Mar 2

Managing "The Itch"

A Clinical Guide for Aged Care Professionals

Managing pruritus (the "itch") in aged care is a daily challenge for IPC leads and clinical staff. It is not "just dry skin" - it is a puzzle where missing a single clue in the diagnosis can lead to a facility-wide outbreak or prolonged resident distress.

Itchy skin in an aged care resident can be classified into three main categories: Environmental/Structural, Infestations, and Systemic. Investigating the cause of the itch will modify treatment approaches and help identify the possibility of an outbreak.

The Three Main Categories of the Itch

1. Xerosis (Dry Skin): This is the most common cause, as ageing skin produces less sebum and retains less moisture.
  • How to identify: Skin looks "crazy-paved" or flaky, usually on the shins and forearms. The itch worsens after hot showers or in low humidity, and there is no primary rash (bumps/blisters).
  • Action: Implement "soap-free" washing protocols, apply thick emollients within 3 minutes of drying, and review room humidity.

2. Scabies (The IPC Priority): A parasitic infestation that requires immediate isolation and reporting.
  • How to identify: Intense itching, much worse at night. Look for small, pearly "burrows" in finger webs, wrists, or the waistline.
  • Crusted Scabies: In elderly residents, look for thick, scaly plaques. These may not itch at all but contain millions of mites and are highly infectious.
  • Action: Implement immediate contact precautions and treat with Permethrin 5% cream or oral Ivermectin.

3. Dermatitis (Eczema or Contact): Inflammation caused by irritants or allergies.
  • How to recognise: Red, inflamed patches. Usually seen as Incontinence Associated Dermatitis (IAD) or a reaction to new laundry detergents or topical medicines.
  • Action: Identify and eliminate the trigger, apply barrier creams for IAD, and use short-term topical corticosteroids as prescribed.

Systemic and Internal Causes

When the skin appears quite normal, but the resident is persistently scratching, consider "internal" triggers.

  • Chronic Kidney Disease (CKD): Known as "Uremic itch"; skin may appear with a greyish hue. Review eGFR
  • Cholestasis (Liver): Itching is often felt on the palms and soles of the feet and may be accompanied by jaundice. Check Liver Function Tests (LFTs).
  • Polypharmacy: Review medications for common “itchy” side effects in culprits such as opioids, ACE inhibitors, and statins.
  • Neuropathic Itch: Manifests as a burning or tingling sensation, usually localised to a specific area such as the back.

The IPC "Red Flags"

IPC Leads should monitor for signs of a cluster to prevent a facility-wide outbreak.

  • Is it spreading? If two residents in the same wing develop a new itch, treat it as Scabies until proven otherwise.
  • Is it crusting? Thick scales on a resident's hands or feet are a sign of a "super spreader" event.
  • Is it nocturnal? If a resident is distressed at 2:00 AM but fine during the day, parasites are likely the main suspect.

Scabies Management: The IPC "Deep Dive"

When a case is suspected, the "Scabies Protocol" must be activated immediately with a coordinated strike.

The "Simultaneous Treatment" Rule
  • Contact Tracing: Identify all staff and family members who had skin-to-skin contact with the affected resident over the past 6 weeks.
  • The "Blitz": To prevent "ping-pong" infections, the index case and all close contacts (including asymptomatic roommates) must be treated simultaneously.
  • Application: Topical creams must be applied from the neck down to the toes, including under fingernails and within skin folds.
Environmental Cleaning & Laundry
Mites can survive off a human host for 48 to 72 hours.

  • Linen & Clothing: All bedding and clothing used in the past 4 days must be laundered.
  • Heat is the Killer: Wash at 60°C (140°F) or higher and use a hot dryer cycle for at least 20 minutes.
  • Non-Washables: Seal items that cannot be washed (e.g., pillows, slippers) in a plastic bag for 7 days to starve the mites.
  • Furniture: Thoroughly vacuum (a vacuum with a hepa-filter) upholstered chairs and mattresses in the resident’s room.

Clinical Management Flowchart for Staff

  • Visual Inspection: Check for burrows, rashes, or scales.
  • History Check: Determine when the itching began, if it's worse at night, and if any new medications have been prescribed.
  • Basic Intervention: Use a soap-free wash product and apply intensive moisturiser for 7 days.
  • Escalation: If there is no improvement or a burrow is observed, notify the GP for a skin scraping or empirical treatment.
  • Pro Tip: Maintain a "Skin Map" of the facility to spot geographic clusters of itchy residents.

Conclusion

The "itch" is an essential diagnostic signal. For the HCW, it indicates the need to moisturise and monitor; for the IPC Lead, it signals the need to investigate and contain. By standardising our approach to these differentials, we shift from "reactive scratching" to proactive clinical management that benefits the entire community.

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