What is the recommended treatment for scabies?

Scabies Treatment Recommendations

Permethrin 5% cream is the first-line treatment for scabies, 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 to entire body from neck down
• Pay special attention to skin folds and creases
• Leave on for 8-14 hours, then wash off
• May require a second application after 1 week
• Safe for use in children (≥2 months), pregnant women, and elderly 1, 2
• Most effective when applied properly covering all skin areas 1
• May temporarily exacerbate pruritus, edema, and erythema 2

Oral Ivermectin

• Effective alternative at 200 μg/kg orally
• Particularly useful for widespread or severe infestations
• Take with food to increase bioavailability
• 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, 3

Treatment for Special Populations

Children

• Permethrin 5% is safe and effective for children ≥2 months of age 2
• Avoid lindane in children under 10 years due to potential neurotoxicity 1

Pregnant/Lactating Women

• Permethrin 5% is the treatment of choice 1, 2
• Avoid lindane due to potential toxicity 1
• Permethrin shows no evidence of harm to fetus in animal studies 2

Immunocompromised Patients

• At higher risk for crusted scabies and recurrence
• Consider combination therapy with oral ivermectin and permethrin 5% cream 1
• Consult with a specialist for management 1

Alternative Treatment Options

Crotamiton 10%

• Apply to entire body from neck down
• Apply nightly for 2 consecutive nights
• Wash off 24 hours after second application 1, 4

Sulfur 6% Ointment

• Apply nightly for 3 nights 1
• Some recent evidence suggests 10% sulfur ointment may be more effective than permethrin in certain populations (96.9% vs 62.4% efficacy) 5

Lindane 1% Lotion/Cream

• Use with caution due to potential toxicity
• Not recommended for patients with extensive dermatitis, pregnant/lactating women, or children under 2 years
• Only use if other treatments fail 1

Management of Complicated Cases

Impetiginized Scabies

• Combination of permethrin 5% with fusidic acid 2% cream is more effective than permethrin alone 6
• Staphylococcus aureus is the most common cause of secondary infection 6

Crusted Scabies

• Requires combination therapy with topical scabicide and oral ivermectin 1, 7

Critical Steps for Successful Treatment

1. Proper Application Technique

   • Cover entire body from neck down
   • Pay special attention to folds, creases, and under fingernails
   • Trim fingernails short before application 1, 4

2. Environmental Decontamination

   • Machine wash and dry bedding/clothing using hot cycle
   • Alternatively, remove items from body contact for at least 72 hours
   • Crucial to prevent reinfestation 1

3. Simultaneous Treatment of Contacts

   • All household members and close contacts should be treated simultaneously
   • Include sexual partners from preceding month
   • Treat even if asymptomatic to break transmission cycle 1, 7

4. Follow-up Evaluation

   • Assess effectiveness after 2-4 weeks
   • Consider retreatment if symptoms persist beyond 2 weeks
   • Note that pruritus may continue for up to 2 weeks after successful treatment 1

Common Pitfalls to Avoid

• Inadequate application coverage - failure to cover all skin areas leads to treatment failure 1
• Failure to treat all contacts - leads to reinfestation 1
• Mistaking post-scabetic itch for treatment failure - pruritus may persist for weeks after successful treatment 1
• Inadequate environmental decontamination - failure to properly clean bedding/clothing 1
• Overuse of lindane - can cause toxicity including seizures and aplastic anemia 1

Treatment Efficacy Comparison

• Permethrin 5% (two applications with one-week interval): 96.9% effective 3
• Oral ivermectin (single dose): 62.4% effective; (two doses): 92.8% effective 3
• 10% Sulfur ointment may be more effective than permethrin in some populations, particularly with emerging permethrin resistance 5