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When your resident has scabies
When Your Resident Has Scabies Scabies is often overlooked in elderly persons because it may be confused with eczema, dry skin, and generalized itching. Look for these signs. By
PAM
HUFFORD
NICHOLLS
ave you noticed residents scratching? Have particular residents seemed a little more irritable? Do not dismiss these clues: They may indicate scabies. The cause of scabies was discovered in 1687. 1 Scabies outbreaks previously occurred in 30-year cycles,1 but a current pandemic exists, with an estimated 300 million cases occurring worldwide every year. 2 The disease can strike anyone, regardless of class, race, age, or personal hygiene habits.
H
Who Is at Most Risk?
Scabies is common among people living in crowded conditions, and should be considered for those spending time in close quarters, such as among those in nursing homes, institutions, day-care, prisons, and the military, as well as the homeless. Most at risk are those who have weakened immune defenses, such as transplant patients, AIDS patients, and older adults. Scabies is often overlooked in elderly persons because it can be confused with eczema, dry skin, generalized itching or scratching due to anxiety. Often secondary infection is already present, complicating the picture and delaying the diagnosis. Clinical Manifestations
Scabies is a transmissible parasitic infestation caused by the itch mite, Sarcoptes scabiei. It is spread by prolonged skin contact and affects both men and women and children. Transmission through clothing and other inanimate objects is uncommon, as the mite can only survive
PAM HUFFORD NICHOLLS, RN,C, is MDS assessment coordinator at the Riverside Nursing Center in Dayton, Ohio. GERIATR NURs 1994;15:271-3. Copyright © 1994 by Mosby-Year Book, Inc. 0197-4572/94/$3.00 + 0 34/1/56891
GERIATRIC NURSING Volume 15, Number 5
out of human skin for approximately 36 hours.' Infestation may occur from cats, dogs, and other small animals. Scabies is characterized by pruritis, and excoriations with secondary infection. Primary lesions most commonly occur in the finger-webs, the flexor surfaces of the wrists and extensor surfaces of the elbows, the axillary folds, the waistline, around the areolae in women and the genitalia in men, the knees, and the lower buttock. Patients who have neurologic disorders or various forms of immunodeficiency may have the highly contagious crusted scabies (also known as Norwegian scabies), characterized by nonpruritic scaling on palms and soles due to infection with a great number of mites. I, 5
A pandemic exists, with an estimated 300 million cases occurring worldwide every year. The adult itch mite has a rounded body about onefiftieth of an inch long. The skin lesions are caused by the female mite, which burrows beneath the skin and digs a short tunnel parallel to the surface, in which it lays its eggs. The mite extends the burrow, which is a few millimeters to 1 em long daily, depositing eggs and feces. The eggs hatch in a few days, and the baby mites find their way to the surface, mate, and multiply. Initially, during the tunneling, the resident may be unaware of what is happening. There is little itching and few lesions. After 1 to 6 weeks, however, due to hypersensitivity to the mite, the itching becomes intense, particularly at night. But if a person has been plagued with scabies in the past, a rash may often develop in 1 to 3 days. The burrows may be seen as a slightly elevated, wavy grayish white to dark line. The burrows may be difficult to find because they are obscured by scratching or
Nicholls
271
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------
--I
i
BOX 1. TREATMENT OF SCABIES
I
PERMETHRIN 5% CREAM-A single overnight dose left on for 8 to 14 hours has proved effective in over 90% of cases. 2 This cream locks systemic toxicity. LINDANE 1 %-AI'l overnight application left on for 8 to 12 hours is effective in 1 to 2 doses, with the second dose not to be given sooner than 7 days. 1t is not recommended for young children, in pregnancy, or in patients with seizure disorders or neurologic disorders.' SULFUR OINTMENT-An older treatment, not as desirable because of odor, messiness, and staining; it is used in children, pregnant and lactating women, and patients with seizure or neurologic disease.' CROTAMITON 10% CREAM-Another treatment option.
by secondary lesions, such as eczema, urticaria, scratch dermatitis, or superimposed bacterial infection. Diagnosis The mite itself may be seen by means of the burrow ink lest. A. blue Or black felt-tipped pen is applied to suspected lesions and partially removed with an alcohol pad; ink is retained in the burrows." With a magnifying glass the mite can sometimes be seen as a tiny black speck at the papule end of a tunnel. Definitive diagnosis is made microscopically. Treatment Treatment is curative and may be suitable in doubtful cases. An anti-infective (scabicide) agent is ordered (see Box l). Lindane, once the standard treatment, has been replaced by a synthetic pyrethroid or insecticide, as the scabies mite has developed some resistance to lindane. I Bathing before the application is no longer recommended because this may increase skin absorption and central nervous system toxicity. Follow specific instructions ordered by physicians. Before applying the cream, trim residents' nails as short as possible without cutting into the quick. With a cotton-tipped applicator or a soft toothbrush, gently work the lotion into the folds of skin at the sides of the nail, into the cuticle, and under the free edge of the nail. It is important to put the cream on every square inch of the body, not just where the rash is. Application is recommended to face, neck, cars, postauricular grooves, and scalp (after regular shampooing). Never apply the cream to eyelids or to lips. Most lotions recommend that they remain on for 12 to 24 hours. Some itching, mild burning, or stinging may occur after application. If hands are washed during this period, more lotion should be reapplied. Reapplication of the scabicide is sometimes recommended a week later to be sure all eggs are killed. Oral antihistamines are usually ordered to decrease pruritis. A topical corticosteroid cream may be used to hasten healing of secondary dermatitis. Concomitant bacterial infections may necessitate the use of systemic
272
Nicholls
antibiotic agents, but often such infections clear spontaneously when scabies is cured. Patients may experience persistent itching for up to 4 weeks after treatment. This is rarely a sign of treatment failure and is not necessarily an indication for retreatment. It takes about a month after the mites have been killed for the rash to disappear. All affected persons should be treated at the same time. Family members in close contact should be encouraged to be treated. Staff members should also be treated, as well as their family members. Everyone must be informed that transmission is possible soon after infestation, during the asymptomatic period before the appearance of rash. Residents who have had close contact with a potentially infected resident, such as dining room partners or those they sit next to in lounges or during activities, should also be considered for treatment. Nursing Care The National Centers for Disease Control recommends the wearing of gowns and gloves for staff and visitors with close contact with an infected person to be continued until 24 hours after initiation of therapy.f Masks are not necessary. Handwashing cannot be stressed enough.
It takes about a month after the
mites have been killed for the rash to disappear. At the beginning and end of the initial treatment course, and at the beginning and end of each succeeding treatment course, all bed linens, previously worn clothing, and washable footwear should be laundered in hot water or dry cleaned. Laundry isolation should be in effect until completion of treatment. Articles of clothing that cannot be laundered or dry cleaned (such as shoes) should be placed in a sealed plastic bag and not worn by the patient for a 14-day period. At the time of initial treatment, the mattress on a resident's bed is to be turned over so that side that was in contact with resident is now all the bottom. Treat combs and brushes with a thorough washing in hot, soapy water. Ordinarily it is not necessary to treat sweaters, jackets, furniture, drapes, or rugs, as the mite does not live long off of the human body.f It is vital that patients, families, and staff be educated, as misconceptions run rampant. Residents may feel embarrassment, resentment, fear of the' treatment, and possible rejection by others. They may also feel isolated. All precautions and treatment plans need to be explained. At no time should blame be assigned. It needs to be continually reinforced that proper treatment is curative. It is not necessary to report isolated cases to the health department, but experts may be called on for assistance for a scabies outbreak within an institution.
September/October 1994 GERIATRIC NURSING
The goal of tre atment is cure, incl uding relief of symptom s, resolution of any seconda ry infection, and prevention of any reinfestation or spr ead of scabies. Thi s can be achieved with an educated staff, an individuali zed treatment plan, sound communication with resident and family, and a cornmittment by st aff to cur e. Although scabies in institutions can be kept to manage able levels by routine surveilla nce of residents and thorough skin examinations of all new residents, the mos t successful, cost-effective approach is a systema tic program to treat all patien ts and health care personnel at the same time' iii R EF ER EN CES
I. Newc omer VD, Young EM . Ger ia tric derma tology / clinical diagnosis a n d practical therapy. New York: Igak u-5hoin Med ical Publishers, 1989:339-4 6. 2. A merica n Academy of Dermatology. Sc ab ies: 1991. Evanston, Illinois: America n Academy of Derma tolog y, ' 991. 3. Fer ri FF, Fre twell MD . Practica l guide to the ca re of the geriatric pati ent. St. Louis: Mosby-Year Book, 1992: 119- 20. 4. T homp son 1M, McFarland GK , Hirsch l E, Tu cker SM . Mosby's clini cal nursing. St. Louis: Mosby, 1993:470· 1. 5. Berkow R, Fletcher Al. T he Merck man ual of diagn osis a nd thera py. Rahway, New J ersey: Me rck, 1992 :2424-5 . 6. Miller DF. Keane CB. Encyclopedia an d dicti o na ry of medicine, nur sing, a nd a pplied hea lth. Philade lphia : WB Saunders, 1987: 1105-6. 7. Sh elle y WB, Sh elley ED. Advanced d er ma to logic d iagnosis . Phila delp hia : WB S au nd ers, 1992:1142-7 .
This Publication is available in Microform.
University Microfilms International Please sc nd add itional info rmation
for ---------------::c~:-cc;-;--' nan )!." ll
Na me
puhh....lll1nl
_
lns titu tio n
_
SlreCL I
_
City' State
_ Z ip
300 North Zeeb Road. Dept. P.R.. Ann Arbor, Mi. 48106
GERIATRIC NURSING Volume 15, Number 5
_
PAM
HUFFORD
NICHOLLS
ave you noticed residents scratching? Have particular residents seemed a little more irritable? Do not dismiss these clues: They may indicate scabies. The cause of scabies was discovered in 1687. 1 Scabies outbreaks previously occurred in 30-year cycles,1 but a current pandemic exists, with an estimated 300 million cases occurring worldwide every year. 2 The disease can strike anyone, regardless of class, race, age, or personal hygiene habits.
H
Who Is at Most Risk?
Scabies is common among people living in crowded conditions, and should be considered for those spending time in close quarters, such as among those in nursing homes, institutions, day-care, prisons, and the military, as well as the homeless. Most at risk are those who have weakened immune defenses, such as transplant patients, AIDS patients, and older adults. Scabies is often overlooked in elderly persons because it can be confused with eczema, dry skin, generalized itching or scratching due to anxiety. Often secondary infection is already present, complicating the picture and delaying the diagnosis. Clinical Manifestations
Scabies is a transmissible parasitic infestation caused by the itch mite, Sarcoptes scabiei. It is spread by prolonged skin contact and affects both men and women and children. Transmission through clothing and other inanimate objects is uncommon, as the mite can only survive
PAM HUFFORD NICHOLLS, RN,C, is MDS assessment coordinator at the Riverside Nursing Center in Dayton, Ohio. GERIATR NURs 1994;15:271-3. Copyright © 1994 by Mosby-Year Book, Inc. 0197-4572/94/$3.00 + 0 34/1/56891
GERIATRIC NURSING Volume 15, Number 5
out of human skin for approximately 36 hours.' Infestation may occur from cats, dogs, and other small animals. Scabies is characterized by pruritis, and excoriations with secondary infection. Primary lesions most commonly occur in the finger-webs, the flexor surfaces of the wrists and extensor surfaces of the elbows, the axillary folds, the waistline, around the areolae in women and the genitalia in men, the knees, and the lower buttock. Patients who have neurologic disorders or various forms of immunodeficiency may have the highly contagious crusted scabies (also known as Norwegian scabies), characterized by nonpruritic scaling on palms and soles due to infection with a great number of mites. I, 5
A pandemic exists, with an estimated 300 million cases occurring worldwide every year. The adult itch mite has a rounded body about onefiftieth of an inch long. The skin lesions are caused by the female mite, which burrows beneath the skin and digs a short tunnel parallel to the surface, in which it lays its eggs. The mite extends the burrow, which is a few millimeters to 1 em long daily, depositing eggs and feces. The eggs hatch in a few days, and the baby mites find their way to the surface, mate, and multiply. Initially, during the tunneling, the resident may be unaware of what is happening. There is little itching and few lesions. After 1 to 6 weeks, however, due to hypersensitivity to the mite, the itching becomes intense, particularly at night. But if a person has been plagued with scabies in the past, a rash may often develop in 1 to 3 days. The burrows may be seen as a slightly elevated, wavy grayish white to dark line. The burrows may be difficult to find because they are obscured by scratching or
Nicholls
271
---_______
------
--I
i
BOX 1. TREATMENT OF SCABIES
I
PERMETHRIN 5% CREAM-A single overnight dose left on for 8 to 14 hours has proved effective in over 90% of cases. 2 This cream locks systemic toxicity. LINDANE 1 %-AI'l overnight application left on for 8 to 12 hours is effective in 1 to 2 doses, with the second dose not to be given sooner than 7 days. 1t is not recommended for young children, in pregnancy, or in patients with seizure disorders or neurologic disorders.' SULFUR OINTMENT-An older treatment, not as desirable because of odor, messiness, and staining; it is used in children, pregnant and lactating women, and patients with seizure or neurologic disease.' CROTAMITON 10% CREAM-Another treatment option.
by secondary lesions, such as eczema, urticaria, scratch dermatitis, or superimposed bacterial infection. Diagnosis The mite itself may be seen by means of the burrow ink lest. A. blue Or black felt-tipped pen is applied to suspected lesions and partially removed with an alcohol pad; ink is retained in the burrows." With a magnifying glass the mite can sometimes be seen as a tiny black speck at the papule end of a tunnel. Definitive diagnosis is made microscopically. Treatment Treatment is curative and may be suitable in doubtful cases. An anti-infective (scabicide) agent is ordered (see Box l). Lindane, once the standard treatment, has been replaced by a synthetic pyrethroid or insecticide, as the scabies mite has developed some resistance to lindane. I Bathing before the application is no longer recommended because this may increase skin absorption and central nervous system toxicity. Follow specific instructions ordered by physicians. Before applying the cream, trim residents' nails as short as possible without cutting into the quick. With a cotton-tipped applicator or a soft toothbrush, gently work the lotion into the folds of skin at the sides of the nail, into the cuticle, and under the free edge of the nail. It is important to put the cream on every square inch of the body, not just where the rash is. Application is recommended to face, neck, cars, postauricular grooves, and scalp (after regular shampooing). Never apply the cream to eyelids or to lips. Most lotions recommend that they remain on for 12 to 24 hours. Some itching, mild burning, or stinging may occur after application. If hands are washed during this period, more lotion should be reapplied. Reapplication of the scabicide is sometimes recommended a week later to be sure all eggs are killed. Oral antihistamines are usually ordered to decrease pruritis. A topical corticosteroid cream may be used to hasten healing of secondary dermatitis. Concomitant bacterial infections may necessitate the use of systemic
272
Nicholls
antibiotic agents, but often such infections clear spontaneously when scabies is cured. Patients may experience persistent itching for up to 4 weeks after treatment. This is rarely a sign of treatment failure and is not necessarily an indication for retreatment. It takes about a month after the mites have been killed for the rash to disappear. All affected persons should be treated at the same time. Family members in close contact should be encouraged to be treated. Staff members should also be treated, as well as their family members. Everyone must be informed that transmission is possible soon after infestation, during the asymptomatic period before the appearance of rash. Residents who have had close contact with a potentially infected resident, such as dining room partners or those they sit next to in lounges or during activities, should also be considered for treatment. Nursing Care The National Centers for Disease Control recommends the wearing of gowns and gloves for staff and visitors with close contact with an infected person to be continued until 24 hours after initiation of therapy.f Masks are not necessary. Handwashing cannot be stressed enough.
It takes about a month after the
mites have been killed for the rash to disappear. At the beginning and end of the initial treatment course, and at the beginning and end of each succeeding treatment course, all bed linens, previously worn clothing, and washable footwear should be laundered in hot water or dry cleaned. Laundry isolation should be in effect until completion of treatment. Articles of clothing that cannot be laundered or dry cleaned (such as shoes) should be placed in a sealed plastic bag and not worn by the patient for a 14-day period. At the time of initial treatment, the mattress on a resident's bed is to be turned over so that side that was in contact with resident is now all the bottom. Treat combs and brushes with a thorough washing in hot, soapy water. Ordinarily it is not necessary to treat sweaters, jackets, furniture, drapes, or rugs, as the mite does not live long off of the human body.f It is vital that patients, families, and staff be educated, as misconceptions run rampant. Residents may feel embarrassment, resentment, fear of the' treatment, and possible rejection by others. They may also feel isolated. All precautions and treatment plans need to be explained. At no time should blame be assigned. It needs to be continually reinforced that proper treatment is curative. It is not necessary to report isolated cases to the health department, but experts may be called on for assistance for a scabies outbreak within an institution.
September/October 1994 GERIATRIC NURSING
The goal of tre atment is cure, incl uding relief of symptom s, resolution of any seconda ry infection, and prevention of any reinfestation or spr ead of scabies. Thi s can be achieved with an educated staff, an individuali zed treatment plan, sound communication with resident and family, and a cornmittment by st aff to cur e. Although scabies in institutions can be kept to manage able levels by routine surveilla nce of residents and thorough skin examinations of all new residents, the mos t successful, cost-effective approach is a systema tic program to treat all patien ts and health care personnel at the same time' iii R EF ER EN CES
I. Newc omer VD, Young EM . Ger ia tric derma tology / clinical diagnosis a n d practical therapy. New York: Igak u-5hoin Med ical Publishers, 1989:339-4 6. 2. A merica n Academy of Dermatology. Sc ab ies: 1991. Evanston, Illinois: America n Academy of Derma tolog y, ' 991. 3. Fer ri FF, Fre twell MD . Practica l guide to the ca re of the geriatric pati ent. St. Louis: Mosby-Year Book, 1992: 119- 20. 4. T homp son 1M, McFarland GK , Hirsch l E, Tu cker SM . Mosby's clini cal nursing. St. Louis: Mosby, 1993:470· 1. 5. Berkow R, Fletcher Al. T he Merck man ual of diagn osis a nd thera py. Rahway, New J ersey: Me rck, 1992 :2424-5 . 6. Miller DF. Keane CB. Encyclopedia an d dicti o na ry of medicine, nur sing, a nd a pplied hea lth. Philade lphia : WB Saunders, 1987: 1105-6. 7. Sh elle y WB, Sh elley ED. Advanced d er ma to logic d iagnosis . Phila delp hia : WB S au nd ers, 1992:1142-7 .
This Publication is available in Microform.
University Microfilms International Please sc nd add itional info rmation
for ---------------::c~:-cc;-;--' nan )!." ll
Na me
puhh....lll1nl
_
lns titu tio n
_
SlreCL I
_
City' State
_ Z ip
300 North Zeeb Road. Dept. P.R.. Ann Arbor, Mi. 48106
GERIATRIC NURSING Volume 15, Number 5
_