Guidance

UKHSA guidelines for the management of scabies cases and outbreaks in communal residential settings

Updated 23 April 2025

Who this guidance is for

This guidance is for Health Protection Teams (HPTs), other community teams and managers of communal residential settings.

Managed communal residential settings include care homes, boarding schools, children바카라 사이트™s homes, secure children바카라 사이트™s estates, prisons and places of detention, accommodation for people seeking asylum and hostels for people experiencing homelessness.

What has changed as of April 2025

Information has now been included on the licensed use of ivermectin for the treatment of scabies.

Clarification that people diagnosed with scabies should be treated as soon as possible and should not wait for wider mass treatment in the setting. This is to minimise their symptoms, reduce risk of complications and reduce risk of further onward transmission.

Specific considerations have been outlined for inclusion health settings, including prisons and places of detention, accommodation for people seeking asylum and hostels for people experiencing homelessness.

Exclusion requirements have been clarified.

Roles and responsibilities

The NHS or other healthcare provider for the setting is responsible for the diagnosis and treatment of cases of scabies as well as prescribing treatment for identified contacts who are residents at the settings. Correct diagnosis may be difficult and on occasion a referral for a specialist opinion may be required.

Where a prescription is required, the NHS is responsible for prescribing or using a Patient Group Direction (PGD) to supply the product for identified staff contacts. Ideally this should be co-ordinated by the healthcare provider for the setting to facilitate co-ordinated treatment of contacts and a speedy resolution of an outbreak.

Scabies is not a notifiable disease, and single cases or outbreaks do not need to be reported to the HPT.

If the setting struggles with any aspect of management despite of following the guidance outlined in this document, they can contact the local HPT for support.

The HPT will require detail of the actions already taken by the setting to control the spread. They can then assist in risk assessment in the outbreak and provide specialist advice and support to settings and infection control teams. They can also provide advice and support to the setting manager on contact tracing, co-ordination of treatment, control measures and communications. The HPT may decide to convene an Incident Management Team (IMT) to support the process.

Summary of public health management of cases and outbreaks of scabies

Actions for the settings managing cases and outbreaks of scabies:

• refer suspected cases to their GP or another clinician for diagnosis
• ensure diagnosed cases receive treatment as soon as possible
• identify close contacts (up to 8 weeks prior to diagnosis) including visitors
• arrange for all identified contacts to receive treatment and ensure this is co-ordinated to break the cycle of transmission
• the case may need to be re-treated when wider treatment is carried out (if there has been a delay in identifying and treating contacts)
• if 2 or more cases occur within an 8-week period, organise a clinical assessment for scabies infection for all residents and support symptomatic staff to access an assessment, and ensure co-ordinated treatment
• seek support from the local UKHSA HPT if the outbreak is difficult to manage and further support is needed after following this guidance
• follow hygiene and exclusion advice and risk assess and manage transfers to and from other settings before and during treatment
• ensure appropriate personal protective equipment (PPE) is available for use
• inform and advise visitors
• ensure effective cleaning and management of laundry and that this is coordinated with treatment

Algorithm summarising the public health management

The algorithm consists of 2 questions which follow each other to help determine if the setting is dealing with an outbreak and to guide public health management.

Text version of the algorithm:

1. Is this a single case of scabies?

There are two options:

If yes, the advice is:

• Refer the case to GP for diagnosis and prompt treatment
• Identify close contacts
• Refer contacts to treatment 바카라 사이트“ co-ordinate the treatment.
• The case may need to be treated again

This leads to generic Infection Prevention and Control (IPC) advice:

Cases, contacts, and staff to follow good IPC practice including using PPE as appropriate until 24 hrs after treatment.

Risk assess transfers to other settings or any new admissions planned before treatment completion.

If no, move to question 2:

2. Is this an outbreak (2 or more cases at the same setting in 8 weeks)?

There are two options:

If no, the answer is the same as for single case above

If yes, the advice is to assess all individuals at the setting

This leads to the next box advising:

• identify contacts and potential further cases
• arrange a co-ordinated treatment for further cases and contacts
• all diagnosed cases must be treated immediately and may need to be re-treated as part of the co-ordinated treatment
• warn and inform visitors

This leads to the same generic IPC advice:

• cases, contacts, and staff to follow good IPC practice including using PPE as appropriate until 24 hours after treatment

• risk assess transfers to other settings or any new admissions planned before treatment completion

This document should be used alongside other resources available for specific settings and population groups including:

• Health protection in children and young people settings, including education
• Outbreak management in short term asylum seeker accommodation
• Skin lesions in newly arrived migrants: recognising and managing infections of public health importance
• Infection control in prisons and places of detention
• Infection prevention and control: resource for adult social care

Definitions

Care homes

Care homes are CQC registered residential settings with provisions for personal and in some cases nursing care for residents with needs due to frailty, disability physical and/or mental illness/disability which may include dementia.

Case

A single case is defined as a diagnosis of any type of scabies in an individual.

Close Contact

Close contacts are likely to include anyone who has skin to skin contact with a case without appropriate personal protective equipment (PPE) within the 8 weeks prior to the case바카라 사이트™s diagnosis. For further information, see the section on Contact Tracing.

Cluster

A cluster is defined as 2 or more cases of scabies within an 8-week period, where no epidemiological link has been identified. Clusters become outbreaks if an epidemiological link is made. 

Crusted scabies

Crusted scabies was historically known as Norwegian scabies. It is a characterised by thickening of the outer layers of skin (Figure 5) which contain up to an estimated 4,700 mites per gram of skin, far more than are found in non-crusted scabies (4). Crusted scabies can sometimes be due to reduced immunity, but this is not always the case.

Higher risk communal accommodation settings

Higher risk communal accommodation settings are residential accommodation for vulnerable adults (and sometimes their dependent children) without onsite health or care teams. Residents often share rooms, bathrooms and/or other facilities. Examples include:

• accommodation for people seeking asylum, for example contingency or initial accommodation centres
• accommodation for people experiencing homelessness, for example, hostels and night shelters
• domestic abuse refuges
• other communal settings used to house individuals for emergency or temporary accommodation

Prisons and places of detention depending on their accommodation type and security category can also be considered in this group though they all have healthcare services on site.

Infestation

A condition caused by parasites on the skin is called an infestation. Scabies infestation means the presence and reproduction of scabies mites on the skin.

Outbreak

An outbreak is defined as 2 or more epidemiologically linked cases of scabies within an 8-week period within a setting.

Scabies

Scabies is an infestation with the mite Sarcoptes scabiei, in which affected people typically host around 11 burrowing female mites, in addition to a larger population of earlier life-stages and males (1, 2, 3).

Semi-closed settings

A communal setting where users remain for more than 8 hours per day and where they are likely to consume at least one meal. It usually has a non-occupational purpose (for example social or educational).

Examples of semi-closed settings include adult day centres.

Closed settings

Closed settings are communal settings where people are normally resident overnight Residents have close contact with each other for example in communal areas or sharing bathrooms. A closed setting includes the staff working within it.

Examples (not exhaustive) of closed settings include:

• care homes
• prisons and places of detention which include:
• prisons, Immigration Removal Centres (IRCs) - Youth Custody Service (YCS) for Youth Offender Institutions (YOI) under 18 units, and Secure Training Centres (STC) and secure schools)

Transient contact

Someone who has had contact with the index case바카라 사이트™s environment but not direct skin-to-skin contact. Note that transient contacts of people with crusted scabies require assessment for contact transmission due to its increased infectivity.

Background

What is scabies Infestation?

Scabies is a skin condition caused by an immune reaction to the presence of the mite (infestation) Sarcoptes scabiei and their saliva, eggs and faeces.

The typical clinical presentation of scabies is intense itching associated with burrows, nodules and redness (1) which generally starts 3 to 6 weeks after infestation However, infestation without these symptoms has been shown to be common in older adults living in care homes (5). When a person has symptoms, they may last for weeks or months, can be hard to recognise and are often mistakenly attributed to other skin conditions, leading to avoidable transmission (6).

Scabies is most often transmitted by skin-to-skin contact. Itching may be severe, particularly at night and scratching may lead to secondary bacterial infection and its complications.

Crusted scabies, formerly known as Norwegian scabies, is a hyperinfestation where a much higher number (7) of mites is present. Crusted scabies often develops due to an insufficient immune response by the person with scabies, genetic predisposition, or immunosuppressive therapy (such as use of corticosteroids) (6).

Epidemiology of scabies

The epidemiology of scabies in the UK is poorly understood and available disease surveillance data is limited.

Reliable estimates of current scabies incidence are not possible, but it has been estimated that 1 in 50 long-term care facilities will experience an outbreak each year (11). In 2016, over 241 institutional scabies outbreaks were reported to HPTs across England (6).

There is considerable stigma associated with scabies (12), which can contribute to under-reporting both in the community and among staff and residents in care facilities.

Outbreaks of scabies are most likely to occur in settings where people live close together, and in settings where individuals receive hands-on personal or health care. Institutional settings such as care homes, hospitals, hostels, and prisons are especially susceptible to outbreaks (6).

Clinical presentation

Clinical scabies is often intensely itchy and distressing, with signs on examination including nodules, papules  (Figure 2), and s-shaped mite burrows (Figure 3). The latter can be seen with the naked eye, but dermatoscopy (Figure 3) may aid diagnostic confirmation as can light microscopy identification of mites, eggs, or faeces in skin samples scraped from affected areas (Figure 1)(5). Rashes may occur anywhere on the body, with burrows commonly observed on the hands (particularly finger-webs) (Figure 4), breasts and genitals (8).

Presentation in older adults

The clinical presentation of scabies may be very different among older adults in long-term care settings. Burrows and rashes may affect parts of the body typically covered by clothing, for example, the torso or legs (Figure 2), therefore careful and thorough examination including the removal of clothing is recommended. Some individuals may have no symptoms, especially in those with underlying cognitive impairment, and so diagnosis can be extremely challenging (6).

People with cognitive impairment may not be able to communicate that they are itching and may not scratch. Secondary bacterial infection may mask an underling scabies infestation.

Crusted scabies

Crusted scabies is characterised by a scaly rash and thickened crusts of skin containing many mites, alongside heavy skin shedding. Itching may be absent. It is harder to treat and may present an increased risk of onward transmission.

Diagnosis of scabies

Scabies infestation is usually diagnosed clinically in the community or healthcare within the settings where available.

UKHSA is not responsible for clinically diagnosing cases of scabies. If clinical advice is required about a case, please contact their GP or other healthcare provider.

Clinicians unaccustomed to seeing scabies cases regularly should consult internationally agreed criteria for scabies diagnosis (9). However, typical symptoms might not be seen in older  people in care homes and diagnostic procedures such as skin scraping followed by microscopy should be carried out for this sub-population with reference to additional guidance (6).

Commonly available tests are not very sensitive in scabies diagnosis (1).  Diagnosis is therefore mainly based on simple examination and history and may be difficult, especially in older adults as noted above.

Skin scraping followed by microscopy can be used to confirm diagnosis.  However negative findings should not be taken to indicate absence of infestation due to its low sensitivity (10).

Specialist dermatology services may be able to support in making a diagnosis of scabies. However, seeking specialist advice should not delay commencing treatment of cases or outbreak control measures on account of  the distressing nature of symptoms and high likelihood of onward transmission in communal settings (5).

Incubation and transmission

Incubation period and onset of symptoms

Scabies infestation occurs when the female Sarcoptes scabiei mites burrow into skin and lay eggs that hatch into larva. The eggs hatch in 3 to 4 days and develop through nymphal stages, and into adult mites in around 2 weeks. Mites on the surface of the skin, or in skin-flakes shed from individuals with crusted scabies, can then infest new individuals. In a first episode, symptoms are usually experienced within 3 to 6 weeks. However, people who have been re-infested after successful treatment may develop symptoms more quickly, in around 1 to 4 days (3, 6).

Period of infectiousness

Scabies is infectious from the point of infestation, whenever S.scabiei mites are present on the skin until 24 hours after the individual바카라 사이트™s  first treatment dose.

Transmission - person to person

Mites quickly dry out and die off-host (within three days when not on a person). For this reason, scabies is primarily transmitted through close skin-to-skin contact with an affected person, for example, sharing a household setting, through the provision of personal care, or via sexual contact. The risk of transmission from cases of crusted scabies may be greater due to the larger number of mites present on the skin.

Transmission - fomites (objects)

The role of fomites (for example, clothing, bed linen and towels) in scabies transmission is unclear and there is conflicting evidence in the literature (13, 14). Some evidence suggests that mites can live away from a host for up to 4 days.  However, the likelihood of mite survival and successful infestation of a new host in that period is not known.

Importantly, fomite transmission is considered to be much more likely in crusted scabies, in which the patient sheds a high volume of skin flakes with a heavy load of mites.

Zoonotic transmission (to and from animals)

S. scabiei transmission between humans and animals has not been reported in the UK and is highly unlikely to be involved in institutional outbreaks. Animals with S. scabiei infestations (which in non-humans is referred to as 바카라 사이트˜Sarcoptic mange바카라 사이트™) should be treated by a veterinarian.

Principles of management

Management of the case and their close contacts, even if asymptomatic, requires:

• identification and categorisation of confirmed and suspected cases and contacts
  • does any case have crusted scabies?
  • is this a single case, cluster or an outbreak of scabies?
  • what is the setting?
  • are there any contacts outside of the setting?
  • is any case/contact pregnant or breast-feeding as this might impact on treatment recommended?
  • is any case/contact an infant?
• selection, timing, and instruction on use of an appropriate anti-scabietic agent by the healthcare provider to ensure the cases receive treatment without delay. Options for treatment include:
  • permethrin 5% cream
  • ivermectin 3 mg oral tablets
  • malathion 0.5% liquid
• Infection Prevention and Control (IPC) measures to reduce environmental contamination and the potential risk of onward transmission. This includes:
  • laundering of clothing and bedlinen
  • cleaning of surfaces
  • risk assessment on the movement of case(s) and contacts
  • appropriate use of personal protective equipment for hands-on care
• consideration of symptom relief, treatment failure and follow-up
  • antihistamines
  • retreatment options
  • follow-up by the healthcare provider

Pharmaceutical treatment

For the clinical management of cases of scabies please follow clinical advice and refer to the and the . Local ICB pharmaceutical formularies should be consulted for local treatment options by the prescribers.

Individuals who have been diagnosed with scabies should be treated promptly to alleviate symptoms and reduce risk of complications. This should never be delayed by waiting for contacts to be treated.

In the United Kingdom (UK) there are 3 licensed anti-scabietic treatments:

• permethrin 5% cream
• ivermectin 3 mg oral tablets
• malathion aqueous 0.5% liquid

Ivermectin 3 mg tablets are licensed for the treatment for scabies once diagnosis has been confirmed clinically or by parasitological examination.  Itching alone, without a formal diagnosis of scabies, does not justify treatment with ivermectin.

A Cochrane systematic review (15) and other systematic reviews of randomised controlled trials (16) have been undertaken to evaluate effectiveness of various treatment combinations. This research can be used to support prescribing decisions.

Specialist dermatology advice for treatment should be sought if:

• the affected individual is under 2 months of age
• crusted scabies is suspected

If itching continues after scabies treatment has been completed, medical advice should be sought to address this.

Management of ongoing symptoms

Affected individuals and relevant care givers should be advised that symptoms, for example itching, can persist for up to 6 weeks after treatment.

If symptoms persist longer than 4 to 6 weeks after the last treatment application, or if new mites or burrows are seen, medical advice should be sought, and retreatment considered.

Although there are no formal studies of alternative management strategies, persistent infections are reported on a regular basis. In some cases, this may be caused by inadequate or incorrectly applied treatment, but in others, because of reduced responsiveness of mites to permethrin.

It is important to ensure that instructions on the use of anti-scabies medications have been followed, that cases (and their contacts) have received two topically applied anti-scabies treatments applied 1 week apart to the whole body and that all contacts have been treated at the same time. If the symptoms persist after properly executed treatment, various alternative options may be effective. These include:

• the concurrent use of two anti-scabies medications e.g., permethrin and malathion 바카라 사이트“ at least two whole-body applications of both are required
• if this still fails to resolve the issue, then oral ivermectin in combination with topical treatment should be considered

Contact Tracing

If a case of scabies is diagnosed in a communal residential setting, it should be treated without delay. All residents or clients should be checked for signs and symptoms of scabies. Staff should be advised to check themselves for scabies signs and symptoms and seek clinical advice as appropriate.  Assessing clinicians should be aware of the potential for asymptomatic infection, particularly in older people.

Contact tracing should identify contacts within the 8 weeks before the case바카라 사이트™s diagnosis.

Contacts should be identified using the definitions of a close contact.

Close contacts may include:

• all residents or clients of the setting unless there is a clear rationale for more limited tracing
• 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 ²¹±è±è°ù´Ç±è°ù¾±²¹³Ù±ðÌýPPE (gloves and aprons)
• visitors to the setting who have had prolonged or frequent skin-to-skin contact with a case such as holding hands
• ancillary staff, for example, hairdressers, podiatrists, community health professionals and agency staff who have had prolonged or frequent skin-to-skin contact without PPE

Personal protective equipment (PPE) for staff in contact with cases of scabies and their contacts

PPE including gloves and disposable aprons, should be used for all activities with cases and their contacts that involve skin-to-skin contact during the infectious period. PPE should be used until 24 hours after the first treatment dose.

A risk assessment should be undertaken. If arms of staff are likely to have prolonged skin-to-skin contact with either the case바카라 사이트™s skin or infected linen, then single use long sleeve gowns or sleeve protectors should be used.

The used PPE can be disposed in accordance with local procedures.

Exclusion or isolation of cases

Clinical scabies

Exclusion or isolation of cases or contacts is not normally required for clinical scabies.

People whose job roles do not involve hands-on care and are able to maintain good hygiene practices and avoid skin to skin contact do not need to be excluded from usual work activities or educational settings.

Staff and carers can continue to work but should wear appropriate PPE (gloves and aprons) to avoid skin바카라 사이트“to-skin contact when handling and providing personal care until 24 hours after their first treatment dose.

Any affected individuals who need to be excluded (those who are unable to avoid skin-to-skin contact) can return to work, school or nursery 24 hours after the first dose of chosen treatment.

Crusted scabies

Crusted scabies is highly transmissible.  However, standard infection control principles and wearing appropriate PPE (gloves and aprons) to avoid skin-to-skin contact should be sufficient to prevent transmission. Isolation of people with crusted scabies is not recommended.

Affected individuals may require combination treatment with both permethrin and oral ivermectin and advice should be sought from a specialist clinician.

Due to the complexities of treating crusted scabies, the decision as to whether the patient is no longer infectious should be guided by the specialist clinician involved in care. Avoiding skin-to-skin contact is advisable until deemed non-infectious.

Staff

Staff members who are diagnosed as having scabies, or identified as contacts of a case, can continue to work but should avoid skin to skin contact. Where hands-on or close contact care is required, staff must wear appropriate PPE (in the affected setting or other care/residential settings they may work in) until 24 hrs after completing their treatment. Staff members바카라 사이트™ treatment should be co-ordinated with the setting바카라 사이트™s treatment dates.

Staff members who are diagnosed with scabies may have household or other contacts identified in the community. They should advise their contacts to co-ordinate their treatment doses as far as possible, to reduce risk of reinfection.

It is the responsibility of the setting management team to determine the most appropriate route for staff to access treatment, for example, through occupational health services, setting healthcare teams, or their own GPs.

Any agency staff diagnosed with scabies should inform their other places of work including home care (domiciliary) recipients so that these settings can also be risk assessed and clients identified.

Return to usual activities following treatment for cases and contacts  

People whose job roles do not involve hands-on care do not need to be excluded from usual activities or educational settings.

Children or adults who are able to maintain good hygiene practices and avoid skin to skin contact do not need to be excluded from usual activities or educational settings.

Staff and carers providing hands-on care can continue to work but should wear appropriate PPE (gloves and aprons) when handling and providing personal care until 24 hours after their first treatment dose. Skin-to-skin contact should be avoided as far as possible.

Any affected individuals who need to be excluded (those that are unable to avoid skin-to-skin contact) following a risk assessment can return to work, school or nursery 24 hours after the first dose of chosen treatment.

Movement/transfer of cases in or out of the setting

Any transfers of cases to other settings should be risk assessed and mitigated until the first 24 hour topical or oral treatment dose has been completed.

Environmental Control Measures

Environmental measures such as cleaning and laundry management are recommended to reduce the potential risk of fomite transmission and reinfection. The evidence for a single optimal approach to environmental management is limited (8).

Cleaning

The aim of cleaning in the event of a case or outbreak of scabies is to remove skin scales and dust in the environment to reduce fomite-based transmission.

• clinical scabies cases and outbreaks
  • normal daily cleaning regimen is sufficient to remove skin scales from the environment, but daily vacuuming is recommended until 3 days after first treatment
• crusted scabies cases (increased skin shedding)
  •  daily vacuuming until 7 days after treatment
  • deep clean after treatment cycles (for example steam cleaning soft furnishings, cleaning touch points, vacuuming mattresses and so on)

Laundry

Settings should already be compliant with guidelines around decontamination of laundry such as

Clothing, bedlinen and towels

Clothing and personal textiles which have been worn or handled by individuals being treated as cases or contacts in the week before, or at any time up to 24 hours from starting first treatment dose, need to be cleaned in accordance with the advice below.

Any items which cannot be laundered in a hot wash may be placed in a sealed plastic bag for at least 4 days prior to laundering: this should be sufficient to kill any mites present.

When laundering items:

• laundry should be done the morning after treatment
• do not mix with items belonging to unaffected individuals
• clothing should be handled using appropriate PPE to avoid skin contact with contaminated clothing
• place laundry into a dissolvable alginate bag (soluble laundry bag) if available, and place the bag without opening it into a washing machine
• wash the laundry on the hottest cycle
• clothing should be tumble dried on a hot cycle for at least 10 minutes immediately following the wash if a hot wash has not been carried out

Outbreak management

Whilst most scabies outbreaks will occur within households, they also occur in communal residential settings including care homes, places of detention, boarding schools, children바카라 사이트™s homes and higher risk communal accommodation settings.

The following section aims to provide guidance on the management of outbreaks in these settings where secondary case identification and breaking the cycle of transmission can be more challenging than in households.

Co-ordination of mass treatment

People diagnosed with scabies should be treated as soon as possible, to reduce symptoms and reduce the risk of complications. Care providers should follow internal policies on the provision of health care to those individuals who lack capacity.

It is recommended that all contacts receive treatment at the same time as each other in a co-ordinated manner as part of the whole setting eradication. It is the responsibility of the setting or management team to ensure that this is coordinated as much as possible. However, this should not delay treatment of people who have been diagnosed with scabies, to reduce their symptoms and reduce the risk of complications. The cases may need to have an additional treatment dose when their contacts are treated even if they have completed two treatment doses before the mass treatment commences.

If staff are off duty at the time of co-ordinated setting eradication treatment, they should complete the first 24-hour treatment dose before returning to work.

A number of studies describe challenges to the co-ordinated approach to an outbreak (1). An Incident Management Team (IMT) led by the HPT may be needed to be set up to oversee the process.

Where occupational exposure of staff has led to their need for treatment, it is recommended that the employer should consider funding any treatment rather than staff paying for their own prescriptions or over the counter medications. This encourages treatment uptake and promotes a prompt return to normal working. Social care settings can consider discussing alternative funding options with their Local Authority public health or social care commissioning teams.

Ivermectin 3 mg tablets are licensed for the treatment of scabies, normally given as a single dose of 200 micrograms per kg body weight, though a repeat dose can be considered (see ). Within closed settings, ivermectin tablets may be a useful option when there are logistical considerations in the successful application of topical therapy, or in the context of immunosuppression or crusted scabies (9).

The decision to prescribe ivermectin off-label for contacts in this context lies with local specialist dermatology or infectious diseases services, or local prescribing guidelines, in discussion with the local HPT. This should be discussed in the context of an Incident Management Team (IMT) if one is convened.

Specific transfer considerations during an outbreak

Transfers out of the setting

If a case or an identified contact requires transfer to a new setting (for example, hospital or care home), the admitting setting should be informed of the outbreak prior to the admission and a risk assessment undertaken. Transfers of cases and contacts should ideally be avoided until 24 hours after the first treatment dose, at which point the risk of onward transmission is minimal. Transfers can take place sooner than this if appropriate mitigations are agreed. The risk assessment should consider at least:

• the need for transfer including the person바카라 사이트™s clinical condition. Diagnosis of scabies must not delay essential transfers based on clinical need
• whether 24 hours has passed since the person requiring transfer commenced their treatment and whether transfer can be delayed until this has taken place
• whether close, prolonged skin-to-skin contact with others can be avoided during the treatment period, for example, whether the person is prone to walking with purpose or hand holding
• whether staff caring for the patient are able to maintain use of ²¹±è±è°ù´Ç±è°ù¾±²¹³Ù±ðÌýPPE to avoid skin-to-skin contact during close contact until the treatment period has ended

People who are not cases or contacts can be transferred as usual.

New admissions into the setting

Management should consider and discuss with their commissioners, community infection control or local HPT the need to temporarily close admissions in the event of a scabies outbreak until the full course of treatment is completed or the outbreak is declared over.

New admissions to settings experiencing a scabies outbreak may be possible with appropriate risk assessments, which should include:

• how new admissions can be separated from affected individuals or staff
• whether new admissions have any pre-existing conditions that may make them more vulnerable to scabies infection or at risk of more severe illness.
• whether admissions can be delayed until at least 24 hours after the first treatment is begun by all cases and contacts
• whether the outbreak is proving challenging to control, for example, difficulties in co-ordinating mass treatment, which may increase risk to others entering the setting

Essential visits by healthcare workers

Visiting healthcare workers (for example, district nurses or physiotherapists) who have close or prolonged physical contact with residents should be informed of the outbreak prior to their visit to setting and advised of the importance of wearing ²¹±è±è°ù´Ç±è°ù¾±²¹³Ù±ðÌýPPE  to avoid skin-to-skin contact with affected residents.

Family and visitors

All visits to the setting and individuals should be risk assessed appropriately. The benefits of visits to residents are likely to greatly outweigh the risks to visitors, which can be managed by recommending avoiding skin-to-skin contact and wearing of ²¹±è±è°ù´Ç±è°ù¾±²¹³Ù±ðÌýPPE. For further advice see guidance to support safer visiting during outbreaks.

Declaring an outbreak over

For the purposes of reporting and determining provision of ongoing support, the initial outbreak response can be considered complete when all cases and contacts have received the full recommended treatment regimen (for example, 2 doses of topical cream application). However, ongoing monitoring and a period of heightened surveillance after all cases and contacts have completed treatment is advised to reduce the risk of outbreaks continuing unchecked.

This period of heightened surveillance should include regular re-assessment of staff and residents for any new symptoms, and to ensure symptoms are resolving as expected following treatment. Heightened surveillance should last for 12 weeks (2 incubation cycles) after the onset date of symptoms in the last known case.

A scabies outbreak can be declared over if no new cases are identified within 12 weeks of symptom onset date of the last known case. Nodules can take several months to resolve after successful treatment.

Recurrent infections and outbreaks

It is important to note that symptoms (such as itch or rash) may continue for up to 6 weeks after treatment completion.  This does not necessarily imply a failure of treatment or re-infestation. It is recommended that resident or staff members who continue to have symptoms after treatment are reviewed by their GP to rule out other possible causes of their symptoms and provide symptomatic relief for itching.

If further scabies cases occur within 12 weeks of the original outbreak this should be flagged to the HPT or relevant Infection Prevention and Control (IPC) teams to review whether this is a new outbreak or a continuation of the original outbreak. In both scenarios, infection control procedures and treatment regimens should be reviewed carefully to identify possible failures in breaking the transmission chain or de-infestation. Medical advice should be sought if re-treatment is considered necessary (see Pharmaceutical treatment for further advice).

Setting-specific considerations

Educational establishments

Guidance outlined in Health protection in children and young people settings, including education - Section on scabies should be followed alongside this guidance for cases and outbreaks in educational settings. This guidance specifies additional actions in these settings which may include exclusion for very young children or those with additional needs.

Adult Social Care  

Dementia and other cognitive impairments 바카라 사이트“ special considerations

Two thirds of residents in care homes for older adults live with dementia or other cognitive impairment, and this will be higher in homes specialising in dementia care.  Many residents in care homes for younger adults have learning disability.  The severe impact of scabies outbreaks in such settings is well documented (11), including the significant difficulties and intrusiveness of using topical treatments.  Some residents may not understand the purpose of treatment and lack the mental capacity to make treatment decisions in this context.  This especially challenging for residents who do not have or cannot communicate symptoms.

Clinicians and care providers should follow appropriate policies for providing medical treatment and support to those individuals who lack capacity and consider the most appropriate treatment options including oral treatment.

Higher risk communal accommodation settings

Asylum seeker accommodation settings

Scabies is the most common infectious disease incident recorded by HPTs in asylum seeker accommodation settings. It can be difficult to assess, diagnose, and manage scabies due to occurrence of other skin lesions, particularly for people that have arrived by small boats. People are frequently moved between settings which can make contact tracing more challenging. Coupled with the stigma around scabies and language barriers, it can be difficult to ensure a coordinated approach to outbreak management within these settings.

Appropriate interpretation and translation services for materials should be made available when managing cases and outbreaks of scabies in asylum seeker accommodation settings.

The Outbreak management in short term asylum seeker accommodation guidance provides guidance for providers of asylum-seeker accommodation.

 Where there are approximately 10% or more people affected, it may be necessary to treat the whole setting (Mass Drug Treatment, or MDT). The local HPT can advise if this is required, in partnership with local stakeholders through an incident management team where necessary.

HPTs and NHS providers should work with trusted local partners and organisations to support clear communication of messages.

Contact tracing considerations

The following applicable points should be considered as part of the contact tracing process:

• consider any recent travel or stays within other settings where cases may have had contact with others
• consider those sharing rooms with cases, close family units, or providing care for others
• consider potential for stigma around discussion of sexual contacts, and how best to ascertain this information
• refer and take advice from sexual health services where appropriate
• staff are advised to see their own GP if they develop any skin conditions

Coordination of mass treatment

There are a number of barriers to successful management of treatment within asylum settings that have been identified (12).

• lack of laundry facilities
  • ensure access to adequate laundry facilities for cases and contacts
  • be aware that asylum seekers may lack spare clothing to wear whilst washing affected items (local voluntary sector organisations may be able to provide support in acquiring clothing)
  • ensure that bedding and other linens and soft furnishings are washed or stored in sealed bags
• providers should provide equipment and products for residents to clean their room and to bag laundry and waste

• residents should leave bagged laundry outside their room (this should be double bagged if sent to a commercial laundry)

• social barriers
  • consider the range of languages spoken as well as literacy and health literacy levels
  • provide translated information sheets with clear treatment instructions
  • ensure widespread understanding of the need for following the treatment
  • actively work to reduce any social stigma
• healthcare barriers
  • work with local healthcare systems to provide specialist dermatology assessment to ensure timely diagnoses
  • where possible, provide areas of privacy for examination
  • ensure a consistent approach to avoid delays in diagnosis and treatment
  • maximise the opportunities to use PGDs alongside prescriptions to enhance prompt access to treatment
• individuals may also be in the setting for a short time, or in transit limiting opportunities for diagnostic testing and follow up assessment

Homeless Hostels

Homeless hostels have a high turnover of residents this can make contact tracing and second dose application of treatment difficult to administer; this needs to be taken into account in the risk assessment.

Prisons and places of detention (PPD)

The transient, communal, and crowded nature of PPDs means that individuals within these settings are at increased risk of infectious diseases, including scabies.

All individuals sharing a room, including in a dormitory-style setting, would be considered contacts.  Individuals who have been exposed to the case바카라 사이트™s clothing, linen or towels should also be considered as contacts.

Clear information should be provided to cases and contacts to ensure understanding of the process and the potential side effects to increase compliance with treatment. The prison healthcare will be best placed to provide this information to those that require it.

Exclusion of cases or contacts is not required for scabies. Only essential transfers of these cases or contacts should occur, to reduce the risk of transmission to other settings, particularly within the treatment window. Where transfers out of the facility cannot be avoided, onward settings should be notified, and continuity of treatment and care ensured. If a case is due to be released mid-treatment, they should be provided with the remaining course of treatment and instructions for use.

The nature of prison healthcare provision for prisoners means that the option for accessing stock of the treatments and use of PGDs for prisoners will facilitate treatment supply during an outbreak. Staff who are close contacts will require a separate route to access the treatment via occupational health or community services.

References

1. Engelman D, Fuller LC, Steer AC, International Alliance for the Control of Scabies Delphi p. 바카라 사이트˜Consensus criteria for the diagnosis of scabies: a Delphi study of international experts바카라 사이트™. PLoS Neglected Tropical Diseases 2018: volume 12, issue 5, e0006549
2. Salavastru CM, Chosidow O, Boffa MJ, Janier M, Tiplica GS. 바카라 사이트˜European guideline for the management of scabies바카라 사이트™. Journal of the European Academy of Dermatology and Venereology 2017: volume 31, issue 8, pages 1248 to 1253
3. Mellanby K. 바카라 사이트˜Scabies in 1976바카라 사이트™. Royal Society of Health Journal 1977: volume 97, issue 1, pages 32 to 36
4. Roberts LJ, Huffam SE, Walton SF, Currie BJ. 바카라 사이트˜Crusted scabies: clinical and immunological findings in seventy-eight patients and a review of the literature바카라 사이트™. Journal of Infection 2005: volume 50, issue 5, pages 375 to 381
5. Cassell JA, Middleton J, Nalabanda A, Lanza S, Head MG, Bostock J and others. 바카라 사이트˜Scabies outbreaks in ten care homes for elderly people: a prospective study of clinical features, epidemiology, and treatment outcomes바카라 사이트™. The Lancet Infectious Diseases 2018: volume 18, issue 8, pages 894 to 902
6. Middleton J, Cassell JA, Walker SL. 바카라 사이트˜Scabies management in institutions바카라 사이트™. Scabies 2023: pages 433 to 458
7. Bernigaud C, Fischer K, Chosidow O. 바카라 사이트˜The management of scabies in the 21st century: past, advances and potentials바카라 사이트™. Acta Dermato-Venereologica 2020: volume 100, issue 9
8. Monsel G, Delaunay P, Chosidow O. 바카라 사이트˜Arthropods바카라 사이트™. Rook바카라 사이트™s Textbook of Dermatology, Ninth Edition 2016: pages 1 to 72
9. Engelman D, Yoshizumi J, Hay RJ, Osti M, Micali G, Norton S and others. 바카라 사이트˜The 2020 international alliance for the control of scabies consensus criteria for the diagnosis of scabies바카라 사이트™. British Journal of Dermatology 2020: volume 183, issue 5, pages 808 to 820
10. Walton SF, Currie BJ. 바카라 사이트˜Problems in diagnosing scabies, a global disease in human and animal populations바카라 사이트™. Clinical Microbiology Reviews 2007: volume 20, issue 2, pages 268 to 279
11. Hewitt KA, Nalabanda A, Cassell JA. 바카라 사이트˜Scabies outbreaks in residential care homes: factors associated with late recognition, burden and impact. A mixed methods study in England바카라 사이트™. Epidemiology and Infection 2015: volume 143, issue 7, pages 1542 to 1551
12. Richardson NA, Cassell JA, Head MG, Lanza S, Schaefer C, Walker SL and others. 바카라 사이트˜Scabies outbreak management in refugee/migrant camps across Europe 2014 to 2017: a retrospective qualitative interview study of healthcare staff experiences and perspectives바카라 사이트™. medRxiv 2021: 2021-04
13. Bernigaud C, Fernando DD, Lu H, Taylor S, Hartel G, Chosidow O and others. 바카라 사이트˜How to eliminate scabies parasites from fomites: a high-throughput ex vivo experimental study바카라 사이트™. Journal of the American Academy of Dermatology 2020: volume 83, issue 1, pages 241 to 245
14. Pallesen K, Lassen JA, Munk NT, Hartmeyer GN, Hvid L, Bygum A. 바카라 사이트˜In vitro survival of scabies mites바카라 사이트™. Clinical and Experimental Dermatology 2020: volume 45, issue 6, pages 712 to 715
15. Rosumeck S, Nast A, Dressler C, Cochrane Infectious Diseases G. 바카라 사이트˜Ivermectin and permethrin for treating scabies바카라 사이트™. Cochrane Database of Systematic Reviews 1996: 2018, issue 4
16. Thadanipon K, Anothaisintawee T, Rattanasiri S, Thakkinstian A, Attia J. 바카라 사이트˜Efficacy and safety of antiscabietic agents: a systematic review and network meta-analysis of randomized controlled trials바카라 사이트™. Journal of the American Academy of Dermatology 2019: volume 80, issue 5, pages 1435 to 1444

Appendices

Pictures

Figure 1. Sarcoptes scabiei mites and eggs under바카라 사이트ˆÃ—10 microscopy

Photo: Middleton, Brighton & Sussex Medical School

Figure 2. Scabies papules on the back and arms of a resident of a care home for older people

Photo: Middleton, Brighton & Sussex Medical School

Figure 3. Characteristic s-shaped scabies burrows, naked-eye and under dermatoscopy

Photo: Middleton, Brighton & Sussex Medical School

Figure 4. Scabies rash on hands

Photo: Dr P N Sashidharan, Homerton University Hospital

Figure 5. Crusted scabies

Hyperkeratotic skin crusts on the hands of a resident of a care home for older people (UK). Resident died in hospital 4 days later, with scabies recorded on their death certificate as a significant contributing condition.

Photo: Middleton, Brighton & Sussex Medical School

 More images can be accessed at

Fact sheet - Scabies explained

Scabies is a skin condition caused by tiny mites called Sarcoptes scabiei. These mites burrow into the outer layer of the skin. Your body reacts to their droppings and saliva, causing an itchy rash.

Signs and symptoms

It can take 3 to 6 weeks after catching scabies for symptoms to appear. The mites create small red bumps, blisters, or thin, wavy lines on the skin. These are most common on the hands, between fingers, wrists, arms, waist, groin, and under the buttocks. In babies, the head, neck, palms, and soles of the feet can also be affected.

The itching is usually worse at night or after a hot bath or shower. Scratching can break the skin, leading to infection.

How scabies spreads

Scabies spreads through close skin-to-skin contact, such as holding hands or sleeping in the same bed. It can also be passed on during sex. Less commonly, it may spread through recently used clothing or bedding, but the mites do not survive long away from the skin. A person with scabies is contagious until they have completed treatment. They should avoid close skin to skin contact with others until then.

Treatment for Scabies

Scabies does not go away on its own, treatment is needed. A cream or lotion is usually used to treat scabies. It can be bought from a pharmacy or prescribed by a doctor.

Follow these steps to treat scabies:

• apply the cream to cool, dry skin all over your body, not just where the rash is
• do not apply it straight after having a bath
• make sure to cover under the nails, between fingers and toes, behind the ears, the face, scalp, genitals, and soles of the feet
• avoid contact with the eyes, nose, and mouth
• put on clean clothes and change your bedding straight after treatment
• leave the cream on for 8 to 12 hours, then wash it off
• if you wash your hands during this time, reapply the cream to them
• repeat the treatment one week later
• everyone in your household and other close contacts should also be treated at the same time
• wash clothes, towels, and bedding at the highest temperature the fabric tolerates on the day you start treatment
• ironing and tumble drying at high heat will help kill the mites
• thoroughly clean and vacuum your home including furniture

After treatment, itching may last for up to 6 weeks. This does not mean the treatment has failed. It happens because the body is still reacting to the mites. A doctor or a pharmacist can advise on medications or lotions to help ease the itching.