Approach

The patient and their close contacts, even those who are asymptomatic, should be promptly treated with topical and/or scabicidal agents with proven efficacy.

Treatment options include the following:

  • Permethrin cream

  • Ivermectin oral tablets

  • Lindane lotion

  • Spinosad suspension

  • Benzyl benzoate lotion

  • Precipitated sulfur lotion

  • Malathion lotion.

It is important that sexual, close personal, and household contacts are also treated, regardless of whether symptoms are present or not, because individuals may be infested without having symptoms. In addition, recently worn clothing and bedsheets should be washed at 140°F or higher (≥60°C) and dried the day after the first treatment to decrease the chance of reinfestation.[6]

Antihistamines are helpful in providing symptomatic relief and are safe for use in children and pregnant females.

Noncrusted scabies

Permethrin is more effective in minimizing treatment failures and relieving itch than lindane. Evidence suggests that permethrin is superior in efficacy to lindane, and precipitated sulfur.[27][28][29] Given the limited efficacy of topical lindane compared with permethrin and the rare cases of associated neurotoxicity, lindane is no longer considered a first-line agent in the US. According to the Centers for Disease Control and Prevention (CDC) guidelines, permethrin cream and oral ivermectin are first-line therapies; lindane is an alternative.[30] Topical spinosad has also been approved in the US for scabies and can also be considered as a treatment option.[31]

European guidelines recommend use of permethrin cream, benzyl benzoate lotion, ivermectin, foam-based synergized pyrethrins, or topical sulfur. Lindane is no longer recommended in Europe.[32]

Topical ivermectin lotion appears to have efficacy similar to permethrin and oral ivermectin, and can be used as an alternative to other topical therapies.[33][34][35] However, the 1% lotion formulation, recommended by the CDC, is not currently available in the US.

Oral ivermectin is an effective, inexpensive, and convenient alternative to permethrin in the treatment of scabies.[27][28][29][36][37] Although evidence suggests that oral ivermectin is less effective than permethrin, similar cure rates have been demonstrated if a second dose of ivermectin is administered 1 to 2 weeks after initial treatment.[36][37][38][39]

Oral ivermectin is recommended for patients who cannot tolerate or are unlikely to comply with a topical regimen.

Malathion has not been widely studied in the treatment of scabies.[27]

Crusted/Norwegian scabies

Given the high parasite load, it is recommended that oral ivermectin be given in conjunction with topical permethrin until all scales and crusts are gone.[28] Benzyl benzoate may be used as an alternative to permethrin if available. The CDC recommends daily application of permethrin (or benzyl benzoate) for 7 days, followed by twice weekly application until cure, plus treatment with oral ivermectin;[30] however, this regimen may cause skin irritation that is intolerable to the patient.

Patients should also apply keratolytics such as urea cream.[2] Urea cream should be applied twice-daily (except for the night that the permethrin is applied) to decrease hyperkeratosis.

Children

Permethrin cream is the most effective and safest treatment modality in children; however, it is not approved for infants younger than 2 months of age. In these cases, precipitated sulfur 6% in petroleum is the treatment of choice.[1]

Pregnant and lactating women

Permethrin cream is recommended as the treatment of choice for scabies during pregnancy.

Treatment failures

These may be secondary to the following:

  • Improper or inadequate application of topical agents

  • Reinfestation

  • Resistance.

All patients should be re-evaluated in 1 month.

Use of this content is subject to our disclaimer