Scabies
Scabies - Summary
Scabies is an intensely itchy skin infestation caused by the human parasite Sarcoptes scabiei. A person with scabies has an average of 12 mites.
Crusted scabies (Norwegian scabies) is a hyperinfestation with thousands or millions of mites present in exfoliating scales of skin. It develops as a result of an insufficient immune response by the host.
The prevalence of scabies is currently rising in the UK and is greatest in urban areas, in the north of the country, in children and women, and during winter.
In classical scabies, person-to-person spread occurs predominantly via direct contact with the skin.
Untreated scabies is often associated with secondary bacterial infection which may lead to cellulitis, folliculitis, boils, impetigo, or lymphangitis. Scabies may also exacerbate other pre-existing dermatoses such as eczema and psoriasis.
Scabies is curable if treated; however, if not treated it may persist indefinitely.
The diagnosis of scabies is usually made from the history and examination of the affected individual, as well as from the history of the family and close contacts. Misdiagnosis is common because of its similarity to other pruritic skin disorders, such as contact dermatitis, insect bites, and psoriasis.
In people with scabies, the following should be assessed:
The severity of the infestation and symptoms.
Whether there are any secondary lesions (eczema or secondary infection).
The risk of sexually transmitted infection (STI).
The likely source of infestation.
If crusted scabies is suspected, the possibility of underlying immunodeficiency should be considered and investigated, if appropriate.
Management of scabies involves:
Simultaneously (within 24 hours) treating all household members, close contacts, and sexual contacts with a topical insecticide (e.g. permethrin 5% dermal cream or malathion 0.5% aqueous liquid), even in the absence of symptoms.
Giving detailed advice (verbal and written) on how the insecticide should be applied.
Considering symptomatic treatment for itching (e.g. topical crotamiton).
Treating any associated conditions (e.g. eczema or infection).
Giving appropriate advice (e.g. close body contact with others should be avoided until their partners and close contacts have been treated).
Scabies is rare in children under 2 months of age. Specialist advice should be sought (e.g. from a paediatric dermatologist) if treatment is required for this age group.
Follow-up is not generally required. However, the person should be reviewed if symptoms have not cleared within 6 weeks after the first application of treatment.
Referral to a dermatologist should be considered if the diagnosis is in doubt, or if two courses of an insecticide have failed.
Specialist advice from a consultant dermatologist should be sought if crusted scabies is suspected. Admission may be required.
Referral to a genito-urinary medicine clinic should be considered for: specialist advice, diagnostic services, partner notification, and contact tracing if there is a history of risk behaviour for STIs.
Institutionalised outbreaks of scabies (e.g. schools, long-stay nursing homes, and prisons) should be referred to the Health Protection Agency, as control measures are necessary to deal with all residents, staff and healthcare workers.
Have I got the right topic?
This CKS topic covers the management of classical scabies and provides advice on what to do if crusted scabies is suspected.
This CKS topic does not offer advice on the management of outbreaks of scabies in residential or nursing homes. The local Consultant in Communicable Disease Control should be contacted for advice during outbreaks of scabies in residential or nursing homes.
There are separate CKS topics on Head lice and Pubic lice.
The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary health care.
How up-to-date is this topic?
How up-to-date is this topic?
Changes
November 2011 — reviewed. A literature search was conducted in October 2011 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. This identified the United Kingdom National Guideline on the Management of Scabies infestation (2007) produced by the British Association of Sexual Health and HIV [BASHH, 2007; BASHH, 2011]. Recommendations within this guideline are consistent with the current CKS topic therefore no changes to recommendations have been made. Issued in December 2011.
Previous changes
March 2011 — topic structure revised to ensure consistency across CKS topics — no changes to clinical recommendations have been made.
October 2010 — minor update. Chlorphenamine is no longer licensed for the treatment of pruritus. Text and prescriptions amended to reflect this. Issued in October 2010.
November 2007 — minor update to text. Malathion is now licensed for a second application after 7 days. (The recommendation for a second application of insecticide 7 days after the first is unlicensed for permethrin, and is different to the information supplied by the manufacturers: their package inserts state that a single application is sufficient.) Issued in December 2007.
February to May 2007 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence. There are no major changes to the recommendations.
September 2003 — reviewed. Validated in December 2003 and issued in February 2004.
December 2000 — rewritten. Validated in March 2001 and issued in June 2001.
September 1997 — written.
Update
New evidence
Evidence-based guidelines
No evidence-based guidelines since 1 October 2011.
HTAs (Health Technology Assessments)
No new HTAs since 1 October 2011.
Economic appraisals
No new economic appraisals relevant to England since 1 October 2011.
Systematic reviews and meta-analyses
No systematic reviews since 1 October 2011.
Primary evidence
No new randomized controlled trials published in the major journals since 1 October 2011.
New policies
No new national policies or guidelines since 1 October 2011.
New safety alerts
No new safety alerts since 1 October 2011.
Changes in product availability
No changes in product availability since 1 October 2011.
Goals and outcome measures
Goals
To support primary health care professionals:
To treat the scabies infestation
To prevent reinfestation
To recognize crusted scabies
Background information
Definition
What is it?
Scabies is an intensely itchy skin infestation caused by the human parasite Sarcoptes scabiei [Johnston and Sladden, 2005].
The main symptoms of scabies are probably caused by an immune response to the mites and their saliva, eggs, or faeces [Flinders and De Schweinitz, 2004; Johnston and Sladden, 2005]. Both immediate and delayed-type hypersensitivity are probably involved [Burns, 2004].
A person with scabies has an average of 12 mites [Johnston and Sladden, 2005]. However, neglected children in under-privileged communities may have hundreds of mites [Heukelbach and Feldmeier, 2006].
The adult female mite measures approximately 0.4 mm by 0.3 mm, and the adult male is smaller measuring 0.2 mm by 0.15 mm. The body is creamy white and has bristles and spines on its dorsal surface. There are four pairs of legs [Burns, 2004].
Crusted scabies (Norwegian scabies) is a hyperinfestation, with thousands or millions of mites present in exfoliating scales of skin. It develops as a result of an insufficient immune response by the host, and presents as a hyperkeratotic skin disorder resembling psoriasis [Heukelbach and Feldmeier, 2006].
Life cycle of the scabies mite
What is the life cycle of the scabies mite?
The entire life cycle is spent on humans and lasts 4–6 weeks [Figueroa, 1998; McCarthy et al, 2004; Chosidow, 2006; Cordoro, 2006; Heukelbach and Feldmeier, 2006]:
Once on the skin the female mite burrows into the epidermis. This can be achieved within 30 minutes. The adult male moves actively between burrows seeking to mate with an unfertilised female. Mites move through the skin by secreting proteases that degrade the stratum corneum.
After copulation in the burrow, the male mite dies and the pregnant female mite enlarges the burrow and starts to lay eggs. The burrow is not confined to the stratum corneum but is inclined downwards into the epidermis. Eggs and faeces are deposited along the burrow behind the female. Approximately 40–50 eggs are laid during the lifespan.
The six-legged larvae hatch after 3–4 days and escape from the burrow by cutting through the roof. The larvae then dig short burrows (moulting pockets) in which they transform into eight-legged nymphs and, after further moults, into adult males and females.
Development from egg to adult takes about 10–15 days and less than 10% of the eggs laid grow into mature mites.
Prevalence
How common is it?
It is estimated that there are 300 million cases of scabies worldwide each year [McCarthy et al, 2004].
In the UK, about 100 people per 100,000 of the population consult their GP with scabies each month [Downs et al, 1999].
The prevalence of scabies is currently rising in the UK, and is greatest [Downs et al, 1999]:
In urban areas.
In the north of the country.
In children and women.
During winter.
There seems to be a cyclical rise in the incidence of scabies every 20 years in the UK, but the reason for this is unknown [Downs et al, 1999].
Recently scabies has become more frequent in the elderly in residential and nursing home environments. Although some outbreaks are related to crusted scabies, others appear to originate from residents who have classical scabies with a large mite population, or from an infected carer. Scabies may spread easily within residential and nursing homes because of close contact between residents and carers (e.g. carers frequently hold the hands of residents to provide support when walking) [Burns, 2004].
Transmission
How is scabies transmitted?
In classical scabies, person-to-person spread occurs predominantly via direct contact with the skin [Johnston and Sladden, 2005]:
Mites dislodged from the skin use odour and heat to find a new host. Close physical contact is necessary for transmission (e.g. prolonged hand holding, sexual intercourse, or sharing a bed) [Heukelbach and Feldmeier, 2006]. Transmission by casual contact (e.g. a handshake or a hug) is unlikely [Fox and Usatine, 2006].
Transfer from clothing and bedding occurs rarely and only if contaminated by infested people immediately beforehand [Johnston and Sladden, 2005].
The more parasites on a person, the greater the risk of transmission.
Mites cannot jump or fly, but crawl at the rate of 2.5 cm a minute on warm skin. They can survive away from the host for 24–36 hours at room temperature and average humidity [Chosidow, 2006]. Transmission rates are higher the greater the number of mites [Figueroa, 1998].
Mites burrowed in the epidermis are resistant to water and soap, and continue to be viable even after daily hot baths [Heukelbach and Feldmeier, 2006].
People are infectious before the rash develops as the itch and rash take 2–6 weeks to develop in a person who has been infested with scabies for the first time [Figueroa, 1998; HPA, 2004].
The mites' infectivity decreases the longer they are off their host [Heukelbach and Feldmeier, 2006].
Crusted scabies is highly contagious and, in addition to transmission by direct contact, is easily transmissible via bedding, towels, clothes, and upholstery owing to the large numbers of mites on an infested individual [Chosidow, 2006]. In crusted scabies, the mites can survive for up to 7 days as they are able to feed on skin in bedsheets, clothing, or chair covers [Cordoro, 2006]. People who have been even minimally exposed (e.g. cleaning staff and laundry employees) should be considered to have been exposed to infested persons, and should also be treated [Chosidow, 2006].
Risk factors
What are the risk factors?
Classical scabies
Close physical contact is the main risk factor:
Children and infants are particularly at risk, due to close personal contact with other children and adults, at home and at school [Johnston and Sladden, 2005].
Anyone living in close or intimate contact with an infested person is at risk, particularly those living in the same household [HPA, 2004].
A study in Sheffield (conducted between 1972 and 1973) of 1492 people with scabies from 609 households found that [Church and Knowelden, 1978]:
Infestations were introduced into a household by school children and teenagers, especially girls.
The commonest sources were friends and relatives outside the home.
Once established in a home, 38% of family contacts became infested.
The place of work or residence may be a risk factor. In the UK, epidemics usually occur in institutional settings or in socially deprived groups. For example, outbreaks may occur amongst elderly people in nursing homes and may be transmitted to nursing staff [Johnston and Sladden, 2005; Heukelbach and Feldmeier, 2006].
Crusted scabies
Person-to-person contact is more likely because of the large number of mites present [Chosidow, 2006].
Contact with contaminated linens (hotels, nursing homes, prisons) may lead to infestation because of the large number of mites present in the skin scales [HPA, 2005].
People who are immunocompetent develop classical not crusted scabies from contact with someone with crusted scabies. There is no evidence that the mite is more virulent: the sheer number of mites increases the risk of becoming infected.
Risk factors for developing crusted scabies [Chosidow, 2000; Burns, 2004; McCarthy et al, 2004]:
People with a primary immunodeficiency or a compromised ability to mount an immune response, including:
Chronic corticosteroid use.
HIV infection.
Human T-cell lymphotropic virus type 1.
Malnutrition.
Other immunocompromised states.
People with a reduced ability to scratch, thus preventing the removal of mites and destruction of burrows:
Lack of perception of the itch due to skin anaesthesia (e.g. secondary to sensory neuropathy or spinal injury).
Inability to scratch due to severe incapacity (e.g. paresis or severe arthropathy).
Physical incapacity.
People with learning difficulties, dementia, or Down's syndrome may also develop crusted scabies. The reason for this is not understood but a lack of recognition of pruritus may be important.
Inappropriate use of potent topical steroids, as there is suppression of sensitivity to the mites which reduces itching, and leads to less scratching and consequent destruction of burrows.
Complications and prognosis
Complications
Untreated scabies is often associated with secondary bacterial infection. Such infections may lead to cellulitis, folliculitis, boils, impetigo, or lymphangitis [Burns, 2004; McCarthy et al, 2004].
Scabies may exacerbate other pre-existing dermatoses including the following [Cordoro, 2006]:
Eczema.
Psoriasis.
Grover's disease (acantholytic dermatosis).
Psychological problems: persistent delusions of parasitosis, shame, guilt.
Crusted scabies has a high mortality rate with death occurring from secondary sepsis. Many people with crusted scabies are immunosuppressed and more prone to serious infections [Huffam and Currie, 1998; McCarthy et al, 2004].
Prognosis
Scabies is curable. If a person with scabies is correctly treated then the itching and eczema should resolve. However, in endemic areas, reinfestation is very likely [Johnston and Sladden, 2005].
Scabies persists indefinitely if not treated [Johnston and Sladden, 2005].
Itching persists for up to 3 weeks after successful treatment.
Even after successful treatment, some people develop persistent, itchy, brown–red nodules up to 2 cm in diameter, predominantly on the genitals and axillae. Nodular scabies usually resolves in 3 months but may take up to one year [Chouela et al, 2002; DynaMed, 2006].
Crusted scabies may be impossible to eradicate in people with HIV and recurrences are common.
Diagnosis
Diagnosis of scabies
Classical scabies
How do I know my patient has classical scabies?
The diagnosis of scabies is usually made from the history and examination of the affected individual (including using magnification techniques), as well as from the history of the family and close contacts. Misdiagnosis is common because of its similarity to other pruritic skin disorders.
History
What history should I take?
Generalized itching is the most common presenting symptom and is most intense at night and when the person is warm:
With initial infestation, itching usually develops within 2–6 weeks, and coincides with a widespread eruption of inflammatory papules.
With reinfestation, symptoms typically occur within 1–3 days, owing to prior sensitization to the mite and its saliva and faeces.
A lack of a history of itching does not exclude scabies:
Some people do not seem to suffer from itch, whilst others may be reluctant to admit to a possible diagnosis of scabies.
Very young babies may not scratch but just seem miserable and feed poorly.
There may be a history of contact with someone with scabies, typically 2–6 weeks previously if the person has never had scabies before, or within the last 24–48 hours if the person has been previously infested.
A history of itching in several family members over the same period of time strongly suggests a diagnosis of scabies.
Basis for recommendation
Basis for recommendation
Recommendations on what questions to ask when taking a history are based on expert opinion from review articles [Chosidow, 2000; Johnston and Sladden, 2005] and text books [Roberts, 2000; Burns, 2004].
Examination
What features might I see on examination?
The most common presenting lesions are papules, vesicles, pustules, and nodules:
Erythematous papular or vesicular lesions are associated with the burrows.
A more generalized, symmetrical, itchy, papular eruption is unrelated to obvious mite activity. This is most commonly seen around the axillae, the peri-areolar region of the breasts in women, and the abdomen, buttocks, and thighs.
Nodules may develop at sites such as the elbows, anterior axillary folds, penis, and scrotum. They are firm, dull red or brown, intensely itchy, and may persist for weeks or months after treatment: they do not necessarily indicate active infestation (they are a result of a chronic allergic reaction to the mite). Inflammatory papules and nodules on the male genitalia, sometimes surmounted by burrows, are diagnostic of scabies.
The presentation may differ according to the age of the host:
In adults and older children, sites of burrows include the interdigital web spaces, wrists, anterior axillary folds, peri-umbilical skin, pelvic girdle including buttocks, ankles, the penis in men, and the peri-areolar region of the breasts in women. Burrows on the trunk are uncommon in adults.
In infants and young children, scabies may also affect the face, head, neck, trunk, scalp, palms, and soles. Very young children often have widespread eczematized erythema, particularly on the trunk, and there may be multiple crusted nodules on the trunk and limbs. In infants, the commonest presenting lesions are papules and vesicopustules which are particularly common on the palms and soles. Pink–brown nodules are particularly characteristic of scabies in babies.
In the elderly, burrows commonly occur on the palms and soles and may be numerous. Papulosquamous lesions on the trunk, often surmounted by burrows, are common. Secondary eczematization is often troublesome.
In immunocompromised people, mites can also infect the face, neck, scalp, and ears.
People who have experienced treatment failure may also have mites in these areas. When topical therapy has only been applied from the neck downwards, then scabies of the scalp may be the cause of the treatment failure.
Papules and vesicles commonly develop into secondary lesions and may confuse the clinical picture.
Secondary infection (e.g. cellulitis, folliculitis, boils, impetigo, or lymphangitis) may be severe and extensive.
Eczematous changes are common, and may be the predominant clinical feature. Eczematous changes can be widespread and range from mild to severe, and may become secondarily infected.
Atypical presentations can occur:
A bullous pemphigoid-like reaction may occur in association with scabies.
In people taking steroids the rash may be atypical (scabies incognito).
Rarely, scabies may present as cutaneous vasculitis (e.g. with a purpuric rash and areas of cutaneous infarction).
Scabies may accompany or simulate seborrhoeic dermatitis of the scalp in infants, children, the elderly, and in people with immunodeficiency syndromes.
Basis for recommendation
Basis for recommendation
Recommendations on examining a person with suspected scabies are based on expert opinion from review articles [Jarrett and Snow, 1998; Chosidow, 2000; Chouela et al, 2002; McCarthy et al, 2004; Johnston and Sladden, 2005; Chosidow, 2006; Heukelbach and Feldmeier, 2006] and text books [Figueroa, 1998; Burns, 2004].
Investigations
What investigations should I consider?
Burrows may be seen with the naked eye although the use of a magnifier is helpful. Look particularly at the hands and wrists: usually about two-thirds of the burrows appear here.
Burrows can be difficult to identify, particularly if the skin has been scratched, has been secondarily infected, or if eczema is present.
Burrows appear as fine, wavy, grey, dark or silvery lines with a minute speck (the mite) at the closed end. Burrows measure a few millimetres to 1.5 cm (mean length 5 mm). The point of entry of the mite, the most superficial part of the burrow, has a slightly scaly appearance, and at the distal end there may be a vesicle next to the mite.
The burrow ink test can help to identify burrows:
Rub the underside of a cartridge pen on a suspected papule, then wipe off with an alcohol pad to remove the surface ink from the lesion.
Alternatively, rub a non-toxic water-soluble felt tip marker over an area suspected of having burrows, wait a few moments and then wash off the ink.
If a burrow is present, the ink will track down the mite burrow, forming a characteristic dark, zigzag line running across and away from the papule.
Finding the mite or its products confirms, but is not necessary for making, a diagnosis of scabies.
Parasitological confirmation of the diagnosis can be made by gently scraping the skin off a burrow with a blunt scalpel blade or a sterile needle. The live or dead mite will adhere to the scalpel or needle point, and may be seen with the naked eye. Place the material on a slide with a drop of 10% potassium hydroxide or mineral oil and, using a low power microscope, look for mites, faecal pellets, eggs, or eggshells. If a mite has not been damaged and the slide is warm, it will walk on the slide. If a diagnosis cannot be made on site, place the scrapings into a container (e.g. a sputum pot) and send to the local microbiology laboratory. Check what sort of container is suitable with the local microbiology laboratory.
It should be understood that although taking skin scrapings to identify the mite or its ova or faeces is recommended, in reality the sensitivity of skin scrapings is so low that it is not very useful, although if a mite or its products are seen it is diagnostic.
Basis for recommendation
Basis for recommendation
Recommendations on investigating a person with suspected scabies are based on expert opinion from review articles [Jarrett and Snow, 1998; Scott, 2001; Chouela et al, 2002; DTB, 2002b; McCarthy et al, 2004; Johnston and Sladden, 2005; Fox and Usatine, 2006; Heukelbach and Feldmeier, 2006], text books [Figueroa, 1998; Burns, 2004], and a personal communication [Stafford, Personal Communication, 2007].
Crusted scabies
How do I know my patient has crusted scabies?
The diagnosis of crusted scabies is mainly made through examination of the affected individual (features are not typical of 'classical' scabies). Crusted scabies is confirmed by analysis of skin scrapings.
History
What history should I take?
Crusted scabies usually only occurs in people who are immunocompromised or who have other risk factors.
Affected individuals often have only slight itch or no itch at all, although occasionally itch may be severe.
Basis for recommendation
Basis for recommendation
Information on the symptoms of crusted scabies are based on expert opinion from a text book [Burns, 2004].
Examination
What features should I look for on examination?
Crusted scabies does not present in the same way as classical scabies.
There are hyperkeratotic, warty crusts, which are usually on the hands and feet but all areas of the skin may be involved:
The grossly thickened horny layer is honeycombed with burrows containing large numbers of mites, although the burrows are difficult to recognize.
The palms and soles may show deep fissuring of the crusts.
Erythema and scaling occur on the face, neck, scalp, and trunk, and may generalise.
The extent of the erythroderma and the warty plaques varies, and either may predominate.
Nail hyperkeratosis is common.
Thick deposits of debris accumulate beneath the thickened and discoloured nails.
There is commonly bacterial secondary infection.
There may be a generalised lymphadenopathy.
Crusted scabies may be localised to one area (e.g. the scalp, the face, or even just one finger, toe nail or sole).
Basis for recommendation
Basis for recommendation
Recommendations on what to look for during examination in a person with suspected scabies is based on expert opinion from a review article [Chosidow, 2000] and a text book [Burns, 2004].
Investigations
What investigations should I consider in a person with suspected crusted scabies?
It is very important to take skin scrapings. Microscopic examination of scrapings (which will be teeming with mites and eggs) readily confirms the diagnosis of crusted scabies.
Eosinophilia may be an incidental finding.
Basis for recommendation
Basis for recommendation
Recommendations on investigations to consider in a person with suspected scabies is based on expert opinion from a review article [McCarthy et al, 2004] and a text book [Burns, 2004].
Differential diagnosis
What else might it be?
Classical scabies
What else might be confused with 'classical' scabies?
Other infestations, including:
Animal scabies:
Animal scabies occasionally infests humans.
Pet dogs are the most common source.
Compared with infestation with scabies from other humans, the incubation period is shorter, the distribution different (lesions mainly occur in areas that have been in contact with the animal), there are no burrows. The infestation tends to be self limiting and often requires no treatment.
Pubic lice — see the CKS topic on Pubic lice.
Body lice — itching is the principal complaint. The body is often covered in excoriations and there may be secondary bacterial infection.
Insect bites — see the CKS topic on Insect bites and stings.
Other dermatological conditions, including:
Acropustulosis — a recurrent, self-limited, pruritic, vesiculopustular eruption of the palms and soles, occurring in infants aged 2–3 years.
Atopic eczema — see the CKS topic on Eczema - atopic.
Bullous pemphigoid — a blistering disease of elderly people, which often starts with pruritus and an urticaria-like rash, although this may occasionally be eczematous. Later, large, tense blisters develop.
Contact dermatitis — see the CKS topic on Dermatitis - contact.
Dermatitis herpetiformis — a rare, chronic, recurrent, papulovesicular disease. It is symmetrical, and consists of erythematous, urticarial, papular, or vesicular lesions located on the extensor surfaces of the elbows, knees, buttocks, and back. It is extremely itchy and the vesicles are often excoriated.
Folliculitis — see the CKS topic on Boils, carbuncles, and staphylococcal carriage.
Grover's disease (acantholytic dermatosis) — this mainly affects the trunk in elderly or middle-aged people, and presents as an acute eruption of discrete, itchy, grey–pink papules or papulovesicles and papules. It is of unknown aetiology.
Impetigo — see the CKS topic on Impetigo.
Langerhans cell histiocytosis — this may present with the following: greasy scales on the scalp; discrete, yellow–brown, scaly papules on the trunk often with areas of purpura which may become nodular, crusted, or eroded; ulceration of the flexures, groin, perianal or vulval regions.
Lichen planus — an itchy eruption characterized by shiny bluish purple, flat-topped, polygonal papules which vary in size from pinpoint to a centimetre across, and may be close together or widely dispersed.
Neurodermatitis (lichen simplex) — this is thickening of the skin with variable scaling that arises secondary to repetitive scratching or rubbing. Pruritus is the predominant symptom.
Prurigo nodularis — consists of discrete, nodular, hyperpigmented/purpuric lesions with surfaces that are scaly, excoriated, and possibly crusted, caused by scratching due to intense localised itchiness. Lesions range from small papules to hard globular nodules 1–3 cm in diameter.
Seborrhoeic dermatitis — see the CKS topic on Seborrhoeic dermatitis.
Systemic lupus erythematosis (SLE) — a discrete maculopapular rash with fine scaling on sun-exposed areas.
Urticaria pigmentosa — numerous reddish-brown or pale, monomorphic maculopapules, plaques, or nodules appearing symmetrically anywhere on the body, except the face, head, palms, or soles.
Basis for recommendation
Basis for recommendation
Information on the differential diagnosis of classical scabies is expert opinion from review articles [Chouela et al, 2002; Breathnach and Black, 2004; Miller, 2005; Cordoro, 2006; Chan, 2006; Chosidow, 2006; Fox and Usatine, 2006; Heukelbach and Feldmeier, 2006; Hogan, 2006; Hogan and Bower, 2006; Pride, 2006] and text books [Burns, 2004; Breathnach and Black, 2004; Judge et al, 2004b; Chu, 2004; Holden and Berth-Jones, 2004; Goodfield et al, 2004; Grattan and Black, 2004; Wojnarowska et al, 2004; Zabawski and Cockerell, 2007].
Crusted scabies
What else might be confused with crusted scabies?
Hyperkeratotic eczema — in chronic eczema, there may hyperkeratosis.
Psoriasis — characterized by red, scaly, sharply-demarcated, indurated plaques, present particularly over the extensor surfaces and scalp.
Dariers's disease (Keratosis follicularis) — characterized by greasy, skin-coloured, brown or yellow-brown, hyperkeratotic papules in seborrhoeic regions, nail abnormalities, and mucous membrane changes. It is inherited (autosomal dominant).
Seborrhoeic dermatitis. See the CKS topic on Seborrhoeic dermatitis.
Contact dermatitis (Contact dermatitis that persists may become hyperkeratotic).
Basis for recommendation
Basis for recommendation
Information on the differential diagnosis of crusted scabies is expert opinion from review articles [Chouela et al, 2002] and text books [Beck and Wilkinson, 2004; Burns, 2004; Griffiths et al, 2004; Holden and Berth-Jones, 2004; Judge et al, 2004a; Kwok and Liao, 2007].
Management
Management
Scenario: Initial presentation: covers the first-line management of scabies and scabies-related itch.
Scenario: Suspected treatment failure: covers the management of scabies and itch when first-line treatment has failed.
Scenario: Initial presentation
Scenario: Initial presentation with scabies
Assessment
What assessment should I make?
Ask about all people with whom skin-to-skin contact has been made for a prolonged period within the previous 2 months, as all of these people are at risk of scabies and should be informed.
In people with scabies, assess:
The severity of the infestation.
The severity of the symptoms (e.g. itch).
Whether there are any secondary lesions:
Eczema.
Secondary infection.
The risk of sexually transmitted infection, if appropriate (sexual partners within the previous 2 months).
The likely source of infestation.
If crusted scabies, consider the possibility of underlying immunodeficiency and investigate if appropriate.
Basis for recommendation
Basis for recommendation
These recommendations are based on pragmatic advice and information from the Health Protection Agency [HPA, 2004].
Managing scabies
How should I manage someone presenting with scabies?
Simultaneously (within 24 hours) treat all members of the household, close contacts, and sexual contacts with a topical insecticide (even in the absence of symptoms).
Encourage the family not to delay treatment.
Pregnant or breastfeeding women should also be treated with an insecticide.
Apply the insecticide twice, with applications one week apart.
Consider symptomatic treatment for itching.
Advise the person that itching may take several weeks to resolve.
Treat associated eczema — see the CKS topic on Eczema - atopic.
Treat scabies that has become infected with an antibiotic.
Machine wash (at 50°C or above) clothes, towels, and bed linen, on the day of application of the first treatment.
Advise the individual to avoid close body contact with others until their partners and close contacts have been treated.
Choice of insecticide
Which insecticide should I use?
Treat the person and all contacts with an insecticide.
Use permethrin 5% dermal cream as a first-line treatment.
Use malathion 0.5% aqueous liquid if permethrin is inappropriate (e.g. the person has an allergy to chrysanthemums).
For children under 2 months old, seek specialist advice from a paediatric dermatologist.
Scabies is rare in children under 2 months old.
If malathion is used, an aqueous preparation is preferred to the alcohol-based lotion.
Children under 6 months old require a prescription for an insecticide to treat scabies. If parents prefer to purchase an insecticide over the counter:
Malathion 0.5% aqueous liquid can be purchased for children over 6 months old.
Children under 2 years old require a prescription for permethrin 5% dermal cream.
Basis for recommendation
Basis for recommendation
These recommendations are based on evidence from a Cochrane systematic review, randomized controlled trials (RCTs), uncontrolled trials, and expert opinion from the medical literature [HPA, 2005; Johnston and Sladden, 2005].
Treatment of all contacts
It is important that all contacts (symptomatic and asymptomatic), including members from the same household, are treated on the same day:
Scabies is highly contagious and there is a latent period before symptoms develop.
Simultaneous treatment is important as this minimizes the chances of reinfestation from an untreated contact.
Recommended treatments
Permethrin:
There is evidence from one systematic review and a subsequent RCT that permethrin 5% is highly effective at achieving clinical and parasitic cure of scabies within 28 days of treatment.
Permethrin 1% cream rinse (licensed for head lice) has been associated with treatment failure [Cox, 2000].
Malathion:
There is limited evidence from uncontrolled trials that malathion is effective for treating scabies. These studies found that malathion 0.5% left on the skin for 24–48 hours cured 70–80% of people within 2–4 weeks [Hanna et al, 1978; Thianprasit and Schuetzenberger, 1984]. Malathion is widely used to treat scabies and is recommended by the Health Protection Agency [HPA, 2005].
Aqueous preparations are easier to apply than alcohol-based lotions. Alcohol-based lotions cause irritation of excoriated skin and the genitalia.
Treatments not recommended
Benzyl benzoate:
Benzyl benzoate 25% is less effective than permethrin or malathion. It requires repeated applications (twice a day for 2–3 days, repeated after 10 days), irritates the skin, and can produce a burning sensation, which all reduce compliance [Heukelbach and Feldmeier, 2006].
Crotamiton:
Crotamiton 10% cream or lotion is less effective than permethrin [Walker and Johnstone, 2000], and is rarely used in the UK for treating scabies because of its poor efficacy [DTB, 2002b]. However, it may help to relieve the itch caused by scabies.
Oral ivermectin:
Ivermectin is available on a named-person basis and has been used in combination with topical treatments for the treatment of hyperkeratotic (crusted or Norwegian) scabies infestation that does not respond to topical treatment alone [HPA, 2005].
Lindane:
Lindane has been withdrawn from the UK market. It is effective for treating scabies, but neurotoxicity (particularly seizures) has been reported in infants, children, and among those with widespread skin damage (e.g. eczema) [McCarthy et al, 2004].
Lindane is systemically absorbed when applied topically, especially when applied to damaged skin. Systemic absorption is higher in infants and small children.
Insecticide choice in pregnancy/breastfeeding
Which insecticide can I use for pregnant or breastfeeding women?
For women who are breastfeeding or pregnant, treat scabies with permethrin 5% dermal cream.
Alternatively use malathion 0.5% aqueous liquid if permethrin is not appropriate (e.g. the person has an allergy to chrysanthemums).
Breastfeeding mothers should remove the liquid or cream from the nipples before breastfeeding, and reapply treatment afterwards.
Basis for recommendation
Basis for recommendation
Neither malathion nor permethrin are specifically licensed for use during pregnancy or breastfeeding, however there is no indication that either product poses any risk to the fetus or child [ABPI Medicines Compendium, 2005; ABPI Medicines Compendium, 2006].
Both products are poorly absorbed following topical application and are widely recommended for use during pregnancy [NTIS, 1999; BASHH, 2001; Johnston and Sladden, 2005; CDC, 2006].
There is more evidence for the effectiveness of permethrin than malathion.
Advising how to apply an insecticide
How should I advise someone to apply an insecticide?
Apply the treatment to the whole body from the chin and ears downwards paying special attention to the areas between the fingers and toes and under the nails. The exceptions to this are people who are immunosuppressed, the very young and elderly people where the insecticide should be applied to the whole body including the face and scalp.
Advise the insecticide should be applied twice, with applications one week apart.
Apply the treatment to cool dry skin (i.e. not after a hot bath).
Allow the lotion or cream to dry before dressing.
Wash the treatment off after prolonged contact with the skin:
Permethrin — 8 to 12 hours.
Malathion — 24 hours.
Reapply treatment if it is washed off during this treatment period (e.g. after washing the hands or nappy area).
To prevent small children and babies sucking the treatment from their hands, mittens can be worn.
Basis for recommendation
Basis for recommendation
These recommendations are based on expert advice from the published medical literature and from the British Association of Dermatologists [HPA, 2005; BAD, Personal Communication, 2007].
Treatment should not be applied after a hot bath, as this increases systemic absorption and removes the drug from its treatment site [Figueroa, 1998; Roberts, 2000; Scott, 2001].
The recommendation for two applications, 7 days apart, is an unlicensed use of permethrin, and is different to the packaging information which states that a single application is sufficient. Malathion is now licensed as a course of two applications of insecticide 7 days apart [ABPI Medicines Compendium, 2007].
Drug treatments for itching
What drug treatments can I recommend for itching?
Treat itching with topical crotamiton.
Apply crotamiton 2–3 times a day. Crotamiton is licensed for children under 3 years old for once a day application only
Alternatively, consider using topical hydrocortisone 1% to help reduce itch and inflammation.
Apply topical hydrocortisone sparingly to the affected area once or twice a day for no longer than 7 days.
Avoid corticosteroid creams if the diagnosis is not certain, as they may mask signs and symptoms of other skin conditions, making diagnosis more difficult.
If creams for itching need to be applied during the application time of the insecticide, allow the insecticide to disappear into the skin or dry, before the cream or lotion for itch is applied.
Consider an oral sedating antihistamine (e.g. chlorphenamine or hydroxyzine) at night if the itch is interfering with sleep.
Basis for recommendation
Basis for recommendation
These recommendations are based on expert opinion from the medical literature [Johnston and Sladden, 2005; Heukelbach and Feldmeier, 2006].
Topical treatments
Crotamiton cream or lotion has soothing qualities and may help to relieve itch, although no controlled studies have been published that assess its efficacy. It is licensed for the relief of itching caused by scabies.
CKS was unable to identify any trial evidence for topical corticosteroids, but they are widely used for the treatment of scabies-related itch [BNF 53, 2007].
Oral antihistamines
There is limited evidence that oral antihistamines are effective in treating pruritus.
Results from a review of 16 randomized controlled trials and other studies (n = 803) suggest that neither first- nor second-generation antihistamines offer relief from itch in conditions such as atopic dermatitis [Klein and Clark, 1999].
However, it may be useful to give a sedating oral antihistamine at night for temporary help with sleeping, to break the itch-scratch-itch cycle. Hydroxyzine is licensed for use in pruritus but chlorphenamine is not (off-label use).
Itching is worse at night when the patient is warm.
Follow-up
What follow up is necessary?
Follow-up is not generally required for people with classical scabies.
Review if symptoms have not cleared within 6 weeks after the first application of treatment.
Basis for recommendation
Basis for recommendation
This recommendation is based on what CKS believes to be good clinical practice.
When to refer or seek specialist advice
When should I refer or seek specialist advice?
Consider referral to a dermatologist if the diagnosis is in doubt, or after continued treatment failure (e.g. if two courses of an insecticide have failed).
Seek specialist advice from a consultant dermatologist for the management of anyone presenting with crusted scabies. Admission may be required.
Consider referral to a genito-urinary medicine clinic for specialist advice, diagnostic services, partner notification, and contact tracing if there is a history of risk behaviour for sexually transmitted infections:
Contact tracing of partners from the previous 2 months should be undertaken.
Refer institutionalised outbreaks of scabies (e.g. schools, long-stay nursing homes, and prisons) to the Health Protection Agency, as control measures are necessary to deal with all residents, staff and healthcare workers.
Scabies is rare in children under 2 months of age. Seek specialist advice (e.g. from a paediatric dermatologist) if treatment is required for this age group.
Basis for recommendation
Basis for recommendation
These recommendation are based on expert opinion from the medical literature and pragmatic advice [HPA, 2005].
Scenario: Suspected treatment failure
Scenario: Suspected treatment failure in scabies
When to suspect treatment has failed
When should I suspect that treatment has failed?
Treatment failure is likely if:
The itch still persists at least 6 weeks after the first application of an insecticide (particularly if it persists at the same intensity or is increasing in intensity).
Treatment was uncoordinated or not applied correctly.
New burrows appear at any stage after the second application of an insecticide.
Basis for recommendation
Basis for recommendation
These recommendations are based on expert opinion from the medical literature [Walker and Johnstone, 2000; Chosidow, 2006; BAD, Personal Communication, 2007].
Itching commonly persists for several weeks after successful treatment and may become more pronounced as the body reacts to the dead mites and their waste products [HPA, 2005].
Management of treatment failure
What should I do if I suspect treatment has failed?
Re-examine the person to confirm that the diagnosis is correct and look for new burrows (see Diagnosis).
Consider alternative diagnoses.
If all contacts were treated simultaneously and treatment was applied correctly, give a course of a different insecticide:
If permethrin 5% dermal cream was used initially then prescribe malathion 0.5% aqueous solution, OR
If malathion 0.5% aqueous solution was used initially then prescribe permethrin 5% dermal cream.
If contacts were not treated simultaneously or treatment was incorrectly applied, either re-treat with the same insecticide, or use a different insecticide.
Ensure that all members of the household, close contacts, and sexual contacts are identified and re-treated simultaneously.
Provide written advice explaining the correct application method.
Basis for recommendation
Basis for recommendation
These recommendations are based on expert opinion from the medical literature [Johnston and Sladden, 2005; Chosidow, 2006].
Advising how to apply an insecticide
How should I advise someone to apply an insecticide?
Apply the treatment to the whole body from the chin and ears downwards paying special attention to the areas between the fingers and toes and under the nails. The exceptions to this are people who are immunosuppressed, the very young and elderly people where the insecticide should be applied to the whole body including the face and scalp.
Advise the insecticide should be applied twice, with applications one week apart.
Apply the treatment to cool dry skin (i.e. not after a hot bath).
Allow the lotion or cream to dry before dressing.
Wash the treatment off after prolonged contact with the skin:
Permethrin — 8 to 12 hours.
Malathion — 24 hours.
Reapply treatment if it is washed off during this treatment period (e.g. after washing the hands or nappy area).
To prevent small children and babies sucking the treatment from their hands, mittens can be worn.
Basis for recommendation
Basis for recommendation
These recommendations are based on expert advice from the published medical literature and from the British Association of Dermatologists [HPA, 2005; BAD, Personal Communication, 2007].
Treatment should not be applied after a hot bath, as this increases systemic absorption and removes the drug from its treatment site [Figueroa, 1998; Roberts, 2000; Scott, 2001].
The recommendation for two applications, 7 days apart, is an unlicensed use of permethrin, and is different to the packaging information which states that a single application is sufficient. Malathion is now licensed as a course of two applications of insecticide 7 days apart [ABPI Medicines Compendium, 2007].
Drug treatments for itching
What drug treatments can I recommend for itching?
Treat itching with topical crotamiton.
Apply crotamiton 2–3 times a day. Crotamiton is licensed for children under 3 years old for once a day application only
Alternatively, consider using topical hydrocortisone 1% to help reduce itch and inflammation.
Apply topical hydrocortisone sparingly to the affected area once or twice a day for no longer than 7 days.
Avoid corticosteroid creams if the diagnosis is not certain, as they may mask signs and symptoms of other skin conditions, making diagnosis more difficult.
If creams for itching need to be applied during the application time of the insecticide, allow the insecticide to disappear into the skin or dry, before the cream or lotion for itch is applied.
Consider an oral sedating antihistamine (e.g. chlorphenamine or hydroxyzine) at night if the itch is interfering with sleep.
Basis for recommendation
Basis for recommendation
These recommendations are based on expert opinion from the medical literature [Johnston and Sladden, 2005; Heukelbach and Feldmeier, 2006].
Topical treatments
Crotamiton cream or lotion has soothing qualities and may help to relieve itch, although no controlled studies have been published that assess its efficacy. It is licensed for the relief of itching caused by scabies.
CKS was unable to identify any trial evidence for topical corticosteroids, but they are widely used for the treatment of scabies-related itch [BNF 53, 2007].
Oral antihistamines
There is limited evidence that oral antihistamines are effective in treating pruritus.
Results from a review of 16 randomized controlled trials and other studies (n = 803) suggest that neither first- nor second-generation antihistamines offer relief from itch in conditions such as atopic dermatitis [Klein and Clark, 1999].
However, it may be useful to give a sedating oral antihistamine at night for temporary help with sleeping, to break the itch-scratch-itch cycle. Hydroxyzine is licensed for use in pruritus but chlorphenamine is not (off-label use).
Itching is worse at night when the patient is warm.
Follow-up
What follow up is necessary?
Follow-up is not generally required for people with classical scabies.
Review if symptoms have not cleared within 6 weeks after the first application of treatment.
Basis for recommendation
Basis for recommendation
This recommendation is based on what CKS believes to be good clinical practice.
When to refer or seek specialist advice
When should I refer or seek specialist advice?
Consider referral to a dermatologist if the diagnosis is in doubt, or after continued treatment failure (e.g. if two courses of an insecticide have failed).
Seek specialist advice from a consultant dermatologist for the management of anyone presenting with crusted scabies. Admission may be required.
Consider referral to a genito-urinary medicine clinic for specialist advice, diagnostic services, partner notification, and contact tracing if there is a history of risk behaviour for sexually transmitted infections:
Contact tracing of partners from the previous 2 months should be undertaken.
Refer institutionalised outbreaks of scabies (e.g. schools, long-stay nursing homes, and prisons) to the Health Protection Agency, as control measures are necessary to deal with all residents, staff and healthcare workers.
Scabies is rare in children under 2 months of age. Seek specialist advice (e.g. from a paediatric dermatologist) if treatment is required for this age group.
Basis for recommendation
Basis for recommendation
These recommendation are based on expert opinion from the medical literature and pragmatic advice [HPA, 2005].
Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://medicines.org.uk/emc), or the British National Formulary (BNF) (www.bnf.org).
Adverse effects of insecticides
What are the adverse effects of insecticides?
Permethrin is normally well tolerated, but burning, stinging, pruritus, and erythema may occur in a few people [ABPI Medicines Compendium, 2006].
Alcohol-based solutions are more irritant than aqueous preparations. Rarely, skin irritation has been reported with aqueous malathion preparations.
Adverse effects of topical corticosteroids
What are the adverse effects of topical corticosteroids?
Mildly and moderately potent topical corticosteroids used for short periods are rarely associated with adverse effects.
Skin atrophy is much more likely with potent and very potent topical corticosteroids.
There is little risk of skin thinning with mild-to-moderately potent topical corticosteroids when used for up to 4 weeks [DTB, 2003].
Adverse effects of antihistamines
What are the adverse effects of antihistamines?
Sedating antihistamines cause sedation in 10–50% of people, which can persist into the next day [DTB, 2002a].
Most non-sedating antihistamines have the potential to cause sedation, especially at higher doses. Advise people taking non-sedating antihistamines that they may cause sedation, and that the sedative effects are enhanced when combined with alcohol.
Antihistamine during pregnancy
Which antihistamine can I prescribe during pregnancy?
Where possible, oral antihistamines should be avoided during pregnancy, especially during the first trimester.
If an oral antihistamine is required to control pruritus during pregnancy, chlorphenamine is the antihistamine of choice [NTIS, 2002].
Evidence
Evidence
Supporting evidence
Insecticides for scabies.
Evidence on the effectiveness of insecticides for scabies.
Permethrin is widely used as a first-line treatment for scabies. There is good evidence from one systematic review and a subsequent randomized controlled trial (RCT) that permethrin is highly effective for treating scabies. The evidence for malathion is less convincing.
A Cochrane review (search date: March 2004) identified 44 RCTs that compared the use of an insecticide with placebo or another treatment. Only 13 trials (n = 1527) met the inclusion criteria and were included in the analysis [Walker and Johnstone, 2000].
The studies were heterogeneous:
A variety of patient groups were studied, including children and adults. Outcome measures were clinical cure, parasitic cure, cure of pruritus, and adverse effects. It was only possible to extract outcome data at 28–30 days for seven of the studies (evidence of cure requires follow-up for about 1 month, as this is the time it takes for lesions to heal and for any eggs and mites to reach maturity if treatment fails).
Eight trials included all randomized patients (i.e. intention to treat analysis); the remaining five trials reported exclusions in their analyses. Seven of the 13 trials reported blinded assessments of outcome, and four of these were double-blind.
Several insecticides were used as the intervention, including benzyl benzoate, crotamiton, lindane, ivermectin, permethrin, and sulphur.
No RCTS including malathion were identified.
Twelve of the 13 studies were conducted in developing countries.
The main results were as follows:
Permethrin versus crotamiton:
Two trials (n = 194) compared these two topical treatments. Permethrin 5% was significantly more effective at achieving clinical cure in both studies (91/97 vs. 72/97; likelihood of clinical failure: OR 0.21, 95% CI 0.10 to 0.47). Parasitic cure was measured in one of these studies, and permethrin was found to be more effective (42/47 vs. 28/47; likelihood of parasitic failure: OR 0.21, 95% CI 0.08 to 0.53).
Permethrin versus lindane:
Four trials (n = 718) compared these two topical treatments. Overall, permethrin 5% was more effective than lindane 1% in achieving clinical cure (60/360 vs. 83/358; likelihood of clinical failure: OR 0.66, 95% CI 0.46 to 0.95). However, two trials (including the largest trial of 467 patients) found no difference between the two treatments.
Crotamiton versus lindane:
One trial (n = 100) compared these two treatments. No statistically significant difference in clinical cure rate was found (OR 0.41, 95% CI 0.15 to 1.10).
Benzyl benzoate versus sulphur:
One trial (n = 158) compared these two treatments. No statistically significant difference in clinical cure rate was found (OR 2.78, 95% CI 0.77 to 10.05).
Ivermectin versus placebo:
Only one trial (n = 55) compared oral ivermectin with placebo. The effectiveness of oral ivermectin over placebo was highly significant at day 7 (clinical cure 23/29 vs. 4/26 OR 0.08, 95% CI 0.03 to 0.23). The blinding was broken for those that had not improved at this time and control patients were given ivermectin.
Ivermectin versus benzyl benzoate or lindane:
Two trials (n = 97) compared oral ivermectin with topical benzyl benzoate or lindane. No differences in effectiveness were detected between the treatments in either trial, but the number of participants in the studies was small. No difference in effectiveness was found when these two trials were combined, i.e. oral ivermectin compared with a topical treatment (either benzyl benzoate or lindane; OR 0.58, 95% CI 0.25 to 1.34).
Adverse effects: no serious adverse drug reactions were reported in any of the included or excluded trials. However, serious adverse drug reactions (including death and convulsions), most notably to lindane, permethrin, and ivermectin, have been reported elsewhere.
The authors concluded that the evidence that permethrin is more effective than lindane is inconsistent. Lindane, permethrin, and ivermectin appear to be associated with rare but serious adverse drug reactions although this is not derived from trial data. More research is needed on the safety and effectiveness of ivermectin and malathion compared with permethrin, on community management, and on different regimens and vehicles for topical treatment.
Subsequent to the Cochrane review:
One RCT (n = 99) found that permethrin 5% significantly increased clinical cure rates compared with lindane at 14 days (failed clinical cure: 8/52 [15%] with permethrin vs. 24/47 [51%] with lindane p < 0.05) [Zargari et al, 2006].
Another RCT (n = 85) compared a single application of topical permethrin 5% with a single dose of oral ivermectin. Treatment was repeated at 2 weeks if there was treatment failure. The outcome measured was the complete disappearance of clinical signs and symptoms and no appearance of new lesions 2 months after treatment. All patients were completely cured at 2 months [Usha and Gopalakrishnan Nair, 2000].
Malathion has only been studied in uncontrolled trials. These have found that a single application of malathion 0.5% left on the skin for 24–48 hours cures 70–80% of people within 2–4 weeks [Hanna et al, 1978; Thianprasit and Schuetzenberger, 1984].
Search strategy
Scope of search
A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of scabies.
Search dates
2007 - October 2011
Key search terms
Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline and these were adapted for other databases. Further details are available on request.
exp Scabies/
Table 1. Key to search terms.| Search commands | Explanation |
|---|---|
| / | indicates a MeSh subject heading with all subheadings selected |
| .tw | indicates a search for a term in the title or abstract |
| exp | indicates that the MeSH subject heading was exploded to include the narrower, more specific terms beneath it in the MeSH tree |
| $ | indicates that the search term was truncated (e.g. wart$ searches for wart and warts) |
Sources of guidelines
National Institute for Health and Clinical Excellence (NICE)
Scottish Intercollegiate Guidelines Network (SIGN)
National Guidelines Clearinghouse
British Columbia Medical Association
Institute for Clinical Systems Improvement
Guidelines International Network
National Library of Guidelines
National Health and Medical Research Council (Australia)
University of Michigan Medical School
Michigan Quality Improvement Consortium
Royal Australian College of General Practitioners
National Resource for Infection Control
NHS Scotland National Patient Pathways
Agency for Healthcare Research and Quality
UK Ambulance Service Clinical Practice Guidelines
RefHELP NHS Lothian Referral Guidelines
Medline (with guideline filter)
Driver and Vehicle Licensing Agency
NHS Plus (occupational health practice)
Sources of systematic reviews and meta-analyses
Systematic reviews
Protocols
Database of Abstracts of Reviews of Effects
Medline (with systematic review filter)
EMBASE (with systematic review filter)
Sources of health technology assessments and economic appraisals
NIHR Health Technology Assessment programme
NHS Economic Evaluations
Health Technology Assessments
Canadian Agency for Drugs and Technologies in Health
International Network of Agencies for Health Technology Assessment
Sources of randomized controlled trials
Central Register of Controlled Trials
Medline (with randomized controlled trial filter)
EMBASE (with randomized controlled trial filter)
Sources of evidence based reviews and evidence summaries
DynaMed
Central Services Agency COMPASS Therapeutic Notes
Sources of national policy
Health Management Information Consortium (HMIC)
Sources of medicines information
The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.
British National Formulary (BNF)
electronic Medicines Compendium (eMC)
European Medicines Agency (EMEA)
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