FOCUS

Scabies: A clinical update

Myra Hardy, Daniel Engelman, Andrew Steer

Background

Scabies is a common, yet neglected, skin

disease. Scabies occurs across Australia,
but most frequently in socioeconomically
disadvantaged populations in tropical
regions, including in remote Aboriginal
and Torres Strait Islander communities.
In temperate settings, the disease clusters
in institutional care facilities.

Objectives

The objective of this article is to provide

updates on the clinical diagnosis and
treatment approaches for scabies in
Australia.

Discussion

Clinical examination remains the

mainstay of diagnosis, although
dermatoscopy is a useful adjunct. Scabies
presents with severe itch and a papular
rash, with a predilection for the hands,
feet and genitalia. The distribution may
be more widespread in infants and older
people. Secondary bacterial infection is
also common in patients with scabies.
Crusted scabies is a rare but highly
infectious variant. Topical permethrin is
highly effective for individual
treatment, but less
practical for treatment of asymptomatic
contacts and control of outbreaks. Oral
ivermectin is a safe and effective
alternative, and is now listed on the
Pharmaceutical Benefits Scheme as a
third-line treatment.
S
cabies is caused by the microscopic
mite Sarcoptes scabiei var. hominis.
The mite is transmitted via person-to-
person contact and, therefore, household
contacts are at highest
risk of infestation. Only 20 minutes of
close contact (eg holding hands or
sexual contact) is required for
successful transmission.1 Scabies
occurs worldwide, affecting an
estimated 100 million people each
year.2 The highest prevalence of
scabies is in tropical areas, especially
in populations with co-existing poverty
and overcrowding.
Scabies affects species other than
humans, including dogs, pigs and
Australian wildlife, but the disease in
264 REPRINTED FROM AFP VOL.46, NO.5, MAY 2017
Practitioners 2017
these animals is caused by S. scabiei
variants, which are genetically distinct
from scabies in humans. These animal
variants cannot reproduce on the
human host and, therefore, are only
able to cause minor, self-limited
infestation.3,4
Most patients present with classical
(also known as typical) scabies
caused by a low burden of mites (5
15), with the rash typically located in an
acral distribution. Rarely, patients may
present with crusted scabies, caused
by hyperinfestation of millions of mites,
which leads to hyperkeratosis.5
Children and older people are at highest
risk of scabies. Infection risk increases in
settings with higher levels of population
density, including residential aged care
facilities (RACFs),
prisons and refugee camps, among
returned travellers to endemic areas,
and within remote Aboriginal and Torres
Strait Islander communities with
overcrowded housing. Patients with
underlying immunodeficiency from any
cause, such as human
immunodeficiency virus (HIV), human
T-lymphotropic virus 1 (HTLV-1) or
corticosteroid treatment, are at an
increased risk of crusted scabies.5,6
Scabies lesions are often secondarily
infected with Streptococcus pyogenes
(Group A Streptococcus [GAS]) and/or
Staphylococcus aureus because of
breaches in the skin barrier.7 These
organisms have the potential to cause
local soft tissue infections such as
impetigo, cellulitis and abscesses, and
can also lead to potentially fatal
bloodstream and other sterile site
infections. Skin infections with GAS can
also lead to post-infectious sequelae,
including post-streptococcal
glomerulonephritis,2 which in turn is a risk
factor for subsequent development of
end-stage
The Royal Australian College of General
SCABIES
FOCUS

After
the first
infestati
on,
there is
a delay
of up to
six
weeks
before
sympto
renal ms
failure.8 begin to
A link develop
has .
also Subseq
been uent
propos infectio
ed ns
betwee become
n GAS appare
impetig nt
o and earlier
acute after
rheuma exposur
tic e.5
fever,
especia
lly
among The
remote clinical
Aborigi features
nal and of
Torres classical
Strait scabies
Islander are
peoples papules
, or
burrows
althoug
in
h this
typical
has yet
location
to be s,
proven. includin
9
g the
web
spaces
of the
Clinic fingers
and
al toes,
featur wrists,
buttocks
es ,
breasts
in
females,
The and
sympto genitals
ms of (Figure
scabies 1).
Young
infectio
children
n are
and
caused
older
by the people
host may
allergic have
respons more
e to the widespr
mite. ead
involve (Figure
ment, 2).
includin Crusted
g palms, scabies
soles is
and charact
scalp.
erised
Scabies
by
is
intensel
plaques
y itchy, and
affecting extensi
the body ve
and scale
limbs, and, in
but severe
usually cases,
sparing deep
the fissures
head may
and develop
neck . In
(except
contrast
in
to
infants).
The itch
classica
is worst l
at night. scabies
Skin ,
breache crusted
s from scabies
mite may not
burrows be
and the itchy.
excoriati
on from
scratchi
ng the The
itch most
often obvious
result in effects
co- of
existing scabies
bacterial on an
skin individu
infection al are
, up the
severe
itch and
subsequ
to 79% ent
in some sleep
studies. disturba
10 nce,
Bacteri both of
al skin which
have an
infectio
impact
n
on
should school
be and
conside work
red attenda
when nce and
scabeti perform
c ance
lesions and,
have ultimatel
surroun y, affect
ding the
erythem economi
a, c
producti
yellow
vity of
crusting
commu
or pus
nities.11
In ink from
addition, a pen
patients over a
with burrow
scabies entranc
are at e can
risk of confirm
seconda its
ry presenc
bacterial e as ink
infection tracks
with all along
of its the
potential burrow.1
complic 2

ations Dermat
as oscopy
describe can be
d above. used to
identify
the
charact
Diag eristic
delta
nosis sign,
represe
nting
the
Diagnos mites
is is mouth
usually parts,
made and the
on the jet with
basis of contrail
clinical pattern
features represe
alone. nting a
Multiple mite
househo and its
ld burrow.1
member 3

s with Definitiv
itch e
should diagnosi
raise s can be
suspicio made
n of by
scabies. taking a
For skin
cases scraping
that do for
not have analysis
the under
typical light
distributi microsc
on or opy. The
finding
of the
mite, its
eggs or
faecal
pellets
are
diagnost
ic for
scabies.
5

Howeve
appeara r,
nce, the dermato
diagnosi socopy
s can be and skin
more scraping
challeng s may
ing.
Applying
not be Practiti
feasible oners
should
in many conside
settings r other
.A different
respons ial
e to diagnos
empiric es that
al may
treatme mimic
nt also classica
support l
s the scabies
diagnos ,
is. includin
g insect
Diagno
sis of bites,
other
crusted
scabies infectio
ns and
require
s inflamm
atory or
confirm
ation by immune
-
skin
scrapin mediate
d
gs
becaus dermat
ological
e of the
intensit conditio
ns
y of
treatme (Table
1).
nt and
public Possibl
e
health
implicat different
ial
ions.
The diagnos
es for
extensi
ve crusted
scabies
scale
and include
other
high
burden conditio
ns that
of mites
makes present
with
specim
en extensi
ve
collecti
on scale,
such as
easier,
and psoriasi
s and
identific
ation seborrh
eic
with
magnifi dermati
tis.
cation
more
sensitiv
e.
Mana
geme
Differ nt
ential
diagn
oses Gener
al
consid
eratio infestati
on is
ns
high if
contact
s are
The not
delay treated,
betwee especia
n lly if
infectio contact
n and s are
sympto infants
ms or
results young
in many children
asympt .14
omatic,
yet
infected
Once
,
scabies
househ
treatme
old
nt has
contact comme
s of the nced, it
index is
case at commo
time of n, and
first almost
diagnos expecte
is. d, for
Therefo itch to
re, it is increase
importa over a
nt in all period
of a few
instanc
days. It
es to
is
treat
importa
househ nt to
old advise
contact patients
s of about
cases. this
The risk phenom
of re- enon to
avoid
Figure 1. Classical
interdigital

papular rash
consistent with
Figure 2.
Infected

scabies scabies in an
infant

The Royal Australian

College of General
Practitioners 2017

REPRINTED
FROM AFP VOL.46, NO.5,
MAY 2017 265
FOCUS
SCABIES

months
after
succes
sful
treatme
nt,
most
likely
represe
nting a
hypers
the ensitivit
percepti
y
on of
reactio
treatme
nt
n to
failure. retaine
The d mite
itching antigen
associa s.
ted with
a
scabies
infestati Treat
on can
be
ment
manag option
ed with s for
moisturi
classi
sers,
mild cal
scabi
es
topical
cortico
steroid The
s or mainsta
oral y of
antihist treatme
amines nt for
. If classica
scabies l
treatme scabies
nt has is a
been topical
succes agent
(Table
sful, all
2).
sympto
First-
ms,
line
includin treatme
g itch, nt for
will scabies
general is
ly topical
resolve permeth
by four rin 5%
weeks. cream,
5 which
Intensi should
be
vely
applied
pruritic,
to the
persist
whole
ent body
nodule (excludi
s ng the
occasio head
nally and
occur neck in
for patients
other asympt
than omatic
infants) contact
and s,
washed
off after
eight
hours.
All
househ
old Table
contact 1.
s Differe
should ntial
be diagno
treated ses of
at the classic
same al
time. If scabies
the first 13
applicat
ion is
thoroug
h, then
no
repeat
dose is
require
d, as
permet
hrin is
active
against
all inadequ
stages ate
of applicati
on or by
incident
al
washing
the
off of
parasite
the
s life
therapy.
cycle. If
Benzyl
sympto
benzoat
ms
e 25%
persist,
is the
we
second-
recomm
line
end a
topical
repeat
agent. It
applicat
commo
ion 7
nly
14 days
causes
after
skin
the first
irritation
treatme
, and
nt.
should
Permet
be
hrin is
diluted
highly
with
effectiv
water
e and
for
generall
children
y well
and
tolerate
infants
d, but
(Table
success
2). It is
applied
and
then left
may be for
hindere
d by
non-
adhere
nce of
24 interven
hours tions,
before recogni
being sed by
washe the
d off. awardin
g of the
2015
Nobel
Prize in
Ivermec
Physiol
tin is a
ogy or
macroc
Medicin
yclic
e to the
lactone
discove
antipar
rers of
asitic
ivermec
derived
tin. The
from
drug is
ferment
active
ation
against
product
the
s of the
scabies
bacteriu
mite,
m
but not
Strepto
its
myces
eggs,
avermiti
and has
lis.15 It a short
has half-life
very of 12
broad 56
antipar
hours.16
asitic
Therefo
activity,
re,
includin
repeat
g
dosing
against
714
onchoc
days
erciasis
after the
(river
first
blindne
dose is
ss),
required
lymphat
to kill
ic
newly
filariasis
hatched
and
mites.
Ivermec
tin is
the only
soil- currentl
transmit y
ted availabl
helmint e oral
hs.15 agent
The that is
use of effectiv
ivermec e
tin in against
mass scabies.
drug Howeve
adminis r,
tration alternati
campai ve oral
gns agents
against with
these longer
disease duration
s has of
been action
hailed are
as one currentl
of the y under
worlds active
great investig
public ation,
with the appeari
related ng to be
drug highly
moxide promisi
ctin ng.17

Insect bites
Infections
Dermatitis
Immune-mediated

Mosquitos
Folliculitis
Eczema
Papular urticarial

Midges
Impetigo
Contact dermatitis
Bullous pemphigoid

Fleas
Tinea

Pityriasis rosea

Bedbugs
Viral exanthems
Table 2. Treatment
of typical scabies

Age
Medication
Brand names
Route
Dose and
administration
Frequency

First-line treatment

Younger than
Crotamiton
Eurax
Topical
Apply to whole body,
wash off
Repeat daily for three
days
2 months of age

after 24 hours
Older than
Permethrin 5%
Lyclear
Topical
Apply to whole body,
wash off
Can repeat after 714
days
2 months of age

after eight hours

if ongoing symptoms

Second-line treatment

Older than
Benzyl benzoate
Ascabiol
Topical
Dilute to 6.25% for
infants 6
Repeat once after 7
14 days
6 months of age
25%
Benzemul
months to 2 years of
age

Dilute to 12.5% for

children

212 years of age

Apply to whole body,

wash off

after 24 hours

Third-line treatment
5 years of age
Ivermectin
Stromectol
Oral
200 g/kg
Repeat once after 7
14 days
or older

Contraindicated if <15
kg,

pregnant, or
breastfeeding

266 REPRINTED FROM

AFP VOL.46, NO.5, MAY

2017 The Royal

Australian College of
General Practitioners 2017
SCABIES
FOCUS

brain
barrier
in
humans
.20
Noneth
eless,
due to
current
limited
safety
The key data,
advanta ivermec
ge of tin is
ivermec not
tin is its recomm
oral ended
formulat for use
ion,
increasi
ng the
likelihoo in
d that children
househ younger
old than 5
contact years of
s will age or
adhere weighin
to g less
treatme than 15
nt. kg.
Adverse Ivermec
effects tin is
include also not
itch, recomm
headac ended
he, for use
dizzines in
s, and pregnan
abdomi t and
nal and breastfe
joint eding
pain, women.
but Ivermec
these tin is
are conside
usually red to
mild be safe
and in older
transien people,
t.18 but
There should
have generall
been y be
concern avoided
s about in the
neuroto very
xicity elderly
when and
ivermec frail.
tin is Ivermec
used in tin is
some now
animals listed
on the
;19
Pharma
howeve
ceutical
r, it
does
not
cross
the Benefit
blood s
Schem measur
e e.21
(PBS), Single-
with dose
streaml ivermec
ined tin was
authorit more
y for effectiv
e than
treatme
most
nt of
topical
classic agents
al in direct
scabies compari
for sons.
patient Howeve
s who r, in the
have only
failed study
sequen that
tial made a
treatme direct
nt with compari
topical son with
permeth
permet
rin, a
hrin
single
and dose of
benzyl ivermec
benzoa tin was
te used less
four effectiv
weeks e.22
prior, or More
have a recent
contrai data
ndicatio from a
n to study of
topical mass
treatme drug
nt. adminis
tration
for
scabies
in Fiji
A
found
Cochra
that
ne
ivermec
review,
tin (two
which
doses)
evaluat
was
ed
superior
randomi
to mass
sed
drug
trials of
scabies
adminis
treatme
tration
nt,
conclud
using
ed that permet
topical hrin
permeth (two
rin was doses).
18
the In
most this
effective study,
agent, in the
when iverme
treatme ctin
nt
arm,
failure
the
was
prevale
used as
the nce of
outcom scabies
e fell by
94%
(preval live
ence mites
32.1% have
at been
baselin recover
e to ed from
the
1.9% at
furniture
12
of
months patients
), with
compar scabies,
ed with 23
there
a fall of
62% in
the
permet is little
hrin evidenc
arm (P e for
<0.001) the
. efficacy
of
environ
mental
Envir measur
onme es.
ntal Scabie
s mites
meas are
ures highly
for suscept
scabi ible to
dehydr
es
ation
infecti away
on from
the
human
host,
The role survivin
of g for
transmi only
ssion of three
scabies
days.1
other
than
Human
person- challen
to- ge
person studies
transmi in the
ssion is first
controv half of
ersial. last
Some century
authoriti sugges
es t that
recomm transmi
end hot ssion
launderi
from
ng of
fomites
clothes
and
is
bedshe uncom
ets, and mon.24
the use Further,
of the Fiji
aerosoli mass
sed drug
insectici adminis
des for tration
furniture trial
and showed
carpets.
very
While
high
efficacy bacteria
that l
was infectio
sustain n,
ed out
to two
years
without
any
environ
mental
interve
ntion.18
Therefo
re, we
sugges initial
t treatme
environ nt with
mental antibioti
cleanin cs and
g for removal
classic of
crusts
al
can be
scabies
followed
is
by
unnece topical
ssary, scabies
aside treatme
from nt.
instituti Fluclox
onal acillin in
settings adults
(see and
below). cephale
xin in
children
(more
palatabl
Treat e than
ment flucloxa
of cillin)
are the
assoc
preferre
iated d
impeti choice
go of
antibioti
cs in
non-
remote
If
settings
impetig
where
o is
S.
severe,
aureus
topical
is the
scabies
most
treatme
likely
nt may
pathoge
be
n.25 In
intolera
remote
ble,
settings
particul
, S.
arly with
pyogen
benzyl
es is
benzoat
the
e.
primary
Therefo
driver of
re, if the
infectio
patient
n, and
has
addition
significa
al
nt
treatme
second
nt
ary
options
include this
short- conditio
course n are
trimetho also
prim- importa
sulfame nt as
thoxazo
patient
le or
s with
intramu
scular
crusted
benzath scabies
ine are
penicilli highly
n G.26,27 infectio
Trimeth us and
oprim- can
sulfame perpetu
thoxazo ate
le is infestati
also on
recomm within a
ended if commu
methicill nity. If a
in case of
resistan
crusted
t S.
scabies
aureus
is
is
suspect suspect
ed or ed,
proven. advice
should
be
sought
Treat from a
local
ment expert.
of Treatm
cruste ent
d usually
require
scabi
s
es hospital
admissi
on for
isolatio
While n and
crusted intensiv
scabies e
is rare, treatme
extensi nt with
ve skin a
involve combin
ment ation of
places topical
patient scabici
s at des,
high oral
risk for iverme
invasiv ctin
e and
bacteri topical
al keratol
infectio ytics.
n, The
sepsis frequen
and cy and
mortalit duratio
y.26 n of
Identific treatme
ation nt are
and based
treatme on the
nt of
severity Widespr
at ead
diagno outbrea
sis.6 ks may
occur in
Environ
closed
mental
commu
measur nities,
es are such as
also hospital
require s,
d to RACFs
prevent and
fomite prisons,
transmi or areas
ssion where
becaus overcro
e of the wding is
excessi commo
ve n. In
these
scale
situatio
and
ns,
mites involve
that are ment of
shed. the
local
public
health
Publi unit,
physicia
c ns,
healt nursing
staff,
h facility
consi infectio
n
derat control
ions and
manage
ment is
crucial
in
Becaus
enablin
e of the
ga
prolong
compre
ed
hensive
asympt
and
omatic
effectiv
phase,
e
scabies
respons
is often
spread e.28
from There
person- are a
to- number
person of key
before a element
diagnos s to the
is is public
made. health
Indeed, manage
a ment of
scabies scabies
outbrea outbrea
k is ks.
indicativ Early
e of detectio
transmi n and
ssion implem
within entation
the
institutio
n for at
least of
several infectio
weeks. n
control with
measur them.
es are Most
key in guidelin
preventi es
ng recomm
further end
transmi some
ssion. form of
Early environ
identific mental
ation of disinfect
any ion,
case of includin
crusted g hot
scabies launderi
is ng of
importa bedding
nt. ,
Once a clothing
case is and
diagnos towels
ed, or is used by
suspect people
ed, the with
patient infestati
should ons any
be time
isolated during
in a the
single three
room days
until 24 before
hours treatme
after the nt, and
first routine
treatme cleanin
nt has g and
been vacuum
complet ing of
ed, if furniture
possible and
, and carpets
staff in
and patients
visitors rooms.
should
use
contact
precauti The
ons most
during success
this ful
period. treatme
The nt
index approac
case h in
should endemi
be c
treated, infestati
along ons is
with mass
staff or drug
visitors adminis
who tration
had treatme
direct nt of all
contact
 The Royal Australian
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Practitioners 2017

REPRINTED
FROM AFP VOL.46, NO.5,
MAY 2017 267
FOCUS
SCABIES

Control
of
Scabies
is a
group of
experts
formed
to
increas
e
awaren
ess,
commu
collabor
nity
ation
membe and
rs progres
regardl s
ess of towards
infectio effective
n control
status.1 measur
8,29 es for
Sustain scabies
(www.c
ed
ontrolsc
prevent
abies.or
ion may
g).30
require
public
health
strategi
There
es to
is
improv
momen
e
tum for
housing
ongoin
and
g
reduce
researc
overcro
h into
wding.
more
suitable
oral
treatme
At a
global nts for
level, all
scabies ages,
is as well
classifie as
d as a integrat
neglect ion of
ed scabies
tropical surveill
disease ance
becaus and
e of its control
substan with
tial
existing
effects
local
on the
health and
and global
wellbein health
g of the progra
worlds ms.31
poorest
populati
ons.
The
Internati
Key
onal point
Alliance
for the
s
 therapy
has
Scabies failed or
should is
be contrain
conside dicated.
red in
any
patient
with an In
itchy endemi
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scabies
older
.
children
and
adults,
as well
Authors
as
palms,
soles
and Myra
scalp in Hardy
MBBS,
infants
BMedSci,
and FRACP,
older Research
people. Fellow,
Centre for
Internatio
Ivermec nal Child
tin is Health,
now University
register of
Melbourn
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the PBS Parkville,
for use Vic;
in Research
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scabies ccal
where Research,
Murdoch
topical
Childrens andrew.st
Research eer@rch.
Institute, org.au
Parkville,
Vic

Competi
ng
Daniel interests:
Engelman None.
MBBS,
BMedSci,
MPHTM,
FRACP,
Consultan Provena
t nce and
Paediatric peer
ian, Royal
review:
Childrens
Commiss
Hospital,
Parkville, ioned,
Vic; externall
Research y peer
Fellow, reviewed
Centre for .
Internatio
nal Child
Health,
University
of Refere
Melbourn nces
e,
Parkville,
Vic;
Research
Fellow, Hay RJ,
Group A Steer AC,
Streptoco
Engelma
ccal
n D,
Research,
Murdoch Walton
Childrens S.
Research Scabies
Institute, in the
Parkville, developi
Vic ng world
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