Nlm-5724 pdf's

This article’s author is Raymond Otero, Ph.D.
A. Introduction
Scabies is an infectious disease of the skin caused by a mite whose penetration is visible as papules or vesicles or as tinylinear burrows containing mites and their eggs. It occurs worldwide and specifically in institutions where hygiene proceduresare suspect. It is also associated with overcrowding and poor hygiene. Scabies can be endemic.
B. Lesions
Lesions are prominent around the webs, anterior surfaces or wrists and elbows, anterior axillary folds, belt line, thighs andexternal genitalia in men, nipples, “ abdomen, and lower portion of buttocks in women. In infants, the head, neck, palms andsoles may be involved. These areas are generally spared in older individuals.
C. Itching
Itching is intense, especially at night, but complications are limited to lesions secondarily infected from scratching.
D. Immunosuppressed and older patients
In immunodeficient individuals and in elderly patients, infestation often appears as a generalized dermatitis more widelydistributed than burrows with extensive scaling and sometimes vesiculation and crusting.
Infestation with Sacroptes scabiei var. hominis, a mite, causes scabies.
Transmission
Transfer of parasites is by direct contact only (skin-to-skin). Transfer from undergarment or bedclothes may occur only ifthese have been contaminated by infected persons immediately beforehand Scabies can be transmitted sexually. Mites canburrow beneath the skin surface in 2.5 minutes. Norwegian scabies is highly infectious due to large numbers of mites in theexfoliating scales.
G. Reservoir
Humans are the most common reservoir for scabies infestation.
H. Incubation period
Incubation period is 2 to 6 weeks before onset of itching in persons with previous exposure. Persons who have beenpreviously infested may develop symptoms in 1- 4 days after re-exposure.
Period of communicability
A person remains communicable until mites and eggs are destroyed by effective treatment.
Complications
Persistent pruritus caused by secondary mite sensitization is a complication of scabies. Intense scratching can lead tosevere excoriation, tissue trauma and secondary bacterial infections, e.g. Staphylococcus aureus, Streptococcus pyogenes.
K. Diagnostic tests
Potassium hydroxide wet mounts of burrows scraping may reveal adults, larvae and eggs. For optimal results a dermatologist ormicrobiologist/technologist on site should perform this on site.
a) gloves
b) magnifying glass
c) gooseneck lamp or flashlight (bright)
d) felt tip pen-green or blue washable ink
e) alcohol swabs
f) #15 scalpel blades, glass slides for scraping, or curettes
g) scalpel holder
h) Kelly clamp or other forceps
i) slides and cover slips
j) mineral oil
k) requisition form, if slides are being sent to a clinical lab (private, hospital, state)
I) sharp
Procedures for doing skin scrapings (From the Kentucky Department of Health Services, Communicable Disease Branch -1996): a) Establish and confirm the diagnosis by skin scraping and microscopic identification of mites, eggs, or scybala (fecalpellets). A nurse from the facility, can be taught this procedure by a dermatologist, the consulting physician or by a nurse ortechnician who has had professional training in doing the procedure.
Mass treatment should not be initiated unless a definite diagnosis has been made in at least I of the symptomatic cases.
Scrape those persons with the most severe rash first. The elderly may present with severe urticaria and bullous lesions.
Shoulders, back and abdomen are choice areas for scraping in the elderly. Other sites; hands, wrists, elbows, feet, ankles,buttocks, axillae, knees, thighs, and breasts.
Use a hand magnifying lens to identify recent burrows or papules. A bright light and magnifying glass will assist in visualizingthe tiny dark speck (the mite) at the end of the burrow.
Identify these high yield lesions by applying mineral oil (best used over dry scaly areas) or by applying the burrow ink test topossible burrows. The burrow ink test is done by using a wide felt tip pen (blue or green are best) over burrows and thenwiping off with an alcohol swab. The alcohol will remove most Of the surface ink, but will not remove the ink taken up by theburrow, thus leaving a dark irregular line.
Apply mineral oil or preferably microscope immersion oil to lesions or scalpel blade and glass slides.
Scrape non-excoriated, non- inflamed areas (burrows and papules) vigorously witb a #15 scalpel blade or glass slide held ata 90 angle to the skin and while holding the skin taut until the stratum corneum is removed. (Vigorous scraping appropriatelyresults in a few red blood cells visible under the microscope, but there should not be frank bleeding.) Some practitionersprefer using a small curette. Change blades or curettes between scraping on different persons. Blades can be placed andremoved from the handle with forceps. Used blades must be placed in a sharps container.
Transfer skin scrapings from 6 different sites to a single slide or to 6 different slides per patient. These scrapings can bepushed onto the slide edge and then moved to the center of the slide.
Place the cover slip over the slide.
10. Examine entire slide methodically under low power at 25-50x magnification for at least 5 minutes. Low power (1.5-4 x) is useful initially. The microscope should be taken to the facility; however, if the practitioner is not trained in reading the slides,the cover slip should be secured to the slide at all edges with clear nail polish and transported personally, by courier, or bymail (in a secure mailer) to:a hospital or rural clinic laboratory with pre-arrangements: or, a physician’s office with pre-arrangements.
L. Method of Control
Education of the public, healthcare workers, patients resident and immediate families on modes of transmission andtreatment should be performed on a regular schedule.
The use of Standard Precautions (formerly called Universal Precautions) is satisfactory. If the patient is unable to be taughtand is threat and to other patients, private room should be considered for 24 hours after start of medication.
Normal laundering procedures at temperatures of 140 F is more than adequate to destroy the mite and their eggs. There isno need to bag items of clothing or linens for 48 hours or longer prior to washing.
Search for unreported or unrecognized cases among companions or household members. Treat persons prophylacticallywho has had skin-to-skin or sexual contact with infested person. Check with medical staff of the possibility of infestation. If astaff member has become infested by a patient and is treated, then an OSHA 200 form must be completed. Treatment
a. Pennethrin (5% cream-Elimite)- thoroughly massage into skin covering the entire body (except the head) from the soles ofthe feet to the neck. For infants, young toddlers, and geriatric patients, it should be applied to the entire body including thescalp, neck, temples and forehead because the mite often infests these areas in those age groups.
After 8-14 hours, shower to remove. Contact with eyes and mouth should be avoided. One application is almost curative.
Note (from the Kentucky Department of Health Services): Elimite is still considered the drug of choice by several
authorities including the 1997 American Academy of Pediatrics “Red Book” and the Medical Letter, January 2, 1998. Both
references recommend alternative drugs, ivermectin and 10% crotamiton (Eurax).
b. Crotamiton 10% (Eurax)- apply from neck down. Cream must be thoroughly massage into skin. Apply twice a day for 5days.
c. Lindane 1 % (gamma benezene hexachloride- Kwell cream)- apply to all areas from neck down. Wash off after 8 hours.
Retreat after one week if no improvement.
Notel: Pruritus and rash may persist for 1 to 4 weeks after treatment. Pruritus and residual rash should not be consideredtreatment failure until 1 month after last treatment. To prevent or lessen the possibility of these signs and symptoms, somedermatologists use 1 % hydrocortisone cream or triamcinocolone cream (0.1% - 0.025% ) applied to the most intense rash and alubricating agent or emollient to the lesser rash for children. A 1% hydrocortisone cream or triamcinolone cream (0.1% ) can beused on adults. Steriod creams should not be applied until after the first scabicide treatment. Overtreatment is common andshould be avoided because of toxicity, especially with Lindane. Close supervision of treatment including bathing is necessary ofresidents in a long-term care to prevent toxicity because of poor application.
NOTE; An excellent document written by Kentucky Department of Health Services, Division of Epidemiology, Frankfort, Kentuckyon the treatment of Scabies can be obtained by calling 502-564-3261.
a. infected or crusted lesions did not allow penetration of scabicide need to soften scaliness; b. re-infestation from untreated contacts
M. Nursing interventions
1. Have the patient’s fingernails cut short to minimize skin breaks from scratching, which may lead to bacterial infections.
2. Suggests that the patient/ resident’s family and other close personal contacts be checked for symptoms.
3. Have the patient notify sexual contact(s).
4. H the patient is a school child, notify the school of his/her condition.
5. Be alert for complications associated with treatment.
6. Encourage the patient/resident to verbalize his/her feels about the infestation, including embarrassment, fear of rejectionby others and body image disturbance.

N. Patient teaching
1. Teach the patient and his! her family to identify the characteristic lesions and the models of transmission.
2. Assure the patient and his/her family that the infestation can be treated successfully with good hygiene and the use ofpeiculicides.
3. Stress the importance of meticulous hand washing to prevent the infection’s spread and recurrence.
4. Show patient/resident the manner or application or pediculicide.
5. Teach the patient/resident the signs of skin irritation and hypersensitivity reactions.
6. Advise the patient/resident to report to the nurse or physician immediately if these signs develop.

0. References
Control or Communicable Disease Manual, A. S. Benenson, Editor. American Public Health Association. Pp. 415 -414. 1995.
American Academy of Pediatrics. 1997 Red book The Medical Letter, Volume 40, Issue 1017. January 2, 1998.
Conn’s Current Therapy. W. B. Saunders. Pp. 845 -846. 1999.
Everything you need to know about diseases. Pp. 572 -573. Springhouse Corporation. 1996.
Saunders Manual of Medical Practice. R. Rakel. W. B. Saunders Company. Pp. 991 -993. 1996.

Source: http://almnet.org/associations/1437/files/scabies.pdf