Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

non-pregnant/non-lactating adults or children over 5 years

1st line – permethrin or ivermectin

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ACUTE
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non-pregnant/non-lactating adults or children over 5 years
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non-crusted scabies
1st line – 

permethrin or ivermectin

Treatment is given to adults with scabies to relieve discomfort of rash and pruritus and to prevent transmission to other people. Treatment should be given at the time of diagnosis. Permethrin cream is generally quite safe and has a low level of toxicity and low percutaneous absorption rate. One study showed that permethrin was associated with a lower rate of post-treatment pruritus than ivermectin.[27] Because of the need to coat the entire body from the neck down, insufficient use can be a barrier to effective treatment. Physicians should advise patients to ensure they apply permethrin to all areas including in between the fingers/toes, in the groin, and under nails. Permethrin should not be used in patients who are allergic to chrysanthemums.

Ivermectin is generally given orally and may be preferred if there are large numbers of patients to treat (e.g., an entire nursing home). Oral therapy is significantly easier to use than topical therapy, so compliance is higher.

It is important that sexual and close personal or household contacts are also treated at the same time as the patient. Recently worn clothing and bed sheets should be washed at 60°C or higher (≥140°F) and dried the day after the first treatment to decrease the chance of re-infestation.[6]

Antihistamines are helpful in providing symptomatic relief.

Primary options

permethrin topical: (5%) apply from neck down to the soles of feet, wash off after 8-14 hours; may need to repeat treatment after 14 days if evidence of live mites

Secondary options

ivermectin: 200 micrograms/kg orally as a single dose, followed by a second dose in 14 days

2nd line – lindane

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ACUTE
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non-pregnant/non-lactating adults or children over 5 years
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non-crusted scabies
2nd line – 

lindane

The Centers for Disease Control and Prevention recommends lindane as an alternative treatment option to permethrin or ivermectin. 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.[27][30] Its use may be banned or restricted in some areas. For example, lindane is no longer recommended in Europe.[32]

Lindane is only suitable for patients who weigh more than 50 kg and do not have any open sores on the skin. It should be used with extreme caution as it has been associated with neurotoxicity resulting in seizures and death. Percutaneous absorption of lindane is 20 times greater than percutaneous absorption of permethrin.[40] It should be used with caution in older people.

It is important that sexual and close personal or household contacts are also treated at the same time as the patient. Recently worn clothing and bed sheets should be washed at 60°C or higher (≥140°F) and dried the day after the first treatment to decrease the chance of re-infestation.[6]

Antihistamines are helpful in providing symptomatic relief.

Primary options

lindane topical: children >10 years of age and adults: (1%) apply from neck down and wash off 8-12 hours later

3rd line – malathion or benzyl benzoate or spinosad

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ACUTE
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non-pregnant/non-lactating adults or children over 5 years
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non-crusted scabies
3rd line – 

malathion or benzyl benzoate or spinosad

These treatments may be chosen if the patient has an allergy or contraindication to ivermectin and permethrin, lindane is not available or is not appropriate to use, or if the higher cost of first-line agents is a concern.[27]

Topical spinosad has been approved in the US for scabies.[31]

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

Benzyl benzoate may be used as an alternative to permethrin if available.

It is important that sexual and close personal or household contacts are also treated at the same time as the patient. Recently worn clothing and bed sheets should be washed at 60°C or higher (≥140°F) and dried the day after the first treatment to decrease the chance of re-infestation.[6]

Antihistamines are helpful in providing symptomatic relief.

Primary options

malathion topical: (0.5%) apply to the whole body, wash off after 8-12 hours; reapply in 10-14 days

Secondary options

benzyl benzoate: consult product literature for guidance on dosage

OR

spinosad topical: (0.9%) apply from neck down to the soles of feet, wash off after at least 6 hours

1st line – combination therapy with permethrin or benzyl benzoate plus ivermectin

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ACUTE
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non-pregnant/non-lactating adults or children over 5 years
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crusted (Norwegian) scabies
1st line – 

combination therapy with permethrin or benzyl benzoate plus ivermectin

Patients with crusted scabies usually have hyperkeratosis of the palms and soles. They have a very high mite burden and are extremely infectious. Combination therapy and a prolonged course of treatment are often necessary. This condition is usually seen in immunosuppressed patients.[6]

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 Centers for Disease Control and Prevention recommend 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.

It is important that sexual and close personal or household contacts are also treated at the same time as the patient. Recently worn clothing and bed sheets should be washed at 60°C or higher (≥140°F) and dried the day after the first treatment to decrease the chance of re-infestation.[6]

Antihistamines are helpful in providing symptomatic relief.

Primary options

permethrin topical: (5%) apply from neck down to the soles of feet, wash off after 8-14 hours; repeat daily for 7 days and then twice weekly until cure

or

benzyl benzoate: (25%) apply from neck down to the soles of feet, wash off after 8-14 hours; repeat daily for 7 days and then twice weekly until cure

-- AND --

ivermectin: 200 micrograms/kg orally once daily on days 1, 2, 8, 9, and 15; additional doses may be required for severe cases on days 22 and 29

Plus – keratolytic

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ACUTE
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non-pregnant/non-lactating adults or children over 5 years
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crusted (Norwegian) scabies
Plus – 

keratolytic

Treatment recommended for ALL patients in selected patient group

Used to enhance drug penetration in crusted scabies, where skin is typically hyperkeratotic.[41]

Urea cream should be applied twice-daily (except for the night that the permethrin is applied) to decrease hyperkeratosis.

Primary options

urea topical: (20-40%) apply to the hyperkeratotic area(s) once or twice daily until resolved

infants and children 2 months to 5 years and pregnant or lactating females

1st line – permethrin

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ACUTE
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infants and children 2 months to 5 years and pregnant or lactating females
1st line – 

permethrin

Permethrin is recommended for use in this population. Permethrin cream has been studied in infants as young as 2 months old and found to be safe. Infants younger than 2 months are rarely diagnosed with scabies and safety data in this group are lacking, although there is no evidence of adverse effects in this population.[40]

It is important that sexual and close personal or household contacts are also treated at the same time as the patient. Recently worn clothing and bed sheets should be washed at 60°C or higher (≥140°F) and dried the day after the first treatment to decrease the chance of re-infestation.[6]

Antihistamines are helpful in providing symptomatic relief.

Primary options

permethrin topical: (5%) apply from neck down to the soles of feet (adults) or apply to scalp, neck and hairline down to soles of feet (children <12 years of age), wash off after 8-14 hours; may need to repeat treatment after 14 days if evidence of live mites

2nd line – sulfur compounds 10% to 25%

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ACUTE
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infants and children 2 months to 5 years and pregnant or lactating females
2nd line – 

sulfur compounds 10% to 25%

Sulfur can be used in patients who cannot use permethrin due to allergy or cost concerns.[27]

It is important that sexual and close personal or household contacts are also treated at the same time as the patient. Recently worn clothing and bed sheets should be washed at 60°C or higher ( ≥140°F) and dried the day after the first treatment to decrease the chance of re-infestation.[6]

Antihistamines are helpful in providing symptomatic relief.

In adults, the medication should be applied from neck down to toes. In infants, the medication should be applied to the head and neck, down to the toes.

infants under 2 months

1st line – sulfur 6% in petroleum

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ACUTE
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infants under 2 months
1st line – 

sulfur 6% in petroleum

Because safety data for the use of permethrin in infants under 2 months are lacking, sulfur compounds may be used in this group. Sulfur can be used in patients who cannot use permethrin due to allergy or cost concerns.[27]

It is important that close personal or household contacts are also treated at the same time as the patient. Recently worn clothing and bed sheets should be washed at 60°C or higher (≥140°F) and dried the day after the first treatment to decrease the chance of re-infestation.[6]

In infants, the medication should be applied to the entire body including the head and neck on 3 consecutive nights. The patient should be bathed 24 hours after each application.

Antihistamines are helpful in providing symptomatic relief.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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