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DOI: 10.1111/j.1468-3083.2010.03618.

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

ª 2010 The Authors


JEADV 2010 Journal compilation ª 2010 European Academy of Dermatology and Venereology
2 Jin-gang et al.

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

ª 2010 The Authors


JEADV 2010 Journal compilation ª 2010 European Academy of Dermatology and Venereology
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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JEADV 2010 Journal compilation ª 2010 European Academy of Dermatology and Venereology
4 Jin-gang et al.

were, first, items 3, 4, 5, 6, 7 and 10. These items refer to the social efficacy was only 60% at 4 weeks. Ivermectin appeared to be an
and emotional effects of scabies. Second, items 1, 2, 8 and 9 refer effective oral treatment, but the primary method of treatment for
to the interpersonal aspects and the extent to which the condition scabies is by topical application. Sulphur has the advantage of
causes symptoms and feelings discomfort. being cheap and may be the only choice in resource-poor areas.
Cronbach’s alpha (scale reliability coefficient) for the DLQI With regular application of sulphur ointment, 78 (81.25%) of
score was 0.840, and the standardized item alpha was 0.842, both patients were considered cured, without new scabies lesions
considerably higher than the traditional threshold of 0.7, indicat- appeared, or healing of the old lesions. The cure rate was lower
ing a high degree of internal reliability of the score. The average than that of ivermectin (88%, 91%),15,16 but higher than that for
inter-item correlation was 0.348 (>0.2), suggesting good reliability. children patients using sulphur (71%).6
The item total correlation ranged from 0.305 to 0.656. The average Treatment of scabies by sulphur ointment may be a burden to
item total correlation was 0.538. scabies patients, because of not only the cumbersome procedures
The median DLQI score for new patients was 9.00 (1–30), but also the odour of the ointment. Question 10 (treatment) was
whereas that for treated patients was 3.00 (1–10). The difference in the highest individual mean score among patients treated, which
DLQI score between the two groups was statistically significant reflects the limitations of the sulphur ointment. Although sulphur
(P < 0.001). can be applied as the therapeutic agent in the treatment of scabies,
and it can also improve the QoL, more effective and easy applied
Discussion drugs are recommended, such as ivermectin.
This is the first study to attempt to measure the impact of scabies A questionnaire is considered to be internally consistent when
on QoL, and we demonstrate that scabies has a moderate impact there is a high correlation among the scores of items. This inter
on QoL. correlation is expressed by Cronbach’s alpha. The minimum
Based on the prospective study of 96 patients with scabies, it is requirement for an instrument to be internally consistent is a
obvious that scabies had a moderate influence on QoL of patients. value of 0.70.17 Several other investigators have assessed the inter-
QoL of most of (78.13%) our patients were moderate to extremely nal reliability of the DLQI, and have demonstrated Cronbach’s
large affected. The mean ± SD DLQI score in our study was alpha scores of between 0.75 and 0.92.18–21 Among patients with
10.09 ± 5.96, which was similar to psoriasis outpatients in China scabies, Cronbach’s alpha was 0.842, indicating high internal reli-
(mean, 10.97);9 however, there is difference when six domains are ability.
compared, the most concerned domains as to psoriasis outpatients In conclusion, scabies moderately affected the QoL of the
were domain 1 (symptoms and feelings) and domain 3 (leisure). patients. People should pay more attention to the contagious dis-
There was significant progress of QoL after treatment in our ease, although it is not life-threatening. Sulphur could be consid-
patients. However, no strong relationship between disease-related ered as an effective treatment for patients with scabies. Although
characteristics and QoL could be found. the adverse effects limit its’ usage, sulphur is still a first choice in
Questions 1 (symptoms), 2 (embarrassment), 7 (work or study) resource-poor regions. The limitations of our study are the lack of
and 9 (sexual difficulties) had the most impact on patients with a longer study and a larger sample, which could be incorporated
scabies. Filariasis is the only parasitic disease in concern with QoL in the planning of future studies in scabies. Another comment is
research.7 Interestingly, we found that there are some overlaps related to the questionnaire itself, for example, part of patients
between the two different disorders. Question 1 (symptoms), 2 worried about the impact of diet on disease which does not exist
(embarrassment), 3 (daily activities) and 7 (work or study) scored in DLQI because of the different culture background.
higher than other questions among patients with filarial lymphoe-
dema,11 while question 1 (symptoms), 2 (embarrassment), 3 (daily Acknowledgements
activities), 4 (clothes) scored higher among patients with filarial We are grateful to Professor Andrew Finlay of the University
lymphoedema in another research.12 It is seemed that question 1 of Wales College of Medicine, Cardiff, UK, for permission to
and 2 are the most concerned items although they may not be the use the DLQI, and Dr Yan HB and Liu ZH for their kind per-
highest scores, other different items concerned may be explained mission to use the Chinese version of DLQI. We are also
by the different cultural background. grateful to all subjects participated in the study. Jingang An
To compare DLQI score between new and treated patients, we and Shengbin Xiao have full access to all the data in the study
chose sulphur for the treatment of scabies. There are many scabi- and take responsibility for the integrity of the data and the
cides for the treatment of scabies. Permethrin cream is considered accuracy of the data analysis.
the drug of choice in the management of scabies in the UK, USA
and Australia.13 Topical ivermectin provides high efficacy, easy References
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JEADV 2010 Journal compilation ª 2010 European Academy of Dermatology and Venereology
Quality of life in patients with scabies 5

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JEADV 2010 Journal compilation ª 2010 European Academy of Dermatology and Venereology