HNY Policy and Pathway Repository - York

• Scabies is an itchy rash caused by the mite Sarcoptes Scabeii which is nearly always spread by skin to skin contact.
• There are intensely itchy red papules and burrows may be seen on fingers, wrists, ankles and feet. It affects the entire skin, but the face and scalp are usually only involved in infants and bed-bound elderly patients.

• Consider crusted (Norwegian) scabies in patients with dementia, neurological disease or immunosuppression
• Consider scabies incognito in patients who have been using topical steroids- this will mask symptoms but the patient will still be infectious

Topical insecticides

• As per local antimicrobial guidance
• First line: permethrin 5% dermal cream. Repeat application after 7 days. Current guidance is to treat the whole body, including the scalp and face in all patients, a larger quantity of treatment will be needed to ensure this is possible (average sized adult will require a total of 3 x 30g tubes to cover 2 applications). Ensure patients know all areas should be treated including folds and under nails. Warn patients to reapply to hands if washing during the application period. Allow the cream to dry before applying clothing.
• Alternative: malathion 0.5% aqueous liquid. Repeat application after 7 days
• Treat all household members and any other significant contacts e.g. childcare, boyfriend/girlfriend etc.
• Clothes, towels and bedding of all potentially infested close contacts (even if asymptomatic) should be washed after first application Bedding, clothing, and towels should be decontaminated by washing at a high temperature (at least 60°C) and drying in a hot dryer, or dry-cleaning, or by sealing in a plastic bag for at least 72 hours. Failure of treatment is usually due to non-adherence to instructions for using insecticide or failure to treat a contact. Do not share bedding, clothing or towels with someone with scabies.
• Breast feeding women should use permethrin 5%, cleaning the nipple of the treatment prior to feeding then reapplying afterwards
• Failure of treatment is usually due to non-adherence to instructions for using insecticide or failure to treat a contact
• Remember contacts may be infected, but remain asymptomatic for weeks.
• Referral to sexual health clinic to be considered for contact tracing if appropriate
• The itch of scabies may persist for at least a month after eradication of the mite. Treatment with crotamiton 10% cream or lotion may help to relieve the itch and is also a mild insecticide.
• Night time sedative anti-histamine may be helpful to alleviate night time itch.
• Stop babies and children sucking treatment from their hands by putting socks or mittens on them.
• Do not have sex or close physical contact until you have completed the full course of treatment.

Oral treatment

Ivermectin is currently off license and not on the formulary. It is prescribed at a dose of 200 micrograms per kg and comes in 3mg tablets. Dosage is at day one, then day 7 and again the whole house should be treated and sexual partners. Research has shown that side effects are minor across the population. A different regimen is needed for crusted scabies, please refer or seek guidance.

Refer to Dermatology if:

• Diagnostic uncertainty

Discuss with Dermatology if:

• Crusted scabies
• An outbreak in nursing or care home
• Resistant scabies suspected (failed to respond to at least 2 courses of topical anti-scabetic, ideally 2 different anti-scabetics)

Information to include in referral letter

• How long the rash has been present
• Treatments that have been tried
• Relevant past medical/surgical history
• Photograph required if diagnostic uncertainty – please refer to the CCG commissioning statement here
• Current regular medication
• BMI/Smoking status

Investigations prior to referral

• None needed

Patient information leaflets/ PDAs (these may not represent local commissioning guidance)

• http://www.patient.co.uk/health/scabies
• Current guidance is to treat the whole body, including the scalp and face in all patients, a larger quantity of treatment will be needed to ensure this is possible. Ensure the patient understands this as some medication leaflets won’t include this instruction.
• BAD – Information on Scabies for patients

References

• Clear information about scabies and how to treat on the Primary Care Dermatology website.
• NICE CKS Management of scabies (Nov 2017)
• https://www.nhs.uk/conditions/scabies