The itching and rash associated with scabies is not due the infestation per se but are the consequence of the body's immune response to the presence of the mite and its waste products.  Consider the diagnosis of scabies in any a patient with a smoldering itchy rash with itchy papules on the genitalia, web spaces, or wrists.

Some patients will have few if any symptoms with their infestation.  While a positive scabies scrape preparation taken from a typical "burrow" is diagnostic, it is frequently negative, even in a "classic" case (figure 7).

While conceptually simple, the treatment of scabies is sometimes difficult to execute properly in practice.  Do not use Kwell shampoo to treat scabies...it won't work.  Use Kwell cream/lotion or Elimite cream at bedtime exactly as written in the PDR.

Thirty to sixty grams of the cream or 60-120 ml of lotion should cover the whole body.  Be sure to treat from the neck all the way to the toes being sure to get every crack and crevice in between.  Be sure to apply the medication to the web spaces, underneath the fingernails, and the genitalia.  Do not wash the hands or fingers before going to sleep.

Retreat the patient the following evening.  The itching usually takes a few days to subside.  All scabies medications are somewhat irritating and drying to the skin.  Use bland emollients or if necessary medium potency topical steroids after the second application is rinsed off to control residual irritation and dryness.

All clothing, underwear and nightclothes, linen and towels used in the past 2 weeks by the patient require washing in hot water or dry cleaning.  All household and/or sexual contacts should be treated.  Aboard ship or in a barracks or any other very "close living" situation, persons nearby should be checked carefully for evidence of infestation.  If in doubt, treat the patient.