Recommended Treatment for Scabies
The first-line treatment for uncomplicated scabies is topical 5% permethrin cream, applied from the neck down, left on for 8-14 hours, and then washed off, with one application generally being curative. 1, 2
First-Line Treatment Options
- Permethrin 5% cream is recommended by both the American Academy of Pediatrics and the Centers for Disease Control and Prevention (CDC) as the first-line topical treatment for uncomplicated scabies 1, 2
- Application should cover the entire body from the neck down, with special attention to all folds and creases, and should be washed off after 8-14 hours 1, 2
- Oral ivermectin (200 μg/kg, repeated in 2 weeks) is an effective alternative first-line treatment for uncomplicated scabies 1, 2
- Ivermectin should be taken with food to increase bioavailability and penetration into the epidermis 2
Special Populations
- For pregnant or lactating women, permethrin is the preferred treatment due to limited safety data for ivermectin in these populations 1, 2
- For infants and young children, permethrin is recommended, while ivermectin should not be used in children weighing less than 15 kg due to potential neurotoxicity 1
- FDA labeling indicates permethrin cream is safe and effective in pediatric patients two months of age and older 3
- Lindane should be avoided in children under 10 years, pregnant or lactating women, and persons with extensive dermatitis due to risk of neurotoxicity 1, 2
Crusted (Norwegian) Scabies
- Combination therapy is recommended for crusted scabies, including: 1, 2
- 5% permethrin cream applied daily for 7 days, then twice weekly until discharge/cure
- Oral ivermectin 200 μg/kg on days 1,2,8,9, and 15
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 1, 2
- Decontaminate bedding and clothing by machine washing/drying using hot cycle, dry cleaning, or removing from body contact for at least 72 hours 2
- Fumigation of living areas is unnecessary for scabies treatment and prevention 2
Follow-Up and Treatment Failure
- Rash and pruritus may persist for up to 2 weeks after successful treatment; approximately 75% of patients treated with permethrin cream who continued to manifest pruritus at 2 weeks had cessation by 4 weeks 1, 2, 3
- Consider retreatment after 2 weeks if symptoms persist or live mites are observed 1, 2
- Recent research suggests that permethrin resistance may be emerging; a 2024 study found a cure rate of only 27% with permethrin compared to 87% with benzyl benzoate 25% 4
- Some studies suggest that two applications of permethrin with a one-week interval is more effective (96.9% cure rate) than a single application 5, 6
Treatment Pitfalls to Avoid
- Failure to treat all close contacts simultaneously can lead to reinfection and treatment failure 2
- Inadequate application of topical treatments (not covering all skin areas or not leaving on for sufficient time) 2
- Using lindane after bathing or in contraindicated populations 2
- Not repeating ivermectin dose after 2 weeks 2
- Expecting immediate resolution of symptoms (may take up to 2-4 weeks) 2, 3
Side Effects and Considerations
- Permethrin may temporarily exacerbate pruritus, edema, and erythema 3
- Permethrin may be mildly irritating to the eyes; patients should avoid eye contact during application 3
- For impetiginized scabies (with secondary bacterial infection), combination treatment with permethrin 5% and fusidic acid 2% cream has shown superior efficacy compared to permethrin alone 7
- Staphylococcus aureus is the most common bacterium causing secondary infection in impetiginized scabies 7