Scabies

Overview

****STOP PRESS - March 2024*****There has been a recent surge in scabies cases leading to  an increase in referrals to dermatology. Often patients have not been treated optimally in primary care and so the advice on this page should be followed carefully to reduce risk of recurrent/persistent scabies and need for secondary care referral.*******

Guidelines:

• PCDS guidelines on Scabies- includes advice on diagnosis including pictures of scabies.
• CKS guidelines on Scabies
• BNSSG Formulary - for the latest prescribing guidance.

Patient Information Leaflet and Additional Measures

Provide the patient with a patient information leaflet British Association of Dermatologists (bad.org.uk) (a BNSSG leaflet is under production) and run through the details with them including:

• how to apply the cream
• treating contacts at the same time including household and any skin to skin contacts
• wash bed sheets, towels and clothes at the same time as treatments.  Any clothes that cannot be washed should not be worn for 3 days. 

Treatment will not be successful if these measures are not followed.

Re-infection is common if patients and contacts are not compliant: re-treat and check contacts.

Ivermectin

Ivermectin is listed on then BNSSG formulary as a blue drug and can be used in the following circumstances:

• Treatment resistant classical scabies, not for children under 15kg.
• To be used following permethrin failure only

Please see Management section below for further advice on use of Ivermectin in primary care.

Management

Treatment Protocol

1. Initial treatment

5% permethrin cream washed off after 12-24 hours.  Cream should be reapplied to the hands if washed off during this time.  Treat contacts and undertake required laundry at the same time.

Repeat after 7 days.

For two applications 2 tubes will be required for adults and 1 for children.

2. Re-presentation

The itch of scabies may not clear for at least a month after successful eradication of the mite. Treatment with Eurax HC ® cream (Crotamiton and hydrocortisone) is available over the counter from a pharmacy for one week use for over 10 years of age, please note this item is non-formulary for prescribing. It helps reduce itch and it also acts as a mild scabicide. Nodules, which are not contagious, can occasionally persist for several months and should be treated with a moderately potent topical steroid.

Night-time use of a sedating antihistamine may help with sleep and reduce scratching.

If symptoms persist for longer than 2-4 weeks after last treatment application and/or if new burrows have appeared since treatment advise retreatment.

Re-treat with 5% permethrin as above including the treatment of contacts and a second application after 7 days. Confirm and re-iterate the importance of compliance with the measures.

3. Scabies still present

If confirmation of compliance with two previous topical treatment courses (including the treatment of contacts and laundry) the use of Ivermectin can be considered.  Ivermectin can be used in adults and children >15kg.  A second dose can be given one week later if scabies is severe or difficult to irradicate.

In children <15kg request Paediatric Advice & Guidance - Dermatology via eRS.

Ivermectin dose is 200micrograms/kg.  It is available as 3mg tablets.

Contacts should be treated with permethrin unless assessed on an individual basis that ivermectin should be used.

Ivermectin is unlicenced and a pharmacy will take a few days to order in.  An English patient information leaflet is available NT007part3v1.pdf (who.int) and patient information from NICE Ivermectin for difficult-to-treat scabies (nice.org.uk)

Complications

Crusted Scabies (syn Norwegian Scabies)

• An uncommon form of scabies
• Highly contagious with huge numbers of mites
• It most commonly arises in patients with neurological impairment (eg dementia and Down's syndrome), immunosuppression, and those inappropriately treated with potent or super-potent topical steroids
• Clinical features - generalised scaly rash. Prominent scale in the finger webs, on wrists, elbows, breasts and scrotum. The itch is often significantly less than with classical scabies. The scalp may be involved

UKHSA should be notified if an institution such as a Nursing or Residential Home has a case(s) of Crusted Scabies.

Untreated scabies

Untreated scabies is often associated with secondary bacterial skin infections which may also need to be treated.

Infants Under 2 Months old with scabies

Specialist advice from a Paediatric Dermatologist will need to be sought. See Paediatric Advice & Guidance - Dermatology page.

Referral

Scabies can normally be diagnosed and managed in primary care but the following options are available if there is diagnostic uncertainty or failure to respond to treatment.

Advice and Guidance from Secondary Care

 Dermatology Advice and Guidance  can be requested via eRS if there is:

• Diagnostic uncertainty / failure to respond to adequate treatment of the patient and contacts
• An outbreak in a nursing or other care home

Referral to Community Dermatology Service (Sirona)

The Community Dermatology Service will accept referrals for patients with scabies if the treatments above have been adequately tried and there has been treatment failure or there is diagnostic uncertainty. 

Referrals to Secondary Care via eRS

Referrals can also be made to secondary care via eRS but given long waits for clinic appointments this is usually not appropriate.

Resources

Patient information leaflet important to highlight steps for Patients and for other family members if they also require treatment. See link below:

 British Association of Dermatology (BAD): bad.org.uk/patient-information-leaflets/scabies

Local clinicians recommend the:

Primary Care Dermatology Society (PCDS): Scabies clinical guidance

National Institute for Health and Care Excellence (NICE): cks.nice.org.uk/scabies#!scenario

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.