What is the recommended treatment for scabies?

Recommended Treatment for Scabies

Permethrin 5% cream is the first-line treatment for scabies, applied from the neck down (or scalp-to-toe in infants, elderly, and cases with head involvement), left on for 8-14 hours, and then washed off. 1, 2

First-Line Treatment: Permethrin 5% Cream

• Application method: Thoroughly massage into the skin from neck down (adults) or including scalp/head (infants, elderly)
• Duration: Leave on for 8-14 hours, then wash off
• Dosage: Usually 30 grams is sufficient for an average adult
• Frequency: One application is generally curative, but a second application after 1 week may increase efficacy 1, 2, 3

Recent evidence suggests that applying permethrin as a cold cream (refrigerated) on two consecutive days may improve efficacy compared to a single application 3. However, concerning new research from 2024 indicates possible reduced sensitivity of scabies mites to permethrin in some regions, with only a 27% cure rate in one study 4.

Alternative Treatments

1. Oral ivermectin:

   • Dosage: 200 μg/kg orally with food
   • Particularly useful for widespread or severe infestations
   • Requires repeat dose after 2 weeks due to limited ovicidal activity
   • Single dose provides 62.4% cure rate, increasing to 92.8% with second dose 1, 5

2. Other alternatives (when first-line treatments fail):

   • Benzyl benzoate 25% lotion (87% cure rate in recent studies) 4
   • Crotamiton 10% (apply nightly for 2 consecutive nights)
   • Sulfur 6% ointment (apply nightly for 3 nights)
   • Lindane 1% lotion/cream (use with caution due to toxicity concerns) 1, 6

Special Populations

• Infants/children: Use permethrin 5% cream, including application to scalp, temple, and forehead 2, 7
• Elderly: Consider scalp-to-toe application as head involvement is more common 7
• Pregnant/lactating women: Permethrin 5% cream is preferred; avoid lindane 1
• Immunocompromised patients: At risk for crusted scabies; consider combination therapy with oral ivermectin and permethrin 5% cream 1

Critical Additional Measures

• Treat all household members and close contacts simultaneously, even if asymptomatic 1
• Decontaminate bedding and clothing by machine washing/drying using hot cycle or removing from body contact for at least 72 hours 1
• Sexual partners from preceding month should be examined and treated 1, 6

Follow-up and Common Pitfalls

• Persistent pruritus may continue for up to 2 weeks after successful treatment and should not be misinterpreted as treatment failure 1, 2
• Evaluate effectiveness after 2-4 weeks; retreatment indicated if live mites observed or new lesions appear 1
• Common mistakes:
  • Inadequate application (not covering all skin areas)
  • Failure to treat all contacts simultaneously
  • Inadequate environmental decontamination
  • Mistaking post-scabetic itch for treatment failure 1

For crusted (Norwegian) scabies, combination therapy with oral ivermectin and topical permethrin is recommended, often requiring multiple treatments under specialist guidance 1, 6.