IPC 3.4C Infestations - Scabies

Contents

1.0 Introduction
2.0 Safeguarding
3.0 Mode of transmission
3.1 Signs and symptoms - clinical indications
3.2 Screening
4.0 Antimicrobial treatment guidance
5.0 Infection prevention and control principles
5.1 Isolation
5.2 Hand hygiene
5.3 Respiratory / Cough hygiene 
5.4 Personal protective equipment
5.5 Equipment
5.6 Environmental cleaning
5.7 Linen
5.8 Body fluids
5.9 Waste standard
5.10 Occupational exposure
6.0 Surveillance
7.0 Outbreaks
8.0 References/Source documents
Appendix 1 - Photographs of Scabies, Classical Scabies, Crusted Scabies/Norwegian Scabies
Appendix 2 - UKHSA Summary Scabies
Records of changes

 

1.0 Introduction

Organism 

Scabies is a common contagious skin infestation caused by the parasitic mite Sarcoptes scabiei. It is transmitted by close, prolonged skin-to-skin contact that typically appears within families, between sexual partners and between patients/individuals and staff. The adult scabies mite burrows under the top layer of skin and lays eggs which will hatch in 3-4 days. They can occur anywhere on the body but typically, a rash is seen in the webs of fingers or toes, and sides of the hands and feet (United Kingdom Health Security Agency (UKHSA), 2013).

 

Types of Scabies

There are two types of scabies, both are caused by the same mite.

 

Classical scabies

• Mites may be few in numbers.
• Itch can start between 3-6 weeks following initial acquisition of the infestation.
• Burrows or rashes may affect areas covered by clothing, therefore full examination is recommended (consider consent and chaperone). In people with cognitive impairment, itching or scratching may not be vocally expressed.

 

Hyperkeratotic scabies

Also known as crusted, Norwegian scabies or atypical scabies. An unusual form of the infestation that is highly contagious occurs in immunodeficient individuals e.g., the frail elderly. Infestation often appears as a generalised dermatitis. Itching may be reduced or absent. Skin becomes thickened, scaled, crusted and unsightly due to the number of mites present.

 

Incubation period

Up to 8 weeks.

The incubation period is up to eight weeks before the rash appears in people without previous exposure. This makes the spread of the disease difficult to identify and contain in healthcare or prison settings. As a result of the extended incubation period there may be asymptomatic carriers who can reinfect others after treatment has been performed. Reinfection of scabies can be sooner (1- 4 days) after a previously successful treatment.

 

Period of communicability

Staff and carers should wear Personal Protective Equipment (PPE) until the first treatment is completed. Patients should avoid close physical contact until the treatment is completed.

 

Individuals at risk

• Staff or patients that have close physical prolonged contact by other affected persons.
• Skin-to-skin contact eg: sleeping together, holding hands and sexual contact. If sexual contact consider referral for sexually transmitted infection screening.
• Transmission from clothing, bed linen and towels to a person is uncertain as the mites can live on surfaces for up to four days but this is not a proven source of transmission.

 

Notifiable disease

No

 

Informing IPC team 

Yes

 

2.0 Safeguarding

Consider safeguarding principles for infestations and refer to Trust Clinical Policies:

• 06.01 (Issue 10) Safeguarding Children
• 06.04 (Issue 13) Safeguarding Adults at Risk
• 01.03 (Issue 3) Chaperone Policy

Investigate if these are recurrent infestations or neglect.

 

3.0 Mode of transmission

• Skin-to-skin contact e.g. sleeping together, holding hands and sexual contact.

 

3.1 Signs and symptoms - clinical indications

The main symptoms of the infestation, a rash and itching, are caused through an allergic response to the presence of the mite under the skin. If a person has had a previous infestation with the scabies mite, the immune response is rapid, and itching develops within hours.

The main symptoms are:

• Mild to severe itching at night
• Allergic rash
• Erythematous papules, vesicles or itchy nodules. Often the rash can be symmetrical. See 
  Appendix 1 - Photographs of Scabies, Classical Scabies, Crusted Scabies/Norwegian Scabies

Early diagnosis is important, and if in doubt, a referral to a dermatologist is recommended, refer to Infection Prevention Control Team (IPCT). If there is spread within a wing/ward/service i.e. more than one case, or a single case of crusted scabies, IPCT to also be contacted, as all patients/individuals and staff may need to be treated simultaneously (Nottinghamshire Area Prescribing Committee, 2023). Skin and soft tissue infections (Notts APC).

• Diagnosis is usually made in the presence of intense itching with a follicular popular rash.
• The diagnosis can be confirmed by seeing mites under a microscope, but this is usually done by an experienced practitioner or dermatologist.

 

3.2 Screening

Identify contacts, within 8 weeks prior to diagnosis, who have had skin-to-skin contact and coordinate so that the treatment is undertaken at the same time.

 

Contact Definition

‘Contacts are defined as anyone who has close physical contact with the case without appropriate Personal Protective Equipment (PPE) e.g. providing personal care with skin-to-skin contact, sharing a room or other similar household setting, and sexual partners, within the eight weeks prior to diagnosis’ (UKHSA, 2023).

 

Who to treat (UKHSA, 2023)

• All patients or individuals using healthcare services unless there is a clear rationale for more limited tracing e.g. if identified on admission.
• Residents on a single affected floor or wing if there is no mixing or movement of staff or residents and between floors or wings.
• All members of staff (including agency staff) exposed to the index case without wearing appropriate PPE.
• Visitors/family members to the setting who have had prolonged or frequent skin-to-skin contact with a case, advice and leaflet to be given - UKHSA guidance on the management of scabies cases and outbreaks in long-term care facilities and other closed settings - GOV.UK (www.gov.uk). Advised to seek treatment from their GP.
• Ancillary staff, e.g. hairdressers, podiatrists, community health professionals and agency staff.
• Individuals with scabies living within their own home.
• All close household contacts i.e. bed partners and children would need treatment as well as the individual, even if asymptomatic.
• Patients/individuals diagnosed with scabies on admission to a ward or nursing/residential home.
• If this is an isolated case, only the patient/individual being admitted needs to be treated along with their close personal contacts, and/or carers i.e. those who have had frequent skin-to-skin contact with the affected individuals.
• After consultation between the ward managers/matrons, Infection Prevention and Control (IPC) and Occupational Health, a decision will be made as to whether to treat all the staff, and their family members and patient/individual, and their family members.
• In other healthcare environments e.g. prisons, schools/nurseries, homeless hostels, all close skin-to-skin contacts should be treated at the same time. Coordination in some of these areas will be more difficult and therefore must not be rushed and should be organised after collaboration with the IPCT and UKHSA.
• Liaise with IPCT regarding the admission of visitors or new admissions to the inpatient area.

 

Staff identified as a contact

A member of staff that is identified as a contact of, or diagnosed with scabies, should not return to work until the first treatment dose has been completed. This should coincide with the patient’s treatment date. Occupational Health should be contacted for advice and possible contact tracing. A further treatment dose 7 days after the first treatment is required.

 

4.0 Antimicrobial treatment guidance

Treatment options:

Topical treatment options in line with the Nottinghamshire Area Prescribing Committee Antimicrobial Guidelines scabies.pdf(nottsapc.nhs.uk).

If crusted scabies/recurrent scabies is suspected, specialist advice from dermatology to be obtained as further treatment may be required.

• Patients or Offender Health (OH) prisoners to be treated by the Trust. If identified within the community setting, GP to be contacted for the prescription. Occupational Health to coordinate staff treatment.

 

Applying treatment

• All those being treated should have the treatment at the same time or within the same 24-hour period to ensure that individuals do not reinfect each other.
• The treatment should be applied to cool dry skin (not after a hot bath) and allowed to dry before the person dresses in clean clothes.
• Apply the cream or lotion to the neck and jaw line and all over the body including the genital area. Pay particular attention to the web of toes and fingers. In children 2 months-2 years, immunosuppressed, and the elderly, it is recommended that the cream should also be applied to the face, neck, scalp and ears (avoiding contact with eyes), as they are at a greater risk of infestation of the face and scalp compared with other children and adults (National Institute of Health and Care Excellence (NICE), 2022).
• Applying the cream at night before going to bed is usually the best time because it can be left on overnight.
• Healthcare staff applying the cream or lotion should wear gloves and a disposable apron (protective clothing) with each individual they are treating.
• In the case of treatment application to those affected with Hyperkeratotic (Crusted/Norwegian scabies) arm protection would be advisable.
• A second person is necessary when treating oneself, to ensure all the body is covered. Ensure consent, offer/consider the use of a chaperone.
• Nails should be trimmed, and medication applied with cotton wool buds underneath the nails, and around the nail bed area.
• If hands are subsequently washed, then further treatment needs to be applied.
• Body areas that are washed within eight hours of Permethrin application or 24 hours of Malathion application should be treated again e.g. changing continence products, breastfeeding.
• The treatment should be left on for the recommended time period.
• Remove the insecticide by thorough washing of all areas of the skin where it has been applied.
• Mittens can be used to prevent infants putting treated hand in their mouths.
• A second application is required 7 days after the first application.

 

Post-treatment Care

The itch and rash may persist for some weeks after infestation has been eliminated and patients/individuals should be advised of this. Symptomatic treatment can be considered. Use of emollients for washing the skin, rather than soap or scented products can provide some relief for dry itchy skin.

Persistent symptoms and the development of new areas of a rash might suggest that scabies eradication may not have been successful, and the patient/individual may require further assessment and treatment by medical staff/dermatologist.

 

5.0 Infection prevention and control principles

 

5.1 Isolation

Classical Scabies Isolation

For single case management individuals can return to work, school or nursery, after completion of the first dose. Individuals to avoid close physical contact until completion of the first treatment dose. If there are any concerns that the person receiving treatment cannot avoid close physical contact, then isolate until completion of the first dose. Transfer of patients to other settings should be avoided until completion of the first treatment dose. If transfer is undertaken after this period ensure good communication and documentation, including when the second treatment dose is due. Transfer of patients with a known/suspected Infection link to policy once completed.

 

Crusted Scabies Isolation

Clinicians to advise on when they are no longer infectious due to complexities, and may require several treatments (UKHSA, 2023). Infection Prevention Control Team (IPC) to be kept informed. No direct skin-to-skin contact until non-infectious.

 

Other Considerations

If uncertain that the treatment has been successful (in the event cream has been removed prematurely), consult dermatology for alternative treatment. See Appendix 2 - UKHSA Summary Scabies

Summary Scabies 

• Patients/individuals in their own homes to complete the treatment and avoid skin-to-skin contact.
• Offender health, prison settings, isolation not required, if shares a cell and the other person requires treatment then keep them together in the cell. Linen, towels and clothing to be washed as infected. Crusted scabies require isolation after institution of treatment. Prevention of infection and communicable disease control in prisons and places of detention (publishing.service.gov.uk).

 

5.2 Hand hygiene

NHS England » Chapter 1: Standard infection control precautions (SICPs)

 

5.3 Respiratory / Cough hygiene

Not applicable.

 

5.4 Personal protective equipment

Contact IPC principles apply with gloves and apron. For close personal care or handling infested linen, single patient-use long-sleeve gowns or sleeve protectors, in conjunction with single-use aprons, can be worn to reduce transmission.

Appendix 5b (england.nhs.uk)

Putting on and Removing PPE v3 (england.nhs.uk)

NHS England » Chapter 1: Standard infection control precautions (SICPs)

 

5.5 Equipment

NHS England » Chapter 2: Transmission based precautions (TBPs)

 

5.6 Environmental cleaning

Ensure cleaning is sufficient to remove skin scales and dust. Crusted scabies requires increased vacuuming and deep clean after treatment cycles (damp dusting soft furnishings, enhanced touch point cleaning, vacuuming mattress if applicable) due to increased shedding. Check the mattress is sealed, no rips/tears.

NHS England » Chapter 2: Transmission based precautions (TBPs)

 

5.7 Linen

Gloves and apron to be worn when handling laundry and clothing.

Bed linen and towels to be treated as infectious, placed in red alginate bags, for inpatient areas.

If clothing is unable to withstand the infected linen process, clothes to be sealed in a bag for at least four days prior to washing. Safe management of linen (NHS England)

NHS England » Chapter 1: Standard infection control precautions (SICPs)

 

5.8 Body fluids

Not applicable

 

5.9 Waste standard

NHS England » Chapter 1: Standard infection control precautions (SICPs)

 

5.10 Occupational exposure

See section “screening and contacts”.

 

6.0 Surveillance

Identify all contacts. Body maps are useful to record rash location.

 

7.0 Outbreaks

An outbreak would be identified if there are two or more cases within an eight-week period. An outbreak can be declared over if the contacts have received both treatments and no new cases identified within 12 weeks from onset date.

 

8.0 References/Source documents

Scabies can be distressing conditions and the dignity of patients/individuals should be maintained throughout. Compliance is important when dealing with this condition, and the patient/individual should be given as much information as possible. Information leaflets can be obtained or downloaded from the UKHSA.

Scabies - NHS (www.nhs.uk)

Department of Health and Social Care (2015) Health and Social Care Act 2008: code of practice on the prevention and control of infections

Health Protection Agency and Department of health (2011) Prevention of infection and communicable disease control in prisons and places of detention: a manual for healthcare workers. (Accessed:1 February 2023).

Joint Formulary Committee (2023) 'Skin infections', in British National Formulary. 

National Health Service England (2023) National infection prevention and control manual (NIPCM) for England. (Accessed 15 February 2024).

National Institute of Health and Care Excellence (2022) Permethrin Cream. (Accessed 25 April 2023).

National Institute of Health and Care Excellence (2022) Scabies. (Accessed: 31 January 2023).

NHS (2020) Scabies. (Accessed: 31 January 2023).

Nottinghamshire Area Prescribing Committee (2023) Skin and soft tissue infections: Scabies. (Accessed: 31 January 2023).

UK Health Security Agency (2023) UKHSA guidance on the management of scabies cases and outbreaks in long-term care facilities and other closed settings. (Accessed: 1 February 2023).

 

Appendix 1 - Photographs of Scabies, Classical Scabies, Crusted Scabies/Norwegian Scabies 

Classical Scabies

Click on the links below to view relevant images:

 

Appendix 2 - UKHSA Summary Scabies

UKHSA guidance on the management of scabies cases and outbreaks in long-term care facilities and other closed settings (GOV.UK)

Accessible text version of summary flowchart

Question 1. Is this a single case?

If yes:

• refer case to GP for treatment
• identify close contacts (including up to 8 weeks prior to diagnosis)
• refer contacts for treatment (at the same time as the index case, on 2 occasions 7 days apart (even if asymptomatic)

If no, go to question 2.

Question 2. Is this an outbreak (2 or more linked cases within 8 weeks)?

If no, go to the 3 steps listed above.

If yes, assess all individuals in setting for scabies prior to treating index case.

Then, further contacts must be identified, with the co-ordination of mass treatment (all contacts must initiate treatment within 24 hours of each other).

Then take the following steps:

• give hygiene and exclusion advice
• PPE recommended for carers (until 24 hours after treatment commenced)
• avoid transfer to other settings (until 24 hours after treatment commenced)
• investigate possible chain of transmission or liaise with other relevant settings

Lastly:

• consider if isolation of residents or exclusion of staff is required
• warn and inform visitors to setting

End of flowchart text.

 

Record of changes

Version	Date	Expert writer	Status (New or edited)	Comments and details of changes being made
1	23/01/2017	Diane Churchill-Hogg	Edited	Three yearly review completed. References updated. Minor amendments only. Section 4.1 Changed in line with research-based evidence regarding safety of Permethrin.
2	June 2018	D. Holmes	Edited	Minor amendments only Section 3.2 Changed to The Adult Scabies mite is approximately 0.4 mms long
3	August 2020	Carol Evans	Edited	Minor Amendments. 3.3.2 Hyperkeratotic Scabies or Crusted Scabies also known as Norwegian Scabies. Amendments to reflect patients and service-users throughout. References amended. Changes to wording in treatment section. Amendment to Equality Impact Assessment (EIA) screening tool. Additional link to prescribing data. Minor terminology changes of titles and group names throughout. Transfer to new Trust policy template.
4	April 2021	L West	Edited	Reference number changed to 07.16
5	May 2023	K.Hodgkiss	Edited	Full review. Policy title changed from ‘Scabies Management’ to ‘Infestation Management’. Related policies reference numbers updated, and further related policies included. Edited as per United Kingdom Health Security Agency (UKHSA) guidance on the management of scabies causes and outbreaks in long-term care facilities and other closed settings. Updated 12 January 2023. Safeguarding statement inserted. Added Pediculosis humanus capitis and Pthirus pubis to for infestation policy.
6	June 2023	I. Brackenridge	Edited	‘Exceptional Circumstances’ section added as per agreement reached by the Trustwide Clinical Policies and Procedures Group (CPPG) members at meeting on 07 June 2023. ‘Service-user’ removed. Some additional restructuring of policy according to Trust approved template.
7	January 2024	K Hodgkiss and Infection Prevention Control team	Edited	Policy reviewed and edited to new Trust approved template. Head lice, Pubic lice and Scabies listed separately. Minor adjustments to treatment section.