Beware, your ‘eczema’ could really be scabies
As cases soar — with care homes and student halls most vulnerable — we reveal how easy it is to misdiagnose...
WHEN raised, itchy red bumps appeared between his thumb and fingers, Benjo Aptroot knew immediately that it was scabies.
‘It looked like eczema, but I knew it was scabies because a friend I saw a lot at college had been diagnosed the day before, and I’d seen her rash,’ says Benjo, 21, a university student.
‘Although my friend had it for a few months, she’d been misdiagnosed with ingrown hairs, and I didn’t panic as I thought it would be something I could treat easily and quickly.’
In fact, the problem is tricky to treat and outbreaks are more common in group-living situations such as care homes, nurseries and university halls of residence.
Scabies is an itchy skin condition caused by a burrowing parasitic mite, Sarcoptes scabiei. Having not been a major problem for decades, cases are now soaring in Europe.
According to the Health Protection Surveillance Centre (HPSC), an increase in the number of scabies outbreaks was also seen in Ireland in 2023, with 27 reported compared to nine in 2022.
Outbreaks have occurred in a variety of settings. Most were reported in congregate settings, including 10 in nursing homes and eight in residential institutions. Four outbreaks occurred in private households.
The mites, which are not visible to the naked eye, burrow into the skin and lay eggs, which then hatch.
The mites and their faeces cause a rash and intense itchiness, which typically starts four to eight weeks after contact with someone who has been infected.
Scratching the itch can lead to bacterial skin infections such as impetigo, and even sepsis if the body overreacts to the infection.
TYPICAL symptoms include red bumps or scabs, and little red marks and pustules often on the webbed skin between the fingers, around the wrist, under the breasts, around the waist and in the groin area, as these areas are warmer.
But the rash can also be widespread and may easily be misdiagnosed by doctors, says Dr Mia Jing Gao, a consultant dermatologist.
She adds: ‘I recently saw a young man with a widespread dry rash all over his body and it didn’t initially look like scabies at all. It’s quite common for it not to look that distinctive and you can mistake it for eczema.
‘You have to check for burrows and tracks, which can be white, grey or skin-coloured.’
She says her scabies patients come from all walks of life. The infection spreads by direct skin-to-skin contact and sometimes by sharing towels, or contact with infected clothing or bedding.
Those affected have an average of a dozen adult mites on their skin. The female burrows into the outer layers of the skin and lives ten to 14 days, laying up to 180 eggs.
These hatch within three days and become adult mites within four to seven days after that — and the cycle is repeated.
The recommended treatment is a cream containing permethrin, an insecticide that kills larvae, nymphs (immature mites), adult mites and eggs by affecting nerve and muscle function; or with malathion lotion, also an insecticide, which blocks an enzyme essential for the mite’s growth and survival. Pharmacy-only products, you can buy them when you speak to the pharmacist. Both are left on for eight to 12 hours before being washed off.
If they have not worked, an oral treatment called ivermectin, which paralyses the mites, has recently been licensed for scabies.
Permethrin and malathion cost around €17.50 per tube; ivermectin costs much more — €135 for a four-tablet dose.
After reading up about scabies Benjo bought permethrin from a pharmacist.
He washed all his clothes, towels and bedlinen at 60c, as recommended, and stored the rest of his clothes in sealed plastic bags for three days. The parasites can’t survive long without a human host.
‘I applied the cream as directed and then reapplied it again after seven days and made sure I didn’t touch or hug anyone in the meantime,’ he recalls, three months on.
‘It was still embarrassing, though, as I had to tell the six people living in my aunt’s house, where I’m staying, and they all had to do the same — although, luckily, no one else has caught them.
‘There’s still stigma around having scabies.
‘When I tell some people, they look like they can’t believe I’ve left the house.’
Even after the second treatment, his rash was spreading up both arms.
‘Every time I looked, it seemed to have spread a few centimetres further. It was quite creepy. There were red spots and burrow-like tracks,’ says Benjo.
‘It wasn’t that itchy during the day but became intensely itchy at night [because the skin is warmer].
DESPITE the treatment, it spread pretty quickly from my armpits, down the side of my torso, across my belly and down to my legs, covering most of my body.
‘At night, I scratched my skin so much I had quite deep cuts, which were really painful.
‘At college, it was pretty hard, too. I stayed off until I’d done both treatments, and when I went back I couldn’t touch anyone or hug my friends — I had to keep my distance.’
Benjo applied the cream for the third time the next week, in mid-November, but with no improvement still, he saw a doctor in A&E.
‘When I told them I’d had my symptoms for almost a month, they prescribed ivermectin. At first, I thought it had worked as the rash seemed to go. But two weeks later I spotted it on my forearms again. I couldn’t believe it.’
By this time, Benjo was back at his family home for Christmas but he managed to get a repeat prescription of ivermectin from his GP.
‘Both permethrin and malathion treatments are effective, but they involve not washing even your hands for eight hours after you’ve applied it and avoiding close contact with other people,’ says Dr Jing Gao. Reinfection is quite common. ‘The whole household needs to be treated at the same time, with the instructions followed to the letter to avoid the risk of reinfection.
‘So compliance can be difficult, especially if people don’t have symptoms as they might not want to bother; and sometimes people don’t inform their contacts, so they can get reinfected.’
It has now been more than three weeks since Benjo was prescribed ivermectin and he still has the rash.
He’s now started on benzyl benzoate, ‘which a specialist recommended to my friend. I have bought it online. It acts by destroying the mites’ immune systems,’ he says.
‘I’m lucky my skin hasn’t become infected, but it’s still a real pain having to cope with all the itching and not being able to touch or hug anyone.’
Crusted scabies, a more severe and rare form, mainly affects people with weaker immune systems, such as those on immunosuppressants or older people in care homes or hospital wards.
In these cases, hundreds of mites might be living on the skin, so it’s more contagious and causes a more severe rash with a crust.
Poppy Jones, 20, a student, had six months of her first year at university blighted by crusted scabies last January.
She had to isolate from friends but, unfortunately, infected her mum and developed skin infections.
‘It made me so anxious and knocked my confidence at a time when I was trying to make new friends,’ Poppy says.
Her symptoms were first misdiagnosed as infected eczema and she was given steroids and antibiotics: not only did the mites continue to multiply but her immune system was weakened by the steroids.
POPPY believes that she caught scabies after being hospitalised on holiday in Vienna in late 2022 for an allergic reaction. ‘Red bumps started to appear in my groin area and spread all over my body. I was itching all the time — it drove me mad at night and really affected my mental health,’ she says.
‘Eventually, at the end of February, my mum paid for me to see a dermatologist after the GP treatments didn’t work. By that stage, the spots were infected.
‘I was diagnosed with crusted scabies. I was absolutely horrified as I’m such a clean person, but the dermatologist explained it’s nothing to do with being dirty.
‘Scratching the spots had infected them and I had impetigo.’
As well as antibiotics for this, Poppy was prescribed permethrin. ‘But it was out of stock in a lot of places — I had to go to four pharmacies before I could get it.’
‘I had to tell my friends at uni, and they all had to get treated. I had to wash my bedlinen and clothes every day, but the machines at the uni launderette only went up to 40c, so I had to go to another launderette in a cab.’
The dermatologist eventually prescribed ivermectin tablets, but it cost €490 for two treatments with a private prescription.
‘Mum paid for the first as we were so desperate,’ says Poppy, ‘but my GP at home then said if we had a letter from a dermatologist confirming it was crusted scabies, he could prescribe it off label for both me and my mum, who’d caught it a second time from me.’
‘I was so badly affected by it all I came home from uni but I wasn’t allowed even to sit on the sofa,’ Poppy recalls.
After four courses of ivermectin, she was finally clear. She says: ‘It dominated my life for six months. I don’t think people realise how hard it is to get rid of.’