Scabies Identification, Treatment and Environmental Cleaning Level III Purpose The purpose of this procedure is to treat residents infected with and sensitized to Sarcoptes scabiei and to prevent the spread of scabies to other residents and staff. Preparation 1. Obtain or verify the existence of a physician s order for this procedure. 2. Review the resident s care plan to assess for any special needs of the resident. 3. Assemble the equipment and supplies as needed. General Guidelines 1. Scabies is an itching skin irritation caused by the microscopic human itch mite, which burrows into the skin s upper layers and eventually causes itching, tiny irregular red lines just above the skin and an allergic rash. 2. Secondary bacterial skin infections may result from untreated scabies. 3. Incubation period can be 2 6 weeks before onset of itching for persons with no previous exposure. Persons who have been previously infested develop more rapid symptoms, 1 4 days after re-exposure. 4. Symptoms sometimes include severe itching, which worsens at night. 5. Common locations of scabies: a. Anterior axillary region or under breasts; b. Around the waist; c. Between fingers and palm of hand; d. On the inner thigh, groin, buttocks; e. Anterior surfaces of wrists and elbows; f. On body parts which may come in contact with contaminated linens, bedding, or clothing; g. Upper backs of nursing home residents; and h. On hands of employees. 6. Scabies is spread by skin to skin contact with the infected area, or through contact with bedding, clothing, privacy curtains and some furniture. 7. Diagnosis may be established by recovering the mite from its burrow and identifying it microscopically. Failure to identify scrapings as positive does not necessarily exclude the diagnosis. It is difficult to obtain a positive scraping because only one or two mites may cause multiple lesions. Often diagnosis is made from signs and symptoms and treatment followed without scrapings, although scrapings are preferred. 8. Affected residents should remain on Contact Precautions until twenty-four (24) hours after treatment. 9. Family and friends of residents who have had close contact should be notified and given instructions regarding self-examination and treatment. 10. Staff members who may have been exposed should report any rashes developing on their bodies to the Infection Preventionist or Director of Nursing Services.
11. A resident sharing a room with someone infected with scabies should be examined carefully for scabies. If signs and symptoms are present, the resident should be treated in accordance with these procedures. If symptoms are not present, daily assessments should be made until the case has resolved. 12. Individuals who come into contact with the infected resident or with potentially contaminated bedding or clothing should wear a gown and gloves or other protective clothing as established by the facility s infection and exposure control programs. 13. During a scabies outbreak among residents and/or personnel, the Infection Preventionist or Committee will coordinate interdepartmental planning to facilitate a rapid and effective treatment program. 14. Control of an epidemic depends on treating all residents at risk. Specific drug selection for each resident will depend on that individual s risk factors, possible medication interactions, etc. 15. The use of Ivermectin po should be considered during widespread outbreak and/or when treatment with topical medication is unsuccessful. Equipment and Supplies The following equipment and supplies will be necessary when performing this procedure. 1. Magnifying glass; 2. Pen light; 3. Felt tip pen; 4. Alcohol swabs; 5. #15 scalpel blade and handle; 6. Glass slides or curettes (for scraping); 7. Mineral oil; 8. Slides and cover slips; 9. Clear nail polish; 10. Forceps; 11. Elimite (or other treatment lotion) or Ivermectin (oral dosage); 12. Disinfectant; and 13. Personal protective equipment (e.g., gowns, gloves, mask, etc., as needed). Steps in the Procedure Skin Scraping for Microscopic Identification 1. Assess the resident s skin with a magnifying lens and look for lesions suggestive of scabies infestation. a. The shoulders, back, abdomen, hands, wrists, elbows, buttocks, axillae, knees, thighs and breasts are common sites for burrows. b. A bright light and magnifying lens will assist in visualizing the tiny dark speck (the mite) at the end of the burrow. 2. Test for burrows: a. Using a wide felt tip pen (blue or green are best) draw over the burrows and then wipe off with an alcohol swab. b. The alcohol will remove most surface ink, but will not remove the ink taken up by the burrow. Look for a dark irregular line. 3. Apply mineral oil to lesions or scalpel blade, and glass slides. 4. Scrape non-excoriated, non-inflamed areas (burrows and papules) with the scalpel blade or glass slide held at a 90-degree angle to the skin.
5. Scrape while holding the skin taut, until the stratum corneum is removed. a. Vigorous scraping appropriately results in a few red blood cells visible under the microscope, but there should not be frank bleeding. 6. If using a curette. a. Change blades or curettes between scrapings on different persons. b. Blades can be placed on and removed from the handle with a forceps. 7. Place used blades in a sharps container. Treatment with Permethrin (Elimite ) 1. Bathe the resident, soaping the body completely, rinse well, and then dry thoroughly. 2. Allow his or her body to cool. 3. Apply Elimite into the skin from the chin to the soles of the feet. a. Scabies rarely infests the scalp of adults, although the hairline, neck, temple, and forehead may be infested in geriatric residents. b. Pay particular attention to skin folds and creases. c. Avoid contact with the eyes. d. Reapply if washed off following use of the toilet, handwashing, etc. 4. Dress the resident with clean clothing. Use freshly laundered bed linens and towels. 5. Leave cream on for at least 8 hours but no more than 12 hours, and then shower or bath the resident in warm water, soaping the body completely, rinsing and drying well. 6. Put on clean clothing. Re-launder towels and bed linens used during treatment. 7. Itching may continue for several days or weeks. 8. A single treatment is generally adequate. Environmental Control: Typical Scabies 1. Place residents with typical scabies on contact precautions during the treatment period; 24 hours after application of 5% permethrin cream or 24 hours after last application of scabicides requiring more than one application. 2. Wear gloves and a long-sleeved gown for direct hands-on contact. 3. Wash hands after removal of gloves. 4. Place bed linens, towels and clothing used by an affected person during the 4 days prior to initiation of treatment in plastic bags inside the resident s room, handled by gloved and gowned staff without sorting, and washed in hot water for at 10-20 minutes. 5. Use the hot cycle of the dryer for at least 10-20 minutes. 6. Place non-washable blankets and articles in a plastic bag for at least 72 hours. These items can also be dry cleaned or tumbled in a hot dryer for 20 minutes. 7. Change all bed linens, towels and clothes daily. 8. Disinfect multiple residents-use items, such as walking belts, blood pressure cuffs, stethoscopes, wheelchairs, etc., before using on other residents. 9. Discard all creams, lotions or ointments used prior to effective treatment. 10. Vacuum mattresses, upholstered furniture and carpeting. Wrap vacuum cleaner bag in a plastic bag and discard. a. General cleaning and thorough vacuuming of furniture, mattresses or rug is recommended. b. Fumigation is not necessary. 11. For non-fabric items, routine disinfection procedures are adequate.
12. Infected employees can return to work as soon as treatment is completed but should use gowns and gloves for direct resident care to prevent reinfestation until all control measures for affected units/areas have been completed. Environmental Control: Crusted/Atypical Scabies: 1. Maintain contact precautions until treatment is complete and/or resident is determined (by dermatologist or primary care provider) to be scabies free. 2. Assign resident to a private room, if possible. 3. Restrict visitors until treatment regimen is complete; alternatively, require visitors to gown and glove as required for contact isolation precautions. a. If resources permit, cohort employees to care for this resident only (no other direct care responsibilities) until effective treatment is completed. 4. Employees must wear gloves and a long-sleeved gown with the wrist area covered to attend to resident needs, for housekeeping duties, and handling of laundry. Remove gown and wash hands before leaving the room. 5. Bed linens, towels and clothing used by the affected persons during the 4 days prior to initiation of treatment should be placed in plastic bags inside the resident s room, handled by gloved and gowned laundry staff without sorting, and laundered in hot water for at least 10 minutes. a. The hot cycle of the dryer should be used 50 ºC (122 ºF) for at least 10-20 minutes. b. Non-washable blankets and articles can be placed in a plastic bag for 7 days, dry cleaned or tumbled in a hot dryer for 20 minutes. 6. Change all bed linens, towels and clothes daily. 7. Blood pressure cuffs, gait belts, stethoscopes, etc. should be designated for single resident use and left in the resident s room. Discard all creams, lotions or ointments used prior to effective treatment. 8. Upholstered furniture containing any cloth fabric should be removed from the room and, if necessary, replaced with plastic or vinyl furniture. Mattresses must be covered with plastic or vinyl. 9. The resident s room should be vacuumed daily with a vacuum cleaner designated for this room alone, followed by routine room cleaning and disinfection. a. The vacuum cleaner bag should be changed daily; b. Seal vacuum cleaner bag in plastic bag and dispose of properly. 10. The room should be terminally cleaned upon discharge or transfer of the resident from the room. Documentation The following information should be recorded in the resident s medical record: 1. The date and time that care was given. 2. The name and title of the individual(s) who assisted with the care. 3. If the resident refused the treatment, the reason(s) why and the intervention taken. 4. The signature and title of the person recording the data. Reporting 1. Notify the supervisor if the resident refuses the care. 2. Report other information in accordance with facility policy and professional standards of practice.
References MDS Items (CAAs) Section M; Section O Revision Dates