Recommended Treatment for Scabies
Permethrin 5% cream is the first-line treatment for scabies, applied from the neck down and washed off after 8-14 hours, with a second application recommended one week later. 1
First-Line Treatment Options
Permethrin 5% Cream (Preferred)
- Apply thoroughly to all areas of the body from neck down
- Pay special attention to skin folds and creases
- Wash off after 8-14 hours
- Repeat application after one week
- Cure rates of 89-95% at 4 weeks after treatment 1
- Safe for use in pregnant and breastfeeding women 1, 2
- Safe and effective in children 2 months of age and older 2
Oral Ivermectin (Alternative)
- Dosage: 200 μg/kg body weight
- Should be taken with food to increase bioavailability
- Requires a second dose after 2 weeks due to limited ovicidal activity
- Less established safety data compared to permethrin for breastfeeding women 1
- Especially indicated for:
- Crusted scabies
- Immunocompromised hosts
- Infestations in crowded communities 3
- When topical treatment fails or is contraindicated
Environmental and Contact Management
- Decontaminate bedding and clothing by:
- Machine washing and drying using hot cycle, or
- Removing items from body contact for at least 72 hours 1
- Fumigation of living areas is unnecessary 1
- Treat all household members and close contacts simultaneously, even if asymptomatic 1, 4
- Treat sexual contacts from the previous month 1, 4
- Avoid sexual contact until patients and partners have been treated 1
Follow-Up and Retreatment
- Evaluate after 1 week if symptoms persist
- Retreatment may be necessary if:
- Mites are still detected
- No clinical response is achieved with initial treatment 1
- Approximately 75% of patients who still have pruritus at 2 weeks will have resolution by 4 weeks 2
Special Considerations
Pregnant or Breastfeeding Women
- Permethrin 5% cream is the preferred treatment 1, 2
- Animal studies show no evidence of impaired fertility or harm to the fetus 2
Children
- Permethrin is safe for children 2 months and older 2
- Safety not established in infants younger than 2 months 2
Crusted (Norwegian) Scabies
- Combination therapy with topical scabicide and oral ivermectin is recommended 4
Alternative Treatments
- Sulfur ointment (6-33%): Some recent evidence suggests 10% sulfur ointment may be effective, particularly where permethrin resistance is a concern 5
- Crotamiton: Apply thoroughly to the skin from chin down, with a second application 24 hours later 6
Common Pitfalls and Caveats
- Temporary exacerbation of pruritus, edema, and erythema may occur after treatment with permethrin 2
- Mild irritant contact dermatitis can develop in some patients 7
- Failure to treat all close contacts simultaneously often leads to reinfection
- Inadequate application of topical treatments is a common cause of treatment failure
- Pruritus may persist for several weeks after successful treatment and does not necessarily indicate treatment failure 2
- Loa loa infection must be excluded before treating with ivermectin in people who have traveled to endemic regions 1