected tropical diseases co-endemic setting of Fiji: A cluster randomised trial. PLoS Negl Trop Dis.2020; 14(3).
77. Anderson KL, Strowd LC. Epidemiology, Diagnosis, and Treatment of Scabies in a Dermatology Office. J Am Board Fam Med. 2017 Jan 02;30(1):78-84.
78. Chaccour C, Hammann F, Rabinovich NR: Ivermectin to reduce malaria transmission I. Pharmacokinetic and pharmacodynamic considerations regarding efficacy and safety. Malar J.2017; 16(1): 161.
79. Gyapong JO, Chinbuah MA, Gyapong M: Inadvertent exposure of pregnant women to ivermectin and albendazole during mass drug administration for lymphatic filariasis. Trop Med Int Health.2003; 8(12): 1093-1096.
80. Nicolas P, Maia MF, Bassat Q, et al. : Safety of oral ivermectin during pregnancy: A systematic review and meta-analysis. Lancet Glob Health.
81. World Health Organisation: Model List of Essential Medications, 21st List. 2019.
82. Levy M, Martin L, Bursztejn AC, et al. : Ivermectin safety in infants and children under 15 kg treated for scabies: A multicentric observational study. Br J Dermatol.2020; 182(4): 1003–1006. 
83. Coscione S, Esau T, Kekeubata E, et al. : Impact of ivermectin administered for scabies treatment on the prevalence of head lice in Atoifi, Solomon Islands. PLoS Negl Trop Dis.
84. World Health Organisation: Model List of Essential Medications, 21st List. 2019. 
85. WHO’s first global meeting on skin NTDs calls for greater efforts to address their burden Geneva. World Health Organisation (2023).
86. WHO informal consultation on a framework for scabies control: meeting report. Manila: World Health Organisation regional office for the Western Pacific (2020).
87. Bernigaud C, Fang F, Fischer K, Lespine A, Aho LS, Dreau D, et al. preclinical study of single dose moxidectine, a new oral treatment for scabies: efficacy, safety, and pharmacokinetics compared to two-dose ivermectin in a porcine model.
88. Mounsey KE, Bernigaurd C, Chosidow O, Mccarthy JS. Prospects for moxidectin as a new oral treatment for human scabies.