Management of Scabies in Pregnancy
Pregnant women with scabies should be treated with permethrin 5% cream applied to all areas of the body from the neck down and washed off after 8-14 hours, as this is the safest and most effective option during pregnancy. 1, 2
First-Line Treatment: Permethrin 5% Cream
Permethrin 5% cream is the treatment of choice for pregnant women because it has minimal percutaneous absorption, low inherent toxicity, and no evidence of teratogenicity in animal studies at doses far exceeding therapeutic levels. 3, 4
Apply the cream to all areas of the body from the neck down (including under fingernails, between fingers and toes, and in skin folds) and wash off after 8-14 hours. 1, 2
The FDA classifies permethrin as Pregnancy Category B, meaning reproduction studies in animals have revealed no evidence of impaired fertility or harm to the fetus, though adequate studies in pregnant women are lacking. 3
Permethrin is rapidly metabolized in the skin and excreted as inactive metabolites in urine, minimizing systemic exposure. 3, 5
Alternative Treatment Option: Ivermectin
Ivermectin (200 μg/kg orally, repeated in 2 weeks) can be considered as an alternative, as human pregnancy data suggest low risk and it is probably compatible with breastfeeding. 1
However, permethrin remains preferred due to its longer safety track record and topical application route. 6
Ivermectin should be taken with food to increase bioavailability and epidermal penetration. 1, 2
Treatments to AVOID in Pregnancy
Lindane is absolutely contraindicated in pregnancy due to associations with neural tube defects and mental retardation, plus its ability to accumulate in the placenta and breast milk. 1
Lindane should never be used in pregnant or lactating women, even as an alternative therapy. 1, 2
Essential Management Considerations
Treatment of Contacts
- All sexual partners, close personal contacts, and household members within the preceding month must be treated simultaneously, even if asymptomatic, to prevent reinfection. 2, 6
Environmental Decontamination
- Machine wash and dry all bedding, clothing, and towels using the hot cycle, or dry clean them, or remove from body contact for at least 72 hours. 1, 2
- Fumigation of living areas is unnecessary. 1, 2
Follow-Up Expectations
- Pruritus and rash may persist for up to 2-4 weeks after successful treatment due to ongoing hypersensitivity reaction to dead mites and their debris—this does not indicate treatment failure. 2, 7
- Reevaluate at 2 weeks if symptoms persist; consider retreatment only if live mites are observed or symptoms worsen. 2
Common Pitfalls to Avoid
Failure to treat all close contacts simultaneously is the most common cause of apparent treatment failure due to reinfection. 2
Inadequate application of permethrin—ensure coverage of all skin surfaces from neck down, including often-missed areas like under nails and between toes. 2
Expecting immediate symptom resolution—counsel patients that itching may temporarily worsen and can persist for weeks after successful mite eradication. 3, 7
Premature retreatment—avoid unnecessary repeat applications within 2 weeks unless live mites are documented, as this increases exposure without benefit. 2