All correctional medical people should be able to recognize scabies by sight.
Just to review, scabies is a tiny mite that burrows beneath the skin and causes intensely itchy lesions. Since the mite wanders (as little animals will do), scabies tends to spread with time, and can be passed from individual to individual. Weirdly, scabies does not cause lesions above the neck, probably because of the increased blood supply there. If you are interested, you can find more detailed information on scabies in Wikipedia.
Scabies is found commonly in correctional facilities. Both nurses and practitioners need to be able to spot scabies, hopefully before it spreads throughout a housing dorm!
Fortunately, scabies is pretty east to diagnose just by looking at it–no other rash really looks like it. A typical scabies infestation has the following characteristics:
1. Pinpoint red dots.
2. That are intensely, drive-you-crazy, itchy.
3. They tend to spread.
4. And are not found above the neck.
If you see a rash that meets all of those characteristics, it’s scabies more than likely. You can double-check the diagnosis by doing skin scrapings and examining them under the microscope. But you can also use your treatment as a diagnostic test. If the treatment cures the rash, it was scabies. If not; then do the scrapings or look for another cause (like a treatment failure, discussed below).
Scabies has two effective treatments, permethrin 5% cream (Elimite) and ivermectin tablets (Stromectol). Permethrin is the treatment that historically has been most commonly used, mostly because it has been less expensive than ivermectin. Permethrin cream is used like this: The patient takes 30 grams of the cream and rubs it into every square inch of their skin from the neck down, including hard-to-reach places like between the toes, the soles of the feet, their backside etc. The cream is left on for 8 hours and then is washed off. This process is repeated in one week.
The problem with permethrin is that it is easy to miss a spot which gives the scabies a safe haven to survive and keep going. In corrections, the best way to avoid a treatment failure like this is to have medical personnel watch the inmate apply the permethrin to make sure they do it right. If you do this, you will find that almost nobody applies the permethrin correctly if not observed.
Ivermectin is much simpler. It comes as a 3 mg tablet. The dose for treating scabies is 200mcg/kg. If you do the calculations for a standard sized adult male (like me), the dose calculates out to 4 tablets, given one time. This dose is repeated in two weeks. No cream. No watching the application. Simple. The main reason permethrin has been historically used rather than ivermectin has been the cost, but that recently changed. A couple of months ago, permethrin cream dramatically jumped up in price.
Which is Cost-Effective?
The most recent acquisition cost of 30 grams of generic permethrin 5% cream is $23.00.
The current acquisition cost of four tablets (3 mg) of brand name Stromectol is $18.44.
Ivermectin is not only easier to give as a treatment for scabies, it is also less expensive! Think about adding it to your formulary as a treatment for scabies.
(Different pharmacies often charge different prices for the same drugs, so be sure to check the exact prices with your pharmacy).
Has your facility had an infestation of scabies? How did you handle it?