From the Guidelines
Permethrin 5% cream is the first-line topical treatment for scabies, as it is the most effective and safest option, with the least amount of side effects, and should be applied from neck to toes, including under fingernails, between fingers and toes, and on the genitals, then washed off after 8-14 hours 1.
Key Considerations
- A second application one week later is recommended to kill newly hatched mites.
- Alternative treatments include benzyl benzoate 25% lotion (applied for 24 hours then washed off, repeated after 7 days) or sulfur 5-10% ointment (applied for 3 consecutive nights).
- For crusted scabies, combination treatment is recommended with a topical scabicide, either 5% topical benzyl benzoate or 5% topical permethrin cream, and treatment with oral ivermectin 200 ug/kg on days 1,2,8,9, and 15 1.
- All household members and close contacts should be treated simultaneously, even if asymptomatic, to prevent reinfestation.
- Clothing, bedding, and towels used in the previous 3 days should be washed in hot water and dried on high heat.
- Itching may persist for 2-4 weeks after successful treatment due to hypersensitivity to dead mites.
Important Notes
- Permethrin works by disrupting the parasite's nervous system, leading to paralysis and death of the mites.
- Treatment failure often occurs due to incorrect application or not treating all close contacts.
- Lindane should be avoided because of the risks for neurotoxicity with heavy applications or denuded skin 1.
From the FDA Drug Label
Permethrin Cream, 5% is indicated for the treatment of infestation with Sarcoptes scabiei (scabies). Permethrin topical treatment is indicated for scabies.
- The drug name is permethrin
- The concentration is 5% 2
From the Research
Scabies Topical Treatment Options
- Topical permethrin and oral ivermectin are commonly used treatments for scabies, with permethrin having a rapid onset of action 3
- A study comparing topical ivermectin and permethrin 2.5% cream found that two applications of topical ivermectin were as effective as two applications of permethrin 2.5% cream at the 2-week follow-up 4
- Topical permethrin is considered the most effective treatment for classic scabies, with a strength of recommendation of A, based on meta-analyses with consistent results 5
- A treatment strategy for endemic scabies using allethrin, permethrin, and ivermectin was found to be effective, with permethrin being more effective and suitable for use in children, pregnant, and nursing women 6
Efficacy of Permethrin and Ivermectin
- Oral ivermectin may lead to slightly lower rates of complete clearance after one week compared to permethrin 5% cream, but by week two, there may be little or no difference 7
- Treatments with one to three doses of ivermectin or one to three applications of permethrin may lead to little or no difference in rates of complete clearance after four weeks' follow-up 7
- Topical ivermectin 1% lotion and permethrin cream may have similar complete clearance rates after four weeks of treatment 7
Safety of Permethrin and Ivermectin
- Reporting of adverse events in studies was suboptimal, but no withdrawals due to adverse events occurred in either the systemic ivermectin or the permethrin group 7
- There is probably little or no difference in the proportion of participants treated with systemic ivermectin or permethrin cream who experienced at least one adverse event 7
- Adverse events in participants treated with topical ivermectin were rare and of mild intensity, comparable to those with systemic ivermectin 7