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Scabies treatment

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scabies treatment permethrin ivermectin

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Here is a thorough summary of scabies treatment based on multiple textbook sources and the latest meta-analysis (2026):

Scabies Treatment

Causative Agent

Scabies is an infestation by the mite Sarcoptes scabiei var. hominis. Over 100 million people are affected annually. The mite burrows into the epidermis, causing intense pruritus (worst at night), papules, pustules, and burrows - classically in the interdigital folds, wrists, genitalia, breasts, buttocks, and subungual skin.

First-Line Treatment: Permethrin 5% Cream

  • Apply from neck to toes (include face/scalp in infants and young children)
  • Get into all skin folds: under nails, umbilicus, around nipples, genitals
  • Leave on 8-14 hours (ideally overnight), then wash off
  • Repeat in 1-2 weeks to increase cure rate
  • Note: scabies resistance to permethrin is increasing

Alternative Treatment: Oral Ivermectin

  • Dose: 200 mcg/kg body weight orally
  • Repeat in 14 days (second dose is required because ivermectin has limited ovicidal activity - it kills live mites but not eggs)
  • Ivermectin may have a modestly lower cure rate than permethrin (see meta-analysis below)
  • Preferred for: crusted/Norwegian scabies, treatment-resistant cases, heavily infested or immunocompromised patients
  • In immunocompromised patients: give once weekly for 2-3 weeks

Permethrin 1% Lotion

  • Alternative to 5% cream
  • Same application (neck down, 8-14 hours)
  • Repeat in 1 week if symptoms persist

Crusted (Norwegian) Scabies

A highly contagious variant with hyperkeratotic plaques (elbows, knees, palms, soles), thick nail dystrophy, and potentially thousands-to-millions of mites. Seen in elderly, immunosuppressed (HIV), dementia, or neuropathy patients. Requires combination treatment: topical permethrin plus oral ivermectin given weekly for 2-3 weeks.

Agents No Longer Recommended

  • Lindane 1% - previously used but now not recommended due to potential neurotoxicity and increasing resistance. Contraindicated in children under 10 years old.

Symptomatic Relief

  • Antihistamines and mid-potency topical corticosteroids for itch
  • Pruritus may persist weeks to months after successful treatment - dead mites and eggs retain antigenic properties causing ongoing inflammation. This does not mean treatment failed.

Environmental Decontamination (Mandatory)

  • Machine-wash all clothing, bed linens, and towels in hot water
  • Items that cannot be washed: dry clean, heat in hot dryer for 15 minutes, or seal in plastic bags for 1 month (mites cannot survive off the host beyond 3 days)
  • Treat all household members and close contacts simultaneously - failing to do so typically causes recurrence within the family

Latest Evidence (2026)

A 2026 systematic review and meta-analysis (PMID: 42098632, BMC Infectious Diseases, 7 RCTs, n=1,216) confirmed:
  • Permethrin has a modest but statistically significant advantage over ivermectin in clinical cure (RR 0.93 favoring permethrin, 95% CI 0.86-0.99)
  • Ivermectin was associated with a higher risk of treatment failure (RR 1.52, 95% CI 1.06-2.20)
  • Ivermectin remains a valuable alternative when topical therapy is not suitable, but optimized dosing is important
This supports permethrin 5% cream as the preferred first-line agent.
Sources: Rosen's Emergency Medicine 10e; Textbook of Family Medicine 9e; Goldman-Cecil Medicine
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