What is the recommended treatment for scabies?

Scabies Treatment Guidelines

The recommended first-line treatment for scabies is permethrin 5% cream applied to all areas of the body from the neck down and washed off after 8-14 hours, or oral ivermectin 200 μg/kg (repeated in 2 weeks). 1, 2, 3

First-Line Treatment Options

• Permethrin 5% cream is considered the most effective topical treatment for uncomplicated scabies, with one application generally being curative 1, 2, 3
• Application should cover all areas from the neck down, with special attention to skin folds and creases 4
• Oral ivermectin (200 μg/kg) is an effective alternative first-line treatment, but requires a second dose after 2 weeks due to limited ovicidal activity 4, 1
• Ivermectin should be taken with food to increase bioavailability and penetration into the epidermis 4, 2

Special Populations

• For pregnant or lactating women, permethrin 5% cream is the preferred treatment option due to established safety profile 1, 3
• For infants and young children, permethrin is recommended as the first-line treatment 4, 3
• Children under 10 years should avoid lindane due to risk of neurotoxicity 4, 2
• Immunocompromised patients are at higher risk for crusted (Norwegian) scabies, requiring more aggressive treatment 1, 2

Alternative Treatment Options

• Lindane (1%) is an alternative regimen but should only be used if the patient cannot tolerate the recommended therapies or if these therapies have failed 4
• Lindane should not be used:
  • Immediately after a bath or shower 4
  • By persons with extensive dermatitis 4, 2
  • By children under 10 years 4, 2
  • By pregnant or lactating women 4, 2
• Sulfur (6%) ointment is another alternative treatment, applied thinly to affected areas nightly for 3 nights 1

Crusted (Norwegian) Scabies Management

• Combination therapy is recommended for crusted scabies 1, 2:
  • 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

Environmental Management

• Decontaminate bedding and clothing by machine washing and drying using hot cycle, dry cleaning, or removing from body contact for at least 72 hours 4, 1
• Keep fingernails closely trimmed to reduce injury from scratching 4
• Fumigation of living areas is unnecessary 4, 2

Contact Management

• Examine and treat all persons who have had sexual, close personal, or household contact with the patient within the preceding month 1, 3
• All contacts should be treated simultaneously to prevent reinfection 1

Follow-Up and Treatment Failure

• Pruritus may persist for up to 2 weeks after successful treatment 1, 5
• Approximately 75% of patients treated with permethrin cream who continue to manifest pruritus at 2 weeks have cessation by 4 weeks 5
• Consider retreatment if symptoms persist beyond 2 weeks, live mites are observed, or other signs of treatment failure are present 1, 2
• Reasons for treatment failure include 1, 2:
  • Resistance to medication
  • Faulty application of topical treatments
  • Reinfection from untreated contacts or fomites
  • Cross-reactivity with other household mites

Treatment Efficacy Comparison

• Research shows that two applications of permethrin with a one-week interval is more effective (96.9% cure rate) than a single dose of ivermectin (62.4% cure rate) 6
• Two doses of ivermectin (92.8% cure rate) is comparable in effectiveness to a single application of permethrin 6
• Recent research suggests that applying permethrin as a cold cream once daily for two consecutive days may be more effective than the single application in adult immunocompetent patients 7

Common Pitfalls to Avoid

• Failure to treat all close contacts simultaneously 1
• Inadequate application of topical treatments 1, 2
• Using lindane after bathing or in contraindicated populations 4, 2
• Not repeating ivermectin dose after 2 weeks 1, 2
• Expecting immediate resolution of symptoms 1, 2