Institutional scabies

What is institutional scabies?

Institutional scabies is defined as scabies that affect the occupants of a residential facility. Residential facilities include:

• Rest / nursing homes
• Interned
• Prisons
• Hospitals
• Camps and other similar facilities.

Only one resident needs to be infested with scabies to be considered institutional scabies.

How is institutional scabies diagnosed?

Institutions must be alert to scabies throughout the year. A eruption Affecting more than one resident or staff member should be considered scabies until proven otherwise.

Scabies can take many different forms and is commonly missed by inexperienced healthcare professionals. Contribution of a specialist dermatologist it should be obtained if there are doubts about the diagnosis.

The main clinical presentations of scabies are:

• Typical scabies: small amounts of striped burrows on hands, wrists and other places with generalized very itchy rash that avoids the scalp and face
• Nodular scabies: as above with clumps of persistent itchy bumps in armpits, groin, and genital areas
• Infant scabies - fluid-filled burrows and blisters on hands and feet, generalized itchy rash that may include a baby's face and scalp

• Crusted scabies: numerous burrows, thick climbing most noticeable bass nail and between the fingers, mild or non-itchy generalized skin rash, peeling of the scalp

• Complicated scabies: any of the other types of scabies accompanied by impetigo (infection), dermatitis, urticaria or other skin disorder
• Asymptomatic scabies: dry skin without symptoms.

All presentations of scabies can occur in institutions, but crusted scabies is more predominant in nursing homes / nursing homes and hospitals than in normal homes, as it mainly affects the elderly, sick or immunosuppressed.

How should institutional scabies be managed?

General measures are taken if there is institutional scabies

Institutional scabies treatment requires careful consideration and planning. Treatment failures are common when it is not coordinated or carried out properly. This substantially increases the costs and time involved in treatment.

Early diagnosis and treatment are key. However, treatment should not be rushed without planning, even in single cases. Two-way communication between a resident's physician and the facility manager is paramount. This is to ensure that you are both aware of new and previous scabies infestations. The facility manager should be notified of all cases of scabies before starting treatment. This allows for coordinated diagnosis and treatment of other residents. Treating an individual for scabies when surrounded by a continuous outbreak of scabies is futile and wastes time and financial resources.

Research has shown that Mites can survive from humans Hosts for 2–5 days at normal room temperature and humidity. Eggs can survive up to 7 days in ideal conditions (90% humidity and 10 ° C / 50 ° F). Therefore, it is important to clean bedding and clothing the morning after each scabicide treatment. This should be done with hot water followed by drying in an electric tumble dryer at the highest setting. Non-washable items should be sealed in a plastic bag and stored above 20 ° C for one week. Alternatively, they can be frozen below -20 ° C for 12 hours. Rooms should be cleaned thoroughly with normal household products. No fumigation or specialized cleaning is required. Carpeted floors and upholstered furniture should be vacuumed and all areas should be cleaned with normal household products. The vacuum cleaner bag must be discarded and the furniture must be covered with plastic or a sheet during treatment and for 7 days afterwards.

Personnel should be restricted to working within an area or wing of a facility during an outbreak. This will help limit the number of cases affected.

Different scenarios require different treatment plans. These are described below.

Prevention of an institutional scabies outbreak

All new residents to a facility must isolate themselves until a full skin examination can be performed. The skin check must be done within 24 hours of arrival. Proper scabies contact precautions should be used until skin control can be performed. Any skin rash found should be diagnosed with minimal delay. A low threshold should be maintained for the treatment of scabies. Treatment is low risk and the downside to treating an individual when the diagnosis is equivocal is minimal compared to treating a facility-wide outbreak.

We do not recommend mandatory and routine treatment of all new residents to a facility that does not have scabies. This approach would be legally and ethically questionable.

Contact precautions for staff of institutions affected by scabies

Necessary contact precautions for scabies include gloves, gowns, and avoiding direct skin-to-skin contact. This should be maintained until at least 8 hours after treatment.

At all other times, staff should use alcohol-containing hand sanitizers / sanitizers frequently.

Infested individual resident

If a single resident is diagnosed with scabies, the facility manager should be notified prior to beginning treatment. Other residents and staff within the same wing should have a full skin check. This should occur even if the resident is asymptomatic, particularly in nursing homes. Residents of nursing homes are often elderly and weakened when unable to complain of itching or scratching. When only one resident is diagnosed with scabies, they should be treated with current treatments alone.

Specific medications and treatment methods are described below.

Two or more infested residents

This requires the coordinated treatment of residents, staff, and frequent visitors. The outbreak will be almost impossible to control If this is not done. The facility manager must be notified before starting treatment. If all people cannot be treated simultaneously, then treatment should be deferred until this is possible.

If all residents diagnosed with scabies reside within the same wing, only residents, staff, and frequent visitors of the affected wing require treatment. However, if more than one wing is affected, the entire facility requires treatment.

People can be treated with topical or oral medications or a combination. Topical applications are time consuming and take up to one hour per resident. Oral treatment is easier and takes much less time to perform. Unfortunately, it can be expensive or even unavailable. Institutions should ask about cost, financing options, and availability in their area.

When more than one resident is affected, a resident within the facility is likely to have crusted scabs. Crusted scabies is highly contagious and an effort should be made to find this person who may be asymptomatic and perhaps diagnosed with another skin disorder such as psoriasis. Crusted scabies requires additional care and treatment.

Specific medications and methods for treatment are described below.

Failure of scabies treatment

The itchy, scabies rash can take up to a month to subside after successful treatment. Examination by an expert (usually a specialist dermatologist) may be appropriate to confirm the diagnosis when there is a persistent rash that lasts for more than a month after treatment.

When scabies persists or reappears within a facility within a few months, all residents and staff should be treated regardless of whether they were previously considered confined to a particular room or wing.

Medicines used to treat scabies.

Topical insecticides

Topical insecticide treatments such as malathion and permethrin are relatively inexpensive and readily available. However, they take a long time to apply properly, taking about 1 hour per application. They are the treatment of choice when only a few residents require treatment, and for staff, visitors, and their families.

Permethrin is often considered a second-line option for community scabies and is reserved for failure after treatment with malathion or another agent. However, due to the difficulties of treating institutional scabies, it should be considered a first-line option in this setting, as it is currently the most effective topical scabicide.

Permethrin 5% lotion or cream should apply to each patch of skin from the neck to the toes. It should be left on for 8-14 hours and then washed off. People should repeat the application after 1 week. It is important that a staff member supervise the treatment to ensure thorough application of the insecticide.

The reported cure rate in research studies has been up to 98% with two applications of permethrin, but the lowest rates often occur in normal practice. People with impaired functional status have lower cure rates with topical permethrin, probably because they carry more mites. Oral treatment should be considered for these people.

Oral treatment for scabies.

Ivermectin is the only oral treatment available. Ivermectin is preferred when many residents require treatment. Coordinated topical treatment of many residents is difficult and time consuming.

The recommended dose for ivermectin is 200 mcg / kg (15 mg for a 75 kg person). This should be repeated in 7 to 14 days. Ivermectin side effects are rare and generally minor. Serious neurological Side effects can rarely occur particularly in weakened people.

Crusted scabies may require three to four doses at 7 to 14 day intervals. Occasionally, weekly treatment may be necessary for a longer period.

The few studies that report on effectiveness of ivermectin have variable cure rates. However, studies indicate that two doses of ivermectin of 200 mcg / kg separated by 1 to 2 weeks result in a cure in more than 90% of cases. Single-dose treatment is less reliable with cure rates of around 70% in immunocompromised patients Low cure rates with a single dose may be due to egg survival and recoveryinfestation.

Combined topical and oral therapy.

A pragmatic approach may be to treat all residents with oral ivermectin, and those with burrows should apply additional topical insecticide to the hands and under the nails. This should improve cure rates and reduce the transmission of mites.

Additional treatment for crusted scabies

Crusted scabies needs careful treatment and careful monitoring to ensure cure.

• Because the thick scale can protect mites from topical insecticides, these should be applied more frequently, even daily, to affected sites.
• Oral ivermectin doses may be needed every 1 to 2 weeks, repeated several times.
• Salicylic acid can be applied to 6% in propylene glycol and / or urea cream to 10% to scaly areas to soften before washing or scraping.
• Take care to apply topical agents to the scale under the fingernails and toenails.