Scabies:
Treating All Close Contacts at the Same Time

1. What is scabies?

Scabies is a contagious skin infestation caused by the itch mite (Sarcoptes scabiei). The fertilised females are only about a third to half a millimetre in size. They burrow into the outer horny layer of the skin, where they dig tunnels over several weeks and deposit eggs and faeces. The tormenting itch is caused mainly by the body's defence reaction to the mites and their excretions.^¹

Scabies has nothing to do with poor hygiene. What matters is close, prolonged skin contact — which is why it affects families, couples, people in need of care and their carers, nurseries and shared accommodation. Having had scabies once does not protect against being infected again.^¹,²

2. Forms of scabies

Depending on the immune system, age and previous treatment, scabies can look very different.^¹,²

3. Symptoms: itching and mite burrows

With a first infestation, it takes two to five weeks for symptoms to appear — that is how long the immune system needs to react. If you are infected again, the itching can start after just one to four days.^¹

• Intense itching, typically worse at night in the warmth of the bed — often the reason for lack of sleep.
• Mite burrows: fine, slightly raised, comma- or line-shaped tracks from a few millimetres to about one centimetre long, sometimes with a dark dot at the end — that is where the mite sits.
• Bumps, blisters and scratch marks, which can spread into a widespread skin rash.

Typical places

The mites prefer warm areas of skin with a thin horny layer: the spaces between the fingers, the inner wrists, elbows, armpit folds, the area around the nipples, the navel, the waistline, buttocks, ankles and the edges of the feet, and in men the penis and scrotum. The head and upper back are usually spared in adults — but not in babies, toddlers and older people.^¹,²

Possible consequences

Scratching can allow bacteria to enter. This leads to weeping, honey-yellow crusted patches or pus-filled spots; less commonly, an infection spreads deeper, for example as erysipelas. An itchy eczema can also develop that masks the scabies.

4. Transmission and risk factors

Scabies mites can neither jump nor fly. They are mainly transmitted through extensive skin-to-skin contact lasting about five to ten minutes — when sleeping in the same bed, cuddling, during sex or when providing personal care for others. With common scabies, shaking hands and brief hugs are considered harmless.^¹

• Close living arrangements: family, relationships, shared flats.
• Care and supervision: care homes, hospitals, nurseries, shared accommodation — outbreaks occur here again and again.
• Objects: bed linen, towels and clothing play a minor role in common scabies, but a major one in crusted scabies.
• Weakened immune defences: old age, being in need of care, dementia and immunodeficiency favour severe forms.

Pets have their own mite species. They can cause brief itching in humans but cannot cause lasting scabies.

5. Diagnosis at the practice

Scabies is often recognised late because it resembles other itchy skin conditions. The combination of itching at night, typical locations and other people nearby who are also itching provides clues.^²

• Targeted questions: Is the itching particularly bad at night? Do your partner, children or flatmates have similar symptoms? Have you had contact with a facility where there have been cases of scabies?
• Dermatoscopy: with a magnifying device, burrows and the mite at the end of the burrow can be seen — often as a small dark triangle.
• Detecting the mite: the mite is lifted out of the end of the burrow with a fine needle, or a skin scraping is examined under the microscope. A negative result does not reliably rule out scabies.
• Ruling out other conditions: eczema and atopic dermatitis, hives, insect bites, drug rashes and fungal infections.

Bring a list of all the creams and medications you have used in recent weeks to your appointment — cortisone in particular can change the picture. Tips in the guide Preparing for a doctor's appointment.

6. Treatment: the options at a glance

Scabies is easy to treat — provided three things come together: an effective remedy, correct application and simultaneous treatment of all close contacts. The treating practice decides which option is right based on age, pregnancy, skin condition and the form of scabies.^¹,²

Permethrin 5% cream and ivermectin tablets are prescription-only; with a prescription, statutory health insurance usually covers the costs. Each contact person who is treated usually needs their own prescription — it is best to raise this at the very first appointment so that everyone can start on the same day.^³

7. Applying it correctly and avoiding mistakes

Most relapses are not due to ineffective remedies but to gaps in application. The most important points according to the RKI and the product information:^¹,³

• Don't bathe beforehand: the skin should be dry and cooled down; after a warm bath, wait about 30 minutes.
• Apply without gaps: from the neck down over the whole body, including between the fingers, the wrists, armpits, navel, genital and anal area, soles of the feet and between the toes. In babies, toddlers, older people and in crusted scabies, also the scalp and face, avoiding the eyes and mouth.
• Don't forget the nails: cut nails short and work cream underneath them — mites like to sit there.
• Enough cream: adults need a whole tube of at least 25 to 30 g.
• Reapply after washing your hands: if you wash your hands while the cream is working, apply it there again.
• Leave it on, then shower: ideally overnight, then wash it off and put on fresh clothes and bed linen.
• Schedule the repeat: firmly plan the second application after 7 to 10 days — on the same day for everyone being treated.

More on technique for creams in general in the guide Applying creams and ointments correctly. According to the product information, ivermectin tablets are taken with water and at a distance from a meal; the itching may briefly increase at first.^³

8. Close contacts, laundry and communal facilities

Who is treated as well

Close contacts are all those who have had prolonged skin contact in recent weeks: partners, children, flatmates, people who sleep in the same bed and carers. They are treated at the same time wherever possible — even without symptoms, as these can take weeks to appear.^¹ With crusted scabies, the circle is drawn considerably wider.

Laundry, clothing and home

Clothing, bed linen and towels used in the days before treatment are changed after the first application:^¹

• Washing: at a minimum of 50 °C for at least ten minutes; a hot tumble dryer or steam are also suitable.
• Not washable: store sealed in a plastic bag for at least 72 hours at a room temperature of at least 21 °C.
• Upholstered furniture and mattresses: vacuum thoroughly. Insect sprays or disinfecting the home are usually not necessary for common scabies.

Nursery, school and care home

Scabies is covered by Section 34 of the German Infection Protection Act: anyone who has it may temporarily not attend communal facilities such as nurseries or schools, and the facility informs the local public health office. According to the RKI, attendance is possible again after the first correct treatment with a cream, or 24 hours after taking ivermectin.^¹ In care homes and hospitals, outbreaks are managed together with the local public health office — often with residents, staff and relatives treated in one coordinated campaign.

9. Pregnancy, children, care homes and treatment failure

Pregnancy and breastfeeding

During pregnancy and breastfeeding, permethrin cream is considered the treatment of choice because hardly any of the active substance enters the body.^⁴ Ivermectin tablets are not used during pregnancy. When breastfeeding, the breasts are cleaned thoroughly before each feed. More in the guide Medications during pregnancy.

Babies and toddlers

In children, the head is treated as well, and the amount depends on age and body surface area. Babies in their first months of life are only treated under close medical supervision, and very young children are sometimes treated in hospital. Cotton mittens or sleepsuits help stop little ones licking off the cream.^²,³ General tips in the guide Medications for children.

Older people and people in need of care

In older age, scabies often presents atypically: few burrows, involvement of the back as well, sometimes hardly any itching. It is therefore easily overlooked in care homes. If you care for a relative and start to itch yourself, take it seriously — see also Medications in care homes.

When scabies won't go away

If new burrows or fresh bumps appear two to four weeks after treatment, this is usually due to reinfection from untreated contacts or a mistake in application. There is also discussion about whether scabies mites have become less sensitive to permethrin; robust data on this are still limited.^⁵ The practice will then check the diagnosis, application and contacts and switch to ivermectin or a combination if needed.

10. After treatment

The most important point for the time afterwards: itching after successful treatment is normal. The dead mites and their remains stay in the skin for a while, and the immune system continues to react. This post-scabies eczema can last two to four weeks, sometimes longer — it is not a sign that treatment has failed.^¹,²

• Don't re-treat on your own initiative — extra permethrin applications irritate the skin and make the eczema worse.
• Care for your skin — moisturising, lipid-replenishing creams soothe stressed skin. For severe eczema, the practice will prescribe a short course of cortisone cream such as mometasone.
• Itching at night — antihistamines such as cetirizine can relieve it; discuss with your practice or pharmacy whether a product is suitable and which one.
• Attend the follow-up appointment — after two to four weeks it is possible to assess whether there are still active burrows.
• Be open about it — involving your contacts in good time protects you from reinfection. Scabies is not a mark of poor hygiene.

Keep track of all the products you and your family are currently using — template in the guide Keeping a medication list.

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