General information about scabies
Typical scabies
Human scabies is an infestation of the skin by the human itch mite called Sarcoptes scabiei. The
female scabies mite burrows into the upper layer of the skin, where it lives and lays its eggs.
When the mites hatch, they move out of their burrows from under the skin. They make more
burrows and lay more eggs. While on the skin’s surface, mites hold on to the skin using sucker-
like pads on the anterior legs.
The mite undergoes four stages in its life cycle: egg, lava, nymph and adult.
Life stages of the human itch mite
1. The female mites deposit two or three eggs per day as they burrow under the skin.
2. Eggs hatch in 3–4 days. After the eggs hatch, the larvae migrate to the skin surface and burrow
into the skin. These short burrows are called molting pouches and are almost invisible.
3. The larval stage lasts about 3–4 days.
4. Mating occurs after the active male penetrates the molting pouch of the adult female.
5. Mating takes place only once and leaves the female fertile for the rest of her life. After mating,
the male dies. The impregnated female leaves the burrow and wanders on the surface of the skin
until she finds a suitable site for a permanent burrow, where she lays eggs for the rest of her life
(1–2 months).
Crusted (Norwegian) scabies
Crusted scabies, also called Norwegian scabies, is a severe form of scabies that can occur in
people who are immunocompromised (have a weak immune system), elderly, disabled or
debilitated.
In typical scabies, the estimated number of mites per person is 10–15. In crusted scabies, mites
are much more numerous (up to 2 million). Because people are infested with a large number of
mites, they are more contagious.
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Epidemiology and risk factors – scabies
Transmission
The scabies mite is usually spread by direct, prolonged, skin-to-skin contact with a person who
has scabies.
Generally, contact must be prolonged, such as sleeping or having sex with a person infested with
scabies. The longer the skin-to-skin contact, the greater the likelihood of transmission. The risk
of transmission from skin-to-skin contact is higher with people who have crusted (Norwegian)
scabies.
Scabies is sometimes spread indirectly by sharing articles such as clothing, towels or bedding
used by an infested person; such indirect spread can occur much more easily when the infested
person has crusted (Norwegian) scabies.
Scabies can also spread more easily in crowded conditions where close body and skin contact is
frequent, such as in families, residential aged care facilities and prisons.
People at risk
Scabies is found worldwide, and can affect people of all races and social classes.
Facilities such as residential aged care facilities and prisons are often sites of scabies outbreaks.
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Common symptoms of scabies
Typical scabies
The common symptoms of scabies are:
intense itching, which may be worse at night, or after a hot bath or shower
a pimple-like itchy skin rash (bumpy red rash); itchy skin may become thick, scaly,
scabbed and criss-crossed with scratch marks
burrows that appear on the skin as short, wavy, raised, reddish or darkened lines and can
be a centimetre or more in length.
The itch and rash are caused by sensitisation (a type of allergic reaction) to mites and their
faeces. Itching and rash may affect much of the body or may be limited to common sites such as:
between the fingers
wrists
elbows
penis
nipple
waist
buttocks
shoulder blades.
The head, face, neck, palms and soles are often involved in infants and very young children, but
not usually in adults and older children.
Burrows may be difficult to find. Look for burrows in the webbing between the fingers; in the
skin folds on the wrist, elbow or knee; and on the penis, breasts or shoulder blades.
Crusted (Norwegian) scabies
Symptoms of crusted (Norwegian) scabies include thick crusts of skin that contain large numbers
of scabies mites and eggs.
The usual severe itch and rash may be absent in people with crusted (Norwegian) scabies.
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Complications of scabies infestations
The intense itching and scratching can cause skin sores. These sores can become infected with
bacteria on the skin, such as Staphylococcus aureus or beta-haemolytic streptococci.
Sometimes bacterial skin infections can lead to an inflammation of the kidneys called post-
streptococcal glomerulonephritis.
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Incubation period of scabies
In people who have never had scabies, it will take 4–6 weeks for symptoms to begin. During this
period, the infested person can spread scabies.
In people who have previously been infested with scabies and are exposed again, symptoms can
begin within 1–4 days.
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Diagnosis of scabies
Diagnosis is usually made clinically by examining the body for a scabies-like rash or burrows.
The diagnosis can be confirmed by taking skin scrapings of non-excoriated or non-inflamed
areas (burrows and pimple-like rash) using a stitch cutter. Gently scrape the suspected area or
burrow using the back of the stitch cutter or by carefully removing the mite from the end of the
burrow using the tip of a needle. Collect the specimen (skin scrapings or mite) into a specimen
container and transfer it to your pathology service, where it will be examined under a
microscope.
A negative result from a person who has had skin scrapings is not conclusive because the
infested person may have few mites, and these can be missed easily.
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General treatment for scabies
Scabies can be treated with anti-scabies lotions or creams.
Treatment lotions and creams are available from pharmacists, and a prescription is not required.
Recommended treatments include:
permethrin preparations (for example, Lyclear scabies cream)
benzyl benzoate 25% preparations (for example, Benzemul application lotion).
Follow the manufacturer’s instructions for application.
Scabicide lotions or creams, including benzoate 25% preparations, should be applied to all areas
of the body from the neck down to the feet and toes. The treatment may also need to be applied
to the face, neck and scalp if these areas are involved.
The lotion or cream should be applied to a clean body and left on for the recommended time
before it is washed off.
Two or more applications, each about 1 week apart, may be necessary to eliminate all mites,
particularly when treating crusted (Norwegian) scabies.
Some patients with severely crusted scabies lesions, or in whom the lotions or creams have
failed, may require treatment with a medication called ivermectin.
Because the symptoms of scabies are due to a hypersensitive reaction (a type of allergic reaction)
to mites and their faeces, itching may continue for several weeks after treatment, even if all mites
and their eggs are killed.
If itching is still present more than 2–4 weeks after treatment, or if new burrows or pimple-like
rash lesions continue to appear, retreatment may be necessary.
Consult an experienced dermatologist for assistance in differentiating skin rashes and confirming
the diagnosis of scabies.
After treatment
Clean clothing should be worn after treatment.
Mites generally do not survive more than 2–3 days away from human skin.
Bedding, clothing and towels used by infested people any time during the 3 days before
treatment should be machine washed and dried using the hot water and hot dryer cycles, or be
dry-cleaned.
Items that cannot be dry-cleaned or laundered can be disinfested by storing in a closed plastic
bag for several days to a week (at least 72 hours).
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Prevention and control of scabies
Early detection, treatment and implementation of appropriate infection control precautions are
essential in preventing scabies outbreaks.
Facilities should maintain a high level of suspicion that undiagnosed skin rashes and conditions
may be scabies, even if the characteristic signs or symptoms of scabies (for example, itching) are
absent.
A scabies outbreak suggests that transmission has been occurring within the facility for several
weeks to months, with the likelihood that some infested staff or patients may have had time to
spread scabies elsewhere in the community, including other facilities.
Measures to control scabies in a facility depend on factors such as how many cases are diagnosed
or suspected, how long infested people have been at the facility while undiagnosed and/or
unsuccessfully treated, and whether any of the cases are crusted (Norwegian) scabies.
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Preventing transmission of scabies
Guidelines for preventing transmission vary depending on the type of scabies, the number of
cases, and the degree and duration of skin exposure that a person has had to an infested person.
Guidelines include the following:
a single case of scabies – see Appendix 1
multiple cases of scabies – see Appendix 2
crusted (Norwegian) scabies (single or multiple cases) – see Appendix 3.
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Role of animals in scabies transmission
Animals do not spread human scabies. Pets can be infested with a different kind of scabies mite
that cannot survive or reproduce on humans. The animal mite causes mange. If the animal has
close contact with humans, the mite can get under the skin of humans, and cause temporary
itching and skin irritation; however, the mite cannot reproduce on the skin and will die in a
couple of days. The animal should receive veterinary treatment for mange.
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Appendix 1 – a single case of scabies
Surveillance
Have an active program for early detection of infested patients and staff.
When a single case is indentified, check that there are no other cases in the facility.
Maintain a high index of suspicion that scabies may be the cause of undiagnosed skin rashes.
Suspected cases should be evaluated by their doctor and, if necessary, confirmed by obtaining
skin scrapings.
All new patients should be screened for scabies.
Maintain records with the patient’s name, age, sex, room number, room-mate names, skin
scraping status and results, and names of all staff who provided hands-on care to the patient
before the implementation of infection control measures.
Diagnostic services
Consult with a dermatologist for assistance in differentiating skin rashes and confirming the
diagnosis of scabies.
Ensure that a staff member is trained and experienced in obtaining skin scrapings to identify
scabies mites.
Control and treatment
Isolation
Where possible, isolate a suspected or confirmed case in a single room until 24 hours after the
first treatment has been completed.
Treatment
Identify and treat all people suspected or confirmed to have scabies, and staff or relatives who
have had prolonged, direct, skin-to-skin contact with an infested person before they were
treated.
Offer treatment to household members (for example, spouses and children) of staff who are
receiving scabies treatment.
Contact precautions
All staff and visitors should wear gloves and gowns on entering the single room or when
having direct patient contact.
Gowns and gloves should be single use.
Gowns and gloves should be changed between each patient.
Hands should be washed thoroughly after removing gloves.
Staff exclusion
Staff can return to work 24 hours after the first treatment has been completed.
Staff should be monitored to ensure that treatment has been effective.
Environmental disinfection
Mites generally do not survive more than 2–3 days away from human skin.
Bedding, clothing and towels used by infested people any time during the 3 days before
treatment should be machine washed and dried using the hot water and hot dryer cycles, or be
dry-cleaned.
Items that cannot be dry-cleaned or laundered can be disinfested by storing in a closed plastic
bag for several days to a week (at least 72 hours).
Ensure that bedding and clothing used by a person with crusted scabies are collected and
transported in a plastic bag, and emptied directly into a washer to avoid contaminating other
surfaces and items.
Ensure that laundry personnel use gowns and gloves when handling contaminated items.
Routine cleaning and careful vacuuming of furniture and carpets in rooms used by people with
suspected or confirmed scabies are recommended.
Communication
Provide information about scabies to all staff (nursing, medical, allied and environmental
services staff).
Maintain an open and cooperative attitude between management, staff and visitors.
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Appendix 2 – multiple cases of scabies
Surveillance
Have an active program for early detection of infested patients and staff.
When multiple cases are indentified, check that there are no cases of crusted (Norwegian)
scabies in the facility.
Maintain a high level of suspicion that scabies may be the cause of undiagnosed skin rashes.
Suspected cases should be evaluated by their doctor and, if necessary, confirmed by obtaining
skin scrapings.
All new patients should be screened for scabies.
Notify other institutions to or from which infested or exposed patients may have transferred.
Maintain records with the patient’s name, age, sex, room number, room-mate names, skin
scraping status and results, and names of all staff who provided hands-on care to the patient
before the implementation of infection control measures.
Use epidemiologic data about distribution of confirmed cases by building, room, floor, wing,
occupation (for staff), date of admission and date of onset of a scabies-like condition to
determine:
levels of risk for patients and staff
the extent of the outbreak (for example, confined or widespread in the facility)
relatedness of cases in time and space.
Diagnostic services
Consult a dermatologist for assistance in differentiating skin rashes and confirming the diagnosis
of scabies.
Ensure that a staff member is trained and experienced in obtaining skin scrapings to identify
scabies mites.
Control and treatment
Isolation
Where possible, isolate a suspected or confirmed case in a single room until 24 hours after the
first treatment has been completed.
Treatment
Identify and treat all people suspected or confirmed to have scabies, and staff or relatives who
have had prolonged, direct, skin-to-skin contact with an infested person before they were
treated.
Offer treatment to household members (for example, spouses and children) of staff who are
receiving scabies treatment.
Contact precautions
All staff and visitors should wear gloves and gowns on entering the single room, or when
having direct contact with patients suspected or confirmed to have scabies.
Gowns and gloves should be single use.
Gowns and gloves should be changed between each patient.
Hands should be washed thoroughly after removing gloves.
Staff exclusion
Staff can return to work 24 hours after the first treatment has been completed.
Staff should be monitored to ensure that treatment has been effective.
Environmental disinfection
Mites generally do not survive more than 2–3 days away from human skin.
Bedding, clothing and towels used by infested people any time during the 3 days before
treatment should be machine washed and dried using the hot water and hot dryer cycles, or be
dry-cleaned.
Items that cannot be dry-cleaned or laundered can be disinfested by storing in a closed plastic
bag for several days to a week (at least 72 hours).
Ensure that bedding and clothing used by a person with crusted scabies are collected and
transported in a plastic bag, and emptied directly into a washer to avoid contaminating other
surfaces and items.
Ensure that laundry personnel use gowns and gloves when handling contaminated items.
Routine cleaning and careful vacuuming of furniture and carpets in rooms used by people with
suspected or confirmed scabies are recommended.
Communication
Establish procedures for identifying and notifying at-risk patients and staff who are no longer at
the institution.
Provide information about scabies to all staff (nursing, medical, allied and environmental
services staff).
Maintain an open and cooperative attitude between management, staff and visitors.
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Appendix 3 – crusted (Norwegian) scabies (single or multiple
cases)
Surveillance
Have an active program for early detection of infested patients and staff. Maintain a high index
of suspicion that scabies may be the cause of undiagnosed skin rashes. Suspected cases should be
evaluated by their doctor and, if necessary, confirmed by obtaining skin scrapings. All new
patients should be screened for scabies.
Notify other institutions to or from which infested or exposed patients may have transferred.
Remember that people with crusted scabies are infested with very large numbers of mites; this
increases the risk of transmission from both brief skin-to-skin contact, and contact with items
contaminated with skin scales and crusts shed by a person with crusted scabies, such as bedding,
clothing, furniture, rugs, carpeting and floors.
Use epidemiologic data about distribution of confirmed cases by building, room, floor, wing,
occupation (for staff), date of admission, and date of onset of a scabies-like condition to
determine:
levels of risk for patients and staff
the extent of the outbreak (for example, confined or widespread in the facility)
temporal relationships among cases.
Maintain records with the patient’s name, age, sex, room number, room-mate names, skin
scraping status and results, and names of all staff who provided hands-on care to the patient
before the implementation of infection control measures.
Maintain ongoing surveillance for scabies among all patients and staff to identify new or
unsuccessfully treated cases of scabies.
Diagnostic services
Consult a dermatologist for assistance in differentiating skin rashes and confirming the diagnosis
of scabies.
Ensure that a staff member is trained and experienced in obtaining skin scrapings to identify
scabies mites.
Control and treatment
Isolation
Isolate suspected or confirmed case of crusted (Norwegian) scabies in a single room until all
treatments have been successfully completed.
With crusted (Norwegian) scabies, treatment may be prolonged.
Treatment
Identify and treat all people suspected or confirmed to have scabies, and staff or relatives who
have had both brief skin-to-skin contact and contact with items such as bedding, clothing,
furniture, rugs, carpeting, floors, and other objects that can become contaminated with skin
scales and crusts shed by a person with crusted scabies.
Offer treatment to household members (for example, spouses and children) of staff who are
receiving scabies treatment.
Treat patients, staff and household members at the same time to prevent exposure and continuing
transmission.
A keratolytic agent may be required. Keratolytic creams soften and thin the skin, causing the
outer layer to loosen and shed.
Generally, crusted (Norwegian) scabies must be treated on more than one occasion, at least 1
week apart. Oral antiparasitic agents (for example, ivermectin) may be necessary.
Contact precautions
All staff and visitors should wear gloves and gowns on entering the single room or when
having direct contact with patients suspected or confirmed to have scabies.
Gowns and gloves should be single use.
Gowns and gloves should be changed between each patient.
Hands should be washed thoroughly after removing gloves.
Staff exclusion
Staff can return to work 24 hours after the first treatment has been completed.
Staff should be monitored to ensure that treatment has been effective.
Environmental disinfection
Mites generally do not survive more than 2–3 days away from human skin.
Bedding, clothing and towels used by infested people any time during the 3 days before
treatment should be machine washed and dried using the hot water and hot dryer cycles, or be
dry-cleaned.
Items that cannot be dry-cleaned or laundered can be disinfested by storing in a closed plastic
bag for several days to a week (at least 72 hours).
Ensure that bedding and clothing used by a person with crusted scabies is collected and
transported in a plastic bag, and emptied directly into a washer to avoid contaminating other
surfaces and items.
Ensure that laundry personnel use gowns and gloves when handling contaminated items.
Routine cleaning and careful vacuuming of furniture and carpets in rooms used by people with
suspected or confirmed scabies are recommended.
Clean the room of patients with crusted scabies regularly to remove contaminating skin crusts
and scales, which can contain many mites.
Communication
Establish procedures for identifying and notifying at-risk patients and staff who are no longer at
the institution.
Ensure a proactive approach to scabies, including providing information about scabies to all staff
(nursing, medical, allied and environmental services staff) and, where appropriate, their
household members, along with visitors to the facility.
Maintain an open and cooperative attitude between management, staff and visitors.
Scabies
Information for
The scabies mite is tiny, almost impossible to see without magnification. This close-up photo shows
multiple burrows with the faint hint of the mite at the end of its superficial skin tunnel.
Images of Scabies (14)
Overview
Scabies is an infestation of the skin caused by a tiny mite called Sarcoptes scabiei var.
hominis. Scabies is very contagious and spreads rapidly in crowded areas such as hospitals,
nursing homes, child care facilities, prisons, and other locations where people spend extended
periods of time in close contact with one another.
The rash of scabies is extremely itchy and develops when a pregnant female mite burrows into
the skin and lays her eggs. The human immune system is very sensitive to the presence of the
mite and produces an allergic response that causes intense itching. Although a person who is
infested with scabies usually only has 10–20 mites on his or her entire body, there may be a large
number of lesions because of this allergic response. Without treatment, the condition will not
usually improve.
Who's at risk?
Scabies is seen in people of all ethnicities, all ages, both sexes, and at all socioeconomic levels.
The infestation is not caused by lack of personal hygiene but is more frequently seen in people
who live in crowded, urban conditions. People at particular risk are those who are in crowded
living situations, such as hospitals, nursing homes, and prisons. Though scabies is extremely
contagious, it usually requires prolonged skin-to-skin contact with a person who is already
infested. Limited contact, such as a hug or handshake, will not normally spread the infection.
However, scabies is easily spread to sexual partners and to other members of the
household. Even if a person does not yet have symptoms, he or she can pass the infestation on to
other people. Less commonly, it may be spread by sharing towels, clothing, or bedding.
Signs and Symptoms
Although the entire body may itch, the most common locations for the lesions of scabies include:
The areas between the fingers (finger webs)
Inner wrists, inner elbows, and armpits
Breasts of females and genitalia of males
Navel (umbilicus)
Lower abdomen
Buttocks
Backs of knees
Although in adults it is rare to see lesions on the face, scalp, and neck, these areas are commonly
affected in children aged younger than 2 years.
The most obvious signs of scabies are pink-to-red bumps, which can look like pimples or bug bites,
sometimes with scale or a scab on them. However, the tell-tale lesion of scabies is the burrow, which is
small and often difficult to see. Typically, a burrow appears as a small, thread-like, scaly line (3–10 mm
long), sometimes with a tiny black speck (the burrowing mite) at one end. The adult mite is about 0.3
mm long and is very difficult to see. Scabies mites crawl; they do not jump or fly.
People who are exposed to scabies may not develop itchy lesions for up to 6 weeks after becoming
infested, as the immune system takes some time to develop an allergic response to the mites. However,
individuals who have had scabies before may develop the rash within several days of re-exposure.
Scabies is intensely itchy, especially at night. Excessive scratching of the itchy lesions can create breaks
in the skin, which may then become infected with bacteria.
A severe form of scabies, called Norwegian scabies or crusted scabies, is seen in:
Elderly people
Individuals with weakened immune systems (such as organ transplant recipients or people with
HIV/AIDS)
Malnourished people
People who are physically and/or mentally impaired or disabled
In people with Norwegian/crusted scabies, the skin is covered with thick, white scales and crusts. The
lesions are widespread, appearing over the scalp, face, elbows, knees, palms, and soles of the feet.
Interestingly, these infestations may not be itchy, although the lesions may contain up to two million
mites.
Self-Care Guidelines
Scabies requires prescription medication in order to stop the infestation. Once you are under a
doctor's care, there are steps you can take to prevent scabies from coming back:
Mites cannot survive off the human body for more than 48–72 hours. Therefore, wash all
clothing, bedding, and towels used by the infested person in the past 72 hours in hot water, and
dry these items in a hot dryer.
Vacuum all carpets, rugs, and furniture, and discard the vacuum bags.
Put anything that cannot be laundered into plastic bags for at least 72 hours.
Pets do not need to be treated because the mite only lives on humans.
You can return to work or school the day after treatment is started.
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When to Seek Medical Care
See your doctor if you develop an extremely itchy rash that does not go away. If other members
of your household or people with whom you are in close contact have similar itchy rashes, they
should also be evaluated by a physician.
Treatments Your Physician May Prescribe
Your physician may be able to diagnose scabies simply by examining your skin for typical
lesions, such as burrows. Your doctor may also diagnose scabies by gently scraping some skin
onto a slide and looking with a microscope for mites, eggs, or mite feces.
In most cases of scabies, your doctor will prescribe a medicated cream or lotion to kill the
infestation, such as:
Permethrin 5% cream (Elimite®) – This is the first choice for treatment because it is very
effective and safe. It is safe even for children and pregnant women. Rinse the cream off after 8–
14 hours, and repeat in 7 days to kill recently hatched larvae.
Crotamiton 10% lotion or cream (Eurax®, Crotan®) – This is not as effective as permethrin and
can be irritating to the skin. Apply once daily for 5 consecutive days.
Precipitated sulfur (5% or 10%) – This is prepared with petroleum jelly and is applied nightly for
3 consecutive nights. This is often the best choice for children aged younger than 2 years and for
pregnant and lactating women because it is very safe to use. Unfortunately, it is greasy, has an
odor, and can stain clothing.
Lindane 1% solution – Lindane can be toxic to the nervous system. Therefore, avoid using it for
young children and infants, pregnant or lactating women, and people with diseases affecting the
nerves (neurological diseases). Apply to the body, rinse in 8 hours, and repeat in 7 days.
When using a topical cream, lotion, or ointment, be sure to follow these steps (unless your physician
gives other instructions):
For adults, apply to the entire body except for the face and scalp.
For children, apply to the entire body, including the face and scalp, as these areas are commonly
infested.
Smear the product beneath the fingernails and toenails.
Apply to body folds, including inside the navel, in the buttocks crease, and between the fingers
and toes.
In more severe cases of scabies, your doctor may prescribe oral medications:
Ivermectin (Stromectol®) pills – Take once and then repeat 1–2 weeks later. Do not give to
children aged younger than 5 years or who weigh less than 15 kg (about 35 lb), or pregnant or
lactating women.
Antibiotic, if any scratched areas appear to be infected with bacteria.
After treatment, the rash and itching may take up to 4 weeks to go away, as your immune system
continues to react to the dead mites. However, new burrows and rashes should stop appearing 48 hours
after effective treatment. If you see new burrows or bumps, or if the itch continues for more than 4
weeks, you may need to be treated again.
Your doctor may also recommend steroid creams or antihistamine pills to relieve the itching. In severe
cases, oral steroids may be required to decrease symptoms.
Because it may take up to 6 weeks after exposure to develop symptoms, people may be unaware that
they are infested. Therefore, household members, sexual partners, and anyone else with prolonged
skin-to-skin contact with an infested person should also be treated. Ideally, everyone should be treated
at the same time in order to prevent reinfestation.
