DOI: 10.1111/j.1468-3083.2010.03618.

x JEADV

ORIGINAL ARTICLE

Quality of life of patients with scabies

A Jin-gang,† X Sheng-xiang,†,* X Sheng-bin,‡ W Jun-min,† G Song-mei,† D Ying-ying,† M Jung-hong,†
X Qing-qiang,† W Xiao-peng†
†
Department of Dermatology, the Second Hospital, Xi’an Jiaotong University, Shaanxi, China
‡
Department of Nutriology and Food Sanitation, Medical School of Xi’an Jiaotong University, Xi’an, Shaanxi, China
*Correspondence: X Sheng-Xiang. E-mail: Xiao_SX@163.com

Abstract
Background Scabies is a highly contagious disease caused by the mite Sarcoptes scabiei, and the disease is still
a major public health problem in many resource-poor regions. Apart from the skin lesions or substantial morbidity,
scabies also leads to social stigma. However, quality of life (QoL) has not been investigated in patients with scabies.
Objectives The aim of this study was to assess the impact of scabies on patients’ QoL using the Dermatology Life
Quality Index (DLQI) questionnaire, and assess its feasibility and internal consistency.
Methods One hundred consecutive outpatients seeking treatment for scabies in the Department of Dermatology,
the Second Hospital of Xi’an Jiaotong University, were assessed for eligibility for this prospective study from 8
August 2008 to 20 December 2008. Sulphur (10%) was selected in the treatment of scabies.
Results A total of 96 patients completed the study. Among them, 78 (81.25%) of patients were considered
cured at the end of the study. The mean ± SD DLQI score in our study was 10.09 ± 5.96. QoL of most of
(71.9%) our patients has moderately affected. Questions 1 (symptoms), 2 (embarrassment), 7 (work or study)
and 9 (sexual difficulties) had the most impact on patients with scabies. Domain 1 (symptoms and feelings) and
5 (personal relationships) scored higher than other domains. There was significant progress of QoL after
treatment in our patients. No strong relationship between disease-related characteristics and QoL could be
found.
Conclusion Scabies moderately affected the QoL of the patients. Sulphur could be considered as an effective
treatment for patients with scabies.
Received: 13 August 2009; Accepted: 21 January 2010

Keywords
Dermatology Life Quality Index, quality of life, scabies

Conflict of interest
None declared.

Introduction imagine, therefore, that scabies may have an impact on patients’

Scabies is a highly contagious disease caused by the mite Sarcoptes
scabiei. The worldwide prevalence has been estimated at about 300
million cases yearly.1 Scabies is still a major public health problem
in many resource-poor regions,2 with prevalence reaching up to
10% in the general population and 50% in children. Besides the
skin lesions, scabies even causes substantial morbidity from sec-
ondary infections and post-infective complications such as acute
post-streptococcal glomerulonephritis.3
Patients with scabies suffered a lot from social stigma because of
the skin lesions seen in exposed positions, and direct person-to-
person body contact is generally necessary for transmission of
scabies, although it is not life-threatening. It is not difficult to
quality of life (QoL).
The Dermatology Life Quality Index (DLQI) is a dermatology-
specific QoL measure that has been well validated in a range of
skin conditions.4 It has been used in 33 different skin conditions
in 32 countries and is available in 55 languages.
Our aim was to investigate QoL in patients with scabies by
using the validated DLQI. Sulphur was selected for the treatment
of scabies. The outcome of sulphur for the treatment of scabies
has been evaluated by using physician’s subjective evaluation;
however, studies analysing the patients’ QoL before and after treat-
ment are completely missing. This is the first time that DLQI is
used among patients with scabies.

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JEADV 2010 Journal compilation ª 2010 European Academy of Dermatology and Venereology
2 Jin-gang et al.
Patients and methods
Study design
One hundred consecutive outpatients seeking treatment for scabies
in the Department of Dermatology, the Second Hospital of Xi’an
Jiaotong University, were assessed for eligibility for this prospective
study from 8 August 2008 to 20 December 2008. The study was
approved by the ethics committee of the hospital.
Patients
The inclusion criteria included confirmation of the diagnosis of
scabies either by identification of mites, larvae, mite eggs, faecal
pellets or by the presence of the following criteria: (i) identification
of mite burrow in the skin, (ii) presence of typical lesions in sites
of predilection, (iii) nightly itching, (iiii) occurrence of the same
symptoms in contact persons.5 Exclusion criteria were patients
younger than 16 years of age, crusted scabies, uncontrolled
chronic disorder and secondary infections.
Treatment
Sulphur ointment (10%) was applied to all patients. Instructions
for the use of sulphur therapy were given verbally. The ointment
was thoroughly rubbed nightly on all body surfaces except head
and face. Twenty-four hours after application of ointment, the
ointment was washed off. This sequence of processes was repeated
for 4 days.6 A course of treatment was repeated 1 week later.
Infested close contacts were asked to accept therapy simulta-
neously. Laundering of clothing and bedding with hot water was
recommended.
Evaluations
Severity of scabies was evaluated according to Hamm H.5 One
body area of typical lesions involvement means mild, 2 body areas
mean moderate, 3 body areas mean severe, ‡4 mean very severe.
The efficacy and safety were evaluated on week 2 and week 4.
The entire body surface was examined. Repeat treatment on week
2 was performed if the patient could not be judged cured with cer-
tainty or if the close contact person of the patients had scabies.
Primary outcome was the cure rate at week 4. A patient was con-
sidered cured if old scabies lesions disappeared, no new lesions
appeared, and no mites were detected.5
Dermatology Life Quality Index is comprised of 10 items, giving
a sum score ranging between 0 and 30.7 It focuses on six domains,
including symptoms and feelings, daily activities, leisure, work and
school, personal relationships and treatment. DLQI is a dermatol-
ogy-specific questionnaire and is suitable both for studies and clin-
ical routine. DLQI has been applied on a variety of skin diseases
for the evaluation of change during therapy. ‘Banding’ of DLQI
scores allows this measure to be clinically useful.8 Grade 1 (0–1)
means no effect at all on patient’s life, similarly, grade 2 (2–5)
means small, grade 3 (6–10) means moderate, grade 4 (11–20)
JEADV 2010 Journal compilation ª 2010 European Academy of Dermatology and Venereology
means very large and grade 5 (21–30) means extremely large effect
on patient’s life.
Possible effects on QoL were measured as pre ⁄ post-treatment
differences in DLQI mean scores, which has been validated in Chi-
nese patients.9 The DLQI questionnaires were distributed at the
first visit of the patients and at the end of the study. The DLQI
was used according to the instructions given by Finlay and Khan.
Ten items were explained to all subjects, and data collectors helped
them to complete the survey questions. More data were obtained
besides DLQI, including age, gender, social status, address, work
status and duration.
Statistical analysis
The Mann–Whitney U-test was used to test the equality of distri-
butions of quantitative outcomes. The mean DLQI score before
and after treatment was analysed using Student’s t-test. The rela-
tionships between DLQI scores and clinical, social, and demo-
graphic factors were analysed using ordinal multiple logistic
regression. Construct validity was tested by factor analysis. Reli-
ability was assessed by average inter-item correlation, item total
correlation and Cronbach’s alpha.10 All analyses were performed
using SPSS software (version 13.0; SPSS Inc., Chicago, IL, USA).
P < 0.05 was interpreted as statistically significant.
Results
Patient demographics
One hundred patients were included in the study. Four patients
were later excluded as they disagreed with our diagnosis, leaving
96 (96%) to be studied. Table 1 shows the distributions of gender,
employment status, educational level, clinical severity, address,
duration of scabies and age. The mean age of the study population
was 29.71 ± 11.47 (16–66) years. The duration of the symptoms
ranged from 2 days to 6 months, with a mean duration of
44.81 days. Involvement with typical skin lesions was severe in 33
patients (33.4%) and very severe in 25 (26.0%). Mild involvement
was found in four patients (4.2%) and moderate involvement in
34 (35.4%); 45 (46.9%) of patients were employed, 60 (62.5%) of
patients had secondary education, and 52 (54.2%) of patients were
from urban areas and the rest were from rural sites.
Dermatology Life Quality Index scores
The overall mean DLQI score was 10.09 (median 9.00). As shown
in Table 2, 6 (6.2%) patients scored ‡21, 33 (34.4%) scored
between 11 and 20, 36 (37.5%) scored between 6 and 10, 17
(17.7%) scored between 2 and 5, and 4 (4.2%) scored between 0
and 1. Scores for the DLQI of patients are given in Figs 1 and 2.
The individual mean score ranged from 0.55 to 2.08 and the med-
ian ranged from 0 to 2. Questions 1 (symptoms), 2 (embarrass-
ment), 7 (work or study) and 9 (sexual difficulties) had the most
impact on patients with scabies. The lowest individual mean score
was for item 6 (sport), whereas the highest individual mean score
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Quality of life in patients with scabies 3

Table 1 Demographic, social and clinical characteristics for

patients with scabies Domain6

Baseline Demographics Domain5

characteristics
Gender, n (%) Domain4
Female 38 (39.6)
Domain3
Male 58 (60.4)
Education, n (%)
Domain2
Primary 4 (4.2)
Secondary 60 (62.5) Domain1
> Secondary 32 (33.3)
0 0.5 1 1.5 2 2.5 3 3.5
Employment status, n (%) Mean
Employed 45 (46.9) Figure 1 Six dimensions’ scores of the patients.
Unemployed 24 (25.0)
Student 25 (26.0)
Retired 2 (2.1)
12
Clinical severity, n (%) P ˘0.001 P ˘0.001
10
Mild 4 (4.2)
8 Before
Moderate 34 (35.4) treatment
Severe 33 (34.4) 6
After
Very severe 25 (26.0) 4
treatment
Address, n (%) 2
Urban 52 (54.2) 0
Mean Median
Rural 44 (45.8)
Range age, years (mean) 16–66 (29.71 ± 11.47) Figure 2 Total Dermatology Life Quality Index scores of the
Range duration of scabies (days) (mean) 2–180 (44.81 ± 48.01)
patients before and after treatment.

difference was not statistically significant. Scores were not associ-

Table 2 Banding of the Dermatology Life Quality Index with the ated with age, duration, education, employment status and clinical
scores for patients with scabies
severity.
Patients before Range of score QoL effect
treatment, n (%)
Internal consistency and concurrent validity
4 (4.17) 0–1 No effect
The value of Kaiser–Meyer–Olkin measure (KMO = 0.837) and
17 (17.70) 2–5 Small effect
Bartlett’s test of sphericity (v2 = 333.04, P < 0.001) support for
36 (37.50) 6–10 Moderate effect
factor analysis. We found item 1 (symptoms) and item 2 (feeling
33 (34.38) 11–20 Very large effect
self-conscious) together accounted for 57.21% of the variance in
6 (6.25) 21–30 Extremely large effect
DLQI score in this setting. Two factors were extracted from the
factor solution of the DLQI items as shown in Table 3. The factors

was for item 1 (symptoms). A total of 78 (81.25%) patients were Table 3 Factor loadings (rotated)* of two-factor solution
considered cured at the end of the study. Treated patients scored
Dermatology Life Factor 1 Factor 2
significantly lower for item 3 (shopping) and 6 (sport), whereas Quality Index items
the highest individual mean score was for item10 (treatment). Q1 )0.066 0.713
When six domains of DLQI were compared, domain 1 (symptoms Q2 0.168 0.716
and feelings) and domain 5 (personal relationships) scored higher Q3 0.703 0.308
than other domains. Q4 0.848 0.037
The relationships between DLQI scores and clinical, social and Q5 0.639 0.395
demographic factors were analysed using multiple logistic regres- Q6 0.776 0.234
sion. Although male patients were 1.26 times more likely to have a Q7 0.547 0.497
high score when compared with female patients (P = 0.574, 95% Q8 0.386 0.525
CI: 0.557–2.866), and patients living in the rural region were 1.11 Q9 0.176 0.720
times more likely to have a high score when compared with that Q10 0.782 )0.067
living in the urban region (P = 0.980, 95% CI: 0.382–2.683), the *Varimax.

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4 Jin-gang et al.
were, first, items 3, 4, 5, 6, 7 and 10. These items refer to the social
and emotional effects of scabies. Second, items 1, 2, 8 and 9 refer
to the interpersonal aspects and the extent to which the condition
causes symptoms and feelings discomfort.
Cronbach’s alpha (scale reliability coefficient) for the DLQI
score was 0.840, and the standardized item alpha was 0.842, both
considerably higher than the traditional threshold of 0.7, indicat-
ing a high degree of internal reliability of the score. The average
inter-item correlation was 0.348 (>0.2), suggesting good reliability.
The item total correlation ranged from 0.305 to 0.656. The average
item total correlation was 0.538.
The median DLQI score for new patients was 9.00 (1–30),
whereas that for treated patients was 3.00 (1–10). The difference in
DLQI score between the two groups was statistically significant
(P < 0.001).
Discussion
This is the first study to attempt to measure the impact of scabies
on QoL, and we demonstrate that scabies has a moderate impact
on QoL.
Based on the prospective study of 96 patients with scabies, it is
obvious that scabies had a moderate influence on QoL of patients.
QoL of most of (78.13%) our patients were moderate to extremely
large affected. The mean ± SD DLQI score in our study was
10.09 ± 5.96, which was similar to psoriasis outpatients in China
(mean, 10.97);9 however, there is difference when six domains are
compared, the most concerned domains as to psoriasis outpatients
were domain 1 (symptoms and feelings) and domain 3 (leisure).
There was significant progress of QoL after treatment in our
patients. However, no strong relationship between disease-related
characteristics and QoL could be found.
Questions 1 (symptoms), 2 (embarrassment), 7 (work or study)
and 9 (sexual difficulties) had the most impact on patients with
scabies. Filariasis is the only parasitic disease in concern with QoL
research.7 Interestingly, we found that there are some overlaps
between the two different disorders. Question 1 (symptoms), 2
(embarrassment), 3 (daily activities) and 7 (work or study) scored
higher than other questions among patients with filarial lymphoe-
dema,11 while question 1 (symptoms), 2 (embarrassment), 3 (daily
activities), 4 (clothes) scored higher among patients with filarial
lymphoedema in another research.12 It is seemed that question 1
and 2 are the most concerned items although they may not be the
highest scores, other different items concerned may be explained
by the different cultural background.
To compare DLQI score between new and treated patients, we
chose sulphur for the treatment of scabies. There are many scabi-
cides for the treatment of scabies. Permethrin cream is considered
the drug of choice in the management of scabies in the UK, USA
and Australia.13 Topical ivermectin provides high efficacy, easy
administration, and lack of side-effects.14However, permethrin
cream and ivermectin may not be available in resource-poor
regions.7 The side-effects limit lindane gel’s usage. Crotamiton’s
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efficacy was only 60% at 4 weeks. Ivermectin appeared to be an
effective oral treatment, but the primary method of treatment for
scabies is by topical application. Sulphur has the advantage of
being cheap and may be the only choice in resource-poor areas.
With regular application of sulphur ointment, 78 (81.25%) of
patients were considered cured, without new scabies lesions
appeared, or healing of the old lesions. The cure rate was lower
than that of ivermectin (88%, 91%),15,16 but higher than that for
children patients using sulphur (71%).6
Treatment of scabies by sulphur ointment may be a burden to
scabies patients, because of not only the cumbersome procedures
but also the odour of the ointment. Question 10 (treatment) was
the highest individual mean score among patients treated, which
reflects the limitations of the sulphur ointment. Although sulphur
can be applied as the therapeutic agent in the treatment of scabies,
and it can also improve the QoL, more effective and easy applied
drugs are recommended, such as ivermectin.
A questionnaire is considered to be internally consistent when
there is a high correlation among the scores of items. This inter
correlation is expressed by Cronbach’s alpha. The minimum
requirement for an instrument to be internally consistent is a
value of 0.70.17 Several other investigators have assessed the inter-
nal reliability of the DLQI, and have demonstrated Cronbach’s
alpha scores of between 0.75 and 0.92.18–21 Among patients with
scabies, Cronbach’s alpha was 0.842, indicating high internal reli-
ability.
In conclusion, scabies moderately affected the QoL of the
patients. People should pay more attention to the contagious dis-
ease, although it is not life-threatening. Sulphur could be consid-
ered as an effective treatment for patients with scabies. Although
the adverse effects limit its’ usage, sulphur is still a first choice in
resource-poor regions. The limitations of our study are the lack of
a longer study and a larger sample, which could be incorporated
in the planning of future studies in scabies. Another comment is
related to the questionnaire itself, for example, part of patients
worried about the impact of diet on disease which does not exist
in DLQI because of the different culture background.
Acknowledgements
We are grateful to Professor Andrew Finlay of the University
of Wales College of Medicine, Cardiff, UK, for permission to
use the DLQI, and Dr Yan HB and Liu ZH for their kind per-
mission to use the Chinese version of DLQI. We are also
grateful to all subjects participated in the study. Jingang An
and Shengbin Xiao have full access to all the data in the study
and take responsibility for the integrity of the data and the
accuracy of the data analysis.
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