Microsoft word - scabies guidelinejanuary 2013.doc

Guideline s for the
Management of Scabies
Warning – Document unc ontrolled when printed
Policy Reference: HP 4.0
Prepared by: Health Protection
Date of Review: January 2015
Lead Reviewer: Lorraine McKee

Version: 5.0
Authorised by: Control of Infection Date: December 2012

Warning – Document uncontrolled when printed
Version: 5.0
Date of Issue: January 2013
Date of Review: January 2015
Guidelines for the Management of Scabies

Scabies is a common public health problem, with an estimated global prevalence of
300 million affected individuals1. It is particularly a problem where there is social
disruption, overcrowding and where personal hygiene is poor2. Immunosuppression,
poor nutritional status, homelessness and dementia are also risk factors.
Species are host specific; transmission between humans and other animals can
occur, but usually only results in short-lived infection, and does not require treatment.
Infants, immobilised elderly, patients with HIV/AIDS, and other medically
compromised patients are particularly predisposed to infection.
Some Facts About Scabies

Scabies is due to a parasitic mite Sarcoptes scabiei variety hominis. They are
minute white disc-like arthropods, just too small to be visible to the naked eye. The
adult female is around 0.4mm long and 0.3mm wide; males are slightly smaller. The
female lays two to three eggs a day in burrows several millimetres in length in the
skin. After two to four days larvae emerge to mature on the skin surface, and then
make new burrows. They mature, mate, and repeat this cycle that takes 10 to 17
days. Males die after a short time, but the females live for up to six weeks.

The characteristic rash is not due to the mite itself but to an allergic reaction to the
mite, its eggs and faeces. It may occur away from the burrows, especially on


Spread is normally from person to person via direct skin contact, including sexual
contact. Although the mites cannot fly or jump, they can crawl as fast as 2.5cm per
minute on warm skin. It was previously believed that prolonged skin-to-skin contact
was necessary for transmission to occur, but there is evidence that they can survive
for at least three days off the skin surface.3 Lower temperatures and higher relative
humidity prolong survival.
However, the average infested adult may have as few as 10 to 15 mites on their
body surface at any one time and in such cases transmission does not normally
occur via the bedding or clothing from an infected person.
In cases of severe infestation (Norwegian or crusted scabies), thousands of mites may be shed daily, and therefore transmission via fomites is possible as the mites survive on the sloughed skin in the environment. Warning – Document uncontrolled when printed
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Date of Issue: January 2013
Date of Review: January 2015
Guidelines for the Management of Scabies
Signs and Symptoms of Classical Scabies

There are three signs diagnostic of scabies:
• Burrows (figure 1) • Erythematous papules (figure 2) • Generalised pruritus (itching) Figure 1 - Scabies burrow in web Spaces between fingers4 Burrows may be found on the web spaces of the hands, the flexure surface of the wrists, elbows, genitalia, axillae, umbilicus, belt line, nipples, buttocks and penile shaft. They appear as slightly elevated pink or grey, straight or tortuous lines one to 10 mm in length. Secondary papules are usually more prominent than the burrows. The main symptom is an intense, itchy symmetrical rash. This pruritus is due to an allergic reaction to the mite, mites’ eggs and excrement. The rash will therefore not appear until the person becomes sensitised to the allergen, which takes three or four weeks. In subsequent infections it may only take one to four days to develop.
Scabies should always be suspected when there is intense pruritus which is worse at
night. The patient may give a history of contact with someone with an itchy rash in
the last two months.
Symptoms may be atypical in the elderly due to a different immunological response, and infection may easily be mistaken for other disease such as psoriasis or eczema. Infection may manifest only as pruritic plaques and patches with faint scale and erythema. Burrows may be seen on unusual sites, and the back is frequently involved, in contrast to younger patients. Warning – Document uncontrolled when printed
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Guidelines for the Management of Scabies
Crusted Scabies

Crusted or Norwegian scabies usually occurs in immuno-compromised patients
including those with AIDS. Due to the poor immune response the itchy rash may not
be present. It can become more severe when unrecognised, and the supposed
condition is treated with topical corticosteroids.
It should be suspected when there is marked thickening and crusting of the skin.
Nails are frequently involved.
It is caused by the same type of mite that causes typical scabies, but there may be one or two million present6. It is therefore highly infectious. The crusts flake off and contaminate the environment where mites can survive for several days. Infection Control Precautions

If scabies is suspected in a hospitalised patient, please contact the Infection
Prevention Control Team for advice.

When caring for people with both typical and crusted scabies in healthcare facilities disposable gloves should be worn during contact and for 24 hours following treatment. Individuals should be isolated until after the first application of treatment. If crusted scabies is suspected, disposable gloves and gowns (with long sleeves) should be worn. Individuals with crusted scabies should be isolated until after the completion of the full course of treatment. The spread of classical scabies without direct person-to-person contact is rare.
However, the recovery of live mites from chairs and couches in the homes of
patients with scabies supports the use of environmental measures. All carpets and
upholstered furniture should be vacuumed, and the vacuum bag immediately
discarded. Ideally, clothes, bed linen and towels should be machine washed at 60°C
and machine dried the day after the first treatment. The mites die quickly at
temperatures >55°C7. Items that cannot be laundered may be kept in a sealed
plastic bag for at least 48 to 72 hours or in a freezer at -20°C for 72 hours.

Occasional secondary infection of the skin lesions following frequent scratching is
possible, often by group A Stretococcus pyogenes, and Staphylococcus aureus.

Permethrin 5% dermal cream is the treatment of choice. It is suitable for children
over the age of two months, and adults, (but not by people who are allergic to
chrysanthemums). It has the advantage of being able to be washed off 8 to 12 hours
following application. N.B Children between two months and two years should be
treated under medical supervision. (See Appendix 3 for dosage)
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Guidelines for the Management of Scabies
Malathion 0.5% in an aqueous basis is also effective and non-irritant and is suitable
for treating adults and children. N.B., It is not to be used on infants less than 6
months except on medical advice. The liquid must remain on the skin for 24 hours.
(See Appendix 3 for dosage). Alcoholic lotions are not recommended owing to the
possibility of further irritating excoriated skin.
Pregnancy – malathion is the treatment of choice.

Both permethrin and malathion may be used; women should be advised
not to exceed the recommended dose and that they should not be used repeatedly.
Treatment of classical scabies consists of two applications of scabicide, one
week apart.
Cases of classical scabies can return to school or work after the first
Treatment of Resistant or Crusted Scabies may require 3 applications of
scabicide on day 1, day 3, and day 7 to ensure that enough penetrates the skin
crusts to kill all the mites.
Method of application:
♦ Remove all clothes, watches and jewellery.
♦ Apply to cool dry skin, i.e., at least five hours after a hot bath or shower.
♦ Treatment should be applied to all parts of the body including the scalp, neck,
face and ears paying special attention to all skin folds and creases (including the umbilicus, genital and natal cleft areas), and in particular the finger nails, and the finger and toe webs. It may be helpful to use a nailbrush for finger and toe nails. (N.B. This is contrary to previous guidance which recommended application from the neck down for healthy adults.)8 Remember the soles of feet! ♦ Ensure help is available for application to the back ♦ The cream/lotion should be allowed to dry (10-15 minutes) before dressing or it ♦ If any area of skin is washed before the end of the stipulated contact time the treatment must be reapplied. If hands will require frequent washing, plastic gloves should be used.
It is essential to apply the treatment as described above, as it will not
otherwise be successful, and resistance will develop.
Systemic Therapy
is available on a named patient basis. Although it is not licensed in the
UK, millions of people have been treated worldwide for various parasitic infections. It
should not be administered in pregnancy, whilst breastfeeding, or to children under
the age of five years7. The dosage is 200 micrograms/kg by mouth. It may be useful
in the treatment of immunocompromised patients, cases with severe crusted lesions,
and in institutionalised outbreaks. There is some evidence that a minimum of two
doses are necessary for successful eradication9. The elimination half-life and the
incubation time of 15 days to egg hatching suggest that administration of a second
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Guidelines for the Management of Scabies
dose of ivermectin on day 14 might be more effective than a single dose, although
comparative studies are lacking.10 Many patients appear to have increased pruritus
for 24-72 hours following administration.
Up to three weekly doses are indicated for crusted scabies when it should be used in
conjunction with topical treatment (two treatments as for classical scabies).
N.B. Ivermectin should only be prescribed if topical therapy is impractical, and not be
considered as a first-line treatment.
Handling of clothing of all cases – on day 2 of treatment (i.e. the day following
application of treatment) all personal laundry should be washed, including towels,
clothing and bed linen. Any items that cannot be washed should be placed aside and
left unworn for five days so that any mites present die.
The itch of scabies persists for some weeks after the infestation has been eliminated and antipruritic treatment may be required, such as a bath emollient, and/or crotamiton. These products are available to purchase over the counter. In some cases it may also be necessary to consider a sedative antihistamine for itch suppression at night, (e.g., alimemazine). In crusted scabies the nails should be trimmed and the areas beneath the nails that are accessible scrubbed daily whilst being treated as they can act as reservoirs. Evidence of cure requires about one month of follow-up as this is the length of time taken for lesions to heal, and for any eggs and mites to reach maturity should treatment fail. Patients and carers should be aware that continuing pruritus is not therefore
necessarily indicative of continuing infection and does not justify additional

Contact Tracing

A contact is defined as someone who has had prolonged (greater than 10 minutes
on any one occasion) skin to skin contact over the previous two months.
All members of the affected household and all close contacts should be treated,
even in the absence of symptoms, on a single occasion at the same time as the
infested subjects.
Where there is a high risk of infestation a full course of treatment
(i.e. two applications) should be given.
11. Schools, Nurseries, and other Children’s Groups
Once the diagnosis has been made, an infected child should not return to school
until after the first application of treatment.
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Guidelines for the Management of Scabies

Should there be several infected children within the class/group, or a child suffers
recurrent infection despite all close contacts being treated, advice should be sought
from the Health Protection Team. Home visits by health visiting/school nursing staff
may be utilised to check that these guidelines are being followed and to advise on
further contact tracing.
From a legal point of view, the Education (Scotland) Act 1980 part 11, section 58
(5&6) makes it clear that is an offence for a parent to send a pupil to school with
recurrent infections due to their failure to ensure adequate treatment. Head teachers
may exclude infected children until they have been treated. However, we
recommend that this should only be done as a last resort after prolonged or recurrent
infection which has been confirmed by a health professional.
Residential Settings

Many skin conditions can look similar to scabies, and they can also have the same
itchy symptoms. It is crucial that any diagnosis of scabies, particularly in a
residential setting, is accurate. This is because, if scabies is definitely diagnosed,
there may be a need to treat all the people who have had close contact with the
case, as well as everyone in the households of the close contacts.
The extent of treatment should be based on a risk assessment which includes the
number of confirmed and symptomatic cases. See flow-chart for suggested
Single cases among residents or staff generally only require treatment of that
particular individual, unless there is evidence of a significant amount of close contact
with others. This should be followed by increased surveillance amongst all residents
and staff for symptoms in the following weeks.
If more than one case of scabies is confirmed in a residential setting the Health
Protection team should be contacted. They will then advise appropriate treatment. It
may be necessary to treat all residents, staff and their families. It is essential in
such cases to treat all relevant contacts simultaneously or at least within the
same 24 hour period.
In such situations symptomatic individuals should have two
applications of treatment, and asymptomatic contacts one application.
Prescriptions for residents need to be obtained from GPs and ideally, everyone
should be treated with the same insecticide. The employer should fund the treatment
of staff.
The treatment day should be planned well in advance and extra staff deployed if
Other services such as Day Care and lunch clubs may continue as normal, as the
clients who attend may well have been exposed to the mite and should be included
in those treated in the event of an outbreak. They should be treated by staff within
the same 24 hour period. If anyone prefers to apply their treatment at home it is
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Date of Review: January 2015
Guidelines for the Management of Scabies
important to ensure that someone is available who can help and apply to areas that they cannot reach. Warning – Document uncontrolled when printed
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Date of Review: January 2015
Guidelines for the Management of Scabies
Two or more probable
Suspected case
Probable single case of
Probable single case of
cases. Patients and/or
classical scabies
classical scabies
crusted Scabies
Stays in own room.
Confused. Wanders
Treat all patients, staff
No contact with other
about the home.
and close family
Fairly tactile.
Low dependency
If confirmed
Treat patient only
Treat all patients and
Observe situation
treat resident as
staff who are close
closely for six to eight
advised by
contacts of case
and seek advice
from Health
Observe situation
Observe situation
closely for six to eight
closely for six to eight
treatment of
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Date of Issue: January 2013
Date of Review: January 2015
Guidelines for the Management of Scabies
Appendix 1
Hengge UR, Currie BJ, Jager G, Lupi O, Schwartz RA (2006) Scabies: a ubiquitous neglected skin disease. Lancet Infectious Disease 6: 769-79 Walker GJA, Johnstone PW. (2004) Interventions for treating scabies. Cochrane database of Systematic Reviews, 2. Johnstone G and Sladden M (2005) Scabies: diagnosis and treatment. BMJ 331:619-622 Centre for Change and Innovation, Patient Pathways. Available at: Vorou R, Remoudaki HD, Maltezou HC. (2007) Nosocomial scabies Journal of Hospital Infection 65: 9-14. Usha V, Gopalakrishnan Nair TV (2000) A comparative study of oral ivermectin and topical permethrin cream in the treatment of scabies. Journal of the American Academy of Dermatology 42: 236-40. Burkhart CG, Burkhart CN, Burkhart KM (2000) An epidemiologic and therapeutic reassessment of scabies. Cutis, 65: 233-236. Chosidow O (2006) Scabies New England Journal of Medicine 354: 1718-29. Buffet M and Dupin N (2003) Current treatment for scabies Fundamental & Clinical Pharmacology 17: 217-225. British National Formulary 64 (September 2012) British Medical Association and the Royal Pharmaceutical Society of Great Britain. Other resources:
Arlian LG, Runyan RA, Estes MD (1984). Survival and infectivity of Sarcoptes scabei
var. canis and var. hominis. Journal of the American Academy of Dermatology; 2(1):
Garcia RG, Lopez-Areal J (2004) Scabies in the elderly. Journal of European
Academy of Dermatology and Venereology 18: 105-107.
Hay RJ (2004) Scabies – Learning from the animals. Journal of the European
Academy of Dermatology and Venerology 18: 129-130.
Jenkins M (2001) Scabies. Nursing Times 97(22) 57-59.
Lee A, Inch S, Fimigon D (eds) (2000) Therapeutics in pregnancy and lactation.
Radcliffe Medical Press.
The Health Protection Team is grateful for the assistance of the Medicines
Information Department in accessing information regarding the use of ivermectin,
and regarding treatment during pregnancy and lactation,

Pictures of scabies:
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Guidelines for the Management of Scabies
Appendix 2
Useful telephone numbers:
Dr Ken Oates, Consultant in Public Health Medicine. 01463 704886
Abhayadevi Tissington, Senior Health Protection Nurse Specialist 01463 704882
Lorraine McKee, Health Protection Nurse Specialist 01463 704975
Appendix 3
Prescribing amounts:
Permethrin 5% dermal cream
Available in 30g tubes.
The approximate amounts are:
Infants 2 months to 1 year

Malathion aqueous lotion 0.5%
Available in 50 and 200 ml.
The approximate amounts needed are:
Children up to 1 year
Warning – Document uncontrolled when printed
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Date of Issue: January 2013
Date of Review: January 2015
Guidelines for the Management of Scabies

What is scabies?
How do you get rid of it?
• Finger/toe nails (It may be helpful to Scabies is a very itchy skin condition. It is Ensure help is available for application pinhead. The rash is not due to the mite itself but to an allergic reaction to the dry for 15 minutes before dressing or it Who needs treatment?
the hands, and are often difficult to find. If any area is washed before the end of How do you know you have it?
must be reapplied. Use plastic gloves if How do you catch it?
How often should the cream/lotion be
It is important to treat everyone on the
same day to make sure the mites do
not pass back to a treated person.
You must apply the cream/lotion twice, one week apart to complete the treatment. You Applying the cream/lotion
may return to school or work after the first care homes. It is not normally caught from After the treatment
Can you catch it again?
Itching may last for 2 to 3 weeks after Warning – Document uncontrolled when printed
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Date of Issue: September 2012
Date of Review: September 2014
Guidelines for the Management of Scabies
Information produced by:
What if you have a skin problem, e.g.,
The lotions and cream are very gentle on people have a little irritation for up to a What about babies, pregnant women,
Further copies of this leaflet can be
and women breastfeeding?
obtained from:
If you are pregnant, use a product that Warning – Document uncontrolled when printed
Version: 5.0
Date of Issue: September 2012
Date of Review: September 2014

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