Scabies

What is scabies?

Scabies is a common skin infestation caused by a mite that burrows into the skin causing an itchy rash. It affects people of any age but is most common in the young and the elderly. Scabies is passed from one person to another by direct skin contact.

What does scabies look and feel like?

Scabies is usually very itchy; the itch is often worse at night.

The mites are mainly found in between the fingers and toes, the palms and soles, wrists, ankles, groins, and breasts. Mites burrow into the skin and lay their eggs, giving the appearance of a silvery line on the skin surface (a ‘burrow’). It can take a couple of weeks for the eggs to develop into adult mites.

The body’s immune system is alerted to the infestation, causing a widespread red (erythematous) rash on the body and limbs; in richly pigmented skin this can be darker than the surrounding skin. The face and scalp are usually not affected, except in infants and bed-bound elderly patients.

Multiple firm bumps on the skin 0.5 to 1 cm in diameter (papules and nodules) may occur, most commonly on the penis, groins and in the armpits (axillae). They can persist for several weeks after the scabies has been successfully treated.

Spots (papules), some with a white head (pustules) on the palms and soles are characteristic of scabies in infancy.

People with crusted scabies (a much less common form of scabies) develop thick areas of crust on the finger webs, wrists, elbows, breasts, and scrotum, which can become widespread. The itch is often significantly less than with normal scabies. 

What causes scabies?

Human scabies is caused by infection with a mite known as ‘Sarcoptes scabiei var. hominis’. The mites are smaller than a pinhead. People get scabies through direct skin contact with someone else who has scabies, or through sharing items such as clothing and towels.

Scabies is not hereditary (i.e. not genetic), but it is common for several members of a family to have scabies at the same time as it spreads easily among people who live together.

What else can contribute to scabies?

People with a weakened immune system (immunosuppressed), neurological impairment (e.g. dementia and Down's syndrome), and those inappropriately treated with strong topical steroids are more likely to get crusted scabies, in which there are very large numbers of mites.

How to treat scabies?

Take advice from a pharmacist as treatment for scabies can be bought without a prescription, though you may choose to see your GP first to confirm the diagnosis. 

The most common medications for scabies are topical insecticide treatments (applied directly to the skin). While several topical treatments are used in the treatment of scabies, use of permethrin 5% cream is often advised first. It is important to follow all the instructions carefully (see further down for detailed advice). 

Anyone with scabies needs two treatments, one week apart. If you have scabies, all your household members, close contacts (e.g. grandparents), and sleeping/sexual partners should also be treated twice - even if they have no symptoms. This is because it can take up to six weeks to develop symptoms after you become affected. Everyone should use their treatment on the same day. You may need to take advice from your GP for young babies. 

Things you can do to help yourself, your partner, and your family 

• Until treatment is complete it is important not to share towels, clothes, and bedding. Avoid direct physical contact with other people
• If you have caught scabies through sexual contact, you should make an appointment to see a health professional in a sexual health clinic as tests will be needed to look for other sexually transmitted infections
• Aside from seeking insecticide treatment, itching may be relieved by the use of moisturising (emollient) creams/ointments, particularly those containing crotamiton
• Children should stay off school until the first application of treatment for scabies has been completed

How to use permethrin 5% cream 

• Apply the treatment at night. Remove all your clothes. Apply the cream when your skin is cool and dry; if you have just had a bath or shower, wait to let your skin cool before you apply the cream
   
• Apply a thin layer of the cream over your whole body including your face, neck, scalp, and ears, but try to take care not to get any into your eyes. Remember to include awkward places such as your back, between your fingers and toes, under your fingernails, your genitals, and in-between your buttocks
   
• Leave the cream on for at least 12 hours. Some people may benefit from leaving it on for a full 24 hours with further application after 12 hours. This will ensure the medication is on their skin for 24 hours.  After this time, you should remove the cream from your skin by having a bath or a shower
   
• If you need to wash your hands during the treatment time, remember to re-apply some cream to your hands afterwards
   
• If you have scabies, you and your family and close contacts need to use the cream a second time, seven days after the first treatment. It is important that everyone begins the treatment on the same day
   
• For the two applications, an adult is likely to need 60-120 g of cream (3-4 tubes ie 1-2 tubes for each application), older children will need 30-60 g cream in total (½ tube for each application) and younger children will need 15-30 g cream in total (¼ tube for each application)
   
• Clothes, towels, and bed linen should be machine-washed at 50°C or above immediately after the first application of treatment. This kills the scabies mites
   
• Place any items of clothing that cannot be washed in plastic bags for at least 72 hours to contain the mites until they die. Other ways to kill mites on clothes and linen are ironing the items with a hot iron, dry cleaning or putting items in a dryer on a hot cycle for 10-30 minutes. You do not need to fumigate living areas or furniture or to treat pets
   
• It is normal for the itching to continue for 2-3 weeks (and sometimes up to six weeks) after scabies mites have been killed. You should; however, see a healthcare professional if the itch lasts longer than 2-3 weeks after treatment. This is because sometimes the first insecticide treatment does not work, and you may need to use a different one
   
• Additional notes related to children and cats:
  • If you are breastfeeding a child, you should wash off the cream from your nipples before you breastfeed, and then re-apply the cream afterwards
  • If you are applying the cream to an infant or young child, put mittens on your child to stop them licking the cream off their hands. Do not apply the cream to areas around their mouth where it could be licked off
  • The medication should be kept away from cats - harm or death to cats may occur from licking treated areas on patients

Make an appointment at your GP surgery

Contact your GP surgery if the creams are not available or not working despite being used by everyone as directed with washing of clothes etc as detailed. An oral medication (tablet) called ivermectin is usually needed for crusted scabies and may be offered for scabies that seems to be resistant to creams/lotions.  

A strong steroid cream may be needed for skin itching that can continue for several weeks after the scabies treatment is complete. Click on this link for more information.  

If scabies is ongoing or recurrent, then all cases and all relevant contacts will need further treatment.

Referral to a specialist

The following groups of people may need to be referred to a specialist, who will be either a Dermatologist or a GPwER/GPwSI (a GP who has been trained in relevant areas of dermatology):

• Where the diagnosis is not clear
• If the scabies has not responded to treatment 
• Some cases of crusted scabies

What will happen when you are referred?

The appointment may be face-to-face (the person attends the clinic), or a video call (teledermatology).

Other resources 

Additional resources on scabies that some adults might find useful can be found on the BASH website.

Helping with other skin conditions

If you, a family member, or friend have an undiagnosed skin condition; or you want to learn more about how to treat skin conditions, please view our short video on how to get the best from this website.