Management of scabies in long term care facilities

Scabies is an extremely contagious and itchy skin condition. Itching is most intense at night. It is caused by the female mite that burrows under the top layer of your skin. The burrows look like thin, wavy, raised lines that are grayish-white in colour. Burrows or rashes can often be found on the webbing between fingers, skin folds on the wrist, elbow, or knee; genitals, breasts, abdomen or shoulder blades. Norwegian scabies, also known as crusted scabies, is an uncommon infestation characterized by widespread crusted lesions which may or may not be itchy. It usually occurs in the elderly or immunocompromised persons. The risk of acquiring scabies is much higher with Norwegian than typical scabies. People with Norwegian scabies have thousands of mites compared to those with typical scabies, who have about 10-15 mites per person In the elderly, infestation often appears as a generalized dermatitis more widely distributed than the burrows, with extensive scaling, and sometimes vesiculation and crusting. The usual severe itching may be reduced or absent. Transmission  Transmission usually occurs directly from person-to-person from prolonged direct contact with infested skin.  Health care activities such as sponge bathing, lifting or applying body lotions have been linked to scabies transmission.  Casual contact (i.e. handshake or hug) rarely leads to infestation  Humans are the only reservoir for the mite  Transfer from undergarments and bedclothes occurs only if these have been contaminated by infested people immediately before the contact  Mites can burrow under the skin surface in minutes  In people who have never had scabies, it can take two to six weeks before the onset of itching. People who have previously been infested will develop symptoms one to four days after an exposure  People remain infectious until all the mites have been killed by treatment.  Diagnosis is commonly made by looking at the burrows or rash. A skin scraping may be taken to look for mites or eggs to confirm diagnosis. If a skin scraping returns negative, it is possible that the person may still be infested due the small number of mites present on the body; this makes it easy for an infestation to be missed.  Residents and staff are treated simultaneously  Treatment is recommended in the evening before the resident goes to bed Peel Public Health - Take Control Guide 2013 PEEL PUBLIC HE INFECTION PREVENTION AND CONTROL RESOURCE GUIDE SECTION 4-22 DISEASE/ORGANISM SPECIFIC  Resident’s skin is clean and dry before treatment  Medicated lotion is prescribed (usually containing 5% permethrin)  Sufficient quantity of lotion is massaged into the skin to cover the entire area from the neck to the soles of the feet, paying particular attention to the areas between fingers and toes, under the fingernails and toenails, wrists, armpits, genital area and buttocks; the face is not included.  Clean clothes are provided for the resident to dress  Resident’s entire body is washed by showering or bathing after 12 – 14  Clean clothes for resident to dress  Re-treatment is only necessary if live mites appear or new lesions develop  Re-treatment may be given 7-10 days after the first treatment  Linen (bed linens, towels, clothing) from 3 days before the beginning of treatment should be sent to laundry in a separate sealed bag  Mites on clothing and linens are killed by regular laundering in the hot  Items that cannot be washed in hot water should be stored in a bag for at  Mattress should be cleaned, disinfected  Routine cleaning of the environment will help eliminate the mites  Thorough cleaning of upholstered furniture and vacuuming of environmental surfaces is recommended after use of a room by a resident with Norwegian (crusted) scabies.  Single room is preferred  Alert all care providers of Additional Precautions needed (Contact)  Contact signage on door of resident room  Dedicated care equipment e.g. blood pressure cup, stethoscope,  Multi use equipment must be cleaned and disinfected between use  PPE includes glove, gown if soiling of clothing is likely for direct care  Upon leaving room PPE is removed and hand hygiene performed Routine practices must be followed and health care providers should wear gloves for any contact with non-intact skin and undiagnosed rashes. When a resident is diagnosed with scabies, the ICP should search for unrecognized cases in other residents and health care providers. It is highly Peel Public Health - Take Control Guide 2013 PEEL PUBLIC HE INFECTION PREVENTION AND CONTROL RESOURCE GUIDE SECTION 4-22 DISEASE/ORGANISM SPECIFIC
unusual to have a single case of scabies. Any rash, regardless of site, should be
investigated and scabies ruled out. Symptoms of itching may not be present and
cannot be relied on as an indicator of infestation. All cases should be treated
simultaneously and individuals who have had skin-to-skin contact should be
treated prophylactically. Contact precautions should be used for all case
residents until after the treatment has been completed. Skin creams and
ointments that have been used by infested residents should be discarded as part
of the treatment process.

Additional Resources:

Heyman, David L. (editor). Control of Communicable Diseases Manual. 19th
edition. American Public Health Association. 2008
Wilson MM, Philpott CD, Breer WA. Atypical presentation of scabies among
nursing home residents.
The Journals of Gerontology 2001 Jul;56A(7):M424-7.
Degelau J. Scabies in Long-Term Care Facilities ICHE 1992 Jul;13(7):421-5
Peel Public Health - Take Control Guide 2013


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