Treatment for Scabies (Burrowing Mite Under Skin)
Apply permethrin 5% cream to all areas of the body from the neck down and wash off after 8-14 hours—this is the first-line treatment recommended by the American Academy of Dermatology and CDC. 1, 2, 3
First-Line Treatment Options
Topical Permethrin (Preferred)
- Permethrin 5% cream is the gold standard topical treatment for uncomplicated scabies in most patients 1, 3
- Apply to the entire body from neck down, including under fingernails, between fingers, wrists, elbows, armpits, genitals, and feet 4
- Leave on for 8-14 hours before washing off 1, 4
- One application is generally curative, though a second treatment after 1-2 weeks may be needed 4, 1
- For infants and elderly patients, also treat the scalp, hairline, neck, temple, and forehead since these areas can be infested in these age groups 4, 5
Oral Ivermectin (Alternative First-Line)
- Dose: 200 μg/kg body weight, taken with food to increase bioavailability 1, 3
- Repeat the dose after 2 weeks—this second dose is essential 1, 3
- Particularly useful for institutional outbreaks, immunocompromised patients, or when treating large numbers of contacts simultaneously 1, 6
Alternative Treatments (When First-Line Options Fail or Are Contraindicated)
Lindane 1%: Apply thinly from neck down, wash off after 8 hours 5, 1
Sulfur 6% ointment: Apply nightly for 3 consecutive nights 1
- Safe for pregnant women and young children when permethrin is unavailable 7
Crotamiton 10%: Apply to entire body nightly for 2 consecutive nights, wash off 24 hours after second application 5, 8
Special Populations
Pregnant and Lactating Women
- Use permethrin 5% cream exclusively—it is the safest option with minimal systemic absorption 1, 2, 3
- Avoid lindane and ivermectin in this population 1, 3
Crusted (Norwegian) Scabies
- Requires aggressive combination therapy: 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 1, 3
- This severe form occurs primarily in immunocompromised patients and requires expert consultation 1
Critical Management Steps Beyond Medication
Environmental Decontamination
- Machine wash and dry all bedding, clothing, and towels using hot cycle 5, 1, 3
- Items that cannot be washed should be dry-cleaned or sealed in plastic bags for at least 72 hours 5, 1
- Fumigation is unnecessary and should not be done 5, 1
- Trim fingernails short and scrub under them during treatment application 1, 8
Contact Tracing and Treatment
- Treat ALL household members, sexual partners, and close personal contacts from the preceding month simultaneously, even if asymptomatic 1, 3
- This is the most common reason for treatment failure—untreated contacts lead to reinfection 1, 3
Follow-Up and Managing Persistent Symptoms
Expected Post-Treatment Course
- Itching may persist for up to 2 weeks after successful treatment—this is NOT treatment failure 1, 3, 4
- This represents an allergic reaction to dead mites and their debris 6
When to Retreat
- Only retreat if live mites are observed after 14 days or symptoms persist beyond 2 weeks 1, 4
- Consider alternative diagnosis if symptoms continue despite appropriate retreatment 1
Common Pitfalls to Avoid
- Failing to treat all contacts simultaneously—the #1 cause of apparent treatment failure 1, 3
- Inadequate application of topical treatment—must cover entire body surface, not just visible lesions 1, 3
- Using lindane after bathing—increases absorption and seizure risk 5, 3
- Forgetting the second dose of ivermectin at 2 weeks—single dose is insufficient 1, 3
- Retreating too early for persistent itching—wait at least 2 weeks before considering retreatment 1, 4
- Not treating the scalp in infants and elderly patients—these populations require scalp treatment 4, 5