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Scabies - Management
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Definition

  • Scabies is an intensely itchy skin infestation caused by the human parasite Sarcoptes scabiei.

How should I manage someone presenting with scabies?

  • Simultaneously (within 24 hours) treat all members of the household, close contacts, and sexual contacts with a topical insecticide (even in the absence of symptoms).
  • Apply the insecticide twice, with applications one week apart.
  • Consider symptomatic treatment for itching.
  • Machine wash (at 50°C or above) clothes, towels, and bed linen, on the day of application of the first treatment.
  • Advise to avoid close body contact with others until their partners and close contacts have been treated.

In depth

Which insecticide should I use?

  • Use permethrin 5% dermal cream as a first-line treatment.
  • Use malathion 0.5% aqueous liquid if permethrin is inappropriate (e.g. if the person has an allergy to chrysanthemums).

In depth

How should I advise someone to apply an insecticide?

  • Apply the treatment to the whole body from the chin and ears downwards. Pay special attention to the fingers and toes and under the nails.
  • People who are immunosuppressed, the very young and elderly should apply the insecticide to the whole body including the face and scalp.
  • Apply the treatment to cool dry skin (i.e. not after a hot bath).
  • Allow the lotion or cream to dry before dressing.
  • Wash the treatment off after prolonged contact with the skin:
    • Permethrin — 8 to 12 hours.
    • Malathion — 24 hours.
  • Reapply treatment if it is washed off during the treatment period (e.g. after hand washing).

In depth

What drug treatments can I recommend for itching?

  • Treat itching with topical crotamiton or topical hydrocortisone 1%.
  • Avoid corticosteroid creams if the diagnosis is not certain.
  • Consider an oral sedating antihistamine (e.g. chlorphenamine or hydroxyzine) at night if the itch is interfering with sleep.

In depth

What follow up is necessary?

  • Follow-up is not generally required for people with classical scabies.
  • Review if symptoms have not cleared within 6 weeks after the first application of treatment.

In depth

When should I refer or seek specialist advice?

  • Refer if:
    • The diagnosis is in doubt, or after two treatment failures.
    • There is a history of risk behaviour for sexually transmitted infections.
    • There is an outbreak of scabies in an institution (e.g. school, prison, or nursing home): report to the Health Protection Agency.
  • Seek specialist advice for:
    • Children under 2 months of age (e.g. from a paediatric dermatologist).
    • The management of crusted scabies (e.g. from a consultant dermatologist).

In depth

Prescriptions

1st choice insecticide: permethrin

Age from 2 months to 1 year 11 months
Permethrin 5% dermal cream (2 months to 1 year 11 months)
Permethrin 5% cream
Apply to the whole body, including the scalp, face, neck, and ears. Leave on for 8-12 hours or overnight. Wash off. Repeat after 7 days.
Supply 30 grams.
Age: from 2 months to 1 year 11 months
NHS cost: £5.52
Licensed use: yes
Patient information: ALL members of your household and close contacts MUST be treated at the same time. Apply to entire skin surface, including the scalp, face, neck and ears, and especially between the fingers and toes and under the nails. A quarter of a tube is usually enough for each application. It is important that the cream remains in contact with the skin for the whole minimum treatment time of 8 hours. If you wash your hands, or any other part of your body during that time you must reapply the cream to that part. Treatment must be repeated after 7 days.
Age from 2 years to 11 years 11 months
Permethrin 5% dermal cream (2 years to 11 years 11 months)
Permethrin 5% cream
Apply to the whole body, from the chin and ears downwards. Leave on for 8-12 hours or overnight. Wash off. Repeat after 7 days.
Supply 30 grams.
Age: from 2 years to 11 years 11 months
NHS cost: £5.52
OTC cost: £9.95
Licensed use: yes
Patient information: ALL members of your household and close contacts MUST be treated at the same time. Apply the treatment to the whole body from the chin and ears downwards. Pay special attention to the fingers and toes and under the nails. A quarter of a tube is usually enough for each application. It is important that the cream remains in contact with the skin for the whole minimum treatment time of 8 hours. If you wash your hands, or any other part of your body during that time you must reapply the cream to that part. Treatment must be repeated after 7 days.
Age from 12 to 60 years
Permethrin 5% dermal cream (12 to 60 years)
Permethrin 5% cream
Apply to the whole body, from the chin and ears downwards. Leave on for 8-12 hours or overnight. Wash off. Repeat after 7 days.
Supply 60 grams.
Age: from 12 years to 60 years
NHS cost: £11.04
OTC cost: £18.90
Licensed use: yes
Patient information: ALL members of your household and close contacts MUST be treated at the same time. Apply the treatment to the whole body from the chin and ears downwards. Pay special attention to the fingers and toes and under the nails. A quarter of a tube is usually enough for each application. It is important that the cream remains in contact with the skin for the whole minimum treatment time of 8 hours. If you wash your hands, or any other part of your body during that time you must reapply the cream to that part. Treatment must be repeated after 7 days.
Age from 12 years onwards
Permethrin 5% dermal cream (immunocompromised or elderly)
Permethrin 5% cream
Apply to the whole body, including the scalp, face, neck, and ears. Leave on for 8-12 hours or overnight. Wash off. Repeat after 7 days.
Supply 60 grams.
Age: from 12 years onwards
NHS cost: £11.04
OTC cost: £19.90
Licensed use: yes
Patient information: ALL members of your household and close contacts MUST be treated at the same time. Apply to entire skin surface, including the scalp, face, neck and ears, and especially between the fingers and toes and under the nails. Pay special attention to the the fingers and toes and under the nails. A quarter of a tube is usually enough for each application. It is important that the cream remains in contact with the skin for the whole minimum treatment time of 8 hours. If you wash your hands, or any other part of your body during that time you must reapply the cream to that part. Treatment must be repeated after 7 days.

2nd choice insecticide: malathion aqueous lotion

Age from 2 to 5 months
Malathion 0.5% aqueous liquid (2 months to 5 months)
Malathion 0.5% aqueous liquid
Apply to the whole body, including the scalp, face, neck, and ears. Leave on for 24 hours. Wash off. Repeat after 7 days.
Supply 100 ml.
Age: from 2 months to 5 months
NHS cost: £5.70
Licensed use: yes
Patient information: ALL members of your household and close contacts MUST be treated at the same time Apply to entire skin surface, including the scalp, face, neck, and ears, and especially between the fingers and toes and under the nails. You will not need to use the whole contents of a bottle to cover the skin surface of a small child - as a guide, 100ml is about enough to cover the entire skin surface of an adult. It is important that the liquid remains in contact with the skin for the whole minimum treatment time of 24 hours. If any part of the body is washed during that time the liquid must be reapplied to that part.
Age from 6 months to 1 year 11 months
Malathion 0.5% aqueous liquid (6 months to 1 year 11 months)
Malathion 0.5% aqueous liquid
Apply to the whole body, including the scalp, face, neck, and ears. Leave on for 24 hours. Wash off. Repeat after 7 days.
Supply 100 ml.
Age: from 6 months to 1 year 11 months
NHS cost: £5.70
OTC cost: £9.99
Licensed use: yes
Patient information: ALL members of your household and close contacts MUST be treated at the same time Apply to entire skin surface, including the scalp, face, neck, and ears, and especially between the fingers and toes and under the nails. You will not need to use the whole contents of a bottle to cover the skin surface of a small child - as a guide, 100ml is about enough to cover the entire skin surface of an adult. It is important that the liquid remains in contact with the skin for the whole minimum treatment time of 24 hours. If any part of the body is washed during that time the liquid must be reapplied to that part.
Age from 2 years to 11 years 11 months
Malathion 0.5% aqueous liquid (2 years to 11 years 11 months)
Malathion 0.5% aqueous liquid
Apply to the whole body from the chin and ears downwards. Leave on for 24 hours. Wash off. repeat after 7 days.
Supply 200 ml.
Age: from 2 years to 11 years 11 months
NHS cost: £11.40
OTC cost: £19.90
Licensed use: yes
Patient information: ALL members of your household and close contacts MUST be treated at the same time Apply the treatment to the whole body from the chin and ears downwards. Pay special attention to the fingers and toes and under the nails. You will not need to use the whole contents of a bottle to cover the skin surface of a small child - as a guide, 100ml is about enough to cover the entire skin surface of an adult. It is important that the liquid remains in contact with the skin for the whole minimum treatment time of 24 hours. If any part of the body is washed during that time the liquid must be reapplied to that part.
Age from 12 to 60 years
Malathion 0.5% aqueous liquid) (12 years to 60 years)
Malathion 0.5% aqueous liquid
Apply to the whole body from the chin and ears downwards. Leave on for 24 hours. Wash off. repeat after 7 days.
Supply 200 ml.
Age: from 12 years to 60 years
NHS cost: £11.40
OTC cost: £19.90
Licensed use: yes
Patient information: ALL members of your household and close contacts MUST be treated at the same time Apply the treatment to the whole body from the chin and ears downwards. Pay special attention to the fingers and toes and under the nails. You will not need to use the whole contents of a bottle to cover the skin surface of a small child - as a guide, 100ml is about enough to cover the entire skin surface of an adult. It is important that the liquid remains in contact with the skin for the whole minimum treatment time of 24 hours. If any part of the body is washed during that time the liquid must be reapplied to that part.
Age from 12 years onwards
Malathion 0.5% aqueous liquid (immunocompromised or elderly)
Malathion 0.5% aqueous liquid
Apply to the whole body, including the scalp, face, neck, and ears. Leave on for 24 hours. Wash off. Repeat after 7 days.
Supply 200 ml.
Age: from 12 years onwards
NHS cost: £11.40
OTC cost: £19.90
Licensed use: yes
Patient information: ALL members of your household and close contacts MUST be treated at the same time. Apply to entire skin surface, including the scalp, face, neck, and ears, and especially between the fingers and toes and under the nails. You will not need to use the whole contents of a bottle to cover the skin surface of a small child - as a guide, 100ml is about enough to cover the entire skin surface of an adult. It is important that the liquid remains in contact with the skin for the whole minimum treatment time of 24 hours. If any part of the body is washed during that time the liquid must be reapplied to that part.

Sedating antihistamine (for itch at night)

Age from 1 year to 1 year 11 months
Chlorphenamine 2mg/5ml oral solution: 1mg at night when required
Chlorphenamine 2mg/5ml oral solution
Take 2.5ml at night when required for relief of itching.
Supply 50 ml.
Age: from 1 year to 1 year 11 months
NHS cost: £0.79
OTC cost: £3.99
Licensed use: no - off-label indication
Age from 1 year to 5 years 11 months
Hydroxyzine syrup: 5 to 15 mg at night when required
Hydroxyzine 10mg/5ml oral solution
Take 2.5ml to 7.5ml at night when required for relief of itching.
Supply 100 ml.
Age: from 1 year to 5 years 11 months
NHS cost: £0.89
Licensed use: yes
Age from 2 years to 5 years 11 months
Chlorphenamine 2mg/5ml oral solution: 1-2mg at night when required
Chlorphenamine 2mg/5ml oral solution
Take 2.5ml to 5ml at night when required for relief of itching.
Supply 100 ml.
Age: from 2 years to 5 years 11 months
NHS cost: £1.59
OTC cost: £3.99
Licensed use: no - off-label indication
Age from 6 years to 11 years 11 months
Chlorphenamine oral 2mg/5ml solution: 2-4 mg at night when required
Chlorphenamine 2mg/5ml oral solution
Take one to two 5ml spoonfuls at night when required for relief of itching.
Supply 100 ml.
Age: from 6 years to 11 years 11 months
NHS cost: £1.59
OTC cost: £3.99
Licensed use: no - off-label indication
Hydroxyzine syrup: 15mg to 25mg at night when required
Hydroxyzine 10mg/5ml oral solution
Take 7.5ml to 12.5ml at night when required for relief of itching.
Supply 200 ml.
Age: from 6 years to 11 years 11 months
NHS cost: £1.78
Licensed use: yes
Age from 12 years onwards
Chlorphenamine tablets: 4 mg at night when required
Chlorphenamine 4mg tablets
Take one tablet at night when required for relief of itching.
Supply 14 tablets.
Age: from 12 years onwards
NHS cost: £0.50
OTC cost: £3.15
Licensed use: no - off-label indication
Hydroxyzine tablets: 25mg at night when required
Hydroxyzine 25mg tablets
Take one tablet at night when required for relief of itching.
Supply 14 tablets.
Age: from 12 years onwards
NHS cost: £0.55
Licensed use: yes

Topical corticosteroid

Age from 1 month onwards
Hydrocortisone 1% cream: apply once or twice a day
Hydrocortisone 1% cream
Apply thinly to the affected area 1 to 2 times a day. Use for a maximum of 7 days unless otherwise directed.
Supply 15 gram.
Age: from 1 month onwards
NHS cost: £4.17
Licensed use: yes
Hydrocortisone 1% ointment: apply once or twice a day
Hydrocortisone 1% ointment
Apply thinly to the affected area 1 to 2 times a day. Use for a maximum of 7 days unless otherwise directed.
Supply 15 grams.
Age: from 1 month onwards
NHS cost: £5.14
Licensed use: yes

Topical antipruritics

Age from 2 months to 2 years 11 months
Crotamiton 10% cream: apply once a day when required
Crotamiton 10% cream
Apply to the affected area once a day when required for relief of itching.
Supply 30 grams.
Age: from 2 months to 2 years 11 months
NHS cost: £2.27
Licensed use: yes
Crotamiton 10% lotion: apply once a day when required
Crotamiton 10% lotion
Apply to the affected area once a day when required for relief of itching.
Supply 100 m.
Age: from 2 months to 2 years 11 months
NHS cost: £2.99
Licensed use: yes
Age from 3 years onwards
Crotamiton 10% cream: apply 2-3 times a day when required
Crotamiton 10% cream
Apply to the affected area 2 to 3 times a day when required for relief of itching.
Supply 30 grams.
Age: from 3 years onwards
NHS cost: £2.27
OTC cost: £3.55
Licensed use: yes
Crotamiton 10% lotion: apply 2-3 times a day when required
Crotamiton 10% lotion
Apply to the affected area 2 to 3 times a day when required for relief of itching.
Supply 100 ml.
Age: from 3 years onwards
NHS cost: £2.99
OTC cost: £4.69
Licensed use: yes

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