What are the recommended medications and doses for treating scabies?

Recommended Medications and Doses for Treating Scabies

For treating scabies, permethrin 5% cream is the first-line treatment, applied to all areas of the body from the neck down (including scalp in infants and elderly) and washed off after 8-14 hours, with oral ivermectin 200 μg/kg as an effective alternative. 1, 2

First-Line Treatment Options

Topical Treatments

• Permethrin 5% cream is the most effective topical treatment for uncomplicated scabies 1, 3
• Application instructions:
  • Apply thoroughly to all skin from head to soles of feet (adults typically need 30 grams) 2
  • Leave on for 8-14 hours before washing off 2
  • One application is generally curative, though treatment may be repeated after 7-10 days 2, 4
• Permethrin is particularly recommended for infants, young children, and pregnant/lactating women due to its safety profile 1, 5

Oral Treatment

• Ivermectin 200 μg/kg orally, repeated in 2 weeks, is the recommended oral medication 1
• Should be taken with food to increase bioavailability 1
• Especially indicated for crusted scabies, immunocompromised patients, or infestations in crowded communities 6

Alternative Treatment Options

• Lindane (1%) lotion or cream: Apply thinly to all areas from neck down and wash off after 8 hours 7
  • Caution: Should not be used following a bath, by persons with extensive dermatitis, pregnant/lactating women, or children under 10 years 7, 1
• Crotamiton (10%): Apply to entire body from neck down nightly for 2 consecutive nights, wash off 24 hours after second application 7
• Sulfur (6%) ointment: Cost-effective option when other treatments aren't available 8

Special Populations

Infants and Children

• Infants should be treated on the scalp, temple, and forehead in addition to the body 2, 9
• Avoid lindane in children under 10 years due to risk of neurotoxicity 1

Pregnant/Lactating Women

• Permethrin 5% cream is the preferred and safe treatment option 1, 5
• Avoid lindane due to potential toxicity 7, 1

Crusted (Norwegian) Scabies

• Combination therapy recommended: 1
  • Topical permethrin 5% 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

Environmental Management

• Decontaminate bedding and clothing by: 7, 1
  • Machine washing/drying using hot cycle
  • Dry cleaning
  • Removing from body contact for at least 72 hours
• Treat all sexual and close personal/household contacts within the last month, even if asymptomatic 7, 1

Follow-Up and Treatment Failure

• Pruritus may persist for up to 2 weeks after successful treatment 7, 1
• Consider retreatment if symptoms persist or if live mites are observed after 14 days 2
• Reasons for treatment failure include: 1
  • Inadequate application of topical treatments
  • Failure to treat all close contacts simultaneously
  • Using lindane after bathing or in contraindicated populations
  • Not repeating ivermectin dose after 2 weeks

Treatment Pitfalls to Avoid

• Applying permethrin incorrectly or insufficiently 1
• Failing to treat all close contacts simultaneously 1
• Expecting immediate resolution of symptoms (pruritus may persist for weeks) 7, 1
• Using lindane in contraindicated populations 1
• Not applying treatment to scalp in infants, elderly, or when head involvement is suspected 9