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Scabies: Treatment & Medication
Updated: Jul 17, 2009
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Treatment
Emergency Department Care
- Prescribe an appropriate scabicide (eg, permethrin, lindane).
- Provide relief of symptoms.
- Itching may persist for 1-2 weeks, even following successful treatment. Pruritus may be alleviated partially with an oral antihistamine, such as hydroxyzine hydrochloride (Atarax), diphenhydramine hydrochloride (Benadryl), or cyproheptadine hydrochloride (Periactin), or with a short course of topical or oral steroids.
- The rash is often misdiagnosed and treated with only steroids, and long-term use with steroids can causes crusting and diffuse erythema.12
- Treat secondary infections with the appropriate antibiotics.
- Treat household members and close personal contacts.
- Notify infection control personnel and a dermatologist when an epidemic in a nursing home or a hospital is suspected.
- Provide reassurance that scabies is not a reflection of poor personal hygiene.
Consultations
Consultation with a dermatologist or an infectious disease specialist may be required for severe, refractory scabies or for disseminated scabies in patients who are immunocompromised. Caution must be exercised when treating pregnant patients and children.
Medication
The goals of pharmacotherapy are to reduce morbidity and prevent complications.
Scabicides
Treatment options include either topical or oral medication. Topical options include permethrin cream (drug of choice), lindane, benzyl benzoate, crotamiton lotion and cream, sulfur, Tea tree oil, or oil of the leaves of Lippia multiflora Moldenke, a shrub found growing in West Africa Savannah. Oral options include ivermectin (not approved by FDA for treatment of scabies). A second course of treatment is often recommended 7-10 days later because of some developing larvae that may survive the initial treatment.12
Special population recommendations are as follows:3
- Infants - Permethrin 5% cream (>2 months age) (Ivermectin and lindane contraindicated)
- Children - Permethrin 5% cream, benzyl benzoate 12.5%
- Pregnant and breastfeeding women - 6% sulfur (Ivermectin, permethrin, and lindane contraindicated)
- Crusted or Norwegian scabies - Oral ivermectin (may require multiple doses, or in combination with a topical scabicide); hyperkeratosis treated with a keratolytic agent (5-10% salicylic acid in petrolatum)
The Centers for Disease Control and Prevention recommends treatment with either permethrin lindane or ivermectin. Permethrin is the drug of choice in the United States and the United Kingdom, but it is not available in France. In some studies, it has been shown to be more effective than a single dose of oral ivermectin, although it has equivalent efficacy when 2 doses of ivermectin are used at time zero and 2 weeks later. In severe cases, a topical medication may be used with oral medication (ivermectin).
A 2002 Cochrane Review that focused on interventions for treating scabies recommended the following:
- Topical permethrin appeared to be the most effective treatment for scabies.
- Topical permethrin appeared more effective than oral ivermectin, topical lindane, and topical crotamiton.
Permethrin cream 5% (Elimite)
CDC recommends as first-line treatment.
Drug of choice particularly for infants >2 months old and small children.
Highly effective, minimally absorbed and minimally toxic.12
Even after successful treatment, post scabietic nodules and pruritus may persist for months. In vitro resistance and treatment failures have been documented. Most expensive of all topical scabicides.3
Adult
Apply 30 g to entire body from chin to toes; shower off the medication 8-14 h after initial application; repeat in 7 d if necessary
Pediatric
Apply as in adults; can apply to head and neck in children <5 y; not recommended for children <2 mo
None reported
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Avoid contact with the mouth, eye, and nose; may transiently exacerbate redness, swelling, and itching
Lindane 1% (Kwell, gamma benzene hexachloride)
Stimulates nervous system of parasite, causing seizures and death. Considered second-line treatment if other agents fail or are not tolerated. Not very safe in children due to transcutaneous absorption leading to neurotoxicity. The systemic absorption rate of lindane is 10 times greater than permethrin, and its serum levels are more than 40 times higher.11 Overall, permethrin is a safer choice.
Adult
Apply a thin layer on cool dry skin from chin to toes (estimated dermal absorption factor 10-20%), and shower off 6-10 h later; do not leave on skin for more than 12 h; repeat in 1 wk
Pediatric
Not recommended
Oil-based hairdressings may increase toxicity
Documented hypersensitivity; neonates; acutely swollen skin or damaged skin; Norwegian scabies
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution if history of seizures; do not apply to eyes, face, or mucous membranes; caution if history of keratinization/ichthyosis disorders, or any condition that has altered skin integrity due to the increased systemic absorption
Sulfur in petrolatum (2 -10%, with 6% preferred, cream or ointment)
Not FDA approved for treatment of scabies. The oldest antiscabietic. One of a few scabicidal treatments that may be used safely in very small children (<2 mo) and in pregnant women.11,15 Sulfur is messy, malodorous, stains clothes, and requires repeat applications, thus reducing compliance.15 . Sulfur should only be used when a patient cannot tolerate permethrin, lindane, or ivermectin.15 It is inexpensive and can be used for mass therapy in resource-poor economies.15
Adult
Apply to entire body below the head on 3 successive nights and bathe 24 h after each application
Pediatric
Apply as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Crotamiton 10% cream or lotion (Eurax)
For the treatment of scabies. Mechanism of action is unknown. Weak antipruritic agent. Success rates vary 50-70%.3
Adult
Apply thin layer on to skin of entire body from neck to toes; repeat in 24 h; take a cleansing bath 48 h after last application; may need to apply twice daily for 5 consecutive days after bathing and changing clothes3
Pediatric
Apply as in adults
None reported
Documented hypersensitivity; can cause seizures
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not apply to face, urethral meatus, eyes, mucous membranes, or swollen skin; can cause seizures
Benzyl benzoate
Ester of benzoic acid and benzyl alcohol. Neurotoxic to mites. Not available in the United States4 and not FDA approved as a scabicide, but used in Europe. Cheaper alternative to other treatments.3
Adult
Use 25% emulsion; apply below neck 3 times within 24 h without an intervening bath
Pediatric
May reduce adult dose to 12.5% or less due to stinging
None reported
Documented hypersensitivity; pregnancy, breastfeeding women; infants and children <2 y
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
May cause stinging
Ivermectin (Mectizan, Stromectol)
Binds selectively with glutamate-gated chloride ion channels in invertebrate nerve and muscle cells, resulting in paralysis and cell death. Half-life is 16 h; metabolized in liver. Single oral dose has similar efficacy to permethrin and may be most successful in patients with immunodeficiency or crusted scabies,13 and in patients with skin conditions that should not use topical medications. Not FDA approved for the treatment of scabies.
Adult
150-200 mcg/kg/d (0.2 mg/kg) PO once; may repeat in 10-14 d; commercially available as 3 mg tab
Pediatric
<5 years: Not recommended
>5 years: Administer as in adults
May interact with other ligand-gated chloride channels, such as those gated by GABA
Documented hypersensitivity; CNS disorder3
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Treat mothers who intend to breastfeed only when risk of delayed treatment outweighs possible risks to the newborn caused by ivermectin excretion in milk
Repeat courses of therapy may be required in immunocompromised patients
May cause nausea, vomiting, and mild CNS depression; may cause drowsiness
More on Scabies |
| Overview: Scabies |
| Differential Diagnoses & Workup: Scabies |
 Treatment & Medication: Scabies |
| Follow-up: Scabies |
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Further Reading
Keywords
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