Scabies

Brijesh Singh Yadav

brijeshbioinfo@gmail.com

Disease Type: Parasitic disease

Common Name: Scabies
Causative Agent: Sarcoptes scabei

Disease Discription:

Scabies is a common skin infection that causes small itchy bumps and blisters due to tiny
mites that burrow into the top layer of human skin to lay their eggs. The burrows
sometimes appear as short, wavy, reddish, or darkened lines on the skin's surface,
especially around the wrists and between the fingers. A child who has contracted scabies
can also develop a bumpy red rash. Scabies is contagious, and is usually transmitted by
skin-to-skin contact or through sexual contact with someone else that is infected with it.
The infection spreads more easily in crowded conditions and in situations where there is a
lot of close contact — like child-care centers or nursing homes. [1] The mites burrow into
the skin but never below the stratum corneum. The burrows appear as raised serpentine
lines up to several centimeters long. Other races of scabies may cause infestations in
other mammals such as domestic cats, dogs, pigs, and horses. It should be noted that
races of mites found on other animals may establish infestations in humans. They may
cause temporary itching due to dermatitis but they do not multiply on the human host. [2]

Fig. Showing the infection

Causes of Disease:
Mites can live their entire life cycles in the skin of humans, causing chronic infection.
(The adult mite can survive without a human host for only 2 or 3 days.) The female mite
burrows into the skin to lay her eggs, from which larvae emerge to copulate and then
reburrow under the skin.
Risk Factors:

The list of risk factors mentioned for Scabies in various sources includes:

• Institutions
• Overcrowding
• Poverty
• Poor hygiene
• Sexual contact
• Skin contact
• Clothing
• Bedding
• Towels
• Furniture
• Child-to-child contagion

Causative Agent:
Pathogen Name: Sarcoptes scabiei

Pathogen Description: Sarcoptes scabiei is a parasitic arthropod, which burrows into

human skin and causes scabies.

The Italian biologist Diacinto Cestoni showed in the 18th century that scabies is caused
by the mite Sarcoptes scabiei, variety hominis. The disease produces intense, itchy skin
rashes when the impregnated female tunnels into the stratum corneum of the skin and
deposits eggs in the burrow. The larvae, which hatch in 3–10 days, move about on the
skin, moult into a nymphal stage, and then mature into adult mites. The adult mites live
3–4 weeks in the host's skin.

The action of the mites moving within the skin and on the skin itself produces an intense
itch which may resemble an allergic reaction in appearance. The presence of the eggs
produces a massive allergic response which, in turn, produces more itching.

Sarcoptes is a genus of skin parasites, and part of the larger family of mites collectively
known as “scab mites”; they are also related to the scab mite Psoroptes, also a mite that
infests the skin of domestic animals. Sarcoptic mange affects domestic animals and
similar infestations in domestic fowls causes the disease known as “scaly leg”. The
effects of Sarcoptes scabiei are the most well known, causing “scabies”, or “the itch”.
The adult female mite, having been fertilised, burrows into the skin, usually the hands or
wrists, however other parts of the body may also be affected, and lays its eggs.
The burrowing is carried out using the mouthparts and special cutting surfaces on the
front legs. While these are being used, the Sarcoptes scabiei anchors itself with suckers
on its feet. Eggs are laid in small numbers as the mite burrows, and as these hatch, six-
legged larvae climb out on to the skin and search for hair follicles, where they feed and
moult (discard old cuticles to grow). It is in the hair follicles that the larvae show the first
nymphic stages, with eight legs. In the nymphic stages, the creature feeds and moults and,
if male, gives rise to the adult. In the case of females, another moult occurs before
adulthood. The female has more moults than a male and therefore takes longer –
seventeen days to the other nine to eleven days for a male to reach adulthood. The female
is about twice the size of the male.

The best conditions in which to harbour Sarcoptes scabiei is in areas where there is
frequent skin to skin contact, therefore (as also mentioned previously) the hands and
wrists, as the mites are transmitted by skin contact with carriers, and they very easily
spread. Infestations of Sarcoptes scabiei are commonly found in pigs. They significantly
depress growth and feeding rate, but usually die out in around five days from in typical
farm conditions. However, once in a herd, the mites are very difficult to eliminate
without great measures being taken.

Taxonoimic Classification:

Kingdom: Animalia
Phylum: Arthropoda
Subphylum: Chelicerata
Class: Arachnida
Subclass: Acarina
Superorder: Acariformes
Order: Astigmata
Suborder: Psoroptidia
Superfamily: Sarcoptoidea
Family: Sarcoptidae
Subfamily: Sarcoptinae
Genus: Sarcoptes
Species: S. scabiei

S. scabiei
Morphology and toxin production:

People with compromised immune systems may not develop antibodies to the mites and
may develop crusted Norwegian scabies. In this case, many form scabs or develop very
red skin especially in the elderly and the mentally handicapped where white or gray
crusted areas develop with little itching and little or no red bumps and mite population
numbers rise to thousands in AIDS patients .These cases require additional treatment
options to ensure a complete kill. Ivermectin is a single oral treatment of choice in these
patients combined with any other topical treatment.The burrowing is carried out using the
mouthparts and special cutting surfaces on the front legs. While these are being used, the
Sarcoptes scabiei anchors itself with suckers on its feet. Eggs are laid in small numbers as
the mite burrows, and as these hatch, six-legged larvae climb out on to the skin and
search for hair follicles, where they feed and moult (discard old cuticles to grow). It is in
the hair follicles that the larvae show the first nymphic stages, with eight legs. In the
nymphic stages, the creature feeds and moults and, if male, gives rise to the adult. In the
case of females, another moult occurs before adulthood. The female has more moults
than a male and therefore takes longer – seventeen days to the other nine to eleven days
for a male to reach adulthood. The female is about twice the size of the male.

History:

Based on archeological evidence including Egyptian drawings depicting people afflicted

with symptoms of scabies, scabies is estimated to have been infecting humans for at least
2,500 years. There are many controversial accounts of the history of discovery of the
infectious agent. Prior to the 17th Century, the condition of scabies was known by many
names and widely believed to be a humoral disease, possibly associated with a mite.

Earliest known drawings of scabies were made by Giovan Cosimo Bonomo in 1687, who
collaborated with Diacinto Cestoni and is disputably the discoverer of the scabies mite.

In Australian literature, the scabies mite S. scabiei was first collected from a wombat in
Tasmania in 1804, but not described as a separate species until eighty years later. [16]
Epidemiology:
The demography of scabies was studied in the sole dermatology practice on the island of
Kauai, Hawaii, over a 50-monlh period. Scabies was observed far more frequently in
whites and Hawaiians than in Japanese and Filipinos. Within the while ethnic group,
scabies was most frequently diagnosed in persons between 15 and 44 years old, while in
Hawaiians, the disease was most common in the 0–14-year age group. It is possible that
learned or acquired behavior patterns may play a significant role in contracting the
disease.

Disease Host: Human and other domestic animals

Disease Transmission:

Scabies is transmitted readily, often throughout an entire household, by skin-to-skin

contact with an infected person (e.g. bed partners, schoolmates, daycare), and thus is
sometimes classed as a sexually transmitted disease. Spread by clothing, bedding, or
towels is a less significant risk, and is almost impossible.
 Fig. Showing the life cycle of Sarcoptes scabei

Sarcoptes scabei undergoes four stages in its life cycle; egg, larva, nymph and adult.
Females deposit 2-3 eggs per day as they burrow under the skin . Eggs are oval and 0.1
to 0.15 mm in length and hatch in 3 to 4 days. After the eggs hatch, the larvae migrate
to the skin surface and burrow into the intact stratum corneum to construct almost
invisible, short burrows called molting pouches. The larval stage, which emerges from
the eggs, has only 3 pairs of legs , and this form lasts 2 to 3 days. After larvae molt,
the resulting nymphs have 4 pairs of legs . This form molts into slightly larger nymphs
before molting into adults. Larvae and nymphs may often be found in molting pouches
or in hair follicles and look similar to adults, only smaller. Adults are round, sac-like
eyeless mites. Females are 0.3 to 0.4 mm long and 0.25 to 0.35 mm wide, and males are
slightly more than half that size. Mating occurs after the nomadic male enters the
molting pouch of the adult female . Mating takes place only once and leaves the
female fertile for the rest of her life. Impregnated females leave their molting pouches
and wander on the surface of the skin until they find a suitable site for a permanent
burrow. While on the skin’s surface, mites hold onto the skin using suckers attached to
the two most anterior pairs of legs. When a mite finds a suitable location, it begins to
make its characteristic serpentine burrow, laying eggs in the process. After the
impregnated female burrows into the skin she remains there and continues to lengthen her
burrow and lay eggs for the rest of her life. Under the most favorable of conditions,
about 10% of her eggs eventually give rise to adult mites. Males are rarely seen. They
make temporary shallow pits in the skin to feed until they locate a female’s burrow and
mate.
Transmission occurs by the transfer of the impregnated females during personal contact.
Mode of transmission is primarily by person by person, skin-to-skin contact.
Occasionally transmission may occur via fomites (e.g., bedding or clothing). Mites are
found predominantly between the fingers and on the wrists. [2]

Signs and symptoms of disease:

A tiny mite (0.3 to 0.9 mm) may sometimes be seen at the end of a burrow. Most
burrows occur in the webs of fingers, flexing surfaces of the wrists and armpits, the
areolae of the breasts in females and on genitals of males, along the belt line, and on the
lower buttocks. The face usually does not become involved in adults.

The rash may become secondarily infected; scratching the rash may break the skin and
make secondary infection more likely. In persons with severely reduced immunity, such
as those with advanced HIV infection, or people being treated with immunosuppressive
drugs like steroids, a widespread rash with thick scaling may result. This variety of
scabies is called Norwegian scabies.

Scabies is frequently misdiagnosed as intense pruritus (itching of healthy skin) before

papular eruptions form. Upon initial pruritus the burrows appear as small, barely
noticeable bumps on the hands and may be slightly shiny and dark in color rather than
red. Initially the itching may not exactly correlate to the location of these bumps.

• Mite tunnels (burrows) may be seen on the skin as fine, dark, or silvery lines
about 2-10 mm long. The most common areas where they occur are the loose skin
 between the fingers, the front of wrists, and the hands. However, they can occur on
any part of the skin. You may not notice the burrows until a rash or itch develop.
• Itch is often severe. Itch tends to be in one area at first (often the hands), and then
spreads to other areas. The itch tends to be worse at night and after a hot bath.
• A rash usually appears soon after the itch starts. It is typically a blotchy, lumpy red
rash that can appear anywhere on the body. The rash is often most obvious on the
inside of the thighs, parts of the abdomen and buttocks, armpits, and around the
nipples in women. The look of the rash is often typical of scabies. However, some
people develop unusual rashes which may be confused with other skin conditions.
• Scratching sometimes causes slight skin damage. In some cases the damaged skin
becomes infected by bacteria - a 'secondary' skin infection. If skin becomes
infected with bacteria it becomes red, inflamed, hot, and tender.

Note: the itch and rash of scabies are due to an allergy (reaction) to the mites. These
symptoms usually take 2-6 weeks to occur after you are first infected (as the allergy
develops). The itch and rash can develop on any part of the skin, away from where the
mites are actually burrowing. So, at first, you may not know that you are infected until a
widespread itch and rash develop. You may pass the mite on to others before you have
any symptoms.

Some people believe that they are 'covered in mites'. This is usually not so. Commonly
there are just a few mites on the skin and just a few burrows. However, the allergy to the
mites can cause you to itch all over, and for a rash to appear on many parts of the body.

The picture above shows some typical mite tunnels (burrows) either side of the wrist skin
crease. It does not show the typical rash that occurs as a reaction to the mites. [14]

Diagnosis:

Generally diagnosis is made by finding burrows - which often may be difficult because
they are scarce, and because they are obscured by scratch marks. If burrows are not found
in the primary areas known to be affected, the entire skin surface of the body should be
examined.

The suspicious area can be rubbed with ink from a fountain pen or alternately a topical
tetracycline solution which will glow under a special light. The surface is then wiped off
with an alcohol pad; if the person is infected with scabies, the characteristic zigzag or S
pattern of the burrow across the skin will appear.

When a suspected burrow is found, diagnosis may be confirmed by microscopy of

surface scrapings, which are placed on a slide in glycerol, mineral oil or immersion in oil
and covered with a coverslip. Avoiding potassium hydroxide is necessary because it may
dissolve fecal pellets. Positive diagnosis is made when the mite, ova, or fecal pellets are
found. The action of the mites moving within the skin and on the skin itself produces an
intense itch which may resemble an allergic reaction in appearance. The presence of the
eggs produces a massive allergic response which, in turn, produces more itching.

Treatment:

Scabies is curable. The usual treatment is with permethrin 5% dermal cream.

Permethrin is an insecticide that kills the mites. If permethrin cannot be used, an
alternative is to use a lotion called malathion 0.5% aqueous liquid. (For example, some
people may be allergic to permethrin.) You can buy both of these products from
pharmacies. You can also get them on prescription. They are easy to apply and normally
work well if used properly. Re-apply the same treatment seven days after the first
application. This helps to make sure that all the mites are killed.

The following is a general guide about treatment which gives tips for success.

• You need to treat all the skin of your body (including the back, soles of the feet,
between fingers and toes, under fingernails, scalp, neck, face, ears, and genitals).
This may be different from what is said on the the package information. The
package may say to only apply from the neck down for adults. However, national
guidelines recommend that all the skin is treated. Pay special attention to the areas
where mite burrows most commonly occur. That is, the front of the wrists and
elbows, beneath the breasts, the armpits, and around the nipples in women.
• An adult needs at least 30g of cream or 100ml of lotion to cover the whole body.
So, for two applications you will need at least 60g of cream or 200ml of lotion per
adult.
• Apply cream or lotion to cool dry skin (not after a hot bath).
• The cream or lotion should be left on for the full recommended time. This time can
vary depending on which one you use. For example, it is 8-12 hours for permethrin
cream and 24 hours for malathion lotion.
 • Children should stay off school until the first application of treatment has been
completed.
• If you wash your hands or any other part of your body during the treatment period,
you should re-apply the cream or lotion to the washed areas.
• Breastfeeding mothers should wash off the lotion or cream from the nipples before
breastfeeding, and re-apply treatment after the feed.
• Put mittens on babies to stop them licking the cream or lotion off their hands.
• Clothes, towels, and bed linen should be machine washed at 50 degrees Celsius
(50°C) or above after the first application of treatment. This kills any mites that
may be present. Keep any items of clothing that cannot be washed in plastic bags
for at least 72 hours to contain the mites until they die. An alternative option to kill
any mites on clothes and linen are: ironing the item with a hot iron, dry cleaning, or
putting items in a dryer on the hot cycle for 10-30 minutes. It is not necessary to
fumigate living areas or furniture, or to treat pets.
• Some people who develop a secondary skin infection may also need antibiotics.

See a doctor if the itch persists longer than 2-3 weeks after treatment. Sometimes the first
treatment does not work, and a different one is then needed. However, the common
reasons why treatment fails, or for scabies to recur, are:

• The cream or lotion is not put on correctly for the full time, or
• A close contact is not treated at the same time, and the infection is passed back.

Medications

• Permethrin[3]: Another pesticide, lacks carcinogenic and teratogenic testing in

humans although animal tests showed no signs of carcinogenic or teratogenic
effects. Toxicity may resemble allergic reactions.[4]
• Eurax (USP Crotamiton)[5]
• Malathion Applied for 24 hours effective in killing adults and eggs.
• Lindane (Kwellada): For use with patients where permethrin has failed or is
contraindicated.[6]

Lindane is FDA approved as safe and effective when used as directed for the
second-line treatment for both scabies and lice. Serious side effects are rare and
have almost always resulted from product misuse.[7][8] Lindane is registered for
use in 50 countries, with restricted-use status in 33 of these countries.[8][9] The
latter includes the U.S. and Canada, which support public health uses of
pharmaceutical lindane but no longer allow agricultural applications.[8][10] Lindane
should be washed off with warm, and not hot, water to avoid absorption through
the skin.[11]

• There is some evidence that a 10% sulfur ointment in petroleum jelly applied
topically is effective. It is cheap and readily available over-the-counter.[12][13] It
 also has the advantange of being able to be used in pregnant women and infants
under two months of age.

Oral

A single dose of ivermectin has been reported to cure scabies. In 1999, a small scale test
comparing topically applied Lindane to orally administered ivermectin found no
statistically-significant differences between the two treatments.[14]

Prevention of disease:

All family and close contacts should be treated at the same time, even if asymptomatic.
Cleaning of environment should occur simultaneously, as there is a risk of reinfection.
Therefore it is recommended to wash and hot iron all material (such as clothes, bedding,
and towels) that has been in contact with scabies infestation.

Cleaning the environment should include:

• Vacuuming floors, carpets, and rugs.

• Disinfecting floor and bathroom surfaces by mopping.
• Cleaning the shower/bath tub after each use.
• Daily washing of recently worn clothes, towels and bedding in hot water, drying
in a hot dryer and steam ironing.
• Consistently rubbing antibacterial lotion on infected areas.
• Trying to keep infested areas covered by clothing or band aids.
• Avoid contact with anus or genital areas, if infected, permanent damage may be
caused

Geographical Distribution:
Scabies mites are distributed worldwide, affecting all races and socioeconomic classes in
all climates.
Disease Statistics:
Prevalence of Scabies: common

Hospitalization statistics for Scabies:

The following are statistics from various sources about hospitalizations and Scabies:

• 0.0032% (414) of hospital consultant episodes were for scabies in England

2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 85% of hospital consultant episodes for scabies required hospital
admission in England 2002-03 (Hospital Episode Statistics, Department of
Health, England, 2002-03)
 • 51% of hospital consultant episodes for scabies were for men in England
2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 49% of hospital consultant episodes for scabies were for women in
England 2002-03 (Hospital Episode Statistics, Department of Health, England,
2002-03)
• 86% of hospital consultant episodes for scabies required emergency
hospital admission in England 2002-03 (Hospital Episode Statistics, Department
of Health, England, 2002-03)
• 8.3 days was the mean length of stay in hospitals for scabies in England
2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 2 days was the median length of stay in hospitals for scabies in England
2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 37 was the mean age of patients hospitalised for scabies in England 2002-
03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 12% of hospital consultant episodes for scabies occurred in 15-59 year
olds in England 2002-03 (Hospital Episode Statistics, Department of Health,
England, 2002-03)
• 36% of hospital consultant episodes for scabies occurred in people over 75
in England 2002-03 (Hospital Episode Statistics, Department of Health, England,
2002-03)
• 4% of hospital consultant episodes for scabies were single day episodes in
England 2002-03 (Hospital Episode Statistics, Department of Health, England,
2002-03)
• 0.0053% (2,782) of hospital bed days were for scabies in England 2002-03
(Hospital Episode Statistics, Department of Health, England, 2002-03)

Refrence:
1. http://kidshealth.org
2. www.dpd.cdc.gov
3. The topical medication of choice is 5% permethrin because it is safe for all age
groups.Scheinfeld NS (2004). "Controlling scabies in institutional settings: a review of
medications, treatment models, and implementation.". Amer J Clin Dermatol 5 (1): 31–7.
PMID 14979741.
4. http://npic.orst.edu/factsheets/permethrin.pdf
5. http://www.nlm.nih.gov/medlineplus/druginfo/uspdi/202170.html
6. FDA Public Health Advisory: Safety of Topical Lindane Products for the Treatment of
Scabies and Lice
7. U.S. Food and Drug Administration (FDA). Lindane Post Marketing Safety Review.
Posted 2003. Available at:
http://www.fda.gov/cder/drug/infopage/lindane/lindaneaeredacted.pdf.
8. http://www.fda.gov/cder/foi/label/2003/006309lotionlbl.pdf.
9. Commission for Environmental Cooperation. North American Regional Action Plan
(NARAP) on lindane and other hexachlorocyclohexane (HCH) isomers. November 30,
2006.
10. U.S. EPA. Assessment of lindane and other hexachlorocyclohexane isomers. February 8,
2006
11. Medication Guide Lindane Lotion USP, 1%. Updated March 28, 2003. Available at:
http://www.fda.gov/cder/drug/infopage/lindane/lindaneLotionGuide.htm.
12. Lin AN, Reimer RJ, Carter DM (1988). "Sulfur revisited". J Am Acad Dermatol 18: 553-
58.
13. Pruksachatkunakorn C, Damrongsak M, Sinthupuan S (2002). "Sulfur for Scabies
Outbreaks in Orphanages". Pediatric Dermatology 19 (5): 448-53. doi:10.1046/j.1525-
1470.2002.00205.x. Retrieved on 2008-08-01.
14. Efficacy and Safety of Therapy for Human Scabies Infestation - January 15, 2000 -
American Academy of Family Physicians
15. http://www.patient.co.uk
16. www.stanford.edu
17.