From the Guidelines
For a homeless patient with dry, mildly itchy scabs from apparent bug bites, I recommend over-the-counter 1% hydrocortisone cream applied thinly to affected areas 2-3 times daily for up to 7 days. This low-potency topical steroid reduces inflammation and relieves itching effectively for mild skin reactions, as supported by general medical knowledge and guidelines for treating allergic reactions, such as those described in the context of stinging insect hypersensitivity 1. Key considerations for this patient include:
- Reducing itch and inflammation to improve comfort and prevent further irritation
- Minimizing the risk of infection by keeping the area clean and avoiding scratching
- Considering the use of oral antihistamines like diphenhydramine (Benadryl) 25-50mg every 6 hours if itching is severe, as these can help reduce the itching or pain associated with cutaneous reactions 1
- Practicing good hygiene when possible to prevent secondary infection, especially since fire ant stings can lead to sterile pseudopustules that should be left intact and kept clean 1
- Seeking medical attention if the condition worsens, shows signs of infection, or doesn't improve within a week, as this could indicate a need for antibiotics or treatment for a more serious skin condition. Given the context, calamine lotion could be an alternative if hydrocortisone is unavailable, but hydrocortisone cream is preferred due to its effectiveness in suppressing the inflammatory response and reducing itching.
From the FDA Drug Label
Uses temporarily relieves itching associated with minor skin irritations, inflammation, and rashes due to: eczema psoriasis poison ivy, oak, sumac insect bites detergents jewelry cosmetics soaps seborrheic dermatitis temporarily relieves external anal and genital itching Purpose Anti-itch PRINCIPAL DISPLAY PANEL - 28.4 g Tube Carton TopCare health ™ MAXIMUM STRENGTH • OUR PHARMACISTS RECOMMEND • NDC 36800-099-02 Hydrocortisone 1% Cream ANTIPRURITIC (ANTI-ITCH) Intensive Healing Formula † NET WT 1 OZ (28.4 g) The most appropriate medication for the homeless patient with dry mildly itchy scabs all over the back that appear to be bug bites is hydrocortisone (TOP), as it is indicated for temporarily relieving itching associated with insect bites 2. This is a topical anti-itch medication 2 and is available in a maximum strength formula 2.
- Key benefits: temporarily relieves itching associated with minor skin irritations and inflammation
- Key uses: eczema, psoriasis, poison ivy, oak, sumac, insect bites
- Formulation: cream, 1% hydrocortisone
From the Research
Diagnosis and Treatment Options
The patient's symptoms of dry mildly itchy scabs all over the back, resembling bug bites, could be indicative of scabies, a common condition among homeless populations 3, 4.
Topical Treatment Options
Topical treatments are usually effective for scabies, but they can be cumbersome and expensive to use, especially for large populations or those who are non-adherent to treatment 5. Some topical options include:
- Benzyl benzoate
- Crotamiton
- Malathion
- Permethrin
- Sulfur compounds
Oral Treatment Options
Oral ivermectin has been shown to be safe, easier to use, cheaper, more effective, and more economical than topicals in widespread institutional scabies, for those non-adherent to topicals, and in crusted scabies 5, 6.
Considerations for Homeless Patients
When caring for homeless patients, it's essential to consider the unique challenges they face, including limited access to healthcare and poor hygiene conditions 7, 4.
Recommended Course of Action
Given the patient's symptoms and the potential diagnosis of scabies, oral ivermectin may be a suitable treatment option, considering its ease of use and effectiveness 5, 6. However, a definitive diagnosis and consultation with a healthcare professional are necessary to determine the best course of treatment.