What is the recommended treatment for scabies?

Treatment of Scabies

Permethrin 5% cream is the first-line treatment for scabies, applied to all areas of the body from the neck down (and including the scalp in infants and elderly) and washed off after 8-14 hours. 1, 2

First-Line Treatment Options

Standard Scabies

• Permethrin 5% cream:
  • Apply thoroughly to all skin from neck down (adults) or including scalp (infants/elderly)
  • Leave on for 8-14 hours then wash off
  • One application is generally curative 2
  • Most effective and safe first-line option 1

Alternative Treatments

• Oral ivermectin (200 μg/kg):

  • Alternative when topical treatments cannot be used
  • Not recommended for children <15 kg or pregnant women 1
  • May require second dose 2 weeks after initial treatment 3
  • Single dose provides 62.4% cure rate, increasing to 92.8% with second dose 3

• Other options (when first-line treatments fail):

  • Lindane 1% (with cautions - see below)
  • Sulfur 6% ointment applied nightly for 3 nights 4
  • Crotamiton 10% 4

Special Populations

Pregnant and Lactating Women

• Permethrin 5% cream is the preferred treatment 1
• Avoid lindane and ivermectin 4, 1

Infants and Young Children

• Permethrin 5% cream with special attention to scalp, temple, and forehead 1
• Apply to entire body including scalp 5
• Avoid lindane in children under 2 years 4

Immunocompromised Patients

• Higher risk for crusted (Norwegian) scabies
• Combination therapy recommended:
  • Oral ivermectin (days 1,2,8,9, and 15)
  • Daily permethrin 5% cream for 7 days, then twice weekly until cure 1
• Consult with specialist for management 1

Crusted (Norwegian) Scabies

• More aggressive treatment required:
  • Combination of topical permethrin and oral ivermectin
  • Multiple doses of ivermectin may be needed (days 1,2,8,9,15,22, and 29) 1
  • Daily permethrin application for first week

Treatment Efficacy

• Permethrin 5% cream (two applications one week apart): 96.9% effective 3
• Two consecutive daily applications of permethrin: 87.2% effective (vs. 61.8% for single application) 6
• Oral ivermectin (single dose): 62.4% effective; (two doses): 92.8% effective 3

Important Considerations

Prevention of Reinfestation

1. Treat all household members and close contacts simultaneously even if asymptomatic 1
2. Decontaminate environment:
   • Machine wash and dry (hot cycle) all bedding and clothing
   • Dry clean items that cannot be washed
   • Remove items from body contact for at least 72 hours 1
3. Treat sexual partners from the preceding month 4, 1

Follow-Up

• Pruritus may persist for up to 2-4 weeks after successful treatment 1
• Retreatment should be considered if:
  • Symptoms persist beyond 2 weeks
  • Live mites are observed
  • New lesions appear 1

Common Pitfalls

1. Inadequate application of topical treatments
2. Failure to treat all close contacts
3. Misinterpreting persistent pruritus as treatment failure
4. Inadequate environmental decontamination
5. Using lindane as first-line therapy despite safety concerns 1

Lindane Cautions

• Should not be used:
  • After bathing
  • In patients with extensive dermatitis
  • In pregnant or lactating women
  • In children under 2 years 4
• Associated with seizures and aplastic anemia 4
• Resistance reported in some areas 4

Secondary Bacterial Infections

• Common complication, especially with Staphylococcus aureus 7
• Consider combination treatment with antibiotics for impetiginized scabies
• Combination of permethrin 5% and fusidic acid 2% cream is more effective than permethrin alone for impetiginized scabies 7