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CDC clinical care of scabies treatment permethrin ivermectin 2025
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Scabies treatment
First choice: permethrin 5% cream
- Apply a thin layer to all skin from the neck down, including between fingers/toes, under nails, groin, buttocks, and soles.
- Leave on for 8 to 14 hours, then wash off.
- Repeat after 7 days to kill mites that have hatched.
- In infants and young children, the scalp, neck, temples, and forehead may also need treatment. Use clinician guidance for children under 2 months.
Permethrin is generally the preferred option in pregnancy and is approved for people aged 2 months or older. The CDC scabies guidance lists it as a first-line treatment.
Oral option: ivermectin
A clinician may prescribe oral ivermectin, especially when topical treatment is impractical, has failed, or in outbreaks:
- 200 micrograms/kg by mouth, then a second dose 7 to 14 days later.
- It should be prescribed by a clinician, since drug interactions and suitability must be checked.
- Avoid or seek specialist advice in pregnancy and in children weighing under 15 kg.
Ivermectin does not reliably kill eggs, which is why a second dose is required. Recent systematic reviews continue to compare ivermectin with permethrin, but correct application and treating contacts are major determinants of success. A 2024 review also found treatment failure is not rare, often reflecting reinfestation or incorrect use rather than true drug resistance (PMID: 37625798).
Treat contacts and household measures
Treatment will often fail if this step is missed:
- Treat everyone in the household and sexual/close skin contacts at the same time, even if they do not yet itch.
- Wash recently used clothes, bedding, and towels in hot water and dry on high heat.
- Items that cannot be washed can be sealed in a plastic bag for at least 72 hours.
- Avoid close skin-to-skin contact until treatment has been completed.
Itching after treatment
Itching can continue for 2 to 4 weeks after effective treatment. This alone does not prove the mites remain. Moisturizer, calamine, and an oral antihistamine at night may help. A clinician may prescribe a short course of a mild topical steroid for post-scabies eczema.
When to see a doctor promptly
- Thick crusted/scaly skin, widespread infestation, or weakened immunity: possible crusted scabies, which needs combined oral and topical treatment.
- Pus, yellow crusts, painful skin, fever: possible bacterial skin infection.
- New burrows or new pimple-like lesions more than 2 to 4 weeks after correctly treating all contacts.
- Pregnancy, infant under 2 months, or uncertainty that the rash is actually scabies.
Do not rely on over-the-counter anti-itch creams alone. They may reduce symptoms but do not eradicate scabies mites.
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