Scabies

A mite burrowing under the skin. Nothing to do with cleanliness, and outbreaks in care homes are common and mishandled.

What it is

Scabies is caused by a tiny mite that burrows into the skin. It spreads by prolonged skin-to-skin contact, which makes personal care an obvious route.

It has nothing to do with hygiene, and that misconception is why people delay reporting it and why care homes sometimes try to handle outbreaks quietly.

The itch is caused by an allergic reaction to the mite, so it takes up to six weeks to develop on a first infestation. During those weeks the person is infectious without symptoms, which is exactly how an outbreak spreads through a home before anybody knows.

Crusted scabies, sometimes called Norwegian scabies, occurs in people who are frail or immunosuppressed. It carries thousands of mites, is enormously infectious, and often does not itch, which means it is regularly mistaken for eczema or psoriasis for months while it spreads.

Signs you might notice

Intense itching, worse at night.

A rash of small red bumps, often between the fingers, on the wrists, in the armpits, around the waist and on the genitals.

Burrows: fine wavy grey lines a few millimetres long, which are diagnostic if you can see them.

In older people, the rash may be on the back and be less typical.

Crusted scabies: thick, scaly, warty crusts, often on the hands, feet and elbows, with surprisingly little itch.

How it can affect day-to-day life

Outbreaks in care homes are the significant issue and they are frequently mismanaged in the same way: treating only the person with symptoms.

Everybody in contact must be treated at the same time, symptomatic or not, or the cycle continues indefinitely.

Itching persists for two to four weeks after successful treatment, which leads to repeated unnecessary re-treatment and to people believing it has failed.

Supporting someone well

Treat everybody at once: the person, all household or unit contacts, and the staff who provide their personal care, on the same day.

Apply the treatment to the whole body from the neck down, and in older people and the immunosuppressed include the scalp, face, and behind the ears. Do not miss between fingers and toes, under nails, and the genitals.

Leave it on for the full time, usually 8 to 12 hours, and reapply after any handwashing.

Repeat after seven days. One application is not enough.

Wash bedding and clothing at 60 degrees, or bag it for 72 hours.

Expect itching for weeks afterwards and treat it with emollient and antihistamine rather than more scabicide.

Suspect crusted scabies in anybody with a persistent scaly rash that has not responded to eczema treatment, and treat it as a serious infection control matter.

Where to get help

A pharmacist can supply treatment; a GP for crusted scabies, treatment failure, or in babies.

Care settings should contact their local health protection team for an outbreak.

Persistent rash despite two correct treatments needs reassessment rather than a third round.