Scabies Treatment
The recommended first-line treatment for scabies is permethrin 5% cream applied to all areas of the body from the neck down and washed off after 8-14 hours, with a repeat application after one week. 1
First-Line Treatment Options
Permethrin 5% Cream
- Apply to all areas of the body from the neck down
- Leave on for 8-14 hours before washing off
- Repeat application after one week
- Advantages: Effective, safe, and less expensive than oral alternatives 1
- Special considerations:
Oral Ivermectin
- Dosage: 200 μg/kg orally
- Must be repeated in 2 weeks due to limited ovicidal activity 1
- Take with food to increase bioavailability and skin penetration 1
- Considerations:
Alternative Treatments
Lindane (1%)
- Should only be used if first-line treatments fail or cannot be tolerated 1
- Apply 1 oz of lotion or 30g of cream to all areas from neck down
- Wash off after 8 hours
- Contraindications:
- Risks: Seizures, aplastic anemia, and reported resistance in some areas 1
Sulfur (6%)
- Apply to all areas nightly for 3 nights 1
- Wash off previous applications before reapplying
- Thoroughly wash off 24 hours after last application
- May be considered when other options are contraindicated 1
- Recent research suggests 10% sulfur ointment may be more effective than permethrin in some regions with developing resistance 2
Crotamiton
- Massage thoroughly into skin from chin down
- Second application advised 24 hours later
- Cleansing bath 48 hours after last application 3
Special Populations
Crusted (Norwegian) Scabies
- Combination therapy recommended:
- Topical scabicide (5% permethrin cream or 5% benzyl benzoate)
- Apply daily for 7 days, then twice weekly until discharge/cure
- PLUS oral ivermectin 200 μg/kg on days 1,2,8,9, and 15
- Severe cases may require additional ivermectin on days 22 and 29 1
- Avoid lindane due to risk of neurotoxicity 1
Immunocompromised Patients
Additional Management Considerations
Environmental Measures
- Decontaminate bedding and clothing:
- Machine wash and dry using hot cycle
- Dry clean
- Or remove from body contact for at least 72 hours 1
- Fumigation of living areas is unnecessary 1
- Keep fingernails closely trimmed to reduce injury from scratching 1
Contact Management
- Treat sexual partners from the previous month 1
- Treat household contacts 1
- Avoid sexual contact until patients and partners have been treated 1
Follow-Up and Treatment Failure
- Rash and pruritus may persist for up to 2 weeks after effective treatment 1
- Causes of persistent symptoms beyond 2 weeks:
- Treatment failure (resistance, improper application)
- Reinfestation from untreated contacts or fomites
- Cross-reactivity with other household mites 1
- Consider retreatment with alternative regimen if symptoms persist 1
Recent Research Insights
- Applying permethrin as a cold cream for two consecutive days may be more effective than a single application 4
- Emerging evidence suggests potential permethrin resistance in some regions, with benzyl benzoate showing better efficacy in recent studies 5
- Two applications of permethrin with a one-week interval (96.9% cure rate) may be more effective than a single dose of ivermectin (62.4% cure rate) 6
Common Pitfalls to Avoid
- Inadequate application of topical treatments (ensure full coverage from neck down)
- Failure to treat contacts and decontaminate bedding/clothing
- Premature discontinuation of treatment due to persistent pruritus
- Using lindane in contraindicated populations (children <10 years, pregnant women, extensive dermatitis)
- Not repeating ivermectin dose after 2 weeks (required due to limited ovicidal activity)
- Bathing immediately before applying lindane