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, with cure rates of 89-95% at 4 weeks after treatment. 1
First-Line Treatment Options
Permethrin 5% Cream
- Apply to all areas of the body from the neck down, paying particular attention to all folds and creases
- Wash off after 8-14 hours
- Safe for use in pregnant and lactating women, making it the preferred option 1
- Safe and effective in pediatric patients two months of age and older 2
- Provides rapid onset of action compared to ivermectin 3
- Low mammalian toxicity and minimal allergic side effects 1, 4
- May temporarily exacerbate pruritus, edema, and erythema 2
Alternative Treatment Options
Oral Ivermectin
- Dosage: 200 μg/kg, repeated in 2 weeks
- Effective alternative when topical treatments fail or in cases of widespread infestation
- Should be taken with food to increase bioavailability 1
- Single dose provides cure rate of 62.4%, increasing to 92.8% with second dose at 2-week interval 5
- Less established safety data in breastfeeding women compared to permethrin 1
Other Options
- Crotamiton lotion: Apply thoroughly and massage into the skin, with a second application 24 hours later 6
- Benzyl benzoate 25% lotion (mentioned in European guidelines) 7
Special Considerations
Crusted (Norwegian) Scabies
- Requires combination therapy with a topical scabicide and oral ivermectin 7
- More aggressive treatment approach due to high parasite burden
High-Risk Populations
- Pregnant or lactating women: Use permethrin 5% cream (Category B) 1, 2
- Children: Permethrin is safe for children ≥2 months; dosing adjustments may be needed 2
- Immunocompromised hosts: May require more aggressive treatment, often with ivermectin 8
Environmental and Contact Management
- Decontaminate bedding and clothing by machine washing and drying using hot cycle
- Alternatively, remove items from body contact for at least 72 hours 1
- Treat all household members and close contacts simultaneously, even if asymptomatic
- Treat sexual contacts within the previous month to prevent reinfection 1
- Avoid sexual contact until patients and partners have been treated 1
- Fumigation of living areas is not necessary 1
Follow-Up and Retreatment
- Evaluate after 1 week if symptoms persist
- Approximately 75% of patients treated with permethrin who continue to manifest pruritus at 2 weeks have cessation by 4 weeks 2
- Retreatment may be necessary if:
- Mites are still detected
- No clinical response is achieved with the initial regimen 1
Common Pitfalls to Avoid
- Inadequate application: Ensure thorough coverage of all skin areas from neck down
- Failure to treat contacts: All household members and close contacts must be treated simultaneously
- Premature discontinuation: Complete the full treatment course even if symptoms improve
- Misdiagnosis: Confirm diagnosis by identifying mites, eggs, or fecal pellets under microscopy when possible 8
- Overlooking environmental measures: Proper decontamination of clothing and bedding is essential