June 2022

Clair Stokes
Infection Prevention and
Control

Scabies
 Introduction
Forms
Infections
Transmission
Diagnosis
Topical treatment
Management and Treatment
Outbreak
General information
Environmental Cleaning
Treatment failure
Management of failure
Referral or transfer
References
Introduction

Scabies is a skin infection caused by mites known as Sarcoptes Scabie.

Females burrow into the skin, laying about 25 eggs and then die. The
new mites hatch from the eggs in 10-15 days, tunnel up to the skin
surface and grow into adults. The main symptoms of scabies are due to
the body’s allergic reaction to the mites and their waste.
Symptoms include an itchy, widespread rash (often worse at night) which
occurs mainly between the fingers, on the waist, armpits, wrists, navel
and elbows. It usually affects both sides of the body alike. The rash does
not correspond to where the mites are located on the body.
Forms

There are two forms of scabies both caused by the same mite.

The most common form of ‘classical scabies’, has fewer than 20 mites all
over the body.

The rarer type of ‘crusted (Norwegian) scabies’, which may be seen in

immunosuppressed individuals, can have thousands or millions of mites
causing a more severe reaction in the skin. It develops due to an
insufficient immune response in the host.
Infections

Scabies is contagious before symptoms occur which is on average 3-6

weeks following infestation, however, if a person has had scabies in the
past, symptoms will develop in 1-3 days.

Untreated scabies is often associated with secondary bacterial infection

which may lead to cellulitis (infection of the deeper layers of the skin),
folliculitis (inflammation of a hair follicle), boils or impetigo. Scabies
may also exacerbate other pre-existing skin conditions, such as eczema
and psoriasis.
Tr a n s m i s s i o n

From an infested person:

• Direct skin to skin contact with a person who is infected with scabies
(approximately 10 minutes uninterrupted skin-to-skin contact)

• The mite cannot jump from person to person, but can crawl from one
individual to another when there is skin to skin contact for a short period
of time, e.g. holding hands
Cont…

• Classical scabies
On average, the mites can survive in the environment for 24-36 hours,
therefore, can be transmitted from clothing or bedding,

• Crusted (Norwegian) scabies (highly contagious due to the large

number of mites)
The mites can survive in the environment for 7 days, therefore, can easily
be transmitted from clothing, bedding, upholstery.
Diagnosis
Diagnosis of scabies is usually made from the history and examination of
the affected person, in addition to the history of their close contacts.
Misdiagnosis is common because of its similarity to other itching skin
disorders, such as contact dermatitis, insect bites, and psoriasis.
• Classical scabies
Diagnosis should be confirmed by a GP or Dermatologist.
• Crusted (Norwegian) scabies
A diagnosis by a Dermatologist is essential as it is highly contagious, it
usually presents itself in the form of ‘crusted lesions’ which are found
mainly around the wrist areas, but can also affect other parts of the body.
A rash is usually found covering the body which appears crusted, but
may not be itchy.
Thousands or millions of mites can be present and are capable of
disseminating into the immediate environment due to the shedding of
skin from the crusted lesions, surviving for a day or two in warm
conditions.
To p i c a l p r e p a r a t i o n s f o r t r e a t m e n t

Treatment is in the form of a lotion or cream that is available on

prescription or from a pharmacy:
Adults usually need 2-3 x 30 g tubes for 1 treatment application (treating
those without symptoms) and 4-6 tubes for 2 treatment applications
(treating those with symptoms). Insufficient lotion is a contributory
factor to treatment failure.
Lyclear Dermal Cream (permethrin 5%): Low toxicity. 8 hour treatment
Derbac – M (malathion): 24 hour treatment
M a n a g e m e n t a n d Tr e a t m e n t
• Residents with crusted (Norwegian) scabies should be isolated until treatment is
completed.
• Residents with classical scabies do not normally need to be isolated, as they do not
usually have skin to skin contact with other residents, even if confused.
• Treatment consists of the application of two treatments, one week apart.
• Clean hands and wear disposable apron and gloves when there is close contact, e.g.
when performing personal hygiene, and gloves, for example when assisting a
resident when walking to the toilet if skin to skin contact is likely until the second
treatment has been completed.
• Mites can harbour themselves under the nails, therefore, the affected person’s nails
should be kept short.
• Clothing, nightwear and bed linen of all those treated should be washed as normal,
• Other residents, staff members, relatives or close contacts may also require
treatment.
• Clean hands after removing and disposing of each item of PPE, e.g. pair of gloves,
apron.
• Following treatment, itching often persists for several weeks and is not an
indication that treatment has been unsuccessful.
Tr e a t m e n t i n a n o u t b r e a k s i t u a t i o n

If an outbreak (two or more cases) is suspected, contact IPC Nurses or

UKHSA Team who will confirm diagnosis. They will give advice and
help coordinate arrangements for treatment of identified individuals to
take place at a specified time and date.
Each resident and staff member should be assessed to determine if they
are high, medium or low risk of infection.
Residents and staff with symptoms should have two treatments, one
week apart. If there are two or more residents/staff with symptoms,
assess all residents and staff for symptoms. Those identified with
symptoms should have two treatments, one week apart.
Those without symptoms should have one treatment.
Treatment should start on the same day for all residents, staff and close
relatives, who have been advised treatment.
General Information

• Linen and clothing should be washed at 60oC or as recommended by

the manufacturer and tumble dried. If a waterproof covered duvet is
used, it is adequate to wash the cover only.
• Any clothing difficult to wash can be pressed with a hot iron if the
fabric is suitable for ironing at a high temperature. Items that cannot
be washed should be placed into plastic bags and sealed to contain the
mites for 72 hours to allow the mites to die.
• Visitors should avoid prolonged skin to skin contact, e.g. holding
hands, until treatment is completed. Brief contact such as kissing and
hugging is acceptable.
Environmental Cleaning
Scabies mites live on and under the skin. They can only survive off the
body for 24-36 hours.
High: Staff members who undertake intimate care of residents and who
move between residents, rooms or units. This will include both day and
night staff; symptomatic residents and staff members
Medium: Staff and other personnel who have intermittent direct personal
contact with residents, asymptomatic residents who have their care
provided by staff members categorised as ‘high risk’
Low: Staff members who have no direct or intimate contact with affected
residents, including asymptomatic residents whose carers are not
considered to be ‘high risk’
• Routine cleaning of hard surfaces in the environment with warm water
and pH neutral detergent is sufficient.
• Soft furnishings with non-wipeable covers should be removed from
use following treatment and placed into plastic bags and sealed for 72
hours, to allow any mites on the fabric to die. The items should be
vacuumed.
S u s p e c t e d Tr e a t m e n t F a i l u r e

Evidence shows that unsuccessful eradication is usually due to failure to

adhere to the correct outbreak procedures and treatment instructions.
Treatment failure is likely if:
• The itch still persists for longer than 2-4 weeks after the first
application of treatment (particularly if it persists at the same intensity
or is increasing in intensity)
• Treatment was uncoordinated or not applied correctly, e.g. scalp and
face not treated, not reapplied after washing hands, etc., during the
treatment time
• New burrows appear (these are not always easily seen) after the
second application of the treatment
Management of treatment failure
Consider alternative diagnosis.
Re-examine the person to confirm that the diagnosis is correct and look
for new burrows.
If all relevant residents, staff members, relatives or close contacts were
treated simultaneously and treatment was applied correctly, a course of a
different treatment should be used:
o If permethrin 5% dermal cream was used initially, then use malathion
0.5% aqueous solution; or
o If malathion 0.5% aqueous solution was used initially, then use
permethrin 5% dermal cream
If contacts were not treated simultaneously or treatment was incorrectly
applied, either re-treat with the same treatment, or use a different
treatment.
All relevant residents, staff members, relatives or close contacts should
be re-treated at the same time.
Referral or transfer to another health or social
care provider

• Prior to a resident’s transfer to and/or from another health and social

care facility, an assessment for infection risk must be undertaken. This
ensures appropriate placement of the resident.
• The ambulance/transport service and receiving area must be notified of
the resident’s infectious status in advance.
References

• Burgess I (2006) Medical Entomology Centre Insect R&D Ltd

Cambridge
• Department of Health (2015) The Health and Social Care Act 2008
• Practice on the prevention and control of infections and related
guidance
• NHS England and NHS Improvement (March 2019) Standard
infection control precautions: national hand hygiene and personal
protective equipment policy
• National Institute for Health and Care Excellence Clinical Knowledge
• Summaries (2017) Management of Scabies cks.nice.org.uk/scabies
• Public Health England (2018) Infection Prevention and Control: An
Outbreak
• Information Pack for Care Homes – “The Care Home Pack”
THANK YOU