Ep 175 – Scabies

Scabies is a condition that can cause significant distress due to the intense itching associated with the condition and concerns about social stigma. In this episode, Dr Kate Chesterman discusses the risk factors for contracting scabies, the signs and symptoms associated with the condition, preferred treatment options and indications for involving secondary care.

Key take-home points

• Scabies is caused by the mite Sarcoptes scabiei and is usually acquired by close skin-to-skin contact with somebody who already has the condition.
• Scabies is not caused by being unhygienic.
• A diagnosis of scabies is suggested by a history of intense itching that worsens at night, the presence of close contacts who are also itchy and typical findings on examination.
• The pathognomonic lesions of scabies are burrows: small, irregular tracks produced by the moving mite. They are commonly found on the sides of the fingers, in the web spaces and the borders of the hands, wrists and feet.
• Other common findings on examination include a generalised rash with erythema and papules. These papules are often excoriated and distributed in a symmetrical pattern over the limbs and trunk.
• The rash usually develops 3–4 weeks after infestation, and patients are contagious prior to becoming symptomatic.
• First-line treatment for scabies is generally considered to be 5% permethrin cream. Advice for applying the cream can be found in the patient information leaflets listed in the references and resources section. A second application should be applied after 7 days.
• Clothes, towels and bed linen should be washed on a hot wash immediately after the first application of cream.
• Any contacts need to be treated at the same time. Asymptomatic contacts require only one treatment; only symptomatic contacts need to repeat the treatment after 7 days.
• Oral ivermectin is considered as an alternative to permethrin cream. It should be prescribed at a dose of 200 µg/kg as a stat dose. This should be repeated after 10–14 days. Oral ivermectin is not recommended in pregnancy.
• The itch associated with scabies can persist for several weeks. It can be treated with emollient creams and ointments containing crotamiton. Night-time sedating antihistamines can also be helpful.
• Crusted scabies can occur in patients with a history of immunosuppression, neurological disorders, institutionalisation or those prescribed systemic or potent topical steroids. The large numbers of mites make this form much more contagious. Early involvement of a dermatologist is recommended.
• A dermatology referral is also recommended if resistant scabies is suspected or if there is diagnostic uncertainty, and for those under the age of 2 months.
• Seeking advice from your local health protection team may be invaluable for support in managing an outbreak in an institution.
• Sexual health clinics are experienced in investigating and managing sexually transmitted infections and supporting partner notification.

Key references

1. Primary Care Dermatology Society. 2025. https://www.pcds.org.uk/clinical-guidance/scabies.
2. UKHSA. 2025. https://www.gov.uk/government/publications/scabies-management-advice-for-health-professionals/ukhsa-guidance-on-the-management-of-scabies-cases-and-outbreaks-in-long-term-care-facilities-and-other-closed-settings.
3. British Association of Dermatologists. 2023. https://cdn.bad.org.uk/uploads/2023/10/Scabies-guidance-OCT-2023.pdf.
4. BMJ Best Practice. 2023. https://bestpractice.bmj.com/topics/en-gb/124.
5. Morris G, et al. Int J STD AIDS. 2025;36(7):516-532. doi: 10.1177/09564624251321264.
6. British Association of Dermatologists. 2023. https://www.bad.org.uk/pils/scabies/.
7. Primary Care Dermatology Society. 2025. https://www.pcds.org.uk/files/pils/PIL-Scabies-Dec-23-PIL_2025-01-31-123426_taqd.pdf.