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. 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
- Permethrin should be applied to all areas of the body from the neck down, left on for 8-14 hours, and then washed off 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
Treatment for Special Populations
- Permethrin is the preferred treatment for pregnant or lactating women due to limited safety data for ivermectin in these populations 1, 2
- For infants and young children, permethrin is recommended; ivermectin should not be used in children weighing less than 15 kg due to potential neurotoxicity 1
- Permethrin cream is safe and effective in pediatric patients two months of age and older 3
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 for scabies treatment and prevention 2
Follow-Up and Treatment Considerations
- Rash and pruritus may persist for up to 2 weeks after successful treatment 1, 2
- Approximately 75% of patients treated with permethrin cream who continue to manifest pruritus at 2 weeks have cessation by 4 weeks 3
- Consider retreatment after 2 weeks if symptoms persist or live mites are observed 1, 2
- Reasons for persistent symptoms include treatment failure, reinfection from untreated contacts or fomites, and cross-reactivity with other household mites 2
Treatment 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 treatment failure 2
- Inadequate application of topical treatments can reduce effectiveness 2
- Not repeating ivermectin dose after 2 weeks can lead to treatment failure 2
- Recent research suggests decreasing sensitivity of scabies mites to permethrin in some regions, with a 2024 study showing only 27% cure rate with permethrin compared to 87% with benzyl benzoate 4
Alternative Treatments
- Benzyl benzoate 25% may be an effective alternative when permethrin resistance is suspected, though it may cause a burning sensation in some patients 4
- Crotamiton lotion can be used as an alternative treatment, applied thoroughly and massaged into the skin of the whole body, with a second application 24 hours later 5
- For impetiginized scabies (with secondary bacterial infection), combining permethrin 5% with fusidic acid 2% cream has shown greater efficacy than permethrin alone 6