May 8

Scabies in Aged Care: Recognition, Treatment, and Outbreak Management in Australia and New Zealand

What is Scabies, and why does it matter in Aged Care?

Scabies is a parasitic skin infestation caused by the microscopic mite Sarcoptes scabiei var. hominis. The fertilised female burrows into the upper layer of the skin to lay eggs, and the resulting hypersensitivity reaction produces the rash and itch recognised clinically.

Scabies is spread through prolonged skin-to-skin contact - typically 15 to 20 minutes or longer - and via shared bedding, towels, clothing, and upholstered furniture, where mites can survive 24 to 36 hours off the host. In a residential aged care facility, close personal care, shared linen, and high-touch communal spaces create conditions for rapid transmission once a single case is missed.

Source: Scabies — CDNA National
Guidelines for Public Health Units (Communicable Diseases Network Australia).
A first infestation can take four to six weeks to produce symptoms; re-infestation may produce symptoms within one to four days. That lag is why outbreaks are usually well established before the index case is identified, and why proactive surveillance beats reactive containment every time.

How does Scabies present in older residents?

In a younger adult, Scabies presents predictably: an itchy rash that worsens at night, with burrows in the finger webs, wrists, axillae, and waistline. In your residents, the picture is rarely that clear - recognising atypical presentations is the single most important clinical message for your team.

Key differences in older people:
  • Reduced or absent itch due to immunosenescence. Residents with cognitive impairment may also be unable to self-report.
  • Atypical distribution. In bed-bound or mobility-impaired residents, the rash often appears on the back, buttocks, scalp, and the back of the ears.
  • Misdiagnosis as eczema, dermatitis, drug reactions, xerosis, or “senile pruritus” - the most common reason outbreaks are not contained early.
  • Crusted Scabies presents as thick, hyperkeratotic plaques on the hands, feet, elbows, or scalp, often without itching. Those at highest risk include residents with advanced dementia, post-stroke immobility, long-term corticosteroid use, or end stage frailty.

How is Scabies treated?

First-line treatment for classic Scabies is permethrin 5% cream, applied from the neck down, including the scalp, hairline, behind the ears, and face (avoiding eyes and mouth) in older or immunocompromised residents, left on overnight, then washed off in the morning. The application is repeated on day seven to kill mites that hatch from eggs laid after the first dose. Missing the second dose is the single most common reason for treatment failure in aged care.

Oral ivermectin (200 micrograms/kg, repeated on days 7–14) is an alternative when topical application is impractical and is used in combination with permethrin for crusted scabies. Crusted Scabies also requires keratolytic agents to soften the crusts and specialist input from dermatology or infectious diseases.

Advise your team, residents, and families that post-scabietic itch can persist for two to four weeks after successful treatment. This is not a treatment failure. Manage it with emollients, antihistamines, and short courses of low-potency topical corticosteroids on a medical officer's order.

How do you manage an outbreak in your facility?

A Scabies outbreak is defined as two or more linked cases in time and place. Activate your Outbreak Management Plan on a single confirmed case of Crusted Scabies, or on two cases of classic Scabies within six weeks on the same wing or care team footprint.

Six workstreams must run in parallel - not sequentially:
  • Confirm and notify. Notify your jurisdictional Public Health Unit (scabies is not nationally notifiable, but outbreaks in residential aged care require PHU involvement). Where the Serious Incident Response Scheme (SIRS) criteria are met, the Aged Care Quality and Safety Commission (ACQSC). In New Zealand, suspected or confirmed outbreaks in residential care must be notified to the local Medical Officer of Health / Public Health Unit under the Health Act framework.
  • Contact tracing. Identify all close contacts from the previous six weeks - residents, care team, allied health, contractors, and visitors with prolonged contact.
  • Mass treatment. Treat everyone on the affected wing on the same day, even if they are asymptomatic. Repeat on day seven. Record both doses in a treatment register.
  • Isolation and PPE. Contact precautions until 24 hours after the first effective treatment (longer for crusted scabies). Long-sleeved gowns and gloves for direct care.
  • Environmental decontamination. Hot wash (≥60°C) all bedding, towels, and clothing used in the past 72 hours. Bag and seal non-washables for 72 hours - 7 days for crusted scabies. Vacuum mattresses, upholstery, and carpets.
  • Communication and documentation. Brief residents, families, and your full care team. Maintain a line list, environmental cleaning logs, and notifications as evidence of compliance with the Strengthened Aged Care Quality Standards and NZS 8134:2021 Ngā Paerewa.

Sources: Scabies — CDNA National Guidelines for Public Health Units (Communicable Diseases Network Australia); Strengthened Aged Care Quality Standards (ACQSC); NZS 8134:2021 Ngā Paerewa (Standards New Zealand).

When is the outbreak over?

An outbreak is closed when no new cases have been identified for at least one full incubation period (6 weeks) after the last treated case, and following Public Health Unit agreement. Premature closure is one of the most consistent failure points in scabies management because a quiet wing at week four can produce three new cases at week five.

During the surveillance window, your IPC Lead should conduct weekly skin checks on the affected unit, monitor team members closely and retreat them at the first sign of recurrence, and audit environmental cleaning weekly. At week eight, debrief on the index case, the time from first symptom to diagnosis, and what your facility will change next time.

Take-Home Message

Scabies in aged care is rarely textbook. Routine skin assessment on admission and at every clinical review detects scabies before it becomes an outbreak. And the difference between treating one resident in week one and managing a wing-wide outbreak for two months is built into your assessment templates, not your outbreak plan.

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