What is the recommended treatment for scabies?

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 as the first-line topical treatment by both the American Academy of Pediatrics and the Centers for Disease Control and Prevention (CDC) 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

Application Instructions for Permethrin

• Apply permethrin thoroughly to all areas of the body from the neck down, paying particular attention to all folds and creases 2
• Leave on for 8-14 hours before washing off 1
• Trim fingernails short and ensure medication is applied under nails as scabies mites commonly hide there 3

Special Populations

• For pregnant or lactating women: Permethrin is the preferred treatment due to limited safety data for ivermectin in these populations 1, 4
• For infants and children:
  • Permethrin is safe and effective in children 2 months of age and older 4
  • Ivermectin is not recommended for children weighing less than 15 kg due to potential neurotoxicity 1, 5

Crusted (Norwegian) Scabies

• Combination therapy is recommended for crusted scabies 1, 2:
  • 5% topical permethrin cream applied daily for 7 days, then twice weekly until cure
  • Plus 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 simultaneously 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 Expectations

• Rash and pruritus may persist for up to 2 weeks after successful treatment 1, 2
• In clinical trials, approximately 75% of patients treated with permethrin cream who continued to have 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

Common Treatment Pitfalls to Avoid

• Avoid 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 2
• Inadequate application of topical treatments (not covering all affected areas) 2
• Not repeating ivermectin dose after 2 weeks 2
• Expecting immediate resolution of symptoms (pruritus may take up to 4 weeks to resolve) 4

Treatment for Secondary Bacterial Infections

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

Alternative Treatments

• Crotamiton 10% cream is an alternative but has significantly lower efficacy compared to permethrin (60% vs 89% cure rate at 4 weeks) 7
• Sulfur (6%) ointment can be used as an alternative treatment when permethrin or ivermectin is not available 2