A recent visit to a prison for a medical outreach revealed that skin disease mainly scabies is the most common disease among the inmates. This is closely follow by malaria and respiratory tract infection. These diseases are associated with overcrowding, poor hygiene and shortage of water. The skin diseases is commoner in the male section of the prison where the crowd of mostly awaiting trial is more. The better hygiene and cleanliness coupled with less crowd in the female section accounts for little or no incidence of scabies. Lack of drugs also contributes to the high incidence of the disease.                                     

Scabies, is a contagious water related skin infestation by the female mite Sarcoptes scabiei. The most common symptoms are severe itchiness and a pimple-like rash. Occasionally tiny burrows may be seen in the skin. When first infected, usually two to six weeks are required before symptoms occur. If a person develops a second infection later in life, symptoms may begin within a day. The itch is often worse at night. Scratching may cause skin breakdown and an additional bacterial infection of the skin.

The mites burrow into the skin to live and deposit eggs. The symptoms of scabies are due to an allergic reaction to the mites. Often only between ten and fifteen mites are involved in an infection. Scabies is most often spread during a relatively long period of direct skin contact with an infected person such as that which may occur during sex.  Spread of disease may occur even if the person has not developed symptoms yet. Crowded living conditions such as those found in child care facilities, group homes, and prisons increase the risk of spread. Areas with a lack of access to water also have higher rates of disease. 

Crusted scabies is a more severe form of the disease. It typically only occurs in those with a poor immune system and people may have millions of mites, making them much more contagious. In these cases, spread of infection may occur during brief contact or via contaminated objects. The mite is very small and usually not directly visible. Diagnosis is based on the signs and symptoms.[

Sexual contacts within the last month and people who live in the same house should also be treated at the same time. Bedding and clothing used in the last three days should be washed in hot water and dried in a hot dryer. As the mite does not live for more than three days away from human skin more washing is not needed. Symptoms may continue for two to four weeks following treatment. If after this time there continue to be symptoms retreatment may be needed.

Scabies is one of the three most common skin disorders in children, along with ringworm and bacterial skin infections. As of 2010 it affects approximately 100 million people (1.5% of the world population) and is equally common in both sexes. The young and the old are more commonly affected. It also occurs more commonly in the developing world and tropical climates. The mites are distributed around the world and equally infect all ages, races, and socio-economic classes in different climates. Scabies is more often seen in crowded areas with unhygienic living conditions.

There are approximately 300 million cases of scabies in the world every year.  The word scabies is from Latin: scabere, "to scratch   Scabies has been observed in humans since ancient times. Archeological evidence from Egypt and the Middle East suggests scabies was present as early as 494 BC. The first recorded reference to scabies is believed to be from the Bible – it may be a type of "leprosy" mentioned in Leviticus circa 1200 BC or be mentioned among the curses of Deuteronomy 28.

The WHO has included scabies on its official list of neglected tropical diseases and other neglected conditions.

Signs and symptoms

The characteristic symptoms of a scabies infection include intense itching and superficial burrows. The burrow tracks are often linear, to the point that a neat "line" of four or more closely placed and equally developed mosquito-like "bites" is almost diagnostic of the disease. Because the host develops the symptoms as a reaction to the mites' presence over time, there is typically a delay of four to six weeks between the onset of infestation and the onset of itching. Similarly, symptoms often persist for one to several weeks after successful eradication of the mites

In the classic scenario, the itch is made worse by warmth, and is usually experienced as being worse at night, possibly because there are fewer distractions. As a symptom, it is less common in the elderly.

Rash

The superficial burrows of scabies usually occur in the area of the finger webs, feet, ventral wrists, elbows, back, buttocks, and external genitals. Except in infants and the immunosuppressed, infection generally does not occur in the skin of the face or scalp. Symptoms typically appear two to six weeks after infestation for individuals never before exposed to scabies. For those having been previously exposed, the symptoms can appear within several days after infestation

The elderly and people with an impaired immune system, such as HIV, cancer, or those on immunosuppressive medications, are susceptible to crusted scabies. On those with weaker immune systems, the host becomes a more fertile breeding ground for the mites, which spread over the host's body, except the face. Sufferers of crusted scabies exhibit scaly rashes, slight itching, and thick crusts of skin that contain thousands of mites.

Transmission

Scabies is contagious and can be contracted through prolonged physical contact with an infested person.  This includes sexual intercourse, although a majority of cases are acquired through other forms of skin-to-skin contact. Less commonly, scabies infestation can happen through the sharing of clothes, towels, and bedding, but this is not a major mode of transmission; individual mites can only survive for two to three days, at most, away from human skin As with lice, a latex condom is ineffective against scabies transmission during intercourse, because mites typically migrate from one individual to the next at sites other than the sex organs.

Healthcare workers are at risk of contracting scabies from patients, because they may be in extended contact with them.

Diagnosis  

Scabies may be diagnosed clinically in geographical areas where it is common when diffuse itching presents along with either lesions in two typical spots or there is itchiness of another household member. The classical sign of scabies is the burrows made by the mites within the skin. To detect the burrow, the suspected area is rubbed with ink from a fountain pen or a topical tetracycline solution, which glows under a special light. The skin is then wiped with an alcohol pad. If the person is infected with scabies, the characteristic zigzag or S pattern of the burrow will appear across the skin; however, interpreting this test may be difficult as the burrows are scarce and may be obscured by scratch marks. A definitive diagnosis is made by finding either the scabies mites or their eggs and fecal pellets. Searches for these signs involve either scraping a suspected area, mounting the sample in potassium hydroxide and examining it under a microscope.

Differential diagnosis

Symptoms of early scabies infestation mirror other skin diseases, including dermatitis, syphilis, erythema multiforme, various urticaria-related syndromes, allergic reactions, and other ectoparasites such as lice and fleas.

Prevention

Mass treatment programs that use topical permethrin or oral ivermectin have been effective in reducing the prevalence of scabies in a number of populations. No vaccine is available for scabies. The simultaneous treatment of all close contacts is recommended, even if they show no symptoms of infection (asymptomatic), to reduce rates of recurrence. Since mites can survive for only two to three days without a host, other objects in the environment pose little risk of transmission except in the case of crusted scabies, thus cleaning is of little importance. Rooms used by those with crusted scabies require thorough cleaning.

Management

A number of medications are effective in treating scabies. Treatment should involve the entire household, and any others who have had recent, prolonged contact with the infested individual. Options to control itchiness include antihistaminesand prescription anti-inflammatory agents. Bedding, clothing and towels used during the previous three days should be washed in hot water and dried in a hot dryer.[

Permethrin

Permethrin is the most effective treatment for scabies, and remains the treatment of choice. It is applied from the neck down, usually before bedtime, and left on for about eight to 14 hours, then washed off in the morning. Care should be taken to coat the entire skin surface, not just symptomatic areas; any patch of skin left untreated can provide a "safe haven" for one or more mites to survive. One application is normally sufficient, as permethrin kills eggs and hatchlings as well as adult mites, though many physicians recommend a second application three to seven days later as a precaution. Crusted scabies may require multiple applications, or supplemental treatment with oral ivermectin. Permethrin may cause slight irritation of the skin that is usually tolerable.

Ivermectin

Oral Ivermectin is effective in eradicating scabies, often in a single dose. It is the treatment of choice for crusted scabies, and is sometimes prescribed in combination with a topical agent. It has not been tested on infants, and is not recommended for children under six years of age.

Others

Other treatments include , benzyl benzoate, crotamiton, malathion, and sulfur preparations. Sulfur ointments or benzyl benzoate are often used in the developing world due to their low cost. 10% sulfur solutions have been shown to be effective, and sulfur ointments are typically used for at least a week, though many people find the odor of sulfur products unpleasant.

Communities

Scabies is endemic in many developing countries, where it tends to be particularly problematic in rural and remote areas. In such settings community wide control strategies are required to reduce the rate of disease, as treatment of only individuals is ineffective due to the high rate of reinfection. Large-scale mass drug administration strategies may be required where coordinated interventions aim to treat whole communities in one concerted effort

The resources required to implement such large-scale interventions in a cost-effective and sustainable way are significant. Furthermore, since endemic scabies is largely restricted to poor and remote areas, it is a public health issue that has not attracted much attention from policy makers and international donors. In the prison community, intervention is also needed in areas of treatment and prevention of these diseases. Drugs provided by government or donated by religious bodies, charitable institutions are always needed. Provision of portable water is essential. The prisons needs to be decongested. Awaiting trials are many. This could mean that our judicial system needs overhauling. Those convicted for an offence of low magnitude could serve the community {not prison} through various means thereby reducing  overcrowding. This is a legislative matter. Finally, the prison clinics should be equipped with some basic equipments needed for diagnosis and treatment not forgetting the safety and  health   of the prison healthcare providers and warders.