When do you repeat Elimite (permethrin) cream treatment for a patient with scabies?

When to Repeat Permethrin (Elimite) Cream for Scabies

For uncomplicated scabies, one application of permethrin 5% cream is generally curative and does not require routine repetition; retreatment is only indicated if living mites are demonstrable after 14 days. 1

Standard Treatment Protocol

• Apply permethrin 5% cream once to the entire body from the neck down (including scalp in infants and elderly), leave on for 8-14 hours, then wash off thoroughly 2, 1
• The FDA label explicitly states that "ONE APPLICATION IS GENERALLY CURATIVE" 1
• A single application provides adequate treatment for the vast majority of immunocompetent patients with ordinary scabies 2, 1

When Retreatment IS Indicated

Retreatment after 14 days is necessary only if:

• Living mites are visible on dermatoscopic examination or microscopy after 14 days 1, 2
• This represents true treatment failure, not persistent allergic symptoms 1

When Retreatment IS NOT Indicated

Do not retreat based solely on persistent itching, as this is a common pitfall:

• Pruritus commonly persists for up to 2 weeks after successful treatment due to allergic reaction to dead mites and their debris 2, 3
• The CDC emphasizes that persistent itching "is rarely a sign of treatment failure and is not an indication for retreatment" 1, 2
• Topical corticosteroids and oral antihistamines can relieve post-treatment itching without requiring additional scabicide 4

Alternative Retreatment Schedules (Not Standard)

While the FDA-approved regimen is a single application, some evidence suggests alternative approaches:

• One small study found that applying permethrin once daily for two consecutive days (repeated 7-10 days later) achieved 87.2% cure rates versus 61.8% with single application 5
• However, this contradicts the FDA label and standard guidelines, which maintain that single application is curative 1
• Some experts recommend retreatment after 1 week for symptomatic patients, though others only recommend it if live mites are observed 6

Critical Management Points to Prevent Treatment Failure

Address these factors that commonly cause apparent "treatment failure":

• Treat all household and sexual contacts from the past month simultaneously, even if asymptomatic 2, 3
• Decontaminate bedding and clothing by hot washing/drying, dry cleaning, or sealing in plastic bags for 72 hours 2, 3
• Ensure complete body coverage from neck to soles, including between fingers/toes, under nails, wrists, elbows, armpits, genitals, and buttocks 3
• Apply to completely dry skin and massage thoroughly into all areas 3

Special Populations Requiring Different Approach

For crusted (Norwegian) scabies:

• Single application permethrin will fail 2
• Requires intensive combination therapy: topical permethrin daily for 7 days then twice weekly PLUS oral ivermectin 200 μg/kg on days 1,2,8,9, and 15 2, 4
• This population has massive mite burden requiring aggressive multi-dose treatment 2

For immunocompromised patients:

• Higher risk of treatment failure and may require closer monitoring 2
• Consider combination therapy similar to crusted scabies if standard treatment fails 2

Timeline for Evaluation

• Evaluate at 2 weeks post-treatment for persistent symptoms 6, 2
• Look specifically for living mites at 14 days to determine if retreatment is needed 1
• Symptoms persisting beyond 2 weeks without living mites suggest reinfection from untreated contacts or environmental sources, not treatment failure 2