BACKGROUND:
Scabies, a neglected tropical disease with rising incidence across Europe, presents health equity challenges in high-income healthcare systems. In Flanders, Belgium, primary care presentations have been increasing by 15% annually (2011-2023), yet systems have not adequately adapted. Little is known about whether current Belgian systems address the psychosocial dimensions of scabies, or how systemic factors affect care quality.

METHODS:
This mixed-methods study investigated diagnostic trajectories, health seeking and access to scabies care across five Belgian cities. Quantitative data from 83 healthcare providers across 96 practices and 115 people affected by scabies were combined with 44 qualitative interviews (11 people affected, 33 providers), exploring experiences across diverse socioeconomic contexts.

RESULTS:
People affected by scabies experienced profound psychosocial impacts (hypervigilance, sleep disruption, social isolation) extending beyond clinical cure, yet psychosocial support was mostly absent. Healthcare providers reported severe time constraints and workload pressures limiting consultation quality. Diagnostic challenges were exacerbated by provider biases, with assumptions about patient socioeconomic status and hygiene influencing clinical suspicion despite scabies affecting all demographic groups. These systemic barriers created inequitable care: 31% initial misdiagnosis rates, average of 2 clinicians visited before diagnosis, average 22-day delays from symptom onset to diagnosis, and treatment failure/reinfection accounting for 50-80% of repeat consultations. Current healthcare systems require strengthening to adequately respond to the condition's full biopsychosocial burden.

CONCLUSIONS:
Addressing scabies equitably in well-resourced settings requires healthcare systems that recognize and respond to its full biopsychosocial impact beyond clinical cure. Key interventions include integrating psychosocial support as standard care, standardizing diagnostic protocols to reduce bias and delays, addressing provider workload constraints limiting care delivery, and developing training that updates epidemiological knowledge and addresses implicit biases. These findings have implications for high-income countries experiencing scabies re-emergence and other neglected diseases where gaps between clinical recognition and holistic care perpetuate health inequities.