Transmission of scabies is predominantly through direct skin-to-skin contact, and for this reason

scabies has been considered a sexually transmitted disease. The mite does not penetrate deeper
than the superficial layer of the epidermis, the stratum corneum.
A person infested with mites can spread scabies even if he/she is asymptomatic.[6] There may be a
prolonged interval (up to 10 wk) between the primary infection, when the patient becomes
contagious, and the onset of clinical manifestations.[7] Scabies is less frequently transmitted by
indirect contact through fomites such as infested bedding or clothing. However, the greater the
number of parasites on a person, as in crusted scabies, the more likely that indirect contact will
transmit the disease.
The S scabiei hominis mite that infects humans is female and is large enough (0.3-0.4 mm long)
to be seen with the naked eye. (The male is about half this size.) The mite has 4 pairs of legs and
crawls at a rate of 2.5 cm/min; it is unable to fly or jump.[8] Although its life cycle occurs
completely on the host, the mite is able to live on bedding, clothes, or other surfaces at room
temperature for 2-3 days, while remaining capable of infestation and burrowing. At temperatures
below 20C, S scabiei are immobile, although they can survive such temperatures for extended
periods. (See the image below.)

Scabies preparation demonstrating a

mite and ova. Courtesy of William D. James, MD.

Mite life cycle

The scabies mite is an obligate parasite that completes its entire life cycle on humans. Other
variants of the scabies mite can cause infestation in other mammals, such as dogs, cats, pigs,
ferrets, and horses, although they can irritate human skin as well. However, they are unable to
reproduce in humans and cause only a transient dermatitis.
The female S scabiei var hominis mite lays 60-90 eggs in her 30-day lifespan, although less than
10% of the eggs result in mature mites. The average patient is infected with 10-15 live adult
female mites at any given time. Life cycle stages are as follows (see the images below)[6] :

1. Eggs incubate and hatch in 3-4 days (90% of the hatched mites die)
2. Larvae (3 pairs of legs) migrate to the skin surface and burrow into the intact stratum
corneum to make short burrows, called molting pouches (3-4 days)
3. Larvae molt into nymphs (4 pairs of legs), which molt once into larger nymphs before
becoming adults
4. Mating takes place once, and the female is fertile for the rest of her life; the male dies
soon after mating
5. The female makes a serpentine burrow using proteolytic enzymes to dissolve the stratum
corneum of the epidermis, laying eggs in the process; she continues to lengthen her
burrow and lay eggs for the rest of her life, surviving 1-2 months
6. Transmission of impregnated females from person-to-person occurs through direct or
indirect skin contact

Scabies mite in the stratum

corneum. Courtesy of William D. James, MD.

In routine scabies, a single

mite is seen. Eosinophilic spongiosis may be present (hematoxylin and eosin; original
magnification, 400X).

In crusted scabies, sections

show multiple mites (arrows) within the hyperkeratotic stratum corneum. The epidermis
is spongiotic (hematoxylin and eosin; original magnification, 100X).

Classic scabies
In classic scabies infection, typically 10-15 mites (range, 3-50) live on the host.[8] Little evidence
of infection exists during the first month (range, 2-6 wk), but after 4 weeks and with subsequent
infections, a delayed type IV hypersensitivity reaction to the mites, eggs, and scybala (feces)
occurs. The time required to induce immunity in primary infestations probably accounts for the
4-week asymptomatic latent period. With reinfestation, the sensitized individual may develop a
rapid reaction (within hours). The resultant skin eruption and its associated intense pruritus are
the hallmarks of classic scabies. (See the images below.)

Scabies. Erythematous vesicles and papules are present

on torso extremities, some with adjacent linear excoriations.

Scabies. Courtesy of William D.

James, MD.
An immunologic study analyzing the cellular infiltrate types and patterns in scabies lesions
concluded that T4-cell dominance is the cause of persistent itching, while an increase in T8 cells
reduces pruritus.[9]

Crusted scabies
Crusted, or Norwegian, scabies (so named because the first description was from Norway in the
mid-1800s) is a distinctive and highly contagious form of the disease. In this variant, hundreds to
millions of mites infest the host individual, who is usually immunocompromised, elderly, or

physically or mentally disabled and impaired. (Assessment of immune function may be indicated
in individuals presenting with crusted scabies.)[10, 11]
Crusted scabies can be easily confused with severe dermatitis or psoriasis because widespread,
crusted lesions appear with thick, hyperkeratotic scales over the elbows, knees, palms, and soles.
The diagnosis of crusted scabies should be considered when suspected dermatitis or suspected
psoriasis does not respond to usual treatments. (See the images below.)[2]

Crusted scabies. Courtesy of William

D. James, MD.

Crusted scabies. Courtesy of Kenneth E.

Greer, MD.

Serum immunoglobulin E (IgE) and IgG levels are extremely high in patients with crusted
scabies, yet the immune reaction does not seem to be protective. Cell-mediated immunity in
classic scabies demonstrates T4-cell predominance in the dermal infiltrate, while one study
suggests a T8-cell predominance in crusted scabies.
Certain patient populations are susceptible to crusted scabies. These include patients with
primary immunodeficiency disorders or a compromised ability to mount an immune response
secondary to drug therapy. A modified host response may be a key factor in patients with
malnutrition. Motor nerve impairments result in the inability to scratch in response to the
pruritus, thus disabling the utility of scratching to remove mites and destroy burrows. Rare cases
have been described in which immunocompetent patients have developed the crusted variant
without clear explanation.