What is the treatment for scabies?

From the Guidelines

Scabies treatment should prioritize a combination of topical scabicide and oral ivermectin for severe or crusted scabies, with permethrin 5% cream being the first-line treatment for mild cases, as recommended by the 2015 sexually transmitted diseases treatment guidelines 1. The treatment of scabies involves the use of prescription medications called scabicides that kill the mites and their eggs.

Treatment Options

• For mild scabies, the first-line treatment is permethrin 5% cream, applied from neck to toes and left on for 8-14 hours before washing off, with a repeat application after 7 days 1.
• Alternatively, oral ivermectin can be used at a dose of 200 mcg/kg, with a second dose given 7-14 days later 1.
• For severe or crusted scabies, a combination treatment is recommended, using a topical scabicide, either 5% topical benzyl benzoate or 5% topical permethrin cream, and oral ivermectin 200 ug/kg on days 1,2,8,9, and 15, with additional doses on days 22 and 29 if necessary 1.

Management Considerations

• All household members and close contacts should be treated simultaneously, even if they don't have symptoms, to prevent reinfestation 1.
• Bedding, clothing, and towels used by infected persons should be washed in hot water and dried on high heat, or removed from body contact for at least 72 hours 1.
• Itching may persist for 2-4 weeks after successful treatment due to an allergic reaction to the dead mites, and can be managed with antihistamines or topical steroids 1.
• Retreatment 2 weeks after the initial treatment regimen can be considered for those persons who are still symptomatic or when live mites are observed, with an alternative regimen recommended for those who do not respond initially to the recommended treatment 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Adults and children Thoroughly massage Permethrin Cream, 5% into the skin from the head to the soles of the feet. Scabies rarely infests the scalp of adults, although the hairline, neck, temple, and forehead may be infested in infants and geriatric patients. Usually 30 grams is sufficient for an average adult. The cream should be removed by washing (shower or bath) after 8 to 14 hours. Infants should be treated on the scalp, temple, and forehead. ONE APPLICATION IS GENERALLY CURATIVE. Patients may experience persistent pruritus after treatment. This is rarely a sign of treatment failure and is not an indication for retreatment. Demonstrable living mites after 14 days indicate that retreatment is necessary. INDICATIONS AND USAGE Permethrin Cream, 5% is indicated for the treatment of infestation with Sarcoptes scabiei (scabies).

The recommended treatment for scabies is to apply Permethrin Cream, 5% from the head to the soles of the feet, leaving it on for 8 to 14 hours before washing off.

• One application is generally curative.
• Retreatment is necessary if demonstrable living mites are present after 14 days 2.
• Permethrin Cream, 5% is indicated for the treatment of scabies 2.

From the Research

Scabies Treatment Options

• Permethrin 5% cream is considered an effective treatment for scabies, with a cure rate of 96.9% when applied twice with a one-week interval 3
• Ivermectin is also a viable treatment option, with a cure rate of 62.4% with a single dose and 92.8% with two doses at a two-week interval 3
• Topical permethrin and oral ivermectin have similar efficacy in treating scabies, with little to no difference in complete clearance rates after four weeks of follow-up 4

Treatment Application and Duration

• Permethrin 5% cream should be applied to the entire skin surface, including the scalp and head, and left on for 24 hours 5, 6
• The treatment should be repeated 7-10 days later to ensure complete clearance of the scabies infestation 5
• Ivermectin can be administered orally or topically, with a standard dose of 200 μg/kg for oral administration 4

Safety and Adverse Events

• Both permethrin and ivermectin are generally well-tolerated, with few and mild adverse events reported 4
• The most common adverse events associated with permethrin and ivermectin include mild irritant contact dermatitis and gastrointestinal symptoms 5, 4
• No withdrawals due to adverse events occurred in the studies comparing permethrin and ivermectin 4

Special Considerations

• Scabies outbreaks in nursing homes and other institutional settings require a special treatment strategy, including the treatment of all individuals, regardless of symptoms, and the use of permethrin or ivermectin 7
• Crusted scabies, a severe form of the disease, may require more aggressive treatment, including the use of ivermectin and permethrin cream 7