Evaluation of family physicians’ knowledge about scabies: An example from a district in Istanbul

Abstract

OBJECTIVE

Scabies is a highly contagious and itchy skin disease that poses a public health problem due to its high prevalence in developing and underdeveloped countries. The aim of this study is to assess the knowledge level of family physicians working in a district of Istanbul regarding scabies and to identify their current awareness level and educational needs.

METHODS

This descriptive, cross-sectional study was conducted between August 1, 2023, and August 1, 2024. The population consisted of 123 active family physicians, and 103 volunteers participated in the study. Participants completed a 27-item online questionnaire assessing their sociodemographic characteristics and knowledge level regarding scabies. Data were analyzed using IBM SPSS 27.0 software. Categorical variables were compared using the chi-square test, with p<0.05 considered statistically significant.

RESULTS

The mean age of participants was 38.99±10.98 years, and 67% were female. 97.1% of physicians had previously seen a scabies case, and 88.3% had experience with >10 cases. The average knowledge score was 10.4±1.61 (min. 7– max. 13). 63.8% of physicians had a satisfactory level of knowledge. 59.2% of participants knew that scabies could be transmitted through sexual contact, 41.7% knew that it could not be transmitted from pets, and 95.1% knew about the use of 5% topical permethrin in treatment. Physicians with ≥10-case experience showed significantly higher accuracy regarding uncomplicated scabies treatment (p=0.01).

CONCLUSION

Although family physicians’ general knowledge level about scabies is acceptable, there are deficiencies in the transmission routes and treatment details. Increasing the knowledge level through online and face-to-face training organized within the scope of continuing medical education will improve early diagnosis and treatment success.

Highlight key points

• The majority (63.8%) of family physicians demonstrated a satisfactory level of knowledge about scabies.

• Misconceptions were most frequent regarding transmission routes, particularly sexual contact and pet-to-human transmission.

• Most participants (95.1%) correctly identified 5% permethrin cream as the first-line therapy for uncomplicated scabies.

• Despite acceptable overall knowledge, continuous education and updated training materials are needed to close existing knowledge gaps.

Scabies, an itchy skin infestation caused by Sarcoptes scabiei var. hominis, is prevalent worldwide and remains a public health concern due to its potential to cause outbreaks [1]. Nearly 300 million cases of scabies are seen worldwide each year, with diagnosis rates increasing in hot climates, crowded environments, and underdeveloped and developing countries with poor sanitation [2]. Scabies was included in the World Health Organization’s “Neglected Tropical Diseases” (NTDs) category in 2017, and global targets have been set for its control and management by 2030 [3].

Although scabies may occur at any age, childhood is a risk group. Generally, scabies burrows are seen on the wrist, but in adults, excoriated papules can be seen on the flexor surfaces of the wrist, between the fingers, periumbilical region, axilla, thigh, gluteal region, and in infants, they can be seen as widespread eczematous erythema on the trunk, and excoriated papules can be localized on the plantar surface [2, 4]. Diagnosis is usually based on history and physical examination. Mites burrow under the epidermis, causing a type IV hypersensitivity reaction with increased itching at night [5]. Microscopic confirmation of the diagnosis is not required for treatment, and skin biopsy is rarely necessary. Permethrin 5% dermal cream/lotion is the most effective, well-tolerated, and least toxic topical agent and is the first choice for topical treatment [6]. It is recommended to apply it twice at one-week intervals to the entire body (including under the nails) [4]. Considering that the incubation period is between 1–6 weeks, the person’s sexual partner, if any, should be treated simultaneously, along with the household members living in the same house, regardless of any signs or symptoms [7].

For individuals weighing over 15 kg, oral ivermectin administered twice at 200 μg/kg doses two weeks apart is also an effective treatment option. It should be noted that itching may persist for up to six weeks after the treatment. Crusted scabies is a type of scabies that is particularly observed in individuals with compromised immune systems for various reasons, where itching may not be present, but mite numbers and contagiousness are very high [8].

Family physicians are the first point of contact for various dermatological diseases [9]. Dermatological disorders account for up to 8% of visits to family physicians [10]. With the increasing incidence of scabies in recent years, early diagnosis by family physicians and initiation of effective and adequate treatment can ensure the cure and control of the disease, preventing possible undesirable individual and societal consequences. Family physicians play an important role not only in the diagnosis and treatment of scabies but also in increasing patients’ health literacy regarding scabies [11]. Therefore, determining the knowledge level of family physicians about scabies is important. The study aimed to determine the current level of knowledge of family physicians regarding the diagnosis and treatment of scabies to establish a basis for planning further intervention studies.

MATERIALS AND METHODS

Study Design and Population

This descriptive analytical cross-sectional study included family physicians working in a district of Istanbul. The study was approved by the Non-Interventional Clinical Research Ethics Committee of Medipol University (decision dated 13/07/2023, number E-10840098-772.02-4200) and was conducted in accordance with the ethical standards of the Declaration of Helsinki. Within the district, there are 123 actively practicing family physicians across 30 Family Health Centers affiliated with the District Health Directorate.

The sample size was calculated using the OpenEpi program, based on an assumed prevalence of 75% for scabies knowledge levels in primary care [12], with a statistical power of 97% and an alpha error of 0.03, resulting in a required sample size of 92 participants. The study was conducted between August 1, 2023, and August 1, 2024, including physicians who voluntarily agreed to participate.

Data Collection

The study aimed to reach all family physicians without applying a sampling method. A total of 27 questions, consisting of nine items related to sociodemographic characteristics and 18 items assessing knowledge and awareness developed based on a literature review, were administered online after undergoing expert evaluation [7, 11]. For the 13 questions evaluating knowledge level, each correct answer was scored as 1 point, while incorrect or “I don’t know” responses were scored as 0. The mean knowledge score was then calculated accordingly. Consistent with similar studies in the literature, a correct response rate of ≥75% was taken as the threshold for a satisfactory level of knowledge [13]. The study was completed with the participation of 103 respondents.

The consent of participating physicians was obtained online before the questionnaire was opened.

Statistical Analysis

All statistical analyses were performed using SPSS version 27.0 (Armonk, New York: IBM Corp.). Descriptive data were presented as mean, standard deviation, interquartile range (IQR), and minimum–maximum values. Categorical variables were compared using the Pearson chi-square test. A p-value of <0.05 was considered statistically significant.

RESULTS

Analysis of the participants’ sociodemographic data showed a mean age of 38.99 years (range: 24–67), with 67% (n=69) being female. The majority, 79.6% (n=82), were practicing as general practitioners. The median year of graduation from medical school was 2013 (range: 1984–2023), and the median duration of employment in family medicine was six years (range: 0–24).

Among the participants, 97.1% (n=100) had previously encountered a scabies case, and 88.3% (n=91) had experience with more than ten cases. Additionally, 36.9% (n=38) reported not having obtained new information on the topic for over a year. The most common source of information was websites (62.1%, n=64), while books were the least preferred (29.1%, n=30) (Table 1).

Table 1.

Sociodemographic characteristics of participants, number of scabies cases encountered, and sources of information

	Mean±SD	Median (Min–Max)
Age	38.99±10,976	34 (24–67)
Year of graduation from medical school	2009.22±11,016	2013 (1984–2023)
Duration of practice as a family physician	6.92±5,088	6 (0-24)
	Frequency (n)	Percentage (%)
Gender
Female	69	67
Male	32	31.1
Type of physician
General Practitioner	82	79.6
Family medicine specialist	19	18.4
Number of scabies cases encountered
<10	10	9.7
>10	91	88.3
Most recent time of acquiring information about scabies
Within one month	27	26.2
Within one year	37	35.9
> one year	38	36.9
Most recent source of information about scabies
Website	64	62.1
Lecture	49	47.6
Book	30	29.1
Journal/Article	37	35.9

SD: Standard deviation; Min: Minimum; Max: Maximum.

Among the participants, 42.7% (n=44) correctly identified the incubation period of scabies as 2–6 weeks, 68% (n=70) knew that transmission does not occur merely by sharing the same room, and 57.3% (n=59) recognized children and young adults as the most susceptible age groups. All participants correctly identified the causative agent as a parasite, recognized contaminated clothing or bedding as possible transmission routes, and knew that the most common clinical manifestations are nocturnal itching and erythema, with burrows being the characteristic lesion.

A total of 98.1% (n=101) knew that diagnosis can be made based on clinical signs and symptoms, 83.5% (n=86) were aware that it cannot be diagnosed by blood culture, and 88.3% (n=91) knew it cannot be diagnosed by stool analysis. Furthermore, 74.8% (n=77) correctly stated that the absence of mites does not exclude a diagnosis of scabies.

However, misconceptions were observed: 40.8% (n=42) were unaware that scabies can be transmitted through sexual contact, 24.3% (n=25) did not know it cannot be transmitted through shared utensils, 32% (n=33) were unaware that sharing the same room does not cause transmission, 58.2% (n=60) did not know it cannot be transmitted from pets to humans, and 33% (n=34) did not know that swimming pools are not a source of transmission.

Based on the scoring system in which each correct answer received one point and incorrect or “I don’t know” responses received zero, the mean knowledge score was calculated as 10.4±1.61 (minimum 7 – maximum 13) (Table 2).

Table 2.

Distribution of correct answers given by participants to questions regarding their level of knowledge about scabies (n=103)

Statements	Correct respondents (%)
It is transmitted by being in the same room as someone with scabies.	68
Scabies is transmitted through sexual contact.	59.2
Scabies is transmitted by using the fork and knife of an infected individual.	75.7
Scabies is spread through contaminated clothing.	100
Scabies is spread through swimming pools.	67
There is a possibility of transmission from domestic pets.	41.7
The diagnosis can be made with a blood culture.	83.5
Diagnosis can be made based on clinical signs and symptoms.	98.1
Diagnosis can be made through stool analysis.	88.3
Diagnosis can be made by microscopic examination of a skin scraping.	97.1
The absence of mites excludes the diagnosis of scabies.	74.8
Treatment should be given to asymptomatic close contacts.	94.2
Permethrin should be applied only to itchy lesions to prevent toxicity.	88.3

A total of 68.9% (n=71) of participants were unaware that crusted scabies presents with a more severe clinical course. Regarding treatment, 95.1% (n=98) correctly identified 5% permethrin cream as the first-line therapy for uncomplicated scabies.

For infants under two months of age, 26.2% (n=27) reported preferring 5–10% sulfur ointment, another 26.2% (n=27) chose 5% permethrin cream, 11.7% (n=12) preferring %1 lindane lotion, while 35.9% (n=37) stated they did not know the appropriate treatment option.

Among participants, 9.7% (n=10) knew that infectivity ceases 24 hours after treatment initiation. The proportion of correct responses regarding the treatment of uncomplicated scabies was significantly higher among participants who had encountered more than 10 scabies cases (p<0.05). However, the total knowledge score did not show a statistically significant difference according to the number of cases seen (p>0.05).

DISCUSSION

This study aimed to assess the knowledge level and treatment approaches regarding scabies among family physicians working in a district of Istanbul. Considering that a study from the United States reported that 45% of patients diagnosed with scabies had previously received an incorrect diagnosis from another physician, determining the knowledge level of primary care physicians is of particular importance [1].

Using a ≥75% correct response rate as the threshold for a satisfactory level of knowledge, consistent with similar studies in the literature, 63.8% of family physicians in this study demonstrated adequate knowledge [13]. In comparison, a similar study conducted among primary care workers in Ordu, Turkiye, reported a higher rate of 86.5% [14].

When the responses were analyzed, all participants correctly identified the causative agent of scabies and recognized it as a parasite. In contrast, a similar study reported that only 51% of respondents answered this question correctly [11]. Scabies is transmitted primarily through direct person-to-person contact. Transmission via clothing or bedding is uncommon and generally occurs only when these items are contaminated immediately before contact with another individual [4]. In the present study, all physicians were aware that contaminated clothing can transmit the disease; however, only 59.2% recognized sexual contact as a possible route of transmission. In other studies, this rate ranged between 26% and 67.7% [11, 12, 14, 15]. Awareness of sexual transmission and the importance of partner treatment are crucial components in controlling scabies; therefore, targeted educational efforts are necessary to increase awareness on this issue.

Only 41.7% of participants knew that transmission from domestic animals to humans is not possible. In a study from Ethiopia assessing patients’ knowledge about scabies, 10% believed it could be transmitted through contaminated water, 4% through blood, and 2.8% through soil. More than two-thirds of patients sought medical attention in primary care centers, 67.3% reported feelings of shame, fear, or frustration, and 87% expressed a desire to learn more about the disease [16].

In another study evaluating fear scores associated with scabies, fear was found to be higher among women, younger individuals, those with higher education levels, and people working in education or healthcare sectors [17]. Poverty and fear of stigmatization have been shown to contribute to delays in both diagnosis and treatment [18].

Among boarding school students in Indonesia, 88.2% were unaware of the etiology of scabies, and only 22% demonstrated good personal hygiene practices [19]. Similar studies reported that the proportion of individuals with good hygiene practices ranged between 32.9% and 37.8% [20, 21] It is well established that lower levels of scabies-related knowledge and poor hygiene practices are associated with higher disease prevalence [22].

Given these findings, it is essential that physicians provide detailed health education to patients presenting with or at risk for scabies—covering modes of transmission, preventive measures, and appropriate hygiene practices.

In this study, 83.5% of participants knew that scabies cannot be diagnosed through blood culture, and 88.3% knew it cannot be diagnosed through stool analysis. In comparison, studies conducted among medical students who had completed dermatology and pediatrics rotations reported lower correct response rates—ranging from 29% to 60.7% in one study and 77.5% to 100% in another [5, 23].

A study from Belgium comparing dermatologists and primary care physicians found that both groups demonstrated acceptable knowledge levels (79% vs. 59%), with knowledge positively correlated with years of practice and the annual number of scabies cases seen [7]. In the present study, 88.3% of physicians had managed more than 10 scabies cases, compared to 82.7% in a similar Turkish study [14]. This suggests that physicians in Turkiye generally have relatively high clinical exposure to scabies.

Our results highlighted that physicians who had encountered more than 10 cases were significantly more likely to give correct responses regarding treatment (p<0.05). However, the overall knowledge scores did not significantly differ according to the number of cases seen (p>0.05). Similar findings have been reported in the literature, suggesting that the number of cases managed may not directly influence overall knowledge levels [14]. It should also be considered that physicians who reported fewer than 10 cases might have underdiagnosed or missed cases of scabies.

No significant relationship was found between physicians’ age, years of experience, and knowledge scores. This finding is consistent with results from a similar study conducted in Pakistan [11]. The absence of such correlation may reflect a lack of ongoing or continuous medical education programs focused on scabies in Turkiye.

In our study, participants achieved a mean knowledge score of 10.40 out of a possible 13 points (80%). In a Belgian study including both dermatologists and family physicians, the average knowledge score was reported as 29/39 (74%) [7]. In contrast, studies from Nigeria, Saudi Arabia, and Pakistan reported substantially lower proportions of participants with adequate knowledge—9.3%, 17.1%, and 36%, respectively [5, 11, 12]. This relatively higher level of knowledge among Turkish physicians may be attributed to the higher prevalence of scabies in Turkiye, greater clinical exposure among primary care physicians, and a more structured healthcare and medical education system, comparable to that of Western Europe.

Among nursing students, the proportion of participants with satisfactory knowledge levels has varied widely across studies—from as low as 17.4% to as high as 75.4%—likely due to differences in sample sizes and in how “adequate knowledge” was defined [15, 24].

In Belgium, 50% of dermatologists and family physicians reported prescribing topical permethrin as a single treatment modality [7] Similarly, in our study, 95.1% of participants correctly identified topical permethrin as the standard treatment for uncomplicated scabies. A comparable Turkish study reported a nearly identical rate of 91.7% [14]. Furthermore, 94.2% of the physicians in our study were aware that close contacts should also receive treatment, reflecting good awareness of transmission control measures.

In our study, 36.9% of family physicians reported not having acquired any new information about scabies for more than a year. Regarding sources of information, websites were the most commonly used (62%), while books were the least preferred (29.1%, n=30).

A study from Saudi Arabia that asked the same question reported a lower proportion (26.4%) of physicians who had not received updated information on scabies for over a year. Similar to our findings, 50.9% of participants in that study identified websites as their primary source of information [12].

In contrast, a study conducted in Australia among nursing home staff investigating preferred methods of acquiring information about scabies found that 57% favored face-to-face education, 53.9% preferred online resources, and 52.3% prioritized official guidelines and standard protocols. Interestingly, online training modules were the least preferred option (27.9%), which contrasts with the results of our study [25].

Our study has several limitations. The questionnaire used was developed by the researchers and was not validated prior to the study; however, the aim was not to design a universal test to measure the global level of knowledge about scabies, but rather to assess the current situation and identify the need for educational programs accordingly. Another limitation is that although the questionnaires were completed anonymously, physicians might have tended to give answers that reflect better knowledge of the subject, which could have influenced the results. Furthermore, the participants were from a single region and there may be recall bias related to the number of cases seen. Due to the limited number of comparable local and international studies, it is difficult to make direct comparisons.

Nevertheless, the findings provide insight into the level of knowledge family physicians have regarding scabies. While the current level of knowledge is acceptable for our country, the presence of knowledge gaps is evident.

Conclusion

In this study, it was determined that family physicians possess some fundamental knowledge about scabies—a common skin disease in our country and one frequently encountered in primary care—yet certain knowledge gaps remain. Effective and timely intervention by primary care physicians can both limit the spread of the disease and reduce the burden on secondary and tertiary healthcare institutions. Regular in-service training programs should be organized to enhance physicians’ knowledge levels. Incorporating organized scabies modules into conventional primary care training programs may enhance the uniformity of clinicians’ methodologies. Well-trained physicians can play a more active role not only in diagnosis and treatment but also in providing patients with essential health education. Consequently, treatment success may increase while transmission rates decrease. Considering that the internet was the most commonly preferred source of information in this study, online educational materials such as training videos and case-based modules could be developed.

Ethics Committee Approval

The Istanbul Medipol University Non-Interventional Clinical Research Ethics Committee granted approval for this study (date: 13.07.2023, number: 574).

Informed Consent

Written informed consents were obtained from participants who participated in this study.

Conflict of Interest

The authors declare that there is no conflict of interest.

Financial Disclosure

The authors declared that this study has received no financial support.

Use of AI for Writing Assistance

Not declared.

Authorship Contributions

Concept – MY; Design – HA, BA; Supervision – HA, NC; Fundings – BA; Materials – CEC; Data collection and/or processing – BA; Analysis and/or interpretation – MY; Literature search – MY, NC; Writing – MY; Critical review – NC.

Peer-review

Externally peer-reviewed.