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Prevention, control and treatment

of scabies
Gould D (2010) Prevention, control and treatment of scabies. Nursing Standard. 25, 9, 42-46.
Date of acceptance: December 21 2009.

Summary

Life cycle of the scabies mite

Scabies is a common, but neglected, skin condition that is becoming

increasingly prevalent globally. It causes distress and is frequently
regarded as a stigmatising condition, although it can affect anyone
of any age or social class. Understanding the epidemiology and life
cycle of the mite Sarcoptes scabiei, which causes scabies, is the key
to effective prevention and control.

Newly mated female mites penetrate the skin,

usually at the hands (Figure 1), wrists, elbows, feet
or groin. They form burrows at the junction of the
epidermis and underlying dermis, where they lay
eggs at a rate of two to three a day for up to two
months. The eggs hatch after three to four days
(Heukelbach and Feldmeier 2006). Less than
10% develop into mature mites. The new larvae
grow, lose their outer coat or moult twice, become
adults, leave their burrows and emerge on to the
skin surface, where they mate. The entire life cycle is
complete in 10-14 days and the mites live for about
30 days. Males do not form burrows, but stay on
the skin surface looking for new females to mate
with. The males die after mating (Chosidow 2006).

Dinah Gould, professor in applied health, St Bartholomew School

of Nursing and Midwifery, City University, London.
Email: D.Gould@city.ac.uk

Keywords
Infestation, mites, scabies, skin conditions
These keywords are based on subject headings from the British
Nursing Index. All articles are subject to external double-blind peer
review and checked for plagiarism using automated software. For
author and research article guidelines visit the Nursing Standard
home page at www.nursing-standard.co.uk. For related articles
visit our online archive and search using the keywords.

SCABIES IS CAUSED BY a mite called Sarcoptes

scabiei. It lives in the skin and is host-specific:
scabies can be contracted only from another
person who is already affected, not from animals.
It is classified as an arthropod a jointed
organism, not a true insect although treatment
is with insecticides. The scabies mite causes
an infestation, not an infection, but secondary
infection can occur in response to scratching.
Scabies is highly contagious, especially in
conditions where there is overcrowding, has
a worldwide distribution and is endemic in
developing countries (Johnston and Sladden
2005). In the UK, it is very common in the
community and in healthcare settings, especially
in nursing and residential care homes (Andersen
et al 2000, de Beer et al 2006). The signs and
symptoms of scabies arise not as a direct result of
the infestation itself, but from an allergic reaction
to faeces, saliva and eggs deposited under the skin
by the mites (Johnston and Sladden 2005).
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Signs and symptoms

Infestation by S. scabiei presents in two ways:
classic scabies and hyperkeratotic scabies.
Classic scabies This occurs in healthy people
with normal immune status. Usually only a few
mites are present on an affected person. For
someone who has never had an infestation before,
symptoms may not appear until two to six weeks
after exposure because the allergic response
develops gradually. It occurs much more quickly
in cases of reinfestation, with symptoms usually
appearing in a week. The burrowing of the mites
FIGURE 1
Classic scabies on the hands

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Author

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causes intense itching which can affect all parts

of the body and is particularly severe at night,
disturbing sleep. Miniature papules, pustules and
excoriations soon appear and the skin often looks
unsightly (Figure 1). Some parts of the body are
especially likely to be affected (Box 1).
Scratching can lead to secondary bacterial
infection (impetigo) or increase the severity of
existing skin conditions such as eczema or
psoriasis (Chosidow 2006). A more generalised,
symmetrical rash may affect any part of the body
without necessarily coinciding with the site
affected by the mites, although itching often seems
to begin at the time that the first rash appears
(Johnston and Sladden 2005). Mite burrows can
sometimes be seen just under the skin, where they
appear as silvery or dark lines up to 1cm long with
a dark speck at the end. They are most easily visible
in skin that has not been scratched (Johnston and
Sladden 2005). The appearance and severity of
symptoms varies between individuals and, as with
all allergic reactions, will depend on their immune
status. Cases of scabies can be missed because some
people do not itch, or on questioning do not admit
to itching (Johnston and Sladden 2005).
Hyperkeratotic scabies This is a hyperinfestation
occurring in individuals who have immature or
impaired immune systems (Box 2). It is highly
contagious because the mites are present in large
numbers in the skin scales (Johnston and Sladden
2005). The condition is sometimes also known
as atypical, Norwegian or crusted scabies because
of the scaly, crusted appearance of the skin
(Health Protection Agency (HPA) 2010).

the result that symptoms take several weeks to

appear, so it may be some time before cases become
apparent (Tjioe and Vissers 2008).

Transmission

Prevalence

Infestation occurs when one or more mites are

transferred directly from the skin of one person to
another either through social or sexual contact. The
risk of transmission increases with the duration and
frequency of direct skin-to-skin contact (Johnston
and Sladden 2005). Mites are passed from one
person to another in close communities, especially
within the same household, through activities such
as prolonged hand holding. Scabies cannot be
contracted through brief contact such as shaking
hands. Scabies mites become dehydrated and weak
if they become detached from their host and do not
survive long in the environment, so transfer on
fomites any item able to transmit infection
such as bedclothes and furnishings is unlikely to
contribute to the spread of classic scabies. However,
the HPA (2010) has suggested that fomites might
contribute to the spread of hyperkeratotic scabies.
Spread can occur rapidly through care homes and
other communities (Andersen et al 2000) and
outbreaks have occurred in hospitals (Obasanjo
et al 2001). People who have not previously been
infested develop the allergic response slowly, with

Scabies occurs worldwide and is common in the

UK. However, the exact number of affected people
is impossible to determine because it is not a
reportable disease (McCroskey and Rosh 2010)
and many people treat themselves without seeking
medical or nursing help. Cases can also be missed
because scabies can be difficult to recognise,
especially if there is severe scratching, inflammation
or secondary infection leading to misdiagnosis,
or because individuals conceal symptoms. Scabies
appears to be more common in urban areas and
women and children are more often affected than
men (Downs et al 1999).

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BOX 1
Parts of the body most frequently affected
by classic scabies
!Fingers.

!Thighs.

!Wrists.

!Genitalia.

!Elbows.

!Nipples.

!Armpits.

!Under the breasts.

!Waist.

!Lower buttocks.

(Chosidow 2006)

BOX 2
People at risk of developing hyperkeratotic
scabies
!Frail older people.
!People with immunodeficient conditions such as
human immunodeficiency virus.

!People undergoing treatment that can affect

immune status, such as treatment for malignancy.

!Infants.
!People with Downs syndrome.
!People who are malnourished.
!Those receiving corticosteroids.
(Chosidow 2006)

Diagnosis
Diagnosis is made on the basis of clinical
examination and the patients history. S. scabiei
is too small to be readily visible to the naked eye.
Adult females are 0.4mm long and males are
0.2mm long. Both are creamy white in colour
(Figure 2). It is not necessary to see the mites to
reach a diagnosis and begin treatment. Scabies
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should be suspected if the following symptoms
have been observed (HPA 2010):
!Itching, especially at night.
!A symmetrical rash.
!Skin lesions at the typically affected sites (Box 1).
Diagnosis should be made by a doctor or a nurse
with specialist dermatology or public health
training. This is because scabies is easily mistaken
for other pruritic skin conditions leading to
inappropriate treatment and increasing the risks
of spread (Johnston and Sladden 2005).

Treatments
Although the scabies mite is not an insect,
treatment is with topical insecticides. Success
depends on the index case the first person
identified and all members of the affected
household or community receiving treatment
at the same time, regardless of whether they have
symptoms. Treatment is necessary twice, with
one week between each application. Two different
topical treatments are available for classic scabies
in the UK. Both act by killing the mites (scabicides).
Healthcare professionals should emphasise the
importance of reading and following the directions
for application carefully as they are slightly
different for the two types of product.
Permethrin 5% dermal cream Permethrin is
an aqueous pyrethoid product derived from
pyrethrum flowers, which belong to the
chrysanthemum family. It is the treatment of choice
in the UK, based on the findings of a systematic
Cochrane review examining the evidence of seven
trials comparing its performance with other
FIGURE 2

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Scabies mite burrowing under the skin

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products (Strong and Johnstone 2007). The

product should be applied to the entire body and
washed off 8-12 hours later. It must be reapplied
if it is washed off within the minimum eight hours
contact time, for example on the hands or face,
if incontinence occurs or a nappy is changed.
Permethrin is not suitable for use on skin that is
broken or in cases of secondary infection, and must
not be used for children under two months without
medical supervision. Permethrin should not be used
by anyone who is allergic to chrysanthemums.
It is frequently used in insecticidal sprays, which
some people find unpleasant and irritating to the
nose and throat, but this should not be confused
with genuine allergy. The treatment of
hyperkeratotic scabies is more challenging
because of the large number of mites present.
Two or three applications of topical scabicide on
consecutive days may be necessary to make sure
that enough of the product penetrates the skin
crusts and reaches the mites.
Malathion 0.5% liquid Malathion is an aqueous
organophosphate used in cases of allergy to
permethrin. There are no randomised controlled
trials to evaluate its effectiveness, but the
evidence of controlled clinical trials undertaken
20-30 years ago indicate that it is effective
(Strong and Johnstone 2007). The product must
be applied to the whole body and washed off
after 24 hours. If it is washed off within the
minimum 24 hours contact time it must be
reapplied. Medical supervision is necessary for
children under six months.
Ivermectin is an oral product sometimes used to
treat hyperkeratotic scabies if there is no response
to topical treatment. It is used to treat a range of
parasitic diseases in developing countries, but its
use is restricted. It is available only from specialist
importers on a named-patient basis because of
concerns about its safety (Coyne and Addiss 1997).
Benzyl benzoate is no longer recommended
for treating scabies. It has to be reapplied after
24 hours without the individual being able to take
a bath between treatments and can cause an
unpleasant burning sensation when applied.
Alcoholic preparations are not recommended
because they are painful if applied to broken skin.
Complementary therapies such as tea tree oil are
not recommended because there is no evidence
that they are effective and reliance on them may
increase the circle of contacts at risk of infestation
(Johnston and Sladden 2005). Such products are
widely available on the internet and patients
should be advised not to purchase them.
Secondary bacterial infections should be
treated with antibiotics. Antipruritic creams or
lotions such as 1% hydrocortisone cream may
help control severe itching. Occasionally a mild
sedative prescribed for a short period of time may
help improve disturbed sleeping.
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Recommended advice

BOX 3

Advice to patients and parents People using

scabicidal preparations should be advised to
apply the product twice, with seven days
between each treatment. It should be gently
rubbed on to all parts of the skin from the neck
downwards and allowed to dry before dressing.
In the case of older people and those who are
immunocompromised, application should also
be to the ears, face and scalp. Individuals can be
reassured that the mite will cease to be
transmitted after the initial application, but
itching can persist for weeks until the allergic
reaction has resolved and the dead mites and
their products no longer persist in the skin.
Patients will find advice for the management of
scabies provided by the National Prescribing
Centre (2008) helpful (Box 3). The following
information is also useful:

Advice on the management of scabies in primary care

!Scabies can affect anyone of any social class.

Spread is not limited to members of the same
family. Those at risk include everyone who has
had intimate contact with the infested person,
especially if contact has been prolonged.

(Based on recommendations from the National Prescribing Centre 2008)

!Advice on the most suitable product and how

to apply it can be obtained from a GP, practice
nurse or community pharmacist.
!Apply enough of the product to cover the entire
skin surface. For someone of average height
and weight, one tube of cream containing 30g
cream or 100ml lotion should be sufficient to
provide adequate cover. For larger people extra
cream or lotion will be required.
!Seek help as necessary to make sure that the
product is applied to all skin surfaces. Special
attention must be paid to the armpits, wrists,
elbows, nipples, beneath the breasts and
between the fingers and toes. Liquid must be
brushed under the ends of the nails. Non-sterile
disposal gloves can be used for application.
!Hot baths are best avoided because they
increase absorption of the active product into
the bloodstream, depleting the amount locally
available in the skin to kill the mite.
!Itching can become more intense when
treatment has taken place because the immune
system continues to react to the dead mites and
their products.
!Fingernails can be trimmed short to reduce
scratching, especially in older, confused adults
and young children.
!Mittens prevent babies and young children
sucking thumbs and removing the product
during the contact time.
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!Try to avoid physical contact with anyone else who is being treated.
!Make sure that all household and other close physical contacts are treated
on the same day. This is important even if they do not have symptoms.

!Launder clothing, bedclothes and towels on the same day as treatment

to kill any mites.

!Apply the product to cool, dry skin from the chin and ears downwards.
For very young and older people, the product must be applied to the
entire body, including the face, ears and scalp.

!Allow to dry before dressing. Leave permethrin products on the skin

for 8-12 hours before washing. Leave malathion products on the skin
for 24 hours before washing.

!Re-apply the product if the area is washed during the contact time.
!Repeat the treatment seven days later.
!Itching can persist after treatment. If it persists after six weeks
reassessment is necessary to rule out cases of treatment failure.

!If scabies has resulted through sexual contact

the individual could be at risk of other sexually
transmitted infections and should be advised
to attend a genitourinary clinic for screening.
Poor compliance reduces the effectiveness of
treatment and may contribute to treatment failure.
However, it may not be deliberate. Many older
people and those with physical disabilities have
problems applying the creams and lotions, and may
not be able to see well enough to read instructions.
Advice to staff and managers in nursing and
residential care homes In recent years, outbreaks
of scabies in care and nursing homes have been
reported with increasing frequency (Andersen
et al 2000, de Beer et al 2006).
Useful guidance for these settings has been
compiled by the Department of Health (2006).
The guidelines emphasise that all staff and residents
with close contact with someone diagnosed with
scabies will require treatment, irrespective of
whether they are exhibiting symptoms. It is
important to co-ordinate treatment to occur within
the same 24-hour period. The HPA (2010) has
recommended that managers in care and nursing
homes take responsibility for purchasing scabicidal
treatment for their staff to ensure a co-ordinated
approach to care and reduce the risk of prolonging
the infestation. Staff do not need to stay away from
work once they have applied the treatment and it
has been in contact with the skin for the minimum
time needed to be effective.
Controlling scabies in care homes may be
challenging and can result in loss of income
for the owners (de Beer et al 2006). Recurrence is
common because of the highly contagious nature
of the infestation, missed cases, poor compliance
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with treatment, practical difficulties applying the
creams and lotions, and because individuals
conceal symptoms as they perceive scabies to
be a stigmatising condition. There is also some
evidence that resistance to scabicidal treatments
is occurring (Van den Hoek et al 2008).

Outbreaks
An outbreak of scabies is defined as a situation
where two or more people have been diagnosed
by an appropriately trained practitioner or have
a rash diagnosed as probable scabies (HPA 2010).
As with all contagious conditions, the control of
an outbreak of scabies depends on the following
important principles:
!Early detection and investigation.
!Prompt and appropriate control measures
to prevent further spread.
Guidance from the HPA (2010) indicates that
if an outbreak or suspected outbreak of scabies
occurs in a care home, it is the responsibility of the
home manager or nominated lead person to obtain
specialist advice from an infection prevention and
control nurse, or a public health nurse in the
primary care trust or local health protection unit.
In some cases, it may also be necessary to liaise with
the Care Quality Commission. The residents GPs
should be informed and requested to see patients
to confirm the clinical diagnosis and provide
treatment and follow-up care. Staff should also
see their GPs. The situation should be explained
to regular visitors to the home so that they can seek
treatment. It may sometimes be necessary to

close the home to admissions, for example if the

outbreak persists or the prospective resident has
a condition affecting the immune system.
In some countries, personal protective clothing
and isolation have been used to help control spread
during prolonged and severe outbreaks (Andersen
et al 2000, Obasanjo et al 2001), but at present
these measures are not officially recommended
in the UK.
Contact tracing The aim of contact tracing
is to identify all those who may be affected
and provide advice about treatment options.
Contact tracing involves following up everyone
who has had intimate skin contact with the
affected person during the previous two to six
weeks and is recommended to continue for at
least two months. If a newly admitted resident
appears to have developed scabies, the
transferring hospital or home should be
informed as part of contract tracing.

Conclusion
Scabies is a common condition that has low
priority among healthcare professionals despite
the distress caused to those affected and the
disruption resulting in households and institutions
during treatment. Outbreaks of scabies are
increasingly common in care and nursing homes,
where they represent a significant public health
problem and potentially pose a threat to the
reputation and revenue of the organisation. As a
result, guidelines have been developed to help
prevent and control scabies. With increasing
recognition of the problem and further research
concerning treatment failure and possible resistance
of the mites to the scabicidal preparations in
common use, it is likely that in future more
attention will be paid to this condition NS

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