What is the recommended treatment for scabies?

Recommended Treatment for Scabies

Permethrin 5% cream is the first-line treatment for scabies, applied from neck to feet (including scalp in infants and elderly), left on for 8-14 hours, and then washed off. 1, 2

First-Line Treatment Options

Permethrin 5% Cream

• Apply thoroughly from head to soles of feet (approximately 30g for an average adult)
• Leave on for 8-14 hours, then wash off
• One application is generally curative 2
• Special considerations:
  • Include scalp, temple, and forehead in infants and geriatric patients 1, 2, 3
  • Persistent pruritus after treatment is common and not necessarily a sign of treatment failure 1, 2
  • Retreatment is indicated only if living mites are found after 14 days 2

Oral Ivermectin

• Alternative treatment: 200 μg/kg (0.2 mg/kg) orally with food
• Requires repeat dose after 2 weeks
• Should be taken with food to increase bioavailability 1
• Less effective as a single dose (62.4% cure rate) compared to permethrin (96.9% cure rate) 4
• Two doses of ivermectin at a 2-week interval can achieve 92.8% cure rate 4

Treatment for Special Populations

Children

• Permethrin 5% cream is safe and effective for children 1, 5
• Infants require application to scalp, temple, and forehead 1, 2
• Avoid lindane in children under 10 years 1

Pregnant or Lactating Women

• Permethrin 5% cream is the recommended treatment 1
• Avoid lindane due to potential neurotoxicity, seizures, and aplastic anemia 1

Immunocompromised Patients

• Higher risk for crusted scabies and recurrence
• May require specialist consultation 1

Treatment for Complicated Scabies

Crusted (Norwegian) Scabies

• Combination therapy with oral ivermectin and topical permethrin 5% cream 1

Impetiginized Scabies

• Combination of permethrin 5% cream with fusidic acid 2% cream is more effective than permethrin alone
• Particularly effective against Staphylococcus aureus, the most common bacterium in secondary infections 6

Enhanced Treatment Protocols

• For improved efficacy, consider:
  • Applying permethrin as cold cream (stored in refrigerator) 7
  • Two applications of permethrin with a one-week interval (96.9% effectiveness) 7, 4
  • Scalp-to-toes application, especially in cases with head involvement 3

Environmental Management and Prevention of Reinfestation

• All bedding and clothing should be washed in hot water or dry cleaned
• Items that cannot be washed should be removed from body contact for at least 72 hours
• All household members and close contacts should be treated simultaneously, even if asymptomatic
• Sexual partners from the preceding month should be examined and treated 1

Treatment Evaluation

• Evaluate effectiveness after 2-4 weeks
• Consider retreatment if:
  • Symptoms persist beyond 2 weeks
  • Live mites are observed
  • New lesions appear 1

Common Pitfalls to Avoid

1. Failing to treat the scalp in infants and elderly patients
2. Mistaking persistent pruritus (which can last up to 2 weeks after successful treatment) for treatment failure
3. Not treating all household contacts simultaneously
4. Inadequate environmental decontamination
5. Using lindane in children under 10 years or pregnant/lactating women
6. Applying permethrin from neck down in all patients - consider scalp-to-toes application, especially when head involvement is suspected 1, 3