What is the recommended treatment for scabies?

Scabies Treatment

Topical permethrin 5% cream is the first-line treatment for uncomplicated scabies, applied from the neck down for 8-14 hours, with oral ivermectin (200 μg/kg, repeated in 2 weeks) as an equally effective alternative. 1, 2

First-Line Treatment Options

Permethrin 5% Cream

• Apply to all areas of the body from the neck down, including under fingernails, between fingers and toes, and all body folds 1, 2
• Leave on for 8-14 hours before washing off 1, 2
• One application is generally curative in most cases 2
• Preferred for pregnant/lactating women, infants, and young children due to excellent safety profile 1, 2
• Safe for children ≥2 months of age 3

Oral Ivermectin

• Dose: 200 μg/kg body weight, must be repeated in 2 weeks 1, 2
• Take with food to increase bioavailability and epidermal penetration 1
• Contraindicated in children weighing <15 kg due to neurotoxicity risk 1, 2
• Avoid in pregnant/lactating women due to limited safety data 1, 2
• No dosage adjustment needed for renal impairment 1

Evidence Quality Note

While permethrin has traditionally been considered first-line, a recent 2024 randomized controlled trial showed permethrin achieved only 27% cure rate compared to 87% for benzyl benzoate 25%, suggesting potential emerging resistance 4. However, current CDC and AAP guidelines still recommend permethrin as first-line 1, 2.

Special Population: Crusted (Norwegian) Scabies

Requires aggressive combination therapy—single-agent treatment will fail 1, 2

• Topical permethrin 5% cream applied daily for 7 days, then twice weekly until cure 1, 2
• PLUS oral ivermectin 200 μg/kg on days 1,2,8,9, and 15 1, 2
• This multi-dose schedule addresses the massive mite burden (thousands to millions of mites) and ivermectin's limited ovicidal activity 1
• Single-application permethrin as used for ordinary scabies will fail 1

Alternative Treatments (When First-Line Options Unavailable)

• Benzyl benzoate 25%: May be more effective than permethrin based on recent data, though causes burning sensation in 43% of patients 4
• Lindane 1%: Apply for 8 hours 1, 5
  • Avoid in children <10 years, pregnant/lactating women, and persons with extensive dermatitis due to neurotoxicity risk 1, 2
  • Never use after bathing, as this increases absorption and toxicity 1, 5
• Sulfur 6% ointment: Apply for 3 consecutive nights 1, 5

Critical Management of Contacts and Environment

Failure to treat contacts simultaneously is the most common cause of treatment failure 5

• Examine and treat ALL persons with close personal, sexual, or household contact within the preceding month, even if asymptomatic 1, 2, 5
• Decontaminate bedding, clothing, and towels by machine washing/drying on hot cycle, dry cleaning, or removing from body contact for ≥72 hours 1, 5
• Fumigation of living areas is unnecessary 1, 5

Follow-Up and Expected Course

• Pruritus and rash may persist for up to 2 weeks after successful treatment—this does NOT indicate treatment failure 1, 2, 5
• Consider retreatment only if symptoms persist beyond 2 weeks AND live mites are observed 1, 2, 5
• Persistent symptoms may indicate: treatment failure, reinfection from untreated contacts, or cross-reactivity with other household mites 1

Common Pitfalls to Avoid

• Not repeating ivermectin dose at 2 weeks—this is essential for complete eradication 1, 5
• Inadequate application of topical treatments (missing under nails, body folds, or stopping at neck when should go to chin) 1
• Failing to treat all close contacts simultaneously 1, 5
• Using lindane after bathing or in contraindicated populations 1, 5
• Expecting immediate symptom resolution—itching can persist 2 weeks post-treatment 1, 2
• Using single-dose therapy for crusted scabies—combination therapy is mandatory 1, 2