Control and Management of scabies Infestation Scabies policy by mikeholy

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									     Scabies Infestation
    Management Policy

     Date of issue/ratification: October 2003
     Reviewed:                 November 2006, June 2009
     Next Review Date:         November 2010
     Policy Number:            5265
     Policy Lead/Author        Director of Nursing
     Department                Clinical Care and Practice

1                                   Barnet, Enfield and Haringey Mental Health Trust
                                            Management of Scabies Infestation 2006
                                                                       Review 2010
     Policy for the control and management of scabies

1. Scope of the policy

This policy is for all staff working within Barnet, Enfield & Haringey Mental Health
Trust (BEHMHT), who may be caring for patients either in hospital or community

The policy aims to:
   a) Provide BEHMHT’s approach to the care and management of in- patients
      with scabies infestation, and for staff in in-patient areas or in the
      community, who may have been in contact with scabies.
   b) Highlight the risks of cross infection from scabies and identify appropriate
      preventative measures to reduce the risk.
   c) Provide staff with a broad outline of what to do, and whom to contact for
      more detailed advice, when dealing with patients or members of staff with

2. National Context

In ‘Getting ahead of the curve’ (2003), and in the Winning Ways, Working
together to reduce healthcare associated infection in England (2004), the Chief
Medical Officer has emphasised the importance of intensifying control measures
to tackle healthcare-associated infections (HAI).

3. Accountability and Responsibility

3.1 Chief Executive
The Chief Executive has ultimate responsibility to ensure that the control of
hospital infection is addressed according to department of health directives. This
responsibility is delegated to the Director of Infection Prevention and Control
(Director of Nursing) who in turn delegates it to the Infection Control Lead. The
Trust board is responsible for ensuring that a robust system is in place and there
is a clear line of accountability.

3.2 Director of Nursing
Is responsible for the organisational adoption of the policy for the control and
management of scabies infestation. The Director of Nursing takes the lead and is
the designated Director for Infection Prevention and Control.

3.3 Infection Control Lead (ICL)
Is the lead person responsible for the preparation and implementation of infection
control policies and guidelines and is responsible for giving expert advice and
training related to all infection control practice. Is responsible for ensuring that the
policy is raised and reviewed at the Infection Control Committee to ensure that

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evidence based guidelines are available for all staff. Is also responsible for
working with the Director of Nursing to develop organisational strategy for
Infection Control.

3.4 Heads of Wards, Services, Departments / Team Leads / Service Managers
Are responsible for ensuring that all staffs are familiar with the policy and that the
management of patients or members of staff diagnosed with scabies is carried out
in their areas in accordance with legislation, Trust policy, and best practice.

3.5 All Staff: Clinical and Non-Clinical
All staffs must ensure they have read and understood the policy, and
incorporate the guidance on the care and management of patients and staff with
scabies into their clinical practice. They should be aware of their role in the
prevention of healthcare-associated infection in the working environment,
including reporting unusual rash and pruritic conditions.

3.7 Occupational Health (OH)
OH is responsible for the preparation and implementation of OH Policies and
guidelines, and providing expert advice, especially relating to scabies infestation
on staff and their family.

4. Introduction

Scabies is an allergic reaction to a mite called Sarcoptes scabiei. The mites
burrow down to the deeper layer of the skin where the females lay eggs that
hatch between 50 to 72 hours. The larvae in turn make new burrows, mature,
and the females lay new eggs.

At all stages the mites produce faecal pellets that are glued down to the tunnel
floor. An allergen seeps from these faecal pellets into the deeper parts of the skin
and eventually into the blood stream. This may take up to 8 weeks before setting
up a reaction. Once the allergen is in the blood stream, itching starts and the
person starts to scratch. This explains why the rash does not generally
correspond with the sites where the mites may be found in the body.

Persons with immune deficiency and those who are physically handicapped may
not always feel the itch or able to scratch, and the presence of scabies may take
a long time to be diagnosed.

Infection with scabies mite is not life threatening but may include severe
discomfort due to intense itching, and may produce secondary skin infection due
to scratching.

Scabies infestation may take two forms:
   • Classical scabies (common)
   • Crusted or Atypical. Also known as Norwegian scabies (more serious).

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                                                       Management of Scabies Infestation 2006
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5. Classical Scabies

This is the usual form of scabies found in the majority of people. It is found in
healthy people with normal immune system. The mites multiply rapidly during the
first few weeks of infestation but once the person is sensitized the immune
system eradicates the majority of the mites.

In some people burrows are difficult to identify unless one looks closely for red or
slightly raised papules or vesicles on wrists, backs of hands and between fingers.
Absence of burrows does not exclude scabies.

The distribution of the rash is characteristic, affects both sides of the body giving
a symmetrical pattern but may not appear in all these sites at once: fingers,
forearms, axillae, sides of chest, waist, genitals, lower quadrant of buttocks,
insides of leg, ankles. In females, the breast is usually affected, and in males, the
penis and scrotum. In the very young, the face, scalp, palms of the hands and
soles of the feet may also be affected.

5.a Signs and Symptoms
   • Severe itching associated with reddened papular eruptions with linear
   • Lesions are commonly bilateral in the axillae, finger webs, wrists, beltline,
       but may also be found in many other areas of the body.
   • Lesions are also found in the genitals and inner thighs and easily
       transmitted by sexual contact.
   • Scratching to relieve itching frequently leads to secondary bacterial
       infections that may become more serious than the actual scabies

5.b Diagnosis
   • The correct diagnosis is very important prior to treatment specially if
      involving a large group of people.
   • It is advisable to obtain advice from a Consultant Dermatologist.
   • A definitive diagnosis is made by taking skin scrapings from burrows to
      identify the mite, egg or faeces by microscopy. This is sometimes not
      possible and an experienced Dermatologist would rely on the history and
      clinical appearance to make a diagnosis.

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5.c Figure 1: Typical distribution of the symmetrical scabies rash

Note: These areas do not always correspond to the sites of the mite burrows.

5.d Figure 2: Common sites of the scabies mite burrows.
             Feet can also be involved

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                                                     Management of Scabies Infestation 2006
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5.e Transmission
       • Scabies is passed from an infested person to another via prolonged
         skin contact such as holding hands or sharing the same bed.
       • Those with scabies, but as yet have no itch, can pass the mite on to
       • Scabies is not transmitted via clothing or bedding, as the mite cannot
         live for long away from the host. The usual wash cycle can be used
         when these items are laundered.

5.f Treatment
       • The development of resistance to scabicides must be considered. One
          type of scabicide preparation should not be used for everybody when
          treating a large number of people. Select several preparations from the
          list given below, when prescribing in such occasions.
       • Remember that the itching may persist for up to two weeks following a
          treatment. During this time, prevent secondary skin infection from
          scratching by applying an antipruritic cream or prescribing an oral form.
       • In general aqueous preparations are preferable to alcoholic lotions,
          although lotions are easier to apply than creams.
       • If treatment for patients and staff are to go ahead:
                  Plan it well. Ensure that the treatment is coordinated. It is better
                  to wait than hurry.
                  Inform staff and decide on a 24-hour period. Treat everyone at
                  the same time to prevent re-infestation.
                  Ward medical staff should write patients’ prescription.
                  Staffs’ prescription:
                      In Edgware, Colindale, and Haringey: OH will provide
                      Lyclear for staff
                      In Barnet and Enfield OH will organize staffs’ prescription if
                      the department’s doctor is available. Otherwise the ward
                      doctor could prescribe for staff who are included in the list of
                      contacts. This list will be copied to OH for record keeping.
                      The Ward Manager will liaise with Pharmacy for the
                      provision of scabicide for the staff that has been prescribed
                      for it.

5.g Guidelines for application of treatment:
   • Scabicides should be applied to cool, dry skin and NOT after a hot bath as
      this may decrease their effectiveness. The perspiration would dilute the
      treatment, and a warm skin would have skin pores open that would allow
      the treatment to get into deeper layers of the skin where they would not be
   • Always wear gloves when applying the treatment on another person
   • If using a lotion, pour into a small bowl and apply with a wad of cotton
      wool for even coverage
   • If using cream, rub it in lightly to the skin

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      •   Pay particular attention to the finger and toe webs and the soles of the
          feet, genitalia, under the breast and any other skin folds. Except for the
          face, all areas of skin must be covered. After hand washing the treatment
          has to be reapplied
      •   Any part of the body that is washed during the required contact time must
          have the cream re-applied to those areas, including the hands after hand
      •   Leave the preparation on as instructed on the container. After the
          recommended contact time, the treatment should be washed off in a
          shower or bath. The patient’s clothing and bed linen may be changed at
          this time.

5.h Examples of Scabies Treatment Available:

    Scabicide       Preparation        Special Points
    Derbac M        Malathion 0.5%       • Apply twice, one week apart.
    Liquid          in an aqueous base   • Not contraindicated in
                                             pregnancy or breast-feeding
    Quellada M      Malathion 0.5%            •   Although it is used for the
    Liquid          in an aqueous base            eradication of scabies,
                                                  Quellada is mainly used for
                                                  head lice treatment.
                                              •   Not known to affect pregnant or
                                                  breast-feeding but caution is
                                                  advised for pregnant or breast-
                                                  feeding women.
    Prioderm        Malathion 0.5 %           •   Apply twice, one week apart.
    (Alcohol        lotion in an alcohol      •   May cause irritation of
    base)           base                          excoriated skin and the
                                              •   Not advisable for use in
                                                  children and in asthmatics due
                                                  its alcohol base.
                                              •   Not contraindicated in
                                                  pregnancy or breast-feeding
    Suleo M         Malathion 0.5%            •   May cause irritation of
    (Alcohol        lotion in an alcohol          excoriated skin and the
    base)           base                          genitalia.
                                              •   Not advisable for use in
                                                  children and in asthmatics due
                                                  its alcohol base.

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    Lyclear        Permethrin 5%            Not for infants under 2 months
                   Dermal cream

    Benzyl                                  An irritant to the skin and has
    benzoate                                been superseded by above agents

Derbac M, Quellada M, Prioderm, Suleo M:
   • Are not licensed for use on children under 6 months.
   • Treatment of children under two years old must be under medical supervision.
Lyclear Dermal Cream:
   • Not licensed for use on infants under two months old
   • Treatment of children under two years old must be under medical supervision.

5.i Isolation
    • Patients with classical scabies do not need isolation. However, they
        should be asked not to have physical contact or skin-to-skin contact with
        another person until the completion of treatment.
    • If the patient cannot be relied upon to comply, isolation should be
        instituted until the completion of treatment.
    • Staff should wear gloves when caring for above patients until completion
        of treatment. If lifting of patients is anticipated, long sleeves should be
        worn to prevent skin-to-skin contact of arms.
    • At the completion of treatment no terminal cleaning is needed except a
        change of bed clothes and bed linen to remove the presence of the

5.j Laundry
    • Laundry can be disposed of as any other laundry, according to Trust

5.k Contact
   • In the event that a patient or staff is confirmed positive to Scabies, please
      inform the Infection Control Lead who would advice on how to trace
      contacts that may need to be treated
   • It is imperative that the list of contacts is complete and nobody is missed
   • Affected patients and their close contacts should be treated at the same
      time, regardless of whether they have symptoms or not. This includes all
      members of the household, as well as all skin-to-skin contacts within the
      last two months.

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                                                           Management of Scabies Infestation 2006
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6. Crusted or Atypical Scabies (Norwegian Scabies

This form of scabies affects people with poor immune systems thereby unable to
produce an immune response to the presence of the scabies mite. The mites
multiply rapidly in numbers spreading all over the body causing the skin to
appear dry and crusted, and there is little or no itching. The grossly thickened
horny layer is honeycombed with cavities that contain large number of mites, and
these are shed into the environment of the patient. An undiagnosed case of
crusted scabies may cause large outbreak of common scabies.

Crusted scabies can mimic a range of dermatological conditions and if
misdiagnosed may cause a big outbreak of scabies infestation in a hospital,
nursing home or residential home settings. A prompt and correct diagnosis is
therefore of great importance.

It is imperative that the patient is referred to a Dermatologist.

6.a Transmission of Crusted/Norwegian Scabies
   • Crusted scabies is far more readily transmissible due to the large number
       of mites present, and the person concerned is highly infectious.
   • Prevention of skin-to-skin contact with the patient must be observed, as
       well as unprotected skin contact with the patient’s laundry and equipment.

6.b Treatment of Crusted/Norwegian Scabies
   • For crusted scabies, the treatment protocol should be repeated on day 4.
   • If it does not respond to treatment, advice should be sought from a
      Consultant Dermatologist
   • Ivermectin (Mectizan) is an oral preparation that has been used especially
      for patients who may be difficult to accept the application of scabicide
      cream or lotion. Some side effects have been reported and they should be
      used only when prescribed by a Consultant Dermatologist.

6.c Laundry for Crusted/Norwegian Scabies
   • Used laundry must be disposed of as infected per infected laundry policy
   • Used laundry must be handled only with gloved hands.
   • It is safe to handle the laundry bag once the used laundry items are inside
   • Patients’ personal clothing should be sent to the Trust’s Laundry as far as
             If this is impossible, and they have to be washed on the ward, care
             must be taken to avoid contaminating the environment and the staff
             when loading the washing machine.
             Wash temperature should be 60oC or above, otherwise, tumble dry.

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                                                        Management of Scabies Infestation 2006
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6.d Isolation for Crusted/Norwegian Scabies
   • Patients with crusted scabies should be nursed in a single room until
       treatment has been completed
   • Any person in contact with the host has to wear protective clothing
       ensuring that no skin to skin contact is possible by ensuring that hands,
       arms and legs are not exposed to contact with the patient’s skin, bedding
       or equipment
   • Disposable long sleeve gowns and well fitting gloves should be worn for
       all contact with the patient, bedding and equipment until both treatments
       have been completed. Gowns are available from NHS Supplies, catalogue
       code: BT004.

6.e Terminal Cleaning following Crusted/Norwegian Scabies
   • When isolation is no longer required, such as completion of treatment or
      patient’s discharge, the room should be thoroughly cleaned.
   • Long sleeve disposable gown and gloves should be worn
   • The bed should be stripped and linen sent to the Laundry as infected
   • The curtains have to be removed and also sent to the laundry
   • Any devices in the room which are disposable should be disposed of in
      clinical waste bag
   • Any devices which are not disposable and cannot be sent for sterilization
      should be wiped down with detergent and water or alcohol wipes
   • The bed must be thoroughly washed with detergent and water. This must
      include the mattress and bed frame
   • All fixtures in the room must be also washed thoroughly with detergent
      and water. Alcohol wipes may be used for electrical components.
   • The floor must be washed with detergent and water and carpets should be
      steamed cleaned

7. Prevention of an Outbreak of Scabies in General:
    • Educate staff on the presentation and transmission of scabies.
    • Maintain a high level of suspicion if patients present with undiagnosed skin
    • Encourage staff to report rashes – (including on themselves and their
    • Promote good surveillance of new clients. Observe for rashes on arrival,
       at three weeks and at six weeks.
    • Refer patient to a Dermatologist if they continue to exhibit signs of
       continued infection four weeks post treatment. If further topical treatment
       is required, an alternative treatment agent should be used.
    • If the patient has been admitted from a Nursing or residential home within
       the last 7 weeks prior to the diagnosis of scabies, the Manager of the
       home should be informed by the ward so that other residents can be
       treated if necessary. In addition the ICL will inform the Health Protection
       Agency, who has responsibility for infection control in these facilities.

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                                                     Management of Scabies Infestation 2006
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8. Useful Contacts:
    • Infection Control Lead (ICL):
                 020 8732 6341 or via switchboard at Edgware, Enfield, or

     •   Occupational Health:
           Barnet                                          020 8937 7920
           Enfield `                                       020 8375 1137
           Haringey                                        020 8442 6349

9. Monitoring

Barnet, Enfield and Haringey Mental Health Trust will ensure that regular
Monitoring of all policies takes place annually at the Policy Development Group
and also at the Clinical Governance Sub Committee, to ensure compliance and
maintain quality standards as in keeping with safe Clinical Practice. The NHSLA
Standards for policy formatting will be used and the dates for review will be
governed by the front-page entries.

Ward/ Team Managers will use the Policy Monitoring Form to collate information
regarding the reviewed or new policy and confirm that all staff are aware of Trust
Policies. The Policy Monitoring Form will be available on the intranet. Managers
will be required to submit this information to the Lead Nurse Education and
Practice Development on a two monthly basis.

10. References

     •   Almond DS, Green CJ, Guerin DM, Evans S. 2000. Norwegian Scabies
         misdiagnosed as an adverse drug reaction. BMJ. 320; 35-36.

     •   Ayliffe GAJ, Fraise AP, Geddes AM, Mitchell. 2000. Control of Hospital
         Infection. A Practical handbook. 4th Edition. Arnold. London

     •   Barrett NJ, Morse DL. The resurgence of scabies. Communicable Disease
         Report. CDR Review 1993; 3:R32-34.

     •   Beesley WN.1998. Scabies and other mite infestations in: Zoonoses:
         Biology, Clinical Practice and Public Health Control. Palmer SR, Lord

     •   Benenson AS ed. 1995. Control of communicable Diseases Manual. 16th
         Edition. American Public Health Association. Washington.

     •   Cox NH. 2000. Permethrin treatment in scabies infestation: Importance of
         the correct formulation. BMJ. 320; 37-38.

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     •   del Guidice P, Marty P. Ivermectin in elderly patients. Archives of
         Dermatology 1999; 135:351-2.

     •   Drugs and Therapeutics Bulletin (2002) 40(6), 43-46

     •   Figueroa J. Scabies. In: Primary health care guide to common UK
         parasitic diseases 1998.

     •   Lice & Scabies. A health professional’s guide to epidemiology and
         treatment. Edited by DT Roberts, 2000. PHLS Publication

     •   Maunder J. 1997. Scabies-a war in the skin. Scope. September.4-5.

     •   National Prescribing Centre.NHS. (

     •   Xavier G.1998. Public relations. Nursing Times (Supplement). 94(4) 74-

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Appendix 1

                           Management of Suspected Scabies Outbreak

                                                   Case Suspected

                            Confirm diagnosis. If necessary consult Dermatologist

                                  YES                                          NO

                                                                        Seek advice for
                                                                     alternative diagnosis
                                                                         and treatment

                        Classical                                               Crusted/Norwegian

           Inform Infection Control Lead                                  Inform Infection Control Lead
     (who will inform HPA if there are 2 or more cases)                         (who will inform HPA )

            Check list of staff & patients                                Check list of staff & patients

       Arrange and Plan treatment over 24
                     hours                                               Plan and give treatment under
                                                                              coordination of HPA

                    Give treatment                                       Repeat treatment if necessary

                Identify close contacts                               Review with HPA and seek further
                Advise/give treatment                                     help from Dermatologist

         Repeat treatment one week later                                   Follow up after one month

             Follow up after one month

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                                                                      Management of Scabies Infestation 2006
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                         EQUALITY IMPACT ASSESSMENT
  Name of the policy/service/function being assessed:

Policy for the control and management of scabies infestation (IC20)

  Person responsible for carrying out the assessment:

Amelia Sookraj (ICLN Forensics), Sharon Spence (ICLN Forensics)

  Main aim, objectives and intended outcomes of the policy / function / service

Provide BEHMHT’s approach to the management of patients or staff infested with Scabies


To highlight the risk of possible transmission of Scabies to patients or staff and
the appropriate actions to take

  Intended outcomes:

Staff would have a broad knowledge of what to do and who to contact for more
detail when dealing with an infestation from Scabies

  Is there reason to believe that the policy / function / service development could have
  a negative impact on a group or groups?


  Which group or groups may be disadvantaged / experience negative impact?

Race :                                    NA
Disability :                              NA

Gender :                                  NA

Age:                                      NA
Sexual Orientation:                       NA
Religion/Belief:                          NA

Other:                                    NA

  What evidence do you have and how has this been collected?

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                                                                    Management of Scabies Infestation 2006
                                                                                               Review 2010



 Have you explained your policy / function / service development to people who might
 be affected by it? YES or NO? If YES, please give further details.


 If the policy / function / service development positively promotes equality, please
 explain how?

It does not disadvantage any group in relation to gender, race, ethnicity

From the screening process, do you consider the policy / function / service
development will have a positive or negative impact of equality groups?

Please rate the level of impact and summarise the reason for your decision.


 Reasons for your decisions:

 Date completed:
26 May 2009


Print Name:
Amelia Sookraj
Sharon Spence

15                                                     Barnet, Enfield and Haringey Mental Health Trust
                                                               Management of Scabies Infestation 2006
                                                                                          Review 2010

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