Scabies

Scabies are tiny mites that burrow into your skin. A Yiddish curse says, “He should have Pharaoh’s plagues sprinkled with Job’s scabies.” Indeed, the hallmark of scabies is God-awful itching (one study calls it “exquisitely pruritic“) that is often unresponsive to over the counter medications and can last for months. “The patients are often so excoriated that scabies burrows cannot be found.”

Excoriated — in more ways than one. In 2021, at least 200 million people around the world had scabies. Yet one study found that over 75% of people with it feel ashamed about it. It’s like modern leprosy!

The standard treatment for scabies is quite tedious. You have to treat yourself, your clothes, your bedding, etc. The worst thing about scabies, however, it is that the information on it is inconsistent and incomplete. This was true when I first got scabies, and it was no better when I got them again, twenty years later.

The first time I got scabies, I was so maligned by my community that I posted an early version of this article to dispel misinformation. I’ve written many articles since, but the last time I checked my site traffic, the most read page has been this one. I had no idea I was onto something; I just knew something was onto me.

This time around, I have finally come up with a simple protocol. Keep in mind that it has not yet been reviewed by any professional; I’m testing it out as I write. I hope the second time’s the charm!

How it Starts

In the U.S., scabies is relatively unknown. It’s different than head, body, or pubic lice. Often people have scabies literally before they know it, while people who think they have scabies really don’t.

Scabies is spread through skin to skin contact that is prolonged (five minutes or more). It is rarely spread through a brief hug or handshake and also rarely through clothing, bedding or upholstery. Nor is it transmitted by animals.

The main problem with scabies is (1) that scratching can lead to secondary infection, which can be dangerous, especially in the case of infants and pregnant women, and (2) that a person can pass on scabies even if they have no symptoms, because symptoms can take from a week to two months to show up.

To prevent the spread of scabies, if you have come into contact with anyone with symptoms (or their recently-used clothing, bedding, couch, etc.), treat yourself as soon as possible. If you have cuddled, traded clothes, had sex, etc. with anyone without symptoms who has done this with anyone who does have symptoms, I recommend treatment.

Of course, in a touchy-feely community, this may mean that practically everyone needs to treat themselves, and, perhaps worse, to avoid touching each other for a while. This may seem extreme, but scabies is considered to be highly contagious, and you could be spreading it before you even know you have it.

In short, scabies is a lot like COVID. According to the National Pediculosis Association, “nothing short of mass therapy at one time for the entire community at risk is likely to have a lasting effect where scabies is epidemic.”

Symptoms

Scabies mites are 0.4 mm across. To the naked eye, that’s invisible. The most classic symptom is itching, often but not necessarily worse at night. However, unless you’ve had scabies before, you don’t itch right away because it takes most people some time to become ‘sensitized’ to the bugs.

Generally the more oily your skin, the milder it is. Perhaps that’s why I’ve read that soap can make the itching worse.

Of course, you can itch for any number of reasons (insect bites, hives, eczema, folliculitis, contact or atopic dermatitis, impetigo, rosacea, psoriasis, lymphoma, drug reactions, and more), so look for little red bumps. These bumps can be very subtle and look like hives, tiny bites or pimples. People get them mostly on the lower body: especially ankles, tops of feet, knees, thighs, as well as elbows or wrists, on the buttocks or belt line, around the nipples for women and on the genitals for men. They are almost never found on the neck or head.

Scabies is supposed to show up most commonly between the fingers, but I’ve not had them there much. Also, don’t bother looking for the short tunnels that books tell you the mites create; you’ve usually already scratched them away, and if not, they are still really hard to find. There’s also microscopic examination of a skin scraping, but even when you know what you’re looking for, they’re extremely hard to find.

Can you have scabies without seeing little red bumps? I don’t know. Overall, it can be very hard to know if you actually have scabies. One winter, a year after getting it for the first time, I got very similar itches again, “right on schedule,” with no apparent cause. I did the standard treatment, but the itches came back. I ignored them, and they went away.

There are cases of spontaneous remission. Or maybe it was something else. So I’d say don’t freak out if you have one or two annoying itches over a few days, especially in the dry winter season.

Then again, twenty years later, I spent a month thinking I had poison ivy when I really did have scabies. I finally ended up with a tell-tale sign: “papules” or “post-scabetic nodules” on my you-know-what. To literally see what I mean, see here or here. I think the black dots in the latter image are from a marker, but they can form dark scabs. Note that even then, if you happen to have been handling prickly pear fruit, you could be reacting to that.

I did the standard treatment and thought it was gone. Six months later, I found out it wasn’t. I did the other standard treatment for when the first one doesn’t work. Six months later, same thing. You can get so used to the itching that you don’t realize it’s still there!

Treatment

To get rid of scabies, you need to treat your body as well as anyone who could have gotten it from you. Also, since scabies can survive for up to 36 hours away from the human body, the usual protocol is to treat any clothing you have worn or fabrics you have sat on in the past couple days. And you need to do this all simultaneously. No problem, right?

Wait, there’s more. Most sources say you have to apply scabicide at least twice, not only because of the chance of reinfection, but more importantly, because no currently available treatment kills their eggs. Some sources say permethrin does, but at least one study shows otherwise.

It’s also not clear when to treat your clothes and fabrics. Let’s say you put on an insecticidal cream overnight. Do you sleep on your old sheets or put on new ones? If you sleep on new ones, how do you know no mites have managed to escape onto them?

I figure any mites on the old sheets that crawl onto you while you have poison on will die, and you certainly shouldn’t put new sheets (and clothes) on until they’re all dead. So I would change them the next day. Or you can go double Dutch and change the sheets before and after treatment!

If you have scabies — which is surely the only reason you’d be reading this — you may not believe that only about a dozen live mites are on you at any given time. Each female lays only 2-3 eggs a day. And only 10% or fewer of those eggs make it to adulthood.

On the other hand, adults live for one to two months. That means each female mite can lay 60-180 eggs in her lifetime. If there’s half a dozen females, 6-18 successful eggs each is plenty.

It’s important, then, not to think that a single treatment will kill off most of the bugs and the second is just to take care of any stragglers. You probably have a lot more eggs on you than adults, and after one treatment, they will go on hatching happily ever after.

To kill these mites once they hatch, some sources say to treat again in seven days. Others recommend ten or fourteen. This is the tricky part. You have to kill them after they hatch but before they start laying eggs themselves.

Eggs hatch in three to five days, so if you treat again a day later, i.e., on the sixth day, you can be sure that any egg laid just before your first treatment will have hatched. But what about eggs laid before that? Eggs laid four days before treatment could hatch the day after treatment. If you kills them five day later, is that long enough for them to grow up and lay eggs themselves? If so, even a second treatment won’t be enough.

One source says the scabies life cycle is 10-17 days. This means it takes at least ten days between an egg being laid and that offspring laying an egg themselves. So if an egg that hatches immediately after treatment was laid five days before, in five more days it can lay an egg itself. If you don’t treat until the seventh day, then there could be new eggs that survive the second treatment.

Fortunately, the life cycle being that short is apparently extremely rare. Most estimates say it’s actually two to three weeks. That’s 14-21 days. Ten to twenty-one days is quite a range, which probably explains why the recommended interval between treatments varies.

Again, it’s also possible that you reinfect yourself because you didn’t treat your house — or housemate(s) — sufficiently. The ideal would be a treatment that kills mites as they hatch. Fortunately, I think there is one.

Treating your body

Here are many options. I will save the best for last.

The cheap medical prescription is usually lindane, a pesticide with the brand name of “Kwell.” It is highly toxic and can cause permanent nerve damage. I don’t recommend it.

More effective, less toxic, and a bit more expensive is another pesticide, synthetic pyrethrin, sold by prescription in 5% concentration as Elimite cream or generic permethrin in a tube that’s enough for at least two treatments. You put it on everywhere from the chin down and leave it on for 8-13 hours. Unfortunately, it often makes the itching worse.

Another treatment, used more in Europe, is ivermectin. Most sources say to take it twice, but the recommended interval varies from one to two weeks.

There are several over the counter 1% pyrethrin treatments for lice that are probably somewhat effective against light infestations. Be sure not to use any of these treatments if they contain piperonyl butoxide (or “PBO”), which is the active ingredient in many bug sprays. “Rid,” for example, has 4% PBO: twice the amount as in a can of Raid, and the directions on the Raid say not to get it on your skin!

With pharmaceuticals, one thing to seriously consider is the increasing prevalence of drug-resistant scabies.  Should you choose to use a topical pesticide, don’t bathe just before applying it. You’ll open your pores and absorb more of the poison, and the mites are on or just beneath the surface anyway. With any treatment, be sure to keep your nails cut short and to treat under them.

There are OTC lice treatments that are enzyme-based. These enzymes basically melt protein, the main ingredient in exoskeletons. Note that they do the same thing to natural dyes.

Sulfur has been used as a scabicide since Roman times. You can buy it as a powder at pharmacies. The directions are to mix it into petroleum jelly at 10% concentration (by volume?), spread it on everywhere up to your chin and leave it on for 3 days straight, reapplying it twice a day and/or after bathing. I have used salve (a wax/oil balm) as a base instead.

Sulfur is far cheaper than pharmaceuticals and said to be equally effective. However, don’t expect the medical establishment to speak highly of cheap options. Crotamiton 10% cream is often listed before sulfur, despite the fact that it’s only 60% effective and has frequent side effects.

The main problem with sulfur is the smell it leaves permanently on the clothes it gets on. It also tends to stain whites grey.

Sulfur is also much more time-consuming than Elimite. But it’s nontoxic– unless you are allergic to it. To check this, put a little on a spot on your skin and wait an hour or so. If you don’t get a rash or drop dead, etc. you’re probably okay.

There’s a whole list of other substances with insecticidal or repellent properties, and these can be used for bathing or on the skin (as well as for laundering, spraying things with, or soaking stuff in). These are available as soaps, powders, extracts, or essential oils. These include: coconut oil, neem oil (the one I tried was surprisingly mild), many other oils (especially olive), borax, rosemary, thyme, peppermint, bergamot, garlic, balsam of Peru, cedar, lavender, tide soap pastes, betadyne (iodine), beer, tobacco juice, etc. Basically, if you were a bug, what would kill or drive you crazy?

Essential oils and other concentrated oils in general should be diluted at least 10:1 into oil or a bath. Since mites are very sensitive to heat (see below), hot baths and esp. saunas can also be effective. Violet tincture taken internally (up to three droppers full a day) is said to be helpful, along with anything that supports your immune system and healthy skin growth.

The best natural option I have found is tea tree essential oil. Although it doesn’t kill scabies eggs, it has actually been shown to be more effective than pharmaceuticals in killing adults (see also here and here). You only need to leave it on for one to two hours. I don’t think you even need to wash it off. I don’t find it irritating at all, not even the smell.

You can use tea tree oil in conjunction with pharmaceuticals. The icing on the cake is that it actually relieves itching rather than making it worse. Just thin it 20:1 into a carrier like coconut oil: up to thirty drops per ounce. Most recommendations are for only ten drops per ounce (five per tablespoon).

Other options for itching include anything cooling, even just water. I’ve also found aloe, poke salve, pine pitch salve, and Solomon seal oil to be helpful. In my experience, the help from all of these things is temporary. You’ll need to reapply as needed: every few hours or less. One commercial product for itching that is longer-lasting and has worked well for me is Cera Ve Itch Relief Moisturizing Lotion.

Treating your home

Again, I’ll save the best for last. Remember that picking up scabies from anything other than someone else’s body is rare. Your biggest concern is their eggs.

The typical recommendation is that any fabrics — clothing, bedding (including pillows and blankets), couches, rugs, etc —  that you’ve rubbed against or spent more than a couple minutes on in the past three days should be treated. Since eggs can take five days to hatch, eggs must not be a concern. Apparently mites won’t lay eggs anywhere except on you (and your ilk).

Most sources say that scabies mites cannot survive for more than 48 hours away from the human body. So why three days (72 hours)? I guess “just to be safe.” However, under normal room temperature and humidity, stranded mites will actually die in 24-36 hours: half as long as is generally recommended (in colder conditions, they will survive longer).

What this means is that you don’t necessarily have to clean anything. The easiest option may be to simply go away for a couple days — as long as everyone who might be infected is prepared to do that. When you’re ready to go, I would treat yourselves before leaving so you don’t contaminate anyone or anywhere else, including your car. I would leave before your treatment ends.

If there aren’t many potentially contaminated items, another option is to simply “quarantine” them for at least 36 hours. Usually, it’s recommended to seal them in a plastic bag. Is that really necessary? Can you just pile it up in the garage, on the porch, in a spare room, a closet, or even in a corner of the room? Can you just not sit on a couch for that long? Scabies sense your heat and smell. Do they crawl toward you, like ticks? How fast? I don’t know.

Heat (over 120 degrees F for 10 minutes; another source says 35) will kill mites and their eggs. Since tap water is usually this hot, you can either wash your things on hot or just soak them in a vat of hot water (as long as it stays hot long enough). Washing in cold or warm water will not harm the bugs.

You can also put fabrics in a dryer. Since I measured one dryer’s temperature and it was only 100 degrees, be careful to pick a suitable length of time.

What about furniture, stuffed animals, car seats, mattresses, carpets, mats? Apparently, for some reason, hard surfaces are not a concern. For upholstery (sofas, etc.), vacuuming is said to be the safest and best option. It’s generally not considered necessary to clean carpets, rugs, drapes, floors, etc.: things people typically don’t spend a lot of time rubbing against. I guess mites don’t abandon ship on purpose, and if they are knocked off, they find something soft to cling to.

It’s also possible to use an ozone generator to basically fumigate a space, as long as you can get the concentration up to six parts per million for several hours. Here’s a formula for that.

Freezing for 48 hours will also kill both the mites and their eggs. That means that if the weather is cold enough, you can just put your stuff outside for a couple days.

All that aside, here’s my idea. If I’m right, you don’t have to treat your house or even leave. You don’t have to take any pharmaceuticals. Too good to be true?

My Protocol

If tea tree oil kills all the adults on you and any eggs on you hatch in 3-5 days, then as long as everyone in the household who might have scabies does the following and none are reinfected by anyone else, the easiest and most foolproof procedure is as follows.

Have tea tree on you constantly for 48 hours (I would apply it twice a day), then apply it once more in six days and again at nine days. That’s it! Here’s how it works:

In two hours, all adults on you will be dead. In 36 hours, all adults in the house will be dead. I say 48 hours just to be sure.

Within five days, all the eggs on you will have hatched. It takes ten days for these new mites to start laying eggs. You kill them all on the sixth day. On the seventh day, you rest. Amen.

It is possible that one of these new mites drops off you on the fourth or fifth day and gets back on you on the seventh. So do one more application of tea tree on day nine. Any new mites that dropped off you and didn’t get back on will be dead by then.

How to know if it worked

Don’t expect the itch to go away immediately, even if you kill all of them. You will be irritated by the presence of their bodies until your body gets rid of them. “Postscabetic itch,” a.k.a., “post-scabies syndrome” could subside in two weeks or it could take months.

During this time, you need to see whether you get bites in new places or not. I hope you can see by now that this is very possible. It’s why scabies has been called the “seven-year itch.”

The first time around, I kept notes. I even made a little graphic chart. Maybe it will be worth something someday. You can also take photos.

But I would just retreat myself. With tea tree oil, it’s simple. Good luck and good riddance!