Scabies Management
Permethrin 5% cream is the first-line treatment for scabies, applied to all areas of the body from the neck down and washed off after 8-14 hours. 1, 2
First-Line Treatment Options
- Permethrin 5% cream: Apply to all areas of the body from the neck down and wash off after 8-14 hours 1
- Oral ivermectin: 200 μg/kg body weight, taken with food to increase bioavailability, with a second dose after 2 weeks 1, 2
Alternative Treatment Options
- Lindane (1%): Apply thinly to all areas from neck down and wash off after 8 hours 2
- Sulfur (6%) ointment: Apply thinly to affected areas nightly for 3 nights, washing off previous applications before reapplying 2
Special Populations
- Pregnant or lactating women: Permethrin 5% cream is the preferred treatment option 3, 4
- Children under 10 years: Avoid lindane due to risk of neurotoxicity; use permethrin instead 2, 3
- Persons with extensive dermatitis: Avoid lindane due to increased absorption and risk of seizures 2
- Immunocompromised patients: At higher risk for crusted (Norwegian) scabies, requiring more aggressive treatment 2
Crusted (Norwegian) Scabies Management
- Combination therapy is recommended: 1
- 5% 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
- Additional ivermectin treatment on days 22 and 29 may be required for severe cases
Environmental Management
- Decontaminate bedding and clothing by: 1, 2
- Machine washing and drying using hot cycle
- Dry cleaning
- OR removing from body contact for at least 72 hours
- Fumigation of living areas is unnecessary 2
- Keep fingernails closely trimmed to reduce injury from scratching 2
Contact Management
- Examine and treat all persons who have had sexual, close personal, or household contact with the patient within the preceding month 2, 1
- For institutional outbreaks, treat the entire population at risk and consult with an expert 2
Follow-Up and Treatment Failure
- Pruritus may persist for up to 2 weeks after successful treatment 2, 1
- Consider retreatment if: 2
- Symptoms persist beyond 2 weeks
- Live mites are observed
- Reasons for treatment failure include: 1
- Resistance to medication
- Faulty application of topical treatments
- Reinfection from untreated contacts or fomites
- Cross-reactivity with other household mites
Recent Evidence on Treatment Efficacy
- Recent studies have reported decreased sensitivity of scabies mites to permethrin 5% in some regions 5, 6
- A 2024 study found benzyl benzoate 25% had higher cure rates (87%) compared to permethrin 5% (27%) 5
- Some evidence suggests applying permethrin as cold cream once daily for two consecutive days may be more effective than a single application 7
- Mass drug administration of oral ivermectin is effective for managing scabies in high-prevalence communities or institutional outbreaks 6