Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Scabies
A skin infestation of a mite that causes an intractable pruritus, which is particularly intense at night when the patient is warm and the mite is more active. It is characterized by a generalized excoriated eruption.
I. Etiology
A. Female mite, Sarcoptes scabiei, burrows into stratum corneum to lay eggs. Larvae hatch within 2 to 4 days and move to the surface of the skin. After 17 to 21 days, the cycle is repeated by the now mature larvae.
B. Sensitization to the ova and feces of the mite occurs about 1 month after the initial infestation, producing the symptom of intense pruritus.
II. Incidence
A. Pandemic
B. Cyclical in nature; believed to occur in 30-year cycles, with an epidemic lasting 15 years
C. Scabies affects all ages and both sexes without regard to socioeconomic status, but it is most common in urban areas where crowded conditions enhance the spread of the mite.
D. It also occurs as a nosocomial outbreak.
III. Incubation period: Usually 1 to 3 weeks, but can be as long as 2 months
IV. Communicability
A. Highly communicable
B. Primarily spread by skin-to-skin contact
C. Live mites have been found in dust and fomites
V. Subjective data
A. Rash
B. Pruritis: Intense and unremitting, worse at night
C. Restlessness; poor sleep
D. History of similar rash in other family members or other exposure to similar rash
E. Symptoms noted 3 to 4 weeks after infestation
F. Local infection
VI. Objective data
A. Characteristic lesions
1. Linear, threadlike, grayish burrows 5 to 20 mm long; burrows may end in a vesicle or papule.
2. Most predominant in finger webs, flexor surface of wrists, and antecubital fossae
B. Other lesions
1. Vesicles, papules (pale pink, pinpoint size), excoriations
2. Pustules present with secondary infection
3. Bullous lesions are often present on face, palms, and soles of infants and small children.
C. Distribution
1. Generally below the neck, but palms, soles, head, and neck may be involved in infants and children.
2. Most common sites of lesions
a. Finger webs
b. Wrists
c. Extensor surfaces of elbows and knees
d. Lateral aspect of feet
e. Axillae
f. Buttocks
g. Intergluteal folds
h. Waist
i. Glans penis and scrotum in males
j. Nipples in females
D. Many lesions are secondarily infected with regional lymphadenopathy present.
VII. Assessment
A. Diagnosis
1. Scrapings of the burrow or papules using a surgical blade may reveal the mite, eggs, or a black speck of feces when viewed under the microscope. These scrapings are best obtained from interdigital areas or the flexor surface of the wrists.
2. Scrapings are often negative, so scabies must then be diagnosed by the clinical signs (scabetic burrows in particular) and symptoms as well as by the epidemiologic data.
3. Scabies should be ruled out in any generalized, excoriated eruption.
B. Differential diagnosis
1. Impetigo: Secondary bacterial infection often occurs and obscures the lesions of scabies. There is a high index of suspicion, however, with widespread impetiginous lesions involving the most frequent sites of involvement of scabies; a history of intense pruritus, especially on retiring; or a positive history of exposure.
2. Contact dermatitis such as Poison Ivy: Linear vesicles generally limited to exposed areas.
VIII. Plan
A. Follow selected treatment plan; do not overtreat. Chemical irritation from medication or a hypersensitivity reaction to the mite may result in persistent itching, which may be interpreted as a treatment failure. Order only enough medication for treatment schedule.
B. Children and adults
1. Elimite (permethrin 5%)—order 30 g for average adult.
a. Safe and effective in children 2 months and older
b. Thoroughly massage into skin from head to soles of feet.
c. Wash off after 8 to 14 hours.
d. One application usually is curative, but a second application can be repeated in 1 week if there is clear evidence of treatment failure.
2. Kwell lotion—not recommended for infants or pregnant women.
a. Bathe thoroughly with soap and hot water using rough washcloth or scrub brush. Towel dry.
b. Apply Kwell lotion from chin down. Apply to facial and scalp lesions, if present.
c. Leave lotion on for 6 to 8 hours, then bathe thoroughly again.
d. Use clean clothing, sheets, and towels after application and after bathing.
e. Consider repeat application in 1 week (scabicides are not ovicidal, so a repeat application is needed to kill newly hatched larvae).
C. Alternative treatment, all ages. Precipitated sulfur (6%–10%) applied every 24 hours for 3 days. It is effective but less commonly used because it is messy and smells like sulfur.
D. Secondary bacterial infections
1. Neosporin or bacitracin ointment tid–qid 24 hours after treatment with Kwell or following treatment regimen with Eurax for one or two infected lesions.
2. If infection extensive, penicillin G for 10 days
F. Pruritus
1. 1% hydrocortisone cream
2. Benadryl 5 mg/kg/d in 4 divided doses as needed, if intense
G. It is reasonable to treat all close contacts (family members, babysitters, and sexual contacts) prophylactically to prevent reinfection.
1. Order
a. 2–4 oz of Kwell (maximum) per adult; 1 oz per child
b. 60 g of Eurax (maximum) per person
2. Do not order refills.
3. Eurax is the primary alternative therapy. It is an antipruritic and a scabicide, although its cure rates are lower than those of Kwell.
IX. Education
A. Recognize that infestation by scabies can be a traumatic emotional experience for many people. Support, education, and reassurance are vital to assist them in coping with and eradicating the parasite.
B. Scabies are acquired by close personal contact. They may also be transmitted through clothing or linens.
C. Treat close family and personal contacts if indicated.
D. Female mite can survive for 2 to 3 days without human contact.
E. Lack of cleanliness does not cause scabies, but scrupulous hygiene can help eradicate and prevent reinfestation.
F. Low economic classes are not the only victims; scabies affects all socioeconomic groups and all ages.
G. Transmission is unlikely 24 hours after treatment is instituted.
H. Symptoms may persist for several weeks after the mites have been killed. Symptoms may be due to persistent infestation, sensitivity to the scabicide, or hypersensitivity to the mite. Patient should call back for an evaluation.
I. Notify school so nurse can be alert for symptoms of infestation in contacts.
J. Laundry
1. Use hot water and detergent.
2. Use hot dryer.
3. Use hot iron.
4. Change all clothing daily.
K. Woolens
1. Dry clean.
2. Press with hot iron.
3. If expense of dry cleaning is prohibitive, place woolens and stuffed animals in plastic bag and seal for 2 weeks.
L. Furniture
1. Use R&C Spray for upholstered furniture.
2. Damp dust or wash other furniture.
M. Teach parent the signs and symptoms of secondary bacterial infection.
N. Scabicide
1. Reapply to hands after washing.
2. Do not use on face or scalp unless lesions are present there.
3. Do not get in eyes or on mucous membrane.
4. Be sure to cover all areas of the body, paying special attention to interdigital webs, body folds, axillae, and under nails. If any areas are missed, treatment may not be successful.
5. Poisonous if ingested
6. Side effects: Eczematous eruptions
7. Do not apply to acutely inflamed skin or raw, weeping surfaces.
X. Follow-up
A. Check babies and small children in 7 to 10 days.
B. Recheck in 3 to 5 days if child presented with secondary infection of lesions.
C. If persistent pruritus after 2 weeks, repeat scraping of lesion to determine presence of mites.
XI. Complications
A. Secondary bacterial infection
B. Reaction to scabicide
XII. Consultation/referral
A. Infants younger than 2 months and pregnant women
B. Failure to respond to therapy
C. Secondary bacterial infection