Scabies best practice in residential aged care Julie Daltrey RN MN (Hon) Clinical Nurse Specialist Gerontology Julie.daltrey@waikatodhb.health.nz 021 2235917
Why a clinical guideline? Variable quality public information, Norwegian (19 th C), linen out in sunlight, apply cream chin down, acquired from children and sexually transmitted, you can see grey trail and black pinhead. Variable quality medical information Topical scabicide apply as a once only or repeated treatment, take skin scrapings Books old (1985 Cutaneous infestations and insect bites) Centres for Disease Control and Prevention (CDC), specifically address institutional settings Public health / Dermatology / Nursing
Why residential care guideline? Trend identified recurring Scabies Scabies contagious (contact) disease of skin characterised by intensely itch rash that is an allergic reaction to mite Special environment Atypical immune responses Close contact living Complicated by dementia and inability to isolate Reputation and media/public perception Logistics and scale - opportunity for treatment failure Incubation period 2-6 weeks for first infestation only 1-2 days in previously infested hosts (immune system sensitivity) Contagious during incubation period
Successful infestation control Surveillance (active early detection program ) Minimise transmission of mites & bacterial infections Adequate diagnostic services Realistic isolation and treatment Practical environmental decontamination Identify & notify at risk residents / staff no longer at facility Active employee health services (includes dermatological consultation for employees & families as indicated) A cooperative attitude management, staff and other facilities
Is this a new problem? 348-323 BC Aristotle - lice in the flesh 1752 John Pringles - Observations of disease of the army 1801 Joseph Adams - for more than 3 weeks little or no inconvenience was felt, then began frequent itching body & arms 1844 - Scabies accepted as infestation not infection 1867 Rudolf Bergh - Crusted & Classical scabies same mite World war 1 and WW2 - major outbreaks
What is Scabies? Contagious inflammatory skin disease, caused primarily by female mite - Sarcoptes Scabiei (humanis) (mites 8L, insects 6L) Characterised: intensely itch rash that is an allergic reaction to the trail of debris, faeces and saliva deposited in the Straum Corneum
Natural history Sarcoptes Scabiei Food: skin cells Shelter: permanent borrows Prime real-estate: hands, wrists, elbows, penis/scrotum, buttocks, axillae, knees, navel, hips, thighs, belly, chest, feet Build time: speed at 2.5cm per minute (head-toe 1 hr), 1 hr to submerge, burrows 0.5-5 mm per day Reproduction: fertile for life (30-60 days) laying 2-3 eggs daily Eggs: hatch 3-4 days Adolescents: surface and have temporary accommodation (often at hair follicle or bottom of a skin fold) until mated
Diagnosis - clinical Clinical findings Suggestive history Examination Dermoscopy Ensure GPs know about all rashes to assist diagnosis Common alerts/challenges Diagnosed rash that does not respond to treatment Undiagnosed rash Persistent rash People treated for Scabies poorly & diagnosis dismissed Nurse/self initiated treatments Dermatitis/ Psoriasis does not exclude Scabies Differential diagnosis for itchy, spotty rash affecting 2 people (staff & residents) in ARRC Scabies until proved otherwise
One mite; many skin presentations Scabies: contagious disease of skin ccharacterised by intensely itchy rash - allergic reaction to mite Classical Scabies Crusted Scabies Nodular Scabies Complicated Scabies Few burrows / mites on hands & wrists, Papular rash on trunk & limbs, Intensely itchy worse at night & after hot bath shower Itch hypersens ty reaction to mite eggs & faeces 1000 s mites In the old, immune compromised. Burrows ++ causing thick scaling crusts. Palms finger webs, under finger nails, soles of feet, Mild/absent itch Easy transmission Delayed diagnosis and outbreaks Clusters of itched persistent 5-15mm nodules in armpits, groin and genital areas Indication of long term infestation Scabies associated with impetigo, cellulitis, dermatitis, pyelonephritis, abscess, pneumonia, septicaemia and other secondary diseases
Classical Typical staff Scabies small excoriations on forearms and hands Polymorphous rash, papules, hive like plaques, scratch marks
Classical Still classical Scabies, but extensive burrows in older adult, example of delayed diagnosis Single burrow
Burrow close-up Burrow Dermoscopy
Crusted
Nodular Burrow
Complicated Infection is usually staphylococci and streptococci
Treatment classical Scabies healthy mobile individuals treat topically 5% permethrin lotion (two doses one week apart) Systemic treatment with ivermectin may be considered to manage the shear logistics of applying topical treatment to multiple residents. Debilitated, bed-bound or immobile resident: oral ivermectin; 200 mcg/kg (two doses one week apart). 5% permethrin is an option, but treatment failure is common.
Treatment Crusted Scabies All individuals with crusted oral ivermectin; 200 mcg/kg. Successful treatment of crusted scabies can require 2-4 doses of ivermectin (each one week apart) Plus topical 5% permethrin all over (weekly) and to crusted areas (daily) esp under fingernails & on hands Plus 6% salicylic acid ointment applied to crusted areas (daily) to soften prior to washing or scraping off. Plus Careful follow up to ensure cure confirmed (dermatology)
5% permetherin Ivermectin Dose: Lotion one bottle/tube healthy, mobile individuals 98% cure rate with 2 treatments (1 week apart) Debilitated / immunosuppres d Treatment failure common Time consuming and logistical challenge apply, need attention to detail Cheap subsidised Dose: 200 mcg/kg, need weight healthy, mobile individuals 98% cure rate with 2 treatments (1 week apart) Debilitated / immunosuppres d superior to permethrin, single dose cure rate 70% Quick and easy Expensive now subsidised for crusted Scabies
Extent of Scabies Treatment One resident 1 unit* classical scabies resident cognitively intact One resident 1 unit classical scabies Resident confused wanders & is tactile One staff member classical scabies Two or more people (residents/staff)** 1 unit Two more people (residents/staff)** more than 1 unit Skin check ALL residents staff & visitors of unit Skin check ALL residents staff & visitors of unit Skin check ALL residents staff & visitors of unit Skin check ALL Residents, staff & visitors WHOLE facility Suspect undiagnosed CRUSTEDSCABIES for all skin conditions Skin check ALL residents, staff & visitors WHOLE facility Suspect undiagnosed CRUSTED SCABIES for all skin conditions Single case confirmed Single case confirmed Single case confirmed Scabies limited to 1 unit confirmed Treat ALL residents, staff, visitors WHOLE facility & close contacts affected staff & visitors Treat single resident & his/her close contacts Treat ALL residents & staff 1 unit & residents close contacts Treat staff member & His/her close contacts Treat ALL residents, staff, visitors 1 unit & close contacts affected staff & visitors
Transmission (contact people & environment)
Infection control precautions - contact Direct care - staff long sleeve impervious gowns & gloves for personal care, contaminated clothing and linen until patient successfully treated Laundry staff dissolvable bags launder without opening, if not possible as above Visitors limit during treatment, if not possible gloves and hand washing and minimise contact Isolation - if crusted isolation is required until at least second ivermectin treatment (may mean isolation of unit) Be aware Scabies can be spread by sexual contact (think about co-habiting residents)
Environment decontamination In a laboratory mite has survived off host for 14 days in warm most environments, in normal circumstances they live only a few days of host (may want to think of up to 1 week) Morning after treatment linen hot wash and hot dry Contaminated clothing (worn immediately prior or frequently handled) Vacuuming Detergent and water surface wiping Clean items shared by multiple residents (BP cuffs, wheelchairs) If you cant hot wash, isolate from host, (seal in plastic bag for 7 days, freeze below -20 for 12 hours)
Key Messages Its common for Outbreak investigations to find the long standing rash or pruritic (itchy) skin condition diagnosed as X is scabies If 2 residents have scabies, go hunting, crusted scabies is likely and it is imperative that this case is found Scabies presents in many different forms Diagnosis is clinical the GP needs to know the whole facility history not just this individual history Skin scraping in classical Scabies leads to false negatives and delayed diagnosis Clinical expertise is often required: Amanada Oakley Clinical Associate Professor of Dermatology, Midland regional expert oakley@wave.co.nz or amanda.oakley@waikatodhb.health.nz
Ivermectin now special authority funded 18 th July 2012 For patients in ARRC facilities, disability care facilities or penal institutions requiring ivermectin, special authority funding requires discussion with dermatology Up to 100 tablets of ivermectin will be subsidised on a practitioners supply order (PSO) which must be endorsed with the name of the institution; or A Bulk Supply Order (BSO) may be used to claim subsidies for patients requiring treatment. Brands Singulair & Stromectol http://www.pharmac.govt.nz/2012/07/19/montelukast%20and% 20ivermectin%20notification.pdf
Reference Oakley, A., reviewer (2009) Scabies diagnosis and management available from Best Practice Advocacy Centre New Zealand http://www.bpac.org.nz/magazine/2009/february/scabies.asp Scabies (DermNet NZ) http://www.dermnetnz.org/arthropods/scabies.html Orkin, M., & Howard, M., Ed (1985) Cutaneous infestations and insect bites Dejkker Inc New York. Michigen department of community health (2005) Scabies prevention and control manual available from http://www.michigan.gov/documents/scabies_manual_130866_7.pdf Centers for Disease Control and Prevention Parasites Scabies Resources for Health Professionals Institutional Settings; available from http://www.cdc.gov/parasites/scabies/health_professionals/institutions.html Lim, D., (2010) DermNet NZ Institutional scabies available from http://www.dermnetnz.org/arthropods/institutional-scabies.html J.Daltrey Guideline http://www.waikatodhb.govt.nz/file/fileid/41337 Walton, S., et al (1999) Genetically distinct human derived and dog derived scarcopites scabiei in scabies-endemic communities in northern Australia American Journal of Tropical Medicine and Hygiene 61(4) 542-547