What is the recommended treatment for scabies management?

Scabies Management

First-Line Treatment Recommendation

Permethrin 5% cream remains the recommended first-line treatment for uncomplicated scabies in most patients, applied to all areas of the body from the neck down and washed off after 8-14 hours, with a second application 7-14 days later. 1, 2 However, emerging evidence suggests benzyl benzoate 25% may be superior in regions where permethrin resistance is suspected. 3

Treatment Algorithm by Patient Population

Standard Adult Treatment

• Permethrin 5% cream: Apply from neck down to entire body surface, including under fingernails, in skin folds, and between fingers/toes 1, 2
• Leave on for 8-14 hours before washing off 1, 2
• Critical: Repeat application after 7-14 days to address newly hatched mites 1
• Alternative oral option: Ivermectin 200 μg/kg with food, repeated in 2 weeks 1, 2

Special Populations

Pregnant and Lactating Women:

• Permethrin 5% cream is the preferred and safest option 1, 2, 4
• Avoid lindane completely due to neurotoxicity risk 2
• Avoid oral ivermectin (insufficient safety data) 1

Infants and Children:

• Permethrin 5% cream is safe for children ≥2 months of age 5
• Never use lindane in children <10 years due to seizure and neurotoxicity risk 1, 2
• Apply to entire body including head and neck in young children 1

Immunocompromised Patients:

• Higher risk for crusted (Norwegian) scabies requiring aggressive treatment 1, 2
• Monitor closely for treatment failure 2

Crusted (Norwegian) Scabies Protocol

This severe form requires combination therapy—single-agent treatment will fail: 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
• Take ivermectin with food to increase bioavailability 1, 2
• Never use single-application permethrin alone—this will fail 2

Alternative Treatments When Permethrin Fails or Is Unavailable

Emerging resistance concerns: A 2024 randomized controlled trial showed permethrin achieved only 27% cure rate versus 87% for benzyl benzoate 25%, suggesting significant permethrin resistance. 3 A 2022 study similarly found sulfur ointment significantly more effective than permethrin. 6

Alternative options:

• Benzyl benzoate 25%: Applied daily for 3 consecutive days; widely used internationally and may be superior where resistance suspected 4, 3
• Sulfur 6% ointment: Applied nightly for 3 nights, washing off previous applications before reapplying 1
• Lindane 1%: Apply thinly from neck down, wash off after 8 hours—contraindicated in children <10 years, pregnant/lactating women, and those with extensive dermatitis 1, 2

Critical Environmental and Contact Management

Treatment fails without these steps:

• Treat ALL close contacts simultaneously within the preceding month, even if asymptomatic 1, 2
• Decontaminate bedding and clothing by machine washing/drying on hot cycle, dry cleaning, or removing from body contact for ≥72 hours 1, 2, 4
• Fumigation is unnecessary 1, 2
• Trim fingernails short and apply medication under nails (use disposable toothbrush then discard) 1, 7

Follow-Up and Managing Persistent Symptoms

Pruritus persisting up to 2 weeks after treatment does NOT indicate failure 1, 2, 4

Consider retreatment if:

• Symptoms persist beyond 2 weeks 1, 2
• Live mites observed on examination 2
• New lesions appear 1

Common reasons for treatment failure:

• Failure to treat contacts simultaneously 1, 2
• Inadequate application (missing body areas, insufficient quantity) 1, 2
• Reinfection from untreated contacts or contaminated fomites 1, 2
• True medication resistance (increasingly common with permethrin) 3, 6
• Not repeating second dose 1, 2

Enhanced Application Technique for Better Efficacy

A 2018 study demonstrated improved cure rates (87.2% vs 61.8%) when permethrin was applied as cold cream stored in refrigerator, left on skin for 24 hours, and applied daily for two consecutive days rather than single application. 8

Common Pitfalls to Avoid

• Using lindane after bathing (increases absorption and neurotoxicity risk) 1, 2
• Expecting immediate symptom resolution (may take 2-4 weeks for pruritus to resolve) 1, 5
• Treating only the index patient without simultaneous contact treatment 1, 2
• Applying only to symptomatic areas rather than entire body from neck down 1, 2
• Using single-dose therapy for crusted scabies (requires combination therapy) 2
• Discontinuing treatment due to mild burning/stinging (occurs in ~75% of patients, usually temporary) 5

Managing Secondary Bacterial Infection

When impetiginization is present, combination permethrin 5% with fusidic acid 2% cream is more effective than permethrin alone (95% vs 35% cure rate at day 14), with Staphylococcus aureus being the most common pathogen. 9