What is the recommended treatment for scabies?

Recommended Treatment for Scabies

Permethrin 5% cream is the first-line treatment for scabies, applied from neck to toes for 8-14 hours, with a cure rate of 89-95% at 4 weeks after treatment. 1, 2

First-Line Treatment: Permethrin 5% Cream

• Apply permethrin 5% cream from neck down (or scalp-to-toes in cases with head involvement) 1, 3
• Leave on for 8-14 hours before washing off 1
• Repeat treatment after 7-10 days to kill newly hatched mites 1, 4
• Two applications of permethrin with a one-week interval has shown effectiveness in 96.9% of patients 5

Application Technique

• For better efficacy, consider applying the cream cold (stored in refrigerator) 4
• Ensure complete coverage of all skin surfaces
• Pay special attention to areas commonly affected: finger webs, wrists, axillae, genitalia, and feet 1

Alternative Treatment: Oral Ivermectin

• Oral ivermectin at 200 μg/kg is an effective alternative when:
  • Topical treatments have failed
  • Patient cannot tolerate topical treatments
  • For widespread or crusted scabies 1, 6
• Should be taken with food to increase bioavailability 1
• Requires a second dose after 14 days due to limited ovicidal activity 1
• Single dose provides cure rate of 62.4%, increasing to 92.8% with second dose at 2-week interval 5

Special Populations

Pregnant and Breastfeeding Women

• Permethrin 5% is preferred due to established safety data 1
• Avoid lindane due to association with neural tube defects 1

Children

• Permethrin 5% is the first-line treatment for children 1
• Ivermectin should be avoided in children under 15 kg 1
• For infants, apply permethrin to the entire body, including the scalp, face, and neck 1, 3

Immunocompromised Patients

• Crusted (Norwegian) scabies requires combination therapy:
  • Topical permethrin AND
  • Oral ivermectin 6
• May require more aggressive and prolonged treatment 1

Impetiginized Scabies

• For scabies with secondary bacterial infection (commonly Staphylococcus aureus):
  • Combination of permethrin 5% with fusidic acid 2% cream is more effective than permethrin alone 7
  • Consider appropriate antibiotics for secondary bacterial infections 7

Prevention and Control Measures

• Simultaneously treat all household members and close contacts, even if asymptomatic 1, 6
• Decontaminate bedding and clothing:
  • Machine wash with hot water (at least 120°F/49°C) 1
  • OR keep items out of body contact for at least 72 hours 1
• Maintain strict personal hygiene when living in crowded spaces 6
• Avoid sexual contact until completion of treatment 6

Follow-Up and Monitoring

• Evaluate after 1 week if symptoms persist 1
• Pruritus may persist for several weeks after successful treatment 1
• Consider repeat treatment if:
  • Mites are detected on follow-up
  • No clinical response is observed 1

Common Pitfalls and Caveats

• Inadequate application: Ensure complete coverage of all skin surfaces
• Failure to treat contacts: All household members and close contacts must be treated simultaneously
• Insufficient decontamination: Bedding and clothing must be properly decontaminated
• Head involvement: Consider scalp-to-toes application in infants and when head involvement is suspected 3
• Persistent symptoms: Itching may persist for weeks after successful treatment; this does not necessarily indicate treatment failure 1
• Recurrence: May indicate reinfection from untreated contacts or fomites 1, 4