What is the recommended treatment for scabies?

Treatment for Scabies

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

First-Line Treatment Approach

Permethrin 5% Cream Application

• Apply permethrin 5% cream from neck down to the entire body
• Pay special attention to all skin folds and creases
• Leave on for 8-14 hours before washing off
• A second application is recommended after 7 days to kill newly hatched mites

Important Application Considerations

• Patients should be advised that itching, mild burning, and/or stinging may occur after application 2
• The medication should be thoroughly massaged into the skin
• For patients with scalp involvement (rare in adults but more common in infants), consider scalp-to-toes application 3
• Permethrin is safe for use in pediatric patients two months of age and older 2

Decontamination and Prevention

• Machine wash and dry all bedding and clothing using hot cycle (at least 120°F/49°C)
• Items that cannot be washed should be removed from body contact for at least 72 hours 1
• Treat all household members and close contacts simultaneously, even if asymptomatic, to prevent reinfection 1

Alternative Treatments

When permethrin fails or is not tolerated:

1. Oral Ivermectin

   • Dosage: 200 μg/kg repeated after 14 days
   • Single dose provides 62.4% cure rate, increasing to 92.8% with second dose 4
   • Note: Before treating with ivermectin, Loa loa infection must be excluded in people who have traveled to endemic regions 1

2. Sulfur 6% Ointment

   • Applied nightly for 3 nights
   • Washed off 24 hours after last application 1
   • Useful alternative for pregnant women and infants under 2 months

3. Crotamiton

   • Thoroughly massage into the skin of the whole body
   • A second application is recommended 24 hours later
   • Take a cleansing bath 48 hours after the last application 5

Special Populations

Pregnant/Lactating Women

• Permethrin is the preferred treatment with no evidence of harm to the fetus 1, 2
• Animal reproduction studies have revealed no evidence of impaired fertility or fetal harm 2

Pediatric Patients

• Permethrin is safe and effective in children 2 months and older 2
• For infants under 2 months, safety has not been established; consider sulfur ointment

Elderly Patients

• No significant differences in response compared to younger patients
• Permethrin is metabolized in the liver and excreted as inactive metabolites, so no dosage adjustment is needed for impaired renal function 2

Management of Complications

Secondary Bacterial Infections

• In cases of impetiginized scabies (secondary bacterial infection), combination of permethrin 5% with fusidic acid 2% cream is more effective than permethrin alone 6
• Staphylococcus aureus is the most common bacterium causing secondary infection 6

Follow-Up and Retreatment

• Evaluate patients after 1 week to assess treatment response
• Retreatment is indicated if live mites are still present after 14 days 1
• Important: Pruritus may persist for several weeks (up to 4 weeks in 75% of patients) after successful treatment and is not an indication for retreatment 1, 2

Treatment Optimization

Research suggests that applying permethrin as a cold cream (stored in refrigerator) and using two consecutive daily applications may improve efficacy to 87.2% compared to 61.8% with a single application 7