Scabies Guideline - Infection Control

Publication: 21/02/2008  
Next review: 30/08/2022  
Clinical Guideline
ID: 1270 
Approved By: Infection Control Committee 
Copyright© Leeds Teaching Hospitals NHS Trust 2019  


This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Scabies Guideline

Summary of Guideline

Actions required to assess and manage cases of scabies in the healthcare setting.

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Scabies is an infestation of the skin with the microscopic mite called Sarcoptes scabei. There are two types of scabies Classical and Norwegian/crusted scabies both are caused by the same mite. The scabies mite can be transmitted through prolonged or frequent brief skin to skin contact. This can range from social contact such as holding hands through to sexual contact. Scabies can affect all groups of people regardless of gender, hygiene, social statues, age or ethnic origin.
Scabies is more common in groups where skin to skin contact is more likely; this includes: children and teenagers, elderly people in institutional care and those living in overcrowded conditions.The prevalence of the disease is cyclical with peaks about every 15-20 years, which last for 2-3 years.

The female mites which are barely visible to the naked eye only takes 2.5 minutes to burrow into the skin and lay their eggs. Approximately three weeks later the eggs hatch and a new generation of mites are ready to reproduce. Once away from the human body, the mites do not survive more than 48 – 72 hours. When living on a person, an adult female mite can live up to a month, producing 40-50 eggs during the lifespan; and it usually takes between 2-6 weeks from the time of the infestation before the itch starts.

Classical scabies
Close physical contact is necessary for transmission (e.g. prolonged hand holding, sexual intercourse, sharing a bed) when the mites dislodged from the skin use odour and heat to find a new host. Transmission by casual contact (e.g. hug or hand shake) is unlikely. Typically people with classical scabies have fewer than 50 mites all over their body. The more mites on a person the more likelihood of transmission. The mites cannot jump or fly but crawl at a rate of 2.5 cm a minute on warm skin

Norwegian/crusted scabies
This is a relatively rare, highly contagious infestation of mites

  • Large numbers of mites are shed in thick, crusted scaling plaques from the body because of a mite population explosion.
  • The elderly and immuno-compromised are mainly affected
  • It develops as a result of an insufficient immune response by the host.
  • Topical agents may be less effective as it may not be able to penetrate the skin
  • Erythema (red rash), hyperkeratosis (thickening of the skin), alopecia (hair loss), hyperpigmentation (excessive skin coloring), pyoderma (skin infection) and eosinophilia (increase of white blood cells usually related to parasitic infection) may be present.
  • The surrounding environment of the patient is highly contaminated with mites.
  • This condition can be the cause of large outbreaks of scabies in care facilities.
  • Norwegian/crusted scabies with its ‘scaly skin’ appearance is frequently misdiagnosed as psoriasis.
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Protocol for the Signs & Symptoms of Scabies

  • The main symptom of scabies is a pruritic rash which is particularly itchy especially at night and covers the whole body.
  • Other symptoms include erythematous (red rash) and papular (bumpy) eruptions, pustules and nodules.
  • Symptoms may also include 3-15mm fine, coloured and irregular burrows, which are often difficult to see.
  • Scabies mites have their favorite areas of the body – the web spaces of the fingers and toes; palms and soles; the wrists; the armpits; the skin around the navel and women’s nipples.
  • Symptoms of scabies occur two to eight weeks after contact with affected individuals, although in individuals who have had a previous infestation with scabies, symptoms may occur much sooner than this.
  • Sores on the body caused by scratching can sometimes become infected with bacteria.
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Protocol for the Diagnosis & Investigation of Scabies

Diagnosis can be made by medical staff on the ward, with support as appropriate by a consultant Dermatologist.
Clinical diagnosis of scabies can be confirmed by obtaining and examining skin scraping or nail clippings. Only staff trained to take skin scrapings should do so - contact the dermatology department for advice.
Negative findings do not rule out the presence of scabies as the skin scrapings are often negative in classical scabies as only a few mites are present, however because so many mites are present in Norwegian/crusted scabies the results will almost always be positive.

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Protocol for the Management of Scabies

Scabies will not disappear by itself, it requires treatment.

  • Treatment of the person and their close contacts should be undertaken as soon as possible after confirmation of scabies. Follow the directions for use supplied with the medicine. The following are suggested treatments for scabies.
  • 1st line treatment, (NICE Scabies Guideline. 2017), is Permethrin - Lyclear Dermal Cream (Permethrin 5%). This should be applied to the whole body and washed off after 12 hours. Suitable for adults and children over 2 months.
  • If Permethrin is contraindicated or not tolerated, Malathion Liquid - Derbac-M Malathion is applied to the whole body and washed off after 24hours. Medical advice should be sought before using Malathion on children under six months
  • Ivermectin - to be used on patients with Norwegian scabies who are unresponsive to Permethrin
    Benzyl benzoate 25% emulsion and Crotamiton 10% cream or lotion – are not recommended.
  • Pregnant staff should consult with the Occupational Health department prior to commencing treatment.


  • All cases and their close contacts should be treated within the same 24 hour period. If possible it is best to treat overnight.
  • Do not bathe or shower in hot water before applying the treatment. This could increase the amount of liquid or cream absorbed into your body, leaving less on your skin to kill the mites
  • Health care workers (HCW) must wear single use gloves and disposable fluid resistant long sleeved gowns during the patients shower and treatment application. Cuffs of the gowns should go under the gloves.
  • Apply the cream to every surface of the body from the chin and ears to the soles of the feet. However, in people who are immunosuppressed, the very young, and elderly people, the insecticide should be applied to the whole body including the face and scalp. (Nice Guidelines Nov. 2017).
  • Pay particular attention to skin folds and webs of fingers and toes. Massage medication under finger nails and toenails.
  • HCW to wash hands, wrists and lower arms after removing gloves and gown after treatment application.
  • Reapply the medication if the patient is incontinent, washes hands, puts feet on floor, or any other activity that may remove the cream prematurely.
  • Leave the cream on for the recommended period of time and remove by thoroughly washing/showering the patient.
  • Directly after applying the treatment ensure that the patient puts on fresh clean clothes
  • After the treatment has been applied all the bed clothes must be discarded as infectious (in red alginate bag) and mattress cleaned with detergent before the bed is remade with clean linen.
  • After the first treatment has been applied to those with classical scabies source isolation can be stopped in patients and staff can return to work.
  • A second treatment should be undertaken 1 week later.
  • The symptoms of itching may persist after successful treatment of Scabies. In these cases anti-pruritic cream may be applied.
  • If after treatment the itching gets worse or new burrows are visible, the treatment may not have worked. The cream may not have been applied correctly of for long enough so some mites are still alive or there may have been a reinfection of scabies and that’s why it is important to treat all cases and contacts at the same time. A medical diagnosis is required.
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Protocol for the Management and prevention of spread of Scabies

  • Cases of suspected/confirmed classical scabies should be nursed in source isolation until after the first active application of appropriate treatment. Follow the Isolation Guideline.
  • If Norwegian/crusted scabies is suspected/confirmed the dermatology department should be involved. In these cases the patient must remain in source isolation until both applications of treatment are applied (seven days apart), and may require further treatment.
  • For patients with classical scabies long sleeved disposable gowns should be worn for any close patient contact, for other activities in the source isolation room a disposable apron is sufficient. If the patient has suspected/confirmed Norwegian/crusted scabies a long sleeved disposable gown should be worn whenever in the source isolation room.


Individual case (staff or patient) - it is important that all members of the household, close contacts and sexual contacts are treated simultaneously within 24hours.

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Protocol for Outbreaks of Scabies

  • One or more suspected/confirmed cases of scabies whether patients or staff should be reported to The Infection Prevention and Control Department.
  • If staff are involved there must be communication between the Occupational Health Department and Infection Prevention and Control Department to risk assess cases and contacts.
  • It is the responsibility of the ward manager to formulate a list of both patient and staff contacts. Staff contacts include those that have had prolonged skin to skin contact with the case(s); this may include Allied Health Professionals (AHPs). However in an outbreak associated with a case of Norwegian/crusted scabies a decision may be made to treat all staff and patients on the ward
  • The Infection Prevention team will assist the ward/CSU managers in coordinating treatment of both patients and staff. In order to avoid reinfection it is important that all identified patients and staff are treated on the same day.
    • If several patients require treatment it is important to have enough staff on the ward to apply the treatment and remake the beds.
    • Liaise with pharmacy to ensure there is enough medication to treat the patients and staff – patients require prescription.
    • Ensure there is enough linen to change the bed clothes and nightwear.
  • The Infection Prevention and Control team may call an outbreak depending on the number of confirmed/suspected cases involved.
  • As scabies is highly infectious to close contacts, the family members of infected staff / patients may require treatment; this would be undertaken and supervised by their GP. Letters may have to be sent to contacts
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Lessons Learnt

“Lessons learnt arising from the recommendations will be disseminated through local clinical governance forums to monitor the progress of the actions.”


Record: 1270

To provide infection prevention and control guidance on the management of patients and staff with scabies.
To provide infection prevention and control guidance on outbreaks of scabies in the healthcare setting.

To provide evidence-based recommendations for appropriate treatment and management of Scabies infestation in the acute healthcare and maternity setting.

Clinical condition: Scabies
Target patient group: All patients at LTHT
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

References and Evidence levels:
BMJ Best Practice (2017) Scabies. BMJ Publishing Group.
NICE Scabies Guidelines November 2017.

A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. (where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other)

Approved By

Infection Control Committee

Document history

LHP version 1.0

Related information

Not supplied

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