Guidelines for Nurse Practitioners in Gynecologic Settings 2016
Care Plan – Scabies
B86: Scabies
I. DEFINITION
A highly contagious papulofollicular skin rash whose chief symptom is pruritus; infestation of the human itch mite that burrows into upper layer of the skin. Rash and itching are thought to be hypersensitivity reactions to the mites and are not confined to the locations of mite burrows. With first exposure, sen- sitization can take several weeks. After reinfestation, pruritus can occur within 24 hours. Transmitted by skin-to-skin contact with an individual who has sca- bies. Scabies among adults may be sexually transmitted.
II. ETIOLOGY
Sarcoptes scabiei mite. The mite burrows into skin and deposits eggs along a tunnel. Larvae hatch in 3 to 5 days and gather around hair follicles. Newly hatched female burrows into the skin, maturing in 10 to 19 days, then mates and starts a new cycle. Crusted scabies (Norwegian scabies) is an aggressive infestation.
III. HISTORY
A. What the patient may present with
1. Pruritus that is worse at night or at times when body tempera- ture is raised (i.e., after exercise). Pruritus exists prior to physical manifestations.
2. Lesions are usually on interdigital webs of hands, flexor aspects of wrists, extensor surfaces of the elbows, areas surrounding the nipples, anterior axillary folds, umbilicus, belt line, lower abdomen, genitalia, and gluteal cleft; male genitals; can be all over body, especially with immunosuppression
B. Additional information to be considered
1. Known contact with scabies. Incubation period in persons without previous exposure is usually 4 to 6 weeks (mean 3 weeks). Persons who were previously infected develop symptoms 1 to 3 days after repeat exposure to the mite. These reinfections are usually milder.
2. Lifestyle: Persons in crowded living conditions and living in proximity with others, such as in nursing homes, dormitories, and shelters, and those who share clothing are at increased risk for nonsexual exposures.
3. History of atopic dermatitis, HIV+, or other immunosuppressed condition; hematologic malignancies may be at higher risk for crusted scabies
IV. PHYSICAL EXAMINATION
A. Skin: thorough examination of lesions and of those areas most frequently involved
1. Linear burrows about 1.5 to 2 cm in length, terminating in a papule or vesicle
2. Lesions: papules or vesicles
3. Scaling, crustation lesions, furuncles, or excoriations may be present with secondary infection.
B. Lymph nodes exhibit generalized lymphadenopathy.
V. LABORATORY EXAMINATION
A. Mineral oil to skin, and then a scraping from several of the excoriated lesions onto a slide, examined under low power. It may be difficult to find mites. Application of water, alcohol, or mineral oil to the skin facili- tates collection of the scraping. Scraping is done at the edge of a burrow.
B. Diagnosis is usually made based on clinical presentation.
VI. DIFFERENTIAL DIAGNOSIS
A. Atopic dermatitis
B. Impetigo
C. Urticaria
D. Psoriasis
E. Drug-induced eruption
F. Insect bites
VII. TREATMENT
A. Medication
1. 5% permethrin cream (Elimite), applied to all areas of the body from neck down and washed off after 8 to 14 hours, then repeat treatment 1 week later; or
2. Ivermectin 200 μg/kg single oral dose, repeated in 2 weeks (safety in children < 15 years of age not determined)
3. In pregnancy and lactation and for children younger than 2 years old, use only permethrin. Do not use ivermectin or lindane.
4. Lindane is not recommended as first-line therapy because of toxicity. Use only as alternative in patients who cannot tolerate other therapies or when other therapies have failed. Use lindane 1% lotion or 30 mg of cream applied in a thin layer to all areas of the body from the neck down and thoroughly washed off after 8 hours. It should not be used immediately after a bath or shower or by persons with extensive dermatitis.
B. Symptomatic treatment
1. Antihistamines may be given to relieve pruritus.
2. Patient should be informed that pruritus may persist for several weeks. If the patient does not respond to therapy and itching is still persistent after 1 week, she should be instructed to contact the health care provider to decide whether further therapy is necessary. The patient may need mild-to-moderate potency topical steroids for pruritus.
C. General measures
1. Clothing, towels, and bed linens should be laundered at 60°C (hot cycle) or dry-cleaned on the day of treatment.
2. If clothing items cannot be washed or dry-cleaned, these should be separated from washed clothes and not worn for at least 72 hours. Mites cannot exist for more than 2 to 3 days away from the body.
3. Sexual partners and close personal or household contacts within the past month should be informed, examined, and treated if necessary.
4. Patient should be instructed to follow treatment regimen carefully.
5. Although fumigation of living areas is not necessary, some patients may wish to decontaminate mattresses, sofas, and other inanimate objects that cannot be washed. OTC sprays and powders are available for this purpose. This is usually discouraged because it is generally unnecessary.
VIII. COMPLICATIONS
A. Secondary infection (may require systemic antibiotics)
B. Reaction to lindane (Kwell, Scabene)
1. Dermatitis
2. Central nervous system toxicity
IX. CONSULTATION AND REFERRAL
A. Secondary infection
B. Generalized widespread inflammatory response
C. Failure to respond to therapy
D. Reaction to lindane (Kwell, Scabene)
E. Patients with coexisting dermatitis or other dermatologic condition
F. Patients with coexisting HIV infection or who are otherwise immunosuppressed; those with crusted scabies
X. FOLLOW-UP
A. Failure to respond to therapy. Some experts recommend retreatment after 1 to 2 weeks for patients who are still symptomatic; others recommend retreatment only if live mites can be observed. Retreatment should be with an alternative regimen.
B. Recurrence
Appendix I may be copied or adapted for your patients.
Website: www.cdc.gov/NCIDOD/DPD/parasites/scabies/factsht_scabies.htm