What is the recommended treatment for scabies?

Recommended Treatment for Scabies

Permethrin 5% cream applied to all areas of the body from the neck down and washed off after 8-14 hours is the first-line treatment for scabies, with cure rates of 89-95% at 4 weeks after treatment. 1, 2

First-Line Treatment

• Permethrin 5% cream:
  • Apply to all areas of the body from the neck down
  • Leave on for 8-14 hours before washing off
  • May require a second application after 1 week if symptoms persist
  • Safe for use in children as young as 2 months, pregnant women, and lactating women 3

Alternative Treatments

When permethrin is not effective or contraindicated:

1. Ivermectin:

   • Oral: 200 μg/kg, repeated after 14 days
   • Topical: 0.8% solution
   • Particularly useful for treatment failures or widespread infestations 2
   • Caution in patients with liver disease as it may affect metabolism 2

2. Lindane 1% lotion or cream:

   • Apply thinly to all areas from neck down
   • Wash off after 8 hours
   • Important safety restrictions:
     • Do not use after bathing
     • Avoid in patients with extensive dermatitis
     • Contraindicated in pregnant/lactating women
     • Contraindicated in children under 2 years 1
     • Risk of seizures and aplastic anemia with improper use

3. Sulfur 6% ointment:

   • Apply nightly for 3 nights
   • Wash off previous applications before reapplying
   • Wash off 24 hours after last application 1

4. Crotamiton 10% cream:

   • Less effective than permethrin (65% vs 85% cure rate at 4 weeks) 4
   • Apply thoroughly to entire body
   • Requires second application 24 hours later 5

Management of Persistent Symptoms

• Pruritus may persist for up to 4 weeks after successful treatment 2, 3
• 75% of patients who still have itching at 2 weeks will have resolution by 4 weeks 3
• Persistent symptoms at 1-2 weeks require evaluation for:
  • Treatment failure
  • Reinfestation
  • Secondary bacterial infection

Prevention of Reinfestation

• Decontaminate bedding and clothing:
  • Machine wash and dry using hot cycle
  • Dry clean
  • OR remove from body contact for at least 72 hours 1, 2
• Treat all household members and close contacts simultaneously, even if asymptomatic 2
• For sexually transmitted cases, treat sexual partners from the preceding month 1

Special Populations

• Pregnant/lactating women: Permethrin is safe and preferred 1, 3
• Children: Permethrin is safe for children ≥2 months 3
• Immunocompromised patients: May develop crusted (Norwegian) scabies requiring combination therapy with topical scabicide and oral ivermectin 6

Follow-Up

• Evaluate patients after 1 week if symptoms persist 1
• Consider retreatment if:
  • Live mites are still present after 14 days
  • New lesions continue to appear
  • Symptoms worsen 2

Common Pitfalls

• Failure to treat all close contacts simultaneously
• Inadequate application of medication (entire body must be treated)
• Premature retreatment due to persistent pruritus (which is expected)
• Inadequate decontamination of fomites
• Misdiagnosis of other pruritic conditions as treatment failure

Permethrin remains the most effective and safe first-line treatment for scabies with superior efficacy compared to alternatives like crotamiton 4 and comparable safety profile to ivermectin 7.