“Mum’s scratching herself raw at the care home — and now my hands are itching too. What is going on?”

Generalised itch in an older care-home resident needs examination and a broad differential (dry skin, drugs, eczema, systemic disease), but itch worse at night affecting the hands, wrists, waist and breasts, with staff, other residents and visitors itching, is scabies until proven otherwise. In older people with dementia or immunosuppression, scabies may be atypical or crusted (hyperkeratotic, Norwegian) scabies: thick, crusted scaling, often on the hands, with very large numbers of mites and high infectivity. Topical steroids alone can mask it and make it worse. UKHSA guidance on scabies in care homes and other closed settings advises that when scabies is suspected in a care home, the home should contact the local health protection team; outbreaks are managed by coordinated, simultaneous treatment of all residents, staff and close contacts (including families), environmental cleaning and laundering, and, in crusted scabies or outbreaks, consideration of oral ivermectin under specialist or UKHSA advice (check the SPC/local formulary). Topical permethrin 5% is applied to the whole body (including scalp, face and neck in older people, avoiding the eyes) and repeated after 7 days. Itch can persist for several weeks after successful treatment. For a resident who lacks capacity, treatment decisions are made in her best interests, involving a registered health and welfare attorney (Mental Capacity Act 2005). Other residents’ information is confidential. When a relative asks about neglect, respond honestly, acknowledge any shortcomings (such as prescribing without examination), and explain routes for concerns; a delayed diagnosis is not in itself neglect, but safeguarding should be considered if there are wider indicators.