One of the least pleasant topics I cover on this site are the many parasites that use humans as hosts and thus create endless headaches for camp nurses everywhere. This week it's scabies. Scabies is the name given to an infestation of the skin by the mite Sarcoptes scabiei. These mites are very small, under 0.5mm, and cannot be seen with the naked eyes. They take up residency on the host's skin and burrow into the skin to deposit eggs. Although not as common as lice and bedbugs, scabies remains one of the most common skin disorders, and it effects persons of all ages, races, and income levels. It is spread by prolonged skin to skin contact with and infested individual, and occasionally through casual contact, or the sharing of clothes, bedding, or towels. The group living, and a frequent potential for prolonged physical contact between campers makes scabies a topic of concern for camp nurses.
Persons infested with scabies generally present with a primary complaint of severe itching, this is often much worse at night. A distinctive rash is generally also present, most commonly in the space between the fingers, but it can also appear on the armpits, elbows, back, genitals, buttocks, and posterior knees. Scabies thrive in warm environments, so they tend to be most severe in areas of the skin that are warmer. The rash is papular in nature appearing to be hives, or small bug bites that may have distinctive linear or s-shaped tracks in between the papules.
The itch and rash will typically present 2-6 weeks after initial infestation, in persons who are experiencing their first infestation. Symptoms will appear more quickly in persons who have been exposed to scabies previously.
Diagnosis of scabies can be complicated by the fact that the mites are not easily visualized, and the characteristic rash may be mistaken for other common skin maladies such as eczema, heat rash, or impetigo. The only conclusive test for scabies is a skin scraping examined under a microscope. In the absence of this test scabies diagnosis is simply a matter of a careful physical exam. Nurses should be on the lookout for itching and rash that is persistent and not easily relieved, especially if these appear in clusters of campers who share living quarters.
Treatment of scabies is most commonly accomplished with the topical application of permethrin cream from the neck down at bedtime. The ointment is left on the skin for eight to fourteen hours, and showered off the next morning. One through application is generally sufficient to eliminate the infestation. However, great care must be taken to not miss any skin areas, as any skin missed with treatment will lead to re-infestation. (this includes in between fingers and toes, the bottom of the feet, the penile shaft, testicles, labia majora, and perianal area). Some doctors may recommend a second application three to seven days after the first, but this is not strictly necessary as permethrin is effective at killing both mite and eggs.
Oral Ivermectin may also be used to treat scabies, although studies show that it is slightly less effective than topical permethrin. Ivermectin has been wildly used worldwide for the treatment of parasites and is generally considered quite safe. Ivermectin has been effectively used to control large institutional outbreaks of scabies where the more time-consuming permethrin treatment may be impractical. Safety of oral Ivermectin has not been studied in children under six, and it is not recommended for woman who is pregnant or breastfeeding.
Permethrin the preferred treatment option for scabies treatment, and is generally the standard of care for simple uncomplicated cases. Unlike lice, scabies has not been scientifically shown to be resistant to permethrin, although anecdotal reports do exist. If permethrin resistance is suspected, then oral ivermectin may be a good treatment choice to recommend to the treating physician.
Generally, if one case of scabies is discovered and treated, any cohabitants with the infested individual should be treated as well, regardless of the presence or lack of symptoms. (for infested adults sexual partners should also be treated) Any clothes that have been worn in the last three days, as well as towels and bed linens, should be laundered and dried on high heat for all treated individuals. Vacuuming of all rugs and upholstered furniture is also helpful to reduce the risk of re-infestation. Scabies mites cannot live off of a host for more than two to three days, so items that have not been in close contact with an infested individuals within that time need not be treated.
As with other parasitic outbreaks a clear and well spelled out plan in place ahead of the outbreak is incredibly helpful. A scabies outbreak will be a public relations nightmare for camps. Make sure you that you clearly communicate the situation to parents via a mass email. It's better that they hear about the outbreak from you, that to get a call or letter home, from their child, with unclear or incorrect information from their child. The office staff should be educated on scabies, and provided with a script to reply to common questions consistently and correctly. Be sure to stress that scabies does not spread disease, and are considered a nuance, not a major health concern.
I hope that this has been a helpful starting point for learning about scabies. If you would like to know more please review the links below.
All opinions expressed are my own and to not represent those of my employer. Remember, anyone can pretend to be anyone on the internet, so please verify all information presented. NEVER take advice from strangers on the internet