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Clinical presentation of scabies in older care home residents differs from classic descriptions

Prospective study of scabies outbreaks in ten care homes for older people

Prospective study of scabies outbreaks in ten care homes for older people 

Staff should look for skin lesions, especially in people with dementia. Picture: Science Photo Library

Scabies is caused by a mite that burrows into the skin. Scratching and parasite-induced inhibition of local immune response can lead to a secondary bacterial infection. Older residents in care homes are missing out on being diagnosed with scabies because symptoms differ from those in younger people.

Unlike the typical presentation on the hand, seen in younger age groups, older people often have burrows only in areas normally covered by their clothes. They may show fewer symptoms of the condition and may not have itching. As a result, vulnerable people may not be getting the necessary treatment.

Scabies outbreaks in residential care homes for older people are challenging to diagnose, stigmatising and costly to manage. The close proximity of individuals and lengthy asymptomatic incubation period enable many residents and staff to become infested before detection. Management of outbreaks comprises repeated simultaneous mass treatment with topical scabicide applied over the whole body and environmental decontamination. Mass treatments are labour-intensive and can distress residents, many of whom have dementia and might not understand why they are receiving treatment.

This study involved dermatology-trained physicians examining all consenting residents in homes that reported an outbreak consisting of two or more cases of scabies. During ten outbreaks in care homes physicians examined 230 residents and found that more than a quarter of those examined had scabies.

People with dementia vulnerable

Of these 61 people, 31 were asymptomatic, and only 25 had burrows. People with dementia were found to be particularly vulnerable. Healthcare staff should be aware of the different presentation of scabies in older people, and should look carefully for skin lesions, especially in those with dementia.


Cassell J, Middleton J, Nalabanda A et al (2018) Scabies outbreaks in ten care homes for elderly people: a prospective study of clinical features, epidemiology, and treatment outcomes. The Lancet. Infectious Diseases 18, 8, 894-902. 

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