dermatology

Scabies

Mite infestation causing ferocious itch, characteristically worse at night, with burrows in the finger webs, wrists, axillae and around the nipples or genitals. The face and scalp are spared in adults. It is not dangerous, and it is here because it…

Treat the patient AND every contact on the SAME day

The pathway

1 · Recognise it

Intense itch, worse at night and after a hot bath
Burrows — short wavy grey lines in the finger webs, wrist flexures, axillae, around the nipples, umbilicus and genitals
Face and scalp spared in adults; involved in infants and the very elderly
Other people in the household itching is close to diagnostic
A widespread itchy rash with excoriation and secondary eczema is common

2 · ⚠ Crusted (Norwegian) scabies — the infection control problem

Thick, scaly, crusted plaques, often on the hands, feet, elbows and scalp
Itch may be minimal or absent, which is why it gets called eczema or psoriasis
Millions of mites rather than a dozen — hugely infectious, and a single case can seed a ward
Occurs in the frail, elderly, immunosuppressed or neurologically impaired
Isolation is NOT recommended in communal residential settings — that is the scope of the UKHSA guidance
Standard IPC with gloves and aprons to avoid skin-to-skin contact is sufficient there; an acute ward is a local IPC decision
Involve infection control and dermatology the same day; treatment is usually permethrin PLUS oral ivermectin, and the specialist decides when the patient is no longer infectious

3 · The treatment

Topical permethrin 5% cream, first line for classical scabies
Apply to the WHOLE body from the jawline down, including under the nails, between the fingers and toes, the genitals and the natal cleft
In the elderly and immunosuppressed, include the face and scalp
Leave on 8 to 12 hours, then wash off. Reapply any washed hands
Repeat the whole treatment after 7 days
Oral ivermectin is used in crusted disease and in outbreaks, on specialist advice

4 · Treat the contacts on the SAME day

Everybody in the household, plus sexual contacts, plus close physical contacts — regardless of whether they itch
Contacts are treated at the same time as each other, coordinated, to break the cycle
The diagnosed case is treated as soon as possible and does NOT wait for that coordination (UKHSA, April 2026) — it reduces their symptoms, complications and onward transmission
The case may need an extra dose later if the contacts were treated days behind them
This is the single commonest reason scabies comes back, and it is a prescribing and communication job rather than a clinical one
In a care home or ward outbreak, that means a coordinated mass treatment, led by infection control and public health

5 · The environment

Wash clothing, bedding and towels at 60°C on the day of treatment
What cannot be hot-washed: seal in a bag for at least 4 days before laundering (UKHSA)
Vacuum soft furnishings
In crusted disease, environmental measures matter far more, because shed scale is infectious

6 · Tell them the itch will continue

Itch can persist for up to 6 weeks after treatment (UKHSA), because it is an allergic response to dead mites
It is NOT treatment failure, and it is the reason people re-present and get treated again unnecessarily
Seek advice and consider retreatment if it persists beyond 4 to 6 weeks after the last application, or if new mites or burrows appear
Manage with emollients, a sedating antihistamine at night, and a topical steroid if needed
Genuine failure looks like new burrows or new contacts itching — that is when to retreat

7 · And what it is not

Persistent itch with no burrows and no contacts affected — reconsider: eczema, drug eruption, urticaria
Itch with no rash at all — think cholestasis, uraemia, iron deficiency, thyroid disease, lymphoma
Topical steroids alone will improve the appearance of scabies and partially mask it without treating it

Drugs

Drug	Dose	Route	Notes
Permethrin 5% cream	Whole body below the jaw; repeat after 7 days	Topical	Include the face and scalp in the elderly and immunosuppressed. Reapply to washed hands.
Malathion 0.5% aqueous	Per BNF; repeat after 7 days	Topical	Alternative where permethrin is unsuitable.
Ivermectin	Per specialist advice; 3mg oral tablets are a licensed option	PO	Crusted scabies is usually treated with permethrin AND oral ivermectin in combination, on specialist advice. Also used in outbreak control.
Sedating antihistamine	Per BNF, at night	PO	For the post-scabetic itch, which lasts weeks and is not treatment failure.

When to escalate

Crusted (Norwegian) scabies suspected — ring infection control and dermatology today. Do NOT isolate: UKHSA advises standard IPC and PPE rather than isolation,Two or more cases within 8 weeks in a communal setting — clinical assessment for all residents, support symptomatic staff to be assessed, and coordinated treatment led by IPC. Scabies is not notifiable; involve the UKHSA health protection team if the outbreak is hard to manage,Treatment failure with new burrows — dermatology, and check the application technique and the contacts first,Secondary bacterial infection with cellulitis or impetigo — treat that alongside

Reference: UKHSA, Management of scabies cases and outbreaks in communal residential settings, updated 29 April 2026 — the source for isolation not being recommended, itch persisting up to 6 weeks, treating the case without waiting for mass treatment, and the licensed use of oral ivermectin. Also NICE CKS scabies and BAD patient guidance. Local infection control policy takes precedence in an outbreak.

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