It starts as an itch you can explain. The heating has been on since October, the house is dry, and your skin has been thinning for years anyway. So you buy a better moisturiser, you change the washing powder, and still, at two in the morning, you are awake and scratching.
That is how scabies gets a six month head start. It is not an exotic diagnosis, it is not a comment on anybody’s housekeeping, and it is entirely treatable. But in people over 60 it is almost always mistaken for something else first, and the delay is where the harm is done.
TL;DR
- Scabies is an infestation of the skin by a microscopic mite, Sarcoptes scabiei. The HPSC is explicit that it is not caused by poor hygiene and does not mean a person or a home is unclean.
- Irish outbreak notifications have risen steeply: four in 2021, nine in 2022, 26 in 2023 and 51 in 2024. Nursing homes accounted for 23 of those 51, with 185 people affected.
- In older adults the rash can involve the scalp, face, palms and soles, which the standard descriptions say it does not. That difference is one reason it gets missed.
- Treatment is two applications seven days apart, with every close contact treated on the same day, and bedding and clothing washed at 50°C on day one.
- Itching can continue for up to six weeks after successful treatment. That is the skin reacting to dead mites, not the treatment failing.
What is actually happening
The mite burrows into the upper layer of the skin and lays its eggs there. The itch is not the burrowing, it is an allergic reaction to the mites and their debris, which is why a first infestation takes three to six weeks to announce itself. By the time you are scratching, it has been there a while.
It spreads by prolonged skin to skin contact: sharing a bed, close personal care, a hand held for a long time. The HPSC states plainly that scabies can affect anyone regardless of age, circumstances or how clean a house is, and that line matters, because shame is one of the reasons people wait.
Why Ireland is seeing more of it
The trend is not subtle. Outbreak notifications went from four in 2021 to nine in 2022, 26 in 2023 and 51 in 2024, a 96% rise in a single year. Nursing homes made up 45% of the 2024 total with 23 outbreaks, ahead of private households, residential institutions and hospitals, and individual outbreaks affected anywhere from two to 18 people. Better reporting explains some of it, and the topical treatment shortages Irish doctors flagged from late 2023 explain more.
Why it gets missed after 60
An itch in your seventies already has a long queue of innocent explanations: dry skin, eczema, thyroid or kidney changes, and a good number of common medicines. Scabies joins the back of it, and the distribution misleads too. In most adults the rash favours the fingers, wrists, elbows, armpits, waist, buttocks, genital area and feet. But the HPSC notes that in older adults and people with weakened immune systems, the scalp, face, palms and soles can be affected as well. A rash on an 80 year old’s face does not rule scabies out the way it might in a 30 year old. It can also look quite different on black or brown skin, and in someone with dementia it may show as broken sleep or agitation rather than a complaint about itch. Scratched skin treated as eczema with a steroid cream looks calmer for a while as the mite population quietly grows.
Crusted scabies, and why it matters here
Crusted scabies is the rare, severe form, and the HPSC lists exactly the circumstances that describe many people in long term care: a weakened immune system, reduced mobility, or neurological conditions. The skin carries an enormous number of mites in thick scaly crusts that shed constantly. It spreads very easily, and the itch is not always the dominant feature, which is precisely why it gets mistaken for psoriasis or severe eczema. If it is suspected, Irish guidance is to seek dermatology or microbiology advice rather than repeat a shop bought cream.
Getting the treatment right
Permethrin 5% cream is the usual first line and can be bought from a pharmacy without a prescription, with malathion lotion as an alternative. Some people are prescribed an oral medicine instead. Whichever it is, two applications are needed, the second exactly seven days after the first. Skipping the second is the most common reason treatment appears to fail. The application detail is the whole ballgame:
- Skin must be clean, dry and cool. Not straight out of a hot bath. Bedtime is the usual advice.
- Pay particular attention to between the fingers and toes, wrists, armpits, groin, buttocks and skin folds. Brush the product under the nails with a soft nail brush and keep nails trimmed short.
- Soles of the feet last, once everything else has dried, sitting with your feet over the side of the bed.
- Reapply to your hands if you wash them mid-treatment, and leave permethrin on for 12 hours before washing it off with cool water and no soap.
One point worth raising with the pharmacist: the manufacturer’s leaflet generally says to apply from the jawline down, and that is the Irish consensus for most adults. For older adults, and for anyone immunocompromised, the head is usually included.
Everyone at once, or not at all
Everyone in the house with close personal contact, all sexual partners, and anyone with prolonged skin to skin contact in the previous six weeks needs treating at the same time, symptoms or not. People carry scabies for weeks before they itch, so an untreated contact who feels perfectly fine is the usual route back in.
On the first day of treatment, clothing, bedding and towels go through a 50°C wash or a hot tumble dry for 30 minutes. Anything that cannot be washed, including shoes, slippers and coats, goes into a sealed bag for four days. Normal household cleaning is enough otherwise, and most people can return to normal activities 24 hours after the first treatment.
The itch that outlasts the mite
Expect to keep itching. The HPSC says it commonly continues for up to six weeks after successful treatment, because the skin is still reacting to dead mites and their debris. Calamine, emollients or antihistamines help. Re-treating over and over does not.
Do seek advice, though, if the skin turns red, sore or hot, if you feel unwell, if new burrows keep appearing, if symptoms improve and then return, or if you are simply not improving four weeks after correctly completing treatment.
If it happens in a nursing home
A HIQA inspection report on a Kilkenny nursing home makes the case. Residents and staff had shown signs of infestation from September 2024, a dermatologist confirmed crusted scabies, and the outbreak was not formally declared until the end of May 2025. HIQA described the response as fragmented and lacking coordination and oversight.
If a relative is affected, the questions that get results are specific ones. Has this been declared as an outbreak with public health involved? Are all identified contacts, residents and staff alike, being treated on the same day? Has anyone with crusted skin been seen by dermatology? And was the second treatment given on day seven, or quietly forgotten?
Scabies is a small problem handled early and a miserable one handled late. If an itch has outlasted every reasonable explanation, and especially if it is worse at night and someone else in the house is scratching too, say the word out loud to your GP or pharmacist. The treatment is on a shelf behind the counter.
At Críonna Health, we write about ageing well in an Irish context: the services, the entitlements and the conversations worth having. This article is general information, not a substitute for advice from your GP or pharmacist.
📷 Photo by أخٌفيالله (@mhrezaa) on Unsplash
