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. 1, 2

First-Line Treatment Options

• Permethrin 5% 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, particularly useful when topical treatment is impractical 1, 2
• Ivermectin should be taken with food to increase bioavailability and penetration into the epidermis 2

Treatment Algorithm Based on Patient Population

Special Populations:

• Pregnant or lactating women: Permethrin is the preferred treatment due to limited safety data for ivermectin in these populations 1, 2
• Infants and young children: Permethrin is recommended; ivermectin should not be used in children weighing less than 15 kg due to potential neurotoxicity 1
• Crusted (Norwegian) scabies: Combination therapy is required, including:
  • 5% topical permethrin cream applied daily for 7 days, then twice weekly until cure 2
  • Plus oral ivermectin 200 μg/kg on days 1,2,8,9, and 15 1, 2

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

• Patients should be advised that itching, mild burning, and/or stinging may occur after application of permethrin 3
• Rash and pruritus may persist for up to 2 weeks after successful treatment; consider retreatment after 2 weeks if symptoms persist or live mites are observed 1, 2
• In approximately 75% of patients treated with permethrin cream who continue to manifest pruritus at 2 weeks, itching ceases by 4 weeks 3

Treatment Efficacy and Alternatives

• Recent research (2024) suggests potential reduced sensitivity of scabies mites to permethrin, with one study showing only 27% cure rate with permethrin versus 87% with benzyl benzoate 25% 4
• Two applications of permethrin with a one-week interval has shown effectiveness in 96.9% of patients in some studies 5
• For impetiginized scabies (with secondary bacterial infection), combining permethrin 5% with fusidic acid 2% cream has shown superior efficacy compared to permethrin alone 6

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
• Common reasons for treatment failure include:
  • Failure to treat all close contacts simultaneously 2
  • Inadequate application of topical treatments 2
  • Not repeating ivermectin dose after 2 weeks 2
  • Expecting immediate resolution of symptoms (may take up to 2 weeks) 2