Scabies Scabies is a very contagious skin disease caused by the barely visible parasitic mite Sarcoptes scabiei. These mites are found worldwide but are more common in places frequented by lots of people, such as prisons, hospitals, rest homes, refugee camps, university or school dormitories. Symptoms A mild rash on the limbs and trunk which is intensely itchy is usually the most common presenting symptom, which can be easily misdiagnosed as dermatitis. The rash associated with scabies typically develops several weeks after infestation, unless the person has been infested before, in which case it may start within a few hours. The itchiness is the result of the affected person developing an allergic reaction to the mite’s eggs, faeces and saliva. The itch tends to worsen at night or after a hot bath or shower. Scabies may also present with itchy lumps or nodules in the armpits and groin or along the shaft of the penis. These nodules usually persist for several weeks after successful eradication of the living mite. Scabies rarely affects the face and scalp, but is more likely to do so in young babies and bed-bound elderly patients. Young children are also more likely to have blisters and pustules on their palms and soles. Transmission of the mite to others is high during the period of time before the infected person becomes itchy and realises that they have scabies. The mite is easily spread through direct skin-to-skin contact for just a few minutes (eg, holding hands, sexual contact). Transmission can also occur from sharing clothing, towels and bedding as the mite can live for up to three days off a human’s skin. Poverty and overcrowding are a factor in transmission although scabies is not due to poor hygiene, or from contact with animal mites. Typically, several mites are responsible for the initial infection. After mating, the male mite dies and the female burrows into the top layer of skin and lays approximately two to three eggs per day during her lifespan of one to two months. It takes 10 to 14 days for an egg to hatch and develop into an adult. Crusted scabies Crusted scabies (also called Norwegian scabies) is an extremely severe form of scabies in which there are thousands or even millions of mites, but very little itch. It is extremely contagious and often responsible for outbreaks of scabies in hospitals, resthomes or prisons. It is frequently misdiagnosed as psoriasis because the thickened crusts of skin containing the mites look like psoriasis plaques. Crusted scabies is more likely to develop in people with a poor immune system, neurological disease, with mental impairment or who are elderly. Oral ivermectin prescribed by a doctor may be necessary for effective treatment. Initial assessment Wearing gloves, search carefully for burrows in customers complaining of severe itch, especially if the rash looks mild. Burrows look like a 5–10mm zigzag line and are most commonly found between the fingers or on the wrists or palms, although may be present in the armpits, buttocks, on the genitalia, insteps of the feet or backs of the heels. In some people, it may be difficult to see the burrows as they may be obscured by scratching, eczema or an infection. Normally the mite is too small to see with the naked eye (a full-grown mite is about the size of a pinpoint). Refer any customer with signs of a secondary bacterial infection of the rash (such as crusted patches or pus) or cellulitis (an infection of the deeper dermal layer of the skin that causes painful swelling, intense redness and fever) to a doctor. Also refer any customers with "yes" answers to the Refer to Pharmacist questions to a pharmacist. Treat all other customers with a suitable scabicide. Treatment Treatment is with a scabicide (eg, permethrin, malathion) which, for adults, is applied to the entire body from the chin and ears downwards. Most people will require help to get to hard-to-reach areas, such as their back. Permethrin products need to be left on for eight to 14 hours, and Malathion for 24 hours before washing off. Advise customers to use a nailbrush to get the product under their nails and to pay particular attention to the finger and toe webs. In children aged six months to two years, the face and scalp may need to be included as well, but this should only be done under further advice from a pharmacist. Products are best applied to the body after a bath or shower once the skin has cooled down. All household members, and anybody with recent direct and prolonged contact with a person with scabies, should be treated at the same TREATMENT OPTIONS Category Examples Comments Treatment products [GENERAL SALE] eg, malathion [GENERAL SALE] eg, crotamiton (Eurax Cream, Itch Soothe Cream) [GENERAL SALE] eg, permethrin (A-Scabies Lotion, Lyderm) Effective against scabies, head lice and body lice. Follow packet dosage instructions. This water-based product may be less irritating to people with asthma or sensitive skin, and less irritating to sensitive areas such as the genitalia. This has been used in the past to treat scabies, although it is not as effective as other products. Best used to treat the itch that persists after scabies treatment (just apply to the affected areas). Effective against scabies. Pregnant women and children aged between two months and two years should be treated under medical supervision. @PharmacyToday. A part of your everyday. New Zealand’s only e-newsletter designed specifically to provide a news snack for pharmacy. With links to PharmacyToday.co.nz you’re only a click away from the full story. Page 130 HEALTHCARE HANDBOOK 2017-2018 Common Disorders
CONTINUING OTC EDUCATION time, even if they are not itchy. It is important to tell people they may still remain itchy for up to four weeks after they have treated their scabies, due to the continuing allergic reaction to the mite’s byproducts until they are cast off by the skin. However, a persistent itch may also be due to incorrectly applied treatment, reinfestation, or ongoing dermatitis. In some circumstances the customer may have had an incorrect diagnosis. Anybody worried about their persisting itch should be re-examined by a doctor or pharmacist. Crotamiton cream, oral antihistamines, 0.5% hydrocortisone cream, or emollients may be applied to relieve this itch. Advice for customers • Follow the product instructions exactly and ensure product stays on for the recommended length of time before being washed off. »» The whole body needs to be treated, not just the itchy areas »» Reapply product to the hands if they are washed within the treatment time. • A second application may be given after at least seven days if there are no signs of the original lesions healing or if new burrows have appeared. • Consider taking oral antihistamines, or using topical crotamiton, moisturisers, or hydrocortisone cream for help with the itch, which may persist for up to four weeks after treatment. • Treat everyone in the house and at the same time, even if they have no signs of scabies. »» Advise family members, friends and babysitters who have been in the house that they will also need to be treated. »» If multiple family members require treatment and cost is an issue, inform customers that some products are subsidised on a prescription from a doctor. • Wash in hot water any bedding, clothing or soft toys that have come into contact with the infected person. Alternatively, seal objects in a plastic bag for one to two weeks. »» Hang other bedding outside in the sun for a day, and thoroughly vacuum carpets and furniture. Refer to PHARMACIST The following questions aim to identify customers who would benefit from further input from a pharmacist. Your initial assessment may have already provided some answers. Decide if any further questions still need to be asked and refer any “yes” answers to a pharmacist. • Does the person have any other health conditions (eg, lung problems, immunosuppression, diabetes, is pregnant or breastfeeding)? • Is the itch severe or extensive? • Is the diagnosis uncertain? • Will the treatment be used on a child under two? • Is there evidence of crusting or pus from scratching? • Is the scratching localised in one specific area? • Does the person also suffer from dermatitis or other skin conditions? • Have the symptoms persisted or recurred despite treatment (note that itch can persist for several weeks)? • Does the person have any allergies to topical medicines? Page 131
According to Stéphane Rossini, incoming Chairman of the Agency Council, the culture of collaboration will remain a factor in ensuring that Switzerland is successful in retaining a high-quality medicines control system: “A globalised economy and the international consumption of therapeutic products entail synergies and collaboration.”
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