Scabies Treatment
The recommended first-line treatment for scabies is 5% permethrin cream applied to the entire body from neck down for 8-14 hours, with a cure rate of 89-95% at 4 weeks after treatment. 1
First-Line Treatment: Permethrin 5% Cream
Application Instructions:
- Apply 5% permethrin cream to the entire body from the chin down
- Pay particular attention to all skin folds and creases
- Leave on for 8-14 hours (typically overnight)
- Take a cleansing bath after treatment
- Repeat application after 7-10 days to kill newly hatched mites
Special Considerations:
- For infants and young children: Apply to entire body including head, neck, face, and scalp (avoiding eyes and mouth) 1
- For pregnant or lactating women: Permethrin 5% cream is preferred over oral ivermectin due to better established safety profile 1
- Permethrin has low mammalian toxicity with minimal allergic side effects 1, 2
Environmental 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 from the previous month to prevent reinfection 1
Alternative Treatments
Oral Ivermectin
- Dosage: 200 μg/kg, repeated in 2 weeks
- Take with food to increase bioavailability 1
- Effectiveness: 62.4% cure rate with single dose, increasing to 92.8% with second dose at 2-week interval 3
- Caution: Not first-line for pregnant/lactating women or children <15kg 1
Sulfur Ointment (10%)
- Some recent evidence suggests it may be more effective than permethrin in certain populations 4
- Can be considered when permethrin resistance is suspected
Treatment Efficacy Comparison
- Permethrin 5% cream (two applications one week apart): 94-97% cure rate 5, 6
- Oral ivermectin (single dose): 62-86% cure rate; (two doses): 93-100% cure rate 3, 6
- Topical ivermectin: Similar efficacy to permethrin 2.5% cream (84-90% with repeated applications) 7
Follow-Up and Management of Treatment Failure
- Evaluate after 1 week if symptoms persist
- Retreatment may be necessary if:
- Mites are still detected
- No clinical response to initial regimen 1
- Persistent pruritus is common and may continue for up to 4 weeks after successful treatment 2
- Consider alternative diagnosis or treatment resistance if symptoms persist beyond 4 weeks
Common Pitfalls to Avoid
- Inadequate application: Ensure complete coverage from neck down (include head/scalp for infants)
- Failure to treat contacts: All household members and close contacts must be treated simultaneously
- Insufficient environmental decontamination: Wash bedding/clothing in hot water
- Premature treatment assessment: Pruritus may persist for weeks after successful treatment
- Single treatment only: Two applications are necessary to kill newly hatched mites
Side Effects and Monitoring
- Permethrin may temporarily exacerbate pruritus, edema, and erythema 2
- Mild irritant contact dermatitis may occur in 7-10% of patients 5
- Avoid eye contact with permethrin; flush with water immediately if exposure occurs 2
The evidence strongly supports permethrin 5% cream as first-line therapy, with oral ivermectin as an effective alternative when topical treatment is impractical or unsuccessful.