Treatment of Scabies
Permethrin 5% cream is the first-line treatment for scabies, applied from head to toe for 8-14 hours, with a cure rate of 89-95%. 1
First-Line Treatment
Permethrin 5% Cream
- Apply thoroughly from head to toe (including scalp), paying special attention to all folds and creases 1, 2
- Leave on for 8-14 hours before washing off
- A second application after 1 week is recommended to ensure complete eradication 1
- Safe for use in:
Application Instructions
- Take a thorough bath or shower before application
- Apply cream to entire body surface from head to toe
- Pay special attention to:
- Finger webs
- Under fingernails (trim nails short first)
- Skin folds and creases
- Genital areas
- Leave on for 8-14 hours (typically overnight)
- Wash off with water
Alternative Treatments
Oral Ivermectin
- Dosage: 200 μg/kg body weight
- Recommended when:
- Topical treatments have failed
- Patient cannot tolerate topical treatments
- For crusted (Norwegian) scabies (in combination with topical therapy)
- Requires a second dose after 14 days 1
- Not recommended for:
- Pregnant women
- Children weighing less than 15 kg
- Patients with Loa loa infection 1
Other Alternatives
- Crotamiton lotion 4
- Benzyl benzoate 25% lotion 5
- Malathion 0.5% aqueous lotion 5
- Sulfur 6-33% preparations 5
Management of Secondary Bacterial Infections
- Secondary bacterial infections (impetiginization) are common with scabies
- Staphylococcus aureus is the most common causative organism 6
- For impetiginized scabies, combination of permethrin 5% with fusidic acid 2% cream is more effective than permethrin alone 6
Environmental Control Measures
- Simultaneously treat all household members and close contacts, even if asymptomatic 1
- Decontaminate clothing and bedding:
- Machine wash in hot water and dry on hot cycle, OR
- Keep items out of body contact for at least 72 hours 1
- Change clothing and bed linen the day after treatment
- Fumigation of living areas is NOT necessary 1
Follow-up and Evaluation
- Evaluate patients after 1 week to assess treatment response 1
- Pruritus may persist for 2-4 weeks after successful treatment and is not an indication for retreatment 1, 3
- Consider retreatment if:
- Live mites are still present after 14 days
- New lesions continue to appear
- Symptoms persist beyond 4 weeks 1
Important Considerations
- Permethrin has a more rapid onset of action compared to ivermectin 7
- Application of permethrin should include the scalp and head, especially in infants and elderly patients, contrary to some product labels that recommend neck-down application 2
- Temporary exacerbation of pruritus, mild burning, or stinging may occur after application of permethrin 3
- Two applications of permethrin with a one-week interval (96.9% cure rate) is more effective than a single dose of ivermectin (62.4% cure rate) 8
- For crusted scabies in immunocompromised patients, combination therapy with both topical scabicide and oral ivermectin is recommended 1, 5