Recommended Treatment for Scabies
The first-line treatment for scabies is permethrin 5% cream applied to all areas of the body from the neck down and washed off after 8-14 hours, with oral ivermectin (200 μg/kg, repeated in 2 weeks) as an effective alternative. 1, 2
First-Line Treatment Options
- Permethrin 5% cream is recommended as the first-line topical treatment for uncomplicated scabies by the Centers for Disease Control and Prevention (CDC), with one application generally being curative 1, 2
- Application should cover all areas of the body from the neck down, with special attention to skin folds and creases, and should be washed off after 8-14 hours 3, 2
- Oral ivermectin (200 μg/kg, repeated in 2 weeks) is an effective alternative first-line treatment 1, 2
- Ivermectin should be taken with food to increase bioavailability and penetration into the epidermis 3, 2
Special Populations
- Permethrin is the preferred treatment for pregnant or lactating women due to limited safety data for ivermectin in these populations 1, 4
- For infants and young children, permethrin is the recommended treatment 3, 1
- Ivermectin is not recommended for children weighing less than 15 kg due to potential neurotoxicity 1
- No dosage adjustments are required for ivermectin in patients with renal impairment 2
Crusted (Norwegian) Scabies
- Combination therapy is recommended for crusted scabies, including: 1, 2
- 5% topical permethrin cream applied daily for 7 days, then twice weekly until 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
- Bedding and clothing should be decontaminated by machine washing/drying using hot cycle, dry cleaning, or removing from body contact for at least 72 hours 3, 2
- Fumigation of living areas is unnecessary 3
Follow-Up and Treatment Failure
- Rash and pruritus may persist for up to 2 weeks after successful treatment 2
- In clinical trials, approximately 75% of patients treated with permethrin 5% cream who continued to manifest pruritus at 2 weeks had cessation by 4 weeks 4
- Consider retreatment after 2 weeks if symptoms persist or live mites are observed 1, 2
- Recent research suggests decreasing efficacy of permethrin in some regions, with one 2024 study showing only 27% cure rate with permethrin compared to 87% with benzyl benzoate 5
Alternative Treatments
- Lindane (1%) can be used as an alternative, but only if the patient cannot tolerate the recommended therapies or if these therapies have failed 3
- Lindane should be avoided in children <10 years, pregnant or lactating women, and persons with extensive dermatitis due to risk of neurotoxicity 3, 1, 2
- Some studies suggest that applying permethrin as a cold cream for two consecutive days may be more effective than a single application (87.2% vs 61.8% cure rate) 6
Treatment Pitfalls to Avoid
- Failure to treat all close contacts simultaneously can lead to reinfection 2
- Inadequate application of topical treatments, particularly missing skin folds and creases 2
- Using lindane after bathing or in contraindicated populations 2
- Not repeating ivermectin dose after 2 weeks, as it has limited ovicidal activity 3, 2
- Expecting immediate resolution of symptoms - pruritus may persist for up to 2 weeks after successful treatment 2
- For impetiginized scabies (secondary bacterial infection), combination treatment with permethrin 5% and fusidic acid 2% cream is more effective than permethrin alone 7