From the Guidelines
The recommended treatment for chronic scabies infestation involves a comprehensive approach using both topical and oral medications, prioritizing permethrin 5% cream and oral ivermectin to minimize morbidity, mortality, and improve quality of life.
Treatment Approach
The treatment approach should include:
- First-line treatment with permethrin 5% cream applied from neck to toes, left on for 8-14 hours, and repeated after 7-10 days 1
- For persistent cases, oral ivermectin at 200 mcg/kg body weight is recommended, with two doses given 7-10 days apart 1
- In severe or resistant cases, a combination of both permethrin and ivermectin may be necessary, with consideration of additional ivermectin treatment on days 22 and 29 for severe cases 1
Additional Considerations
- All household members and close contacts should be treated simultaneously, even if asymptomatic, to prevent reinfestation, as recommended by the 2015 sexually transmitted diseases treatment guidelines 1
- Decontamination of the environment is crucial, including washing all bedding, clothing, and towels in hot water and drying on high heat, and sealing items that cannot be washed in plastic bags for at least 72 hours
- Antihistamines and topical steroids may help manage itching, which can persist for 2-4 weeks after successful treatment
- Chronic scabies often results from incomplete treatment, reinfestation from untreated contacts, or development of resistance to medications, making thorough adherence to the complete treatment regimen essential for eradication 1
From the FDA Drug Label
Permethrin Cream, 5% is indicated for the treatment of infestation with Sarcoptes scabiei (scabies). Adults and children Thoroughly massage Permethrin Cream, 5% into the skin from the head to the soles of the feet. ONE APPLICATION IS GENERALLY CURATIVE. Demonstrable living mites after 14 days indicate that retreatment is necessary.
The recommended treatment for chronic scabies infestation is to apply permethrin cream, 5% from the head to the soles of the feet, with one application generally curative. However, if living mites are still present after 14 days, retreatment may be necessary 2 2.
- Key points:
- Apply permethrin cream, 5% to entire body
- Leave on for 8 to 14 hours
- Retreatment may be necessary if living mites are present after 14 days
From the Research
Treatment Options for Chronic Scabies Infestation
- Topical permethrin is considered the most effective treatment for scabies, including chronic infestations 3, 4, 5.
- The recommended treatment regimen for topical permethrin is a 5% cream applied once daily for two consecutive days, with a repeat treatment 7-10 days later 3.
- Oral ivermectin is also an effective treatment option, particularly for cases that are resistant to topical permethrin or for patients who have difficulty applying topical treatments 4, 6, 5.
- A combination of permethrin and ivermectin may be used to treat otherwise intractable cases, including crusted scabies 7.
Factors to Consider in Treatment
- Proper application of topical medications is crucial, including application to all skin surfaces, under the fingernails, and up to the edge of all body orifices 6.
- All household and sexual contacts must be treated, whether or not they have symptoms 6.
- Incomplete decontamination of furnishings and clothes, failure to simultaneously treat contact persons, and absence of written documents explaining treatment modalities can contribute to treatment failure 7.