Recommended Treatment for Scabies
The first-line treatment for uncomplicated scabies is 5% permethrin cream applied from the neck down (including the entire body in infants), left on for 8-14 hours, and then washed off, with one application generally being curative. 1, 2
First-line Treatment Options
Topical 5% permethrin cream is the recommended first-line treatment for uncomplicated scabies in most patients 1, 2
- Apply thoroughly from head to soles of feet (including scalp, temple, and forehead in infants and elderly)
- Leave on for 8-14 hours before washing off
- One application is generally curative, but retreatment may be necessary if live mites are found after 14 days 2
Oral ivermectin (200 μg/kg, repeated in 2 weeks) is an effective alternative first-line treatment 1
Special Populations
- Pregnant or lactating women: Permethrin is the preferred treatment due to limited safety data for ivermectin in these populations 3, 1
- Infants and young children: Permethrin is recommended; ivermectin should not be used in children weighing less than 15 kg 3, 1
- Immunocompromised patients: Same regimens as immunocompetent patients for uncomplicated scabies, but higher risk for crusted scabies requiring specialized management 3
Crusted (Norwegian) Scabies
- Combination therapy is recommended for crusted scabies 3, 1:
- 5% topical permethrin cream (daily for 7 days, then twice weekly until cure) PLUS
- Oral ivermectin 200 μg/kg on days 1,2,8,9, and 15
- Additional ivermectin doses on days 22 and 29 may be needed for severe cases 3
Management of Contacts and Environment
- All persons with close personal, sexual, or household contact within the preceding month should be examined and treated if infested 3, 1
- Decontaminate bedding and clothing by machine washing/drying using hot cycles or removing from body contact for at least 72 hours 1
Follow-Up and Treatment Failure
- Rash and pruritus may persist for up to 2 weeks after successful treatment 3, 1
- Consider retreatment after 2 weeks if symptoms persist or live mites are observed 3
- Reasons for treatment failure include 3, 1:
- Resistance to medication
- Faulty application of topical scabicides
- Reinfection from untreated contacts or fomites
- Cross-reactivity with other household mites
Treatment Pitfalls to Avoid
- Avoid lindane due to risks of neurotoxicity, especially in children <10 years, pregnant women, and those with extensive dermatitis 3, 1
- Failure to treat all close contacts simultaneously 1
- Inadequate application of topical treatments 1
- Not repeating ivermectin dose after 2 weeks 1
- Expecting immediate resolution of symptoms (may take up to 2 weeks) 3, 1
Recent Research Developments
- A 2024 study suggests benzyl benzoate 25% may be more effective than permethrin 5% (87% vs 27% cure rate), though it causes more burning sensation (43% of patients) 5
- Applying permethrin as cold cream for two consecutive days may be more effective than a single application (87.2% vs 61.8% cure rate) 6