What is the recommended treatment for scabies?

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

• Apply thoroughly from head to soles of feet (adults typically need 30 grams)
• Leave on for 8-14 hours then wash off with shower or bath 2
• For infants and geriatric patients, include treatment of the scalp, hairline, neck, temple, and forehead 2
• One application is generally curative 2

Application Instructions:

1. Thoroughly massage cream into all skin areas
2. Remove by washing after 8-14 hours
3. Treat all household members and close contacts simultaneously, even if asymptomatic 1

Alternative Treatment: Oral Ivermectin

When permethrin cannot be used or has failed:

• Dosage: 200 μg/kg of body weight 1, 3
• Take with food to increase bioavailability 1
• May require a second dose after 2 weeks due to limited ovicidal activity 1
• Single-dose cure rate is lower (62.4-85.9%) compared to permethrin 4, 5

Special Populations

• Pregnant or lactating women: Permethrin 5% cream is preferred over ivermectin 1
• Infants and children: Permethrin 5% cream is safe and effective in children 2 months and older 2
• Immunocompromised patients: May develop crusted scabies requiring combination therapy with topical permethrin and oral ivermectin 3

Treatment Considerations

• Persistent pruritus: Common after treatment and not necessarily a sign of treatment failure 2
  • In clinical trials, approximately 75% of patients with persistent pruritus at 2 weeks had resolution by 4 weeks 2
• Treatment failure: Demonstrable living mites after 14 days indicates need for retreatment 2
• Environmental measures:
  • Decontaminate bedding and clothing by machine washing and drying using hot cycle
  • Alternatively, remove items from body contact for at least 72 hours 1

Comparative Efficacy

• Permethrin 5% cream (twice application with one-week interval): 92.5-96.9% cure rate 4, 5
• Oral ivermectin (single dose): 62.4-85.9% cure rate 4, 5
• Oral ivermectin (two doses): 92.8% cure rate 5

Common Pitfalls and Caveats

1. Failure to treat all contacts: All household members and close contacts should be treated simultaneously even if asymptomatic 1
2. Inadequate application: Ensure thorough coverage of all skin areas
3. Retreating too early: Persistent pruritus after treatment is common and not necessarily a sign of treatment failure 2
4. Missing follow-up: Evaluate after 1-2 weeks if symptoms persist 1
5. Neglecting environmental decontamination: Bedding and clothing should be properly cleaned 1

Follow-up

• Evaluate after 1 week if symptoms persist 1
• Retreatment may be necessary if mites are still detected or no clinical response is achieved 1
• A look-back period of 2 months is recommended for partner management 3