Scabies Rash: Diagnosis and Treatment

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Is It Really Scabies? Felt-Tip Markers and Other Diagnostic Tricks

Is it a scabies rash?

by James Hubbard, M.D., M.P.H.

The seven-year itch they used to call it, and if you’ve ever had it, you know the scabies rash itches like crazy—even worse at night.

As with head lice, I see more scabies cases when school starts back. It can also become a problem for shelters, nursing homes, even hospitals. Like head lice, the scabies mite feeds on the human body and likes to jump ship, so to speak, when people are in close contact.

But, in my opinion, tiny scabies mites aren’t as simple to diagnose as the bigger bugs.

6 Tricks to Diagnosing a Scabies Rash

All sorts of other things can cause an itchy rash that looks the same as scabies, such as other insect bites, dry skin, impetigo (bacterial infection), allergic reactions, and eczema. There’s even a condition called delusional parasitosis, which I’ll write about in my next post. But over the years, I’ve learned some tricks that make the scabies rash easier to diagnose.

  1. Don’t look for the mite. It’s so tiny you’re not going to see it. And there are only ten to fifteen mites on your body. The bumps and itch don’t start until the mites have been on your body for a couple of weeks. They, their eggs, and their feces cause you to have an allergic reaction with the resultant itchy rash. Doctors can scrape the skin and sometimes see a mite under the microscope, but diagnosing it this way in a disaster situation isn’t worth it because there are easier ways.
  2. If you’re lucky you can spot little streaks where the mites have burrowed just underneath the skin to lay eggs. But, just like the mites, these tunnels can be very hard to see, especially with an untrained eye.
  3. An easier way to see the burrows is to use a washable felt-tip marker to color in a square a couple or three square inches around some bumps. Clean off the ink with some alcohol pads. The burrows will be outlined by the ink they’ve soaked up and appear as thin, dark streaks.
  4. Also, a scabies rash can be on any part of the body except the face. It sometimes gets on the scalps of small kids but doesn’t affect their faces either.
  5. Another good clue I look for is the scabies rash often involves the webs between the fingers. That won’t be the only area of the rash, but scabies is the only itchy rash I can think of that involves other parts of the body and in-between the fingers at the same time.
  6. Especially in children, the itchy scabies rash can be on the soles of the feet. As with the webs of the fingers, that won’t be the only rash area, but in children, if there’s an itchy rash on various parts of the body, and it includes the feet, think scabies.

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Treatment for the Scabies Rash

Treatment options for a scabies rash are listed below. With any of them, be sure to:

  • Treat all close contacts.
  • Apply the treatment to every nook and cranny of your body, from the neck down. In small kids include the scalp. Don’t forget to treat under your fingernails since you may have eggs there from scratching.
  • Test your sensitivity to any topical medicine before putting it all over your body. Apply some to a patch of skin and wait a few hours to make sure you don’t have a reaction.
  • Treat everyone at the same time so no one will get reinfected. That means treating all close contacts even if they have no symptoms. You can have the mites up to two weeks before you have the slightest rash or itch.

As part of the treatment:

  • Wash all clothes and bed linens in hot water and dry them in a hot dryer if available. Do this at the same time you’re treating everyone. If a washer and dryer are not available, put everything in a sealed plastic bag for a couple of weeks to give time for all the mites to die. The mite can live up to three days off the body.
  • Vacuum rugs and cloth furniture and put the contents in a plastic bag.

Don’t be surprised if the itching continues for several weeks. It can take that long for the allergic reaction to go away. If you’ve diligently done all of the above, all you can do is wait it out and use something for the itching such as Benadryl, a steroid ointment, or whatever’s your favorite home remedy for itching.

Medicines for the Scabies Rash

Permethrin 5 percent (Elimite)
This is over-the-counter (correction-this is prescription) and can be used for children older than two months. Follow the directions to the letter, and rinse off the lotion after eight to fourteen hours. That should do it, but we compulsive types like to repeat it in seven days just to make sure.

This is oral medicine used for other parasites. If you’re in disaster and have some, it’ll work on scabies but be sure to read the precautions and drug interactions. The dose for scabies is a single dose of 200 micrograms per kilogram (2.2 pounds). Repeat in two weeks.

Neem oil
It can be used like the permethrin. (For adults: Rub it over clean, dry skin from your neck to the soles of your feet. After eight to fourteen hours, wash it off.)

Tea tree oil
A five percent solution can be used like the permethrin.

Sulfur mixed in petroleum
You can use anywhere from a two to a ten percent mixture. The problem, other than the odor and the discoloration of whatever it touches, is that it only kills the mites, not the eggs. I’d use it like the permethrin but repeat for three consecutive days, wait a week, and repeat one last time. Be sure you’re not allergic to sulfa products.


So, what about you? Are you prepared? What have you tried? How did it work?

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  • xoltol

    question, i’ve had scabies before (I worked in dorms and in public school settings) but this itch has presented itself differently than it has in the past. appearing on the scalp (no its not lice, i’ve checked), face, eye lids, back, not so much fingers and toes, with no real marks. i did find these “scratches” on my back and tried the marker test, wasn’t sure if this is what you meant by the darkening along the line. i’m sorry its not a better picture, i’m kinda solo. i have no other signs that indicate as such, but i’m so paranoid about it its always the first thing i go to when i get itchy. i also suffer from eczema and have noticed a lot of contact dermatitis, and allergies in the last few year that I never had issues with in the past. I just lost my job so i’m without insurance and don’t have the $80 for the perimethrin cream unless that’s what it is. i’m about to treat my house and i just wanted to check before i called the dr to treat my skin. my boyfriend thinks i’m paranoid, and maybe so… any help is appreciated

    • James Hubbard, MD, MPH

      I can’t diagnose specifically without a direct exam. Though, in general, scabies affects the top of the hands, the arms, and around the waist more than anywhere else. It also causes intense itching. Again, in general, scabies does not tend to affect the back only.

      • xoltol

        awesome, i realize you are unable to “diagnose” without a direct exam, and i do not take this advice as a diagnosis; but i figured you could offer the best professional opinion for me. I appreciate your getting back with me so quickly.

  • jo

    There is a rash on my middle finger, which started with a mosquito bite seven years ago! Up until today, I have tried most of the over-the counter ….azole treatments, most from our pharmacy, and a few home remedy leaves with no change. The last doctor I saw (about a month ago) confirmed it is “Fungus Element”. Our local hospital does not have a dermatologist or special skin doctor. The rash will “almost” completely go away, and then dries up really fast creating one or more red lines of cracked skin. HELP!

    • James Hubbard, MD, MPH

      There are anti fungal creams such as terbinafine (Lamisil). Or some like to try tea tree oil. Surely there’s a dermatologist in a nearby town, but also many family doctors would feel comfortable treating that. See if you can find one with an interest in dermatology.

  • maegan delorme

    My 2 year old started with a rd rash on the bottom of her feet, Dr said heat rash. 2 weeks later it is becoming dry and discolored. But it has spread to tops of her feet, legs, and now lots on her but. Some are red some are skin colored, barely any on tummy or arms. She doesn’t scratch, except every once in a while on her feet since theyve become dry. We went to a children’s hospital, and they said contact dermatitis, but the next day is when it got worse on her butt. Any ideas? We sleep together and shower together and I’ve yet to get it.

    • James Hubbard, MD, MPH

      Why couldn’t it be contact dermatitis? Anyway, my suggestion is to find one pediatrician, make an appt. and then go back to that one for follow up so they’ll know your daughter, know what the rash looked like before treatment, and have a better understanding of the next step if treatment is not working. Eczema? There are quite a few possibilities.

  • Worried mom

    How do u know if it’s scabies if there is no rash? Just some itching ? My 2yo woke up last night and said her feet were itchy, I put hydrocortisone cream on them and she fell asleep shortly after and didn’t itch anymore over the night.

    • James Hubbard, MD, MPH

      I’m not clear on why you think it would be scabies? Certainly most itching is not especially unless you think she has been exposed to someone with it. In general scabies causes a rash and persistent itching, usually spreading a bit.

  • Brainbuster

    Most popular, well-reviewed remedy for scabies on earthclinic is borax + hydrogen in the bath.
    Fill tub with water, pour in a cup or two of borax (you can usually find it in the laundry section of the store) and a cup or two of hydrogen peroxide.

  • hate rashes

    Would cortisone cream on its own make the rash go away and start up in another area? For instance has rash under right breast ..put cortisone on it and it cleared up after 3 days of this. a week later it appeared on left breast..did same thing and it is clearing up but have a couple patchy spots on my stomach now. It itches and is really red and swollen when the rash is there.

    • James Hubbard, MD, MPH

      If you’re talking about a general rash and not scabies, cortisone cream can definitely help many times, and it would not make a rash start up somewhere else. Perhaps it’s a yeast infection. One thing you could try is yeast infection cream and make sure your breasts are not directly touching the skin of your trunk by putting a piece of cotton cloth between the two. But if it continues, or is spreading, you should see your doctor.

  • joe

    i’ve been diligent with cleaning, used the permethrin (two doses, 6 days apart) -this was about 2 months ago- and still experienced the biting itch. went with natural scabies killer oil (neem and tea tree) and enzyme cleaner; nothing. still seeing new rash (which i’m beginning to debate whether it is scabies or something else???) … should i just simply try another permethrin round? i hate the idea of insecticide all over my body though with possible carcinogens … any suggestions? i’m waiting for a sulfur soap to arrive to give that a try. pretty sure i got this rash/biting from a camping trip and the symptoms arrived about 3 weeks later. any ideas before approaching doc again for iver or something else??

    • James Hubbard, MD, MPH

      Joe, you should have a doctor check and make sure that’s what it is.

  • Liz

    Hi, can you have a burrow with no itching initially?

    • James Hubbard, MD, MPH

      Liz, I guess it’s possible. But it’s not the usual case.

      • Liz

        Thank you so much! You really provide a very valuable service. There is a lot of misinformation out there and it’s hard to know what to believe. It’s certainly enough to drive a sane person crazy with worry.

        • James Hubbard, MD, MPH

          You’re welcome, Liz. Thanks for the encouragement.

  • Danielle May

    My son was diagnosed with Scabies, and prescribed the cream to put on overnight. We did that On Friday night it is now Sunday and it seems the rash is spreading..Does it spread BEFORE it gets better? Also the itching he said seems less.

    • James Hubbard, MD, MPH

      It shouldn’t spread much. If it’s still spreading tomorrow, check with or call your doctor.

      • Danielle May

        Thank you…

  • Juniper

    Can you get scabies without human contact? I was just diagnosed with Scabies, but I am not close with anyone at the moment (single/work long hours). I did stay in a hotel room about three weeks ago, but I didn’t think that would be possible. Any ideas?

    • James Hubbard, MD, MPH

      You can get scabies from infected bed linen. See treatment.

      • LM

        That’s how I got it…from a hotel in Oceanside, CA. Been driving me crazy now for almost 4 months! According to my past two dermatologists visits, I am clear of scabies, but still have the itching, biting sensations, and worst of all–the creepy crawlies on my whole body including my face! Btw, I used the permethrin 5% cream back in early October, and used Ivermectin 4 times, 4 weeks in a row, just to make sure I killed any possible living mite (not to mention all the insane cleaning I did for months, including my car!). And that was 9 weeks ago now!! My dermatologist said that I have “Ehlers-Danlos” syndrome, and that I’m still itching because my skin is SO sensitive, plus I have food allergies and dust mite/dust allergies. I don’t really have any rashes/burrows on my skin, and he scraped two single bumps on my body and found absolutely nothing. So, Dr. Hubbard, what is your professional opinion on his diagnosis? I don’t have anything on my body that looks like it did when I know for a fact I had scabies. I was almost convinced I had been re-infested somehow (not from the same place, though) because of all the itching, plus some pimple-like bumps on my back, but everyone is convinced that I’m cured, just still dealing with the allergic reaction part of post-scabies. How long can this last for? It’s going on 4 months since I was first diagnosed (by a scraping) with scabies. I’ve since moved to another state and had everything packed away for 2 weeks, as well! Thank you.

        • James Hubbard, MD, MPH

          I would go with your dermatologist, who knows and has examined you.

          • LM

            Wow, thanks for your quick response! Have you ever known anyone else to have such a long-lasting allergic reaction to it (also called “post-scabies” syndrome), but not still have an active scabies infection?