Clinical Care of Scabies

Treatment options

Products used to kill scabies mites are called scabicides. No "over-the-counter" (non-prescription) products have been tested and approved to treat human scabies.

The following medications for the treatment of scabies are available only by prescription.

Classic scabies: one or more of the following may be used

First line medications:

• Permethrin cream 5%: Permethrin is approved by the U.S. Food and Drug Administration (FDA) for the treatment of scabies in people who are at least 2 months of age. Permethrin is a synthetic pyerthroid similar to naturally occuring pyrethrins (extracts from the chrysanthemum flower). Permethrin 5% cream applied to all areas of the body from the neck down and washed off after 8–14 hours. Permethrin is safe and effective with a single application. However, two (or more) applications, each about a week apart, may be necessary to eliminate all mites.
• Ivermectin oral tablet: Oral ivermectin is not FDA approved for the treatment of scabies. However, topical permethrin and oral ivermectin have similar efficacy for cure of scabies. If used for classic scabies, two doses of oral ivermectin (200µg/kg/dose) should be taken with food, each 7 to 14 days apart. The safety of ivermectin in children weighing less than 15 kg and in pregnant women has not been established. Note that although ivermectin guidelines recommend taking on an empty stomach, scabies experts recommend taking with a meal to increase bioavailability.

Choice between the above treatments might be based on patient preference for topical versus oral therapy, drug interactions with ivermectin (e.g., azithromycin, trimethoprim/sulfamethoxazole, or cetirizine, and cost.

Alternative medications (in no particular order):

The following are alternative medications for the treatment of scabies. Providers may take into consideration availability, efficacy, cost, adverse effects, and patient preferences when selecting an alternative therapy for scabies. Limited data is available directly comparing alternative treatments.

• Crotamiton lotion 10% and Crotamiton cream 10%: Crotamiton is approved by the US Food and Drug Administration (FDA) for the treatment of scabies in adults; it is considered safe when used as directed. Crotamiton is not FDA-approved for use in children. Frequent treatment failure has been reported with crotamiton.
• Sulfur ointment 5%-10%: In the U.S. the ointment must be compounded. Sulfur in an ointment base (petrolatum) is safe for topical use in children, including infants under 2 months of age. The odor may make it unpleasant to use.
• Malathion lotion 0.5%: Malathion is not FDA approved for the treatment of scabies but has been recommended in scabies treatment guidelines from other countries. Published data on the efficacy of malathion for scabies is limited.
• Spinosad topical suspension 0.9%: This topical treatment was FDA approved in 2021 for the treatment of scabies infestations in patients 4 years of age and older. Data on efficacy is limited to two randomized controlled trials.
• Lindane lotion 1%: Although FDA-approved for the treatment of scabies, lindane is not recommended as a first-line therapy. Currently Lindane is not available in the U.S. Overuse, misuse, or accidentally swallowing lindane can be toxic to the brain and other parts of the nervous system; its use should be restricted to patients who have failed treatment with or cannot tolerate other medications that pose less risk. Lindane is contraindicated in premature infants, persons with known uncontrolled seizure disorder, crusted scabies, and persons with skin conditions that may increase systemic absorption of the drug. It should not be used to treat women who are pregnant or breast-feeding, persons who have very irritated skin or sores where the lindane will be applied, infants, children, the elderly, and persons who weigh less than 110 pounds.

Crusted scabies: both oral and topical agents should be used

• Ivermectin oral tablet: For crusted scabies, ivermectin should be administered together with a topical agent. There is no consensus on the optimal frequency of ivermectin administration. Some experts recommend administering oral ivermectin (200µg/kg/dose) in three doses (approximately days 1, 2, and 8), five doses (approximately days 1, 2, 8, 9, and 15), or seven doses (approximately days 1, 2, 8, 9, 15, 22, and 29), depending on infection severity. The safety of ivermectin in children weighing less than 15 kg and in pregnant women has not been established. Note that although ivermectin guidelines recommend taking on an empty stomach, scabies experts recommend taking with a meal to increase bioavailability.
• Permethrin cream 5%: For crusted scabies, topical permethrin should be applied to the entire body and administered together with an oral agent. There is no consensus on the optimal frequency of permethrin 5% application for the treatment of crusted scabies and experts have recommended anywhere from an initial daily application to application every 2-3 days for the first 1-2 weeks.
• Keratolytic cream: A topical keratolytic cream may also be used to help reduce the crusting of the skin and aid in the penetration of the topical permethrin in those areas. The cream may be applied to areas of crusting on days that permethrin is not given, until crusting has resolved.

Permethrin is a synthetic pyerthroid similar to naturally occurring pyrethrins (extracts from the chrysanthemum flower).