What is the recommended treatment for scabies?

Treatment for Scabies

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
• Safe, effective, and less expensive than alternatives 1
• Safe for use in children 2 months and older 2
• Safe for pregnant and lactating women 1, 2
• May require a second application after one week for complete eradication 1

Oral Ivermectin

• Effective alternative treatment at 200 μg/kg orally
• Particularly useful for:
  • Widespread or severe infestations
  • Patients who cannot tolerate topical treatments
• Should be taken with food to increase bioavailability
• Requires repeat dose after 2 weeks due to limited ovicidal activity 1
• Single dose provides cure rate of 62.4%, increasing to 92.8% with second dose 3

Special Populations

Children

• Permethrin 5% cream is safe for children 2 months and older 2
• Safety not established for infants under 2 months 2
• Avoid lindane in children under 10 years due to potential neurotoxicity 1

Pregnant/Lactating Women

• Permethrin 5% cream is the treatment of choice 1, 2
• Animal studies show no evidence of harm to fetus 2
• Avoid lindane due to potential toxicity 1

Immunocompromised Patients

• At higher risk for crusted (Norwegian) scabies
• May require combination therapy with oral ivermectin and permethrin 5% cream 1
• Consider specialist consultation 1

Alternative Treatments

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 areas with resistance 5

Lindane 1% Lotion/Cream

• Use with caution due to potential toxicity
• Not recommended for:
  • Patients with extensive dermatitis
  • Pregnant or lactating women
  • Children under 2 years
• Should only be used if other treatments fail 1

Critical Steps for Treatment Success

1. Proper Application Technique

   • Cover all skin areas from neck down
   • Pay special attention to finger webs, wrists, axillary folds, abdomen, buttocks, and genitalia 6
   • Trim fingernails and apply medication under nails 4

2. Simultaneous Treatment of Contacts

   • All household members and close contacts should be treated simultaneously, even if asymptomatic 1
   • Sexual partners within the preceding month should be examined and treated 1

3. Environmental Decontamination

   • Machine wash and dry bedding and clothing using hot cycle
   • Alternatively, remove items from body contact for at least 72 hours 1
   • Change clothing and bed linen the day after treatment 4

4. Follow-up Evaluation

   • Evaluate treatment 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

• Mistaking post-scabetic itch for treatment failure: Pruritus may persist for up to 2-4 weeks after successful treatment 1
• Inadequate treatment application: Failure to cover all skin areas can lead to treatment failure 1
• Failure to treat all contacts: Can lead to reinfestation 1
• Inadequate environmental decontamination: Can lead to reinfestation 1
• Overuse of lindane: Can cause toxicity, including seizures and aplastic anemia 1

Treatment Response Expectations

• Approximately 75% of patients treated with permethrin cream who still have pruritus at 2 weeks will have resolution by 4 weeks 2
• Permethrin-treated patients typically recover earlier than those treated with single-dose ivermectin 3
• Two applications of permethrin with a one-week interval is effective in approximately 97% of patients 3