Comments from Expert Advisory Group
History
- Itchy rash over hands/feet and genital areas, worse at night and after a bath
- Household contacts itchy
Exam
- Burrows at wrist and webspaces, papules in interdigital web spaces of hands/wrists and feet
- Rash on feet/fingers/webspaces/wrist/elbow/axilla/umbilicus/areolae
- Also seen on palms & soles in infants
General advice for scabies
- Treatment of scabies is recommended for all members of the infected household (even if asymptomatic) and all members must be treated simultaneously within 24 hours.
- Visiting asymptomatic relatives and sexual contacts within the last month could be potential sources of infestation and may also require treatment.
- Seek specialist advice for children under two months of age.
- For difficult to treat scabies, cases in congregate settings or immunocompromised hosts, seek advice from microbiology/ public health.
- Adults and children can return to work or school 24 hours after the first application of scabicide.
- Most people with scabies are cured after two applications of scabicide but itching may continue for a few weeks after successful treatment. If this is problematic it may be relieved using an oral antihistamine and/or a topical steroid.
- If new burrows appear after a treatment course (two applications) consider a second treatment course.
- Bedding and clothing should be washed at a high temperature to destroy the mites. Items that can’t be washed or dry cleaned should be sealed in a plastic bag for at least 72 hours or put in a freezer.
Treatment-Resistant Scabies
- True resistant scabies is rare. In cases of suspected treatment failure with topical scabicides, ensure that the strict treatment protocols have been followed correctly including treatment of all household contacts (including asymptomatic contacts).
- Seek advice from Dermatology or Microbiology if you suspect treatment-resistant scabies.
- Consider all contacts that are potential sources for re-infestation and ensure they have been assessed and treated if necessary (e.g. a relative that lives in another household but regularly stays with the family such as a college student returning at the weekends).
- Patients should also be advised that residual itching can persist for a number of weeks following eradication and appropriate topical and/or oral antipruritics may be offered.
- Oral ivermectin (unlicensed and usually prescribed in tertiary care) has been shown to be effective in treating resistant scabies.
- If oral ivermectin is prescribed, patients must still be advised of the requirement to follow the usual general advice for scabies regarding close contact and environmental management as detailed above.
Crusted Scabies
- Patients who have impaired mobility or are immunocompromised may be susceptible to a severe form of scabies known as crusted scabies. Seek advice from a specialist if you suspect crusted scabies.
Outbreaks
- For outbreaks, particularly in congregate settings, the local Public health office should be contacted.
Treatment
| Scabies |
|
Technique of application of topical agents listed below is extremely important to ensure effectiveness.Manufacturer's directions for product use need to be followed closely. Do not apply after a hot bath.
Adults & Children over 2 years:
- Apply to the whole body below the ears paying particular attention to the areas between the fingers and toes, wrists, axillae, external genitalia, buttocks and under finger and toenails.
- Face, neck & scalp application is necessary in immunosuppressed and adults over 65 years.
Children 2 months-2 years:
- As per adults but also apply to face, neck, scalp and ears.
The product should be re-applied to the hands if they are washed with soap and water
Pregnancy & Breastfeeding: Either product may be used in Pregnancy. Care must be taken that a breastfeeding infant does not suckle on treated skin (thereby avoiding oral ingestion of the scabicide).
|
| Drug |
Dose |
Contact time |
Repeat application |
|
Permethrin 5% Cream
(Lyclear® Dermal Cream)
30g tube
|
Adults & Children > 12yrs:
Apply up to 30g at night
Children 6-12yrs:
Apply up to 15g (½ of a 30g tube) at night
Children ≥ 2mths-5yrs:
Apply up to 7.5g (¼ of a 30g tube) at night
|
12 hours
|
One week later
|
| 2nd line option |
|
Malathion 0.5% Liquid
(Derbac M®)
|
Adults & Children ≥6mths:
Apply as directed
|
24 hours
|
One week later
|
|
Due to intermittent supply shortages of Lyclear® Dermal Cream and Derbac M®, a third line option for the topical treatment of scabies has been added: benzyl benzoate 25%w/v. It should be reserved for third line use as it may be irritant to the skin. Benzyl benzoate 25%w/v should not be applied to the face and neck or to mucous membranes.
|
| 3rd line option |
|
Benzyl Benzoate
25%w/v Application
|
Adults
Apply to the entire body (including soles of the feet, but excluding head and neck) for two consecutive nights
Children
Dosing as for adults but dilute solution with equal parts water prior to use
Infants
Dosing as for adults but dilute solution with 3 parts water prior to use
|
8–12 hours
|
One week later
|
| Treatment-Resistant Scabies |
| In cases of treatment-resistant scabies, advice should be sought from dermatology or microbiology. If urgent treatment is required then oral ivermectin may be considered, giving due consideration to the unlicensed nature of the drug, the age and co-morbidities of the patient, and other prescribed or non-prescribed drugs they may be taking. It is generally available through unlicensed suppliers in 3mg tablets. |
| Drug |
Dose |
Duration |
Notes |
|
Ivermectin
|
200 micrograms/kg
|
Two doses
one week apart
(Day 1 and day 8)
|
Should be taken on an empty stomach with a glass of water.
Safety has not been established in pregnancy.
Please document patient’s weight on prescription.
Sample Calculation
Body weight = 70kg
Dosing = 200 micrograms /kg
Dose = 70 x 200 = 14,000 micrograms = 14mg
Tablets available = 3 mg, so rounding to the nearest 3mg, dose is 5 tablets (15mg)
Ivermectin dosing table:
| Body Weight (kg) |
Number of 3mg tablets per dose |
| 45 - 52 |
3 |
| 53 - 67 |
4 |
| 68 - 82 |
5 |
| 83 - 97 |
6 |
| 98 - 112 |
7 |
| 113 - 127 |
8 |
| 127 + |
200 micrograms/kg |
|
Patient Information
Scabies Patient Information Leaflet February 2022.pdf (size 618.4 KB)
- Doses are for adults unless otherwise stated.
- Safety in Pregnancy and Lactation
- Visit the Health Products Regulatory Authority (HPRA) website for detailed drug information (summary of product characteristics and patient information leaflets). Dosing details, contraindications and drug interactions can also be found in the Irish Medicines Formulary (IMF) or other reference sources such as British National Formulary (BNF) / BNF for children (BNFC).
Reviewed: December 2022 - minor update November 2023
