Recommended Treatment for Scabies
Topical 5% permethrin cream is the first-line treatment for uncomplicated scabies, 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
- 5% permethrin cream is recommended by the Centers for Disease Control and Prevention (CDC) as the first-line topical treatment for uncomplicated scabies, applied to all areas of the body from the neck down and washed off after 8-14 hours 1, 2
- Oral ivermectin (200 μg/kg, repeated in 2 weeks) is an effective alternative first-line treatment, which should be taken with food to increase bioavailability 1, 2
- Ivermectin should not be used in children weighing less than 15 kg due to potential neurotoxicity 1
Application Instructions for Permethrin
- Thoroughly massage permethrin into the skin of the whole body from the chin down, paying particular attention to all folds and creases 3
- Apply under fingernails after trimming them short, as scabies mites often remain there 4
- Clothing and bed linen should be changed the day after application 3, 4
- A cleansing bath should be taken 48 hours after the last application 4
Special Populations
- Permethrin is the preferred treatment for:
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
- 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 2
Follow-Up and Treatment Failure
- Rash and pruritus may persist for up to 2 weeks after successful treatment 1, 2
- Consider retreatment after 2 weeks if symptoms persist or live mites are observed 1, 2
- In clinical trials, approximately 75% of patients treated with permethrin cream who continued to manifest pruritus at 2 weeks had cessation by 4 weeks 3
Common Pitfalls to Avoid
- Avoid using lindane due to risks of neurotoxicity, especially in children <10 years, pregnant women, and those with extensive dermatitis 1, 2
- Failure to treat all close contacts simultaneously can lead to reinfection and treatment failure 2
- Inadequate application of topical treatments, especially in skin folds and under fingernails 2
- Not repeating ivermectin dose after 2 weeks 2
- Expecting immediate resolution of symptoms (may take up to 2-4 weeks) 2, 3
Secondary Bacterial Infections
- For impetiginized scabies (secondary bacterial infection), combining permethrin 5% with fusidic acid 2% cream has shown greater efficacy than permethrin alone 5
- Staphylococcus aureus is the most common bacterium causing secondary infection in impetiginized scabies 5