What is the treatment for scabies?

Treatment of Scabies

First-line treatment for scabies is oral ivermectin 200 μg/kg (repeated in 2 weeks) or topical permethrin 5% cream applied to all areas of the body from the neck down and washed off after 8-14 hours. 1

First-Line Treatment Options

Permethrin 5% Cream

• Apply thoroughly to all areas of the body from the neck down
• For infants and young children: include scalp, temple, and forehead in application
• Leave on for 8-14 hours, then wash off
• Usually 30 grams is sufficient for an average adult 2
• One application is generally curative, but a second application after one week may be necessary in some cases 2
• Safe for use in pregnancy and lactation 3, 1

Oral Ivermectin

• Dosage: 200 μg/kg orally, repeated in 2 weeks
• Take with food to increase bioavailability and skin penetration 1
• Contraindicated in:
  • Children weighing <15 kg
  • Pregnant women 1

Treatment Algorithm

1. For most patients:

   • Either permethrin 5% cream OR oral ivermectin is appropriate
   • Permethrin is effective, safe, and less expensive than ivermectin 3

2. For specific populations:

   • Pregnant/lactating women: Use permethrin 5% cream 3, 1
   • Infants and young children: Use permethrin 5% cream with special attention to scalp 1
   • Patients with extensive dermatitis: Avoid lindane, use permethrin or ivermectin 3

3. For severe/crusted scabies:

   • Consider combination therapy with oral ivermectin AND permethrin 5% cream
   • More intensive regimen may be required: ivermectin on days 1,2,8,9, and 15 1

Additional Management Considerations

• Treat all household members and close contacts simultaneously, even if asymptomatic 1
• Decontaminate bedding and clothing: Machine wash and dry using hot cycle or dry clean; alternatively, remove from body contact for at least 72 hours 3, 1
• Treat sexual partners from the preceding month 3
• Persistent pruritus may continue for up to 2 weeks after successful treatment and is not necessarily an indication for retreatment 2

Follow-Up and Treatment Failure

• Evaluate for treatment success 2-4 weeks after initial treatment 1
• Consider retreatment if:
  • Live mites are observed after 14 days 2
  • New lesions appear
  • Symptoms persist beyond 2 weeks 1

Common Pitfalls to Avoid

1. Inadequate application of topical treatments: Ensure complete coverage of all affected areas
2. Failure to treat all close contacts: This is a common cause of reinfestation
3. Misinterpreting persistent pruritus as treatment failure: Itching may persist for up to 2 weeks after successful treatment
4. Inadequate environmental decontamination: Ensure all bedding and clothing are properly treated
5. Using lindane as first-line therapy: Lindane should only be used if patients cannot tolerate or have failed first-line treatments due to risk of neurotoxicity, seizures, and aplastic anemia 3, 1

Special Considerations

• Recent research suggests potential decreased efficacy of permethrin in some regions, with a 2024 study showing only 27% cure rate with permethrin compared to 87% with benzyl benzoate 4
• For impetiginized scabies (with secondary bacterial infection), consider adding topical antibiotics like fusidic acid 2% cream to address bacterial superinfection 5