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Scabies: Management

Scabies: Management
Literature review current through: Jan 2024.
This topic last updated: Oct 31, 2022.

INTRODUCTION — Scabies is a cutaneous infestation caused by the mite Sarcoptes scabiei (picture 1A-B).

Classic scabies is typically characterized by an intensely pruritic eruption with small, often excoriated, papules in sites such as the fingers, wrists, axillae, areolae, waist, genitalia, and buttocks (figure 1 and picture 2A-E). Crusted scabies, a less common clinical variant, typically presents with scaly, crusted, fissured plaques and primarily occurs in immunocompromised individuals (picture 3A-E). (See "Scabies: Epidemiology, clinical features, and diagnosis".)

The successful management of scabies involves:

Eradication of the infestation

Management of pruritus

Management of complications

Treatment of close personal contacts

Implementation of environmental measures to minimize transmission and recurrence of infestation

The management of scabies will be reviewed here (algorithm 1). The clinical manifestations and diagnosis of scabies are discussed separately.

(See "Scabies: Epidemiology, clinical features, and diagnosis".)

ERADICATION OF INFESTATION — The approach to the eradication of scabies mites is dependent upon the clinical presentation (classic or crusted scabies) and patient population (algorithm 1) (see 'Special populations' below). Treatment of both the patient and close personal contacts is suggested to prevent recurrent infestation. (See 'Contacts and environment' below.)

Treatment options — The availability of antiscabietic agents for classic scabies varies worldwide [1,2]. Topical permethrin and oral ivermectin are the most common first-line treatments in the United States [3].

Topical benzyl benzoate (10 or 25%) is commonly used in resource-limited countries because of low cost. Benzyl benzoate is not available in the United States.

Other therapeutic options include topical sulfur, topical ivermectin, topical spinosad, topical crotamiton, and topical lindane. (See 'Alternative therapies' below.)

Classic scabies — Classic scabies presents as pruritus in association with small, often excoriated papules and burrows (picture 2B-C, 2F-J). Prominent scale, crusts, and fissures are absent. (See "Scabies: Epidemiology, clinical features, and diagnosis", section on 'Classic scabies'.)

Preferred initial therapies — Permethrin and ivermectin are our preferred initial treatments (algorithm 1). Topical permethrin is highly effective, with cure rates in randomized trials approximating or exceeding 90 percent [4,5]. Oral ivermectin is an alternative first-line treatment that has the advantages of ease of administration and lower cost.

Special considerations are warranted for young children and pregnant individuals. (See 'Special populations' below.)

Permethrin — Permethrin is a topical synthetic pyrethroid agent that impairs function of voltage-gated sodium channels in insects, leading to disruption of neurotransmission [6].

Permethrin is considered safe for use in infants as young as two months of age, children, adults, and pregnant or lactating individuals [7] (see 'Special populations' below):

Administration – Patients should massage permethrin cream thoroughly into the skin from the neck to the soles of the feet, including areas under the fingernails and toenails [8]. A 30 g tube contains a sufficient quantity for a single application for an average adult.

In young children, scalp involvement is common. Therefore, permethrin should also be applied to the scalp and face (sparing the eyes and mouth) in this population.

Permethrin should be removed by washing (shower or bath) after 8 to 14 hours. Treatment is often performed overnight.

A second application one to two weeks later may be necessary to eliminate mites and is typically performed [6,9]. However, the relative efficacy of one versus two applications of permethrin is unclear.

Limited data suggest that other regimens may also be effective [10].

Efficacy – High-quality trials comparing scabies treatments are limited [4,5]. In a systematic review and meta-analysis of randomized trials, topical permethrin and oral ivermectin appeared similarly effective [11]. A network meta-analysis of 52 randomized trials that compared a topical or oral intervention for scabies with placebo or another therapy supports a higher cure rate for permethrin compared with other topical therapies, including sulfur, malathion, lindane, crotamiton, and benzoyl benzoate [12].

Adverse effectsPermethrin is generally well tolerated. Skin irritation is a potential side effect.

Oral ivermectin — Oral ivermectin is an antiparasitic alternative to permethrin that has the advantage of ease of administration. This mode of treatment may be particularly useful for large scabies outbreaks in nursing homes and other facilities where topical therapy can be impractical. (See 'Institutional setting' below.)

Oral ivermectin is not a recommended first-line treatment for pregnant individuals and children who weigh less than 15 kg because of safety concerns (algorithm 1) [7] (see 'Special populations' below):

AdministrationIvermectin therapy for classic scabies consists of a 200 mcg/kg single oral dose followed by a repeat dose after one to two weeks [7,13,14]. The second treatment is necessary because ivermectin has limited ovicidal activity.

Efficacy – Various studies support the efficacy of oral ivermectin. One randomized trial (n = 55) found a higher cure rate at seven days with single-dose ivermectin (200 mcg/kg) than placebo (79 versus 16 percent) [15]. In addition, based upon a systematic review and meta-analysis of randomized trials, oral ivermectin appears to be as effective as topical permethrin [11]. A network meta-analysis supports similar efficacy of oral ivermectin and topical permethrin as well as greater efficacy of oral ivermectin compared with topical malathion, lindane, crotamiton, and benzyl benzoate [12]. (See 'Permethrin' above.)

Adverse effects – Oral ivermectin is generally well tolerated in patients treated for scabies. Most, but not all, reports of severe adverse effects have occurred in patients with helminthic infections [16-18]. The validity of an isolated report of increased deaths among residents of a nursing home treated with oral ivermectin for scabies has been questioned [19-21]. (See "Anthelminthic therapies", section on 'Ivermectin'.)

Alternative therapies — Alternative topical therapies for scabies include benzoyl benzoate, sulfur, ivermectin, spinosad, crotamiton, malathion, and lindane. These agents have not been shown to be more effective than permethrin [12].

Benzyl benzoate — Benzyl benzoate is commonly used in resource-limited countries because of the drug's low cost. Benzyl benzoate is not available in the United States:

Administration – Treatment regimens vary. Benzyl benzoate may be applied once daily at night on two consecutive days, with a repeat treatment cycle after seven days [1]. Typical treatment concentrations for benzyl benzoate are 25% for adults and 10 or 12.5% for children over the age of one year [14,22].

Efficacy – Efficacy data on benzyl benzoate are limited but suggest benefit [23,24]. An open-label trial that randomly assigned children and adults with scabies to either one of two application regimens for 12.5% benzyl benzoate or oral ivermectin, followed by repetition of the same treatment on day 7 for patients with worsening symptoms, supports efficacy [23]. Cure at day 14 (disappearance of skin lesions and itching) occurred in 70 percent of patients in whom each treatment with benzyl benzoate consisted of two 24-hour applications separated by 24 hours, in 54 percent of patients in whom each treatment with benzyl benzoate consisted of a single 24-hour application, and in 25 percent of patients treated with 150 to 200 mcg/kg of oral ivermectin. Some limitations of the trial included disproportionate loss to follow-up and early trial cessation due to perceived superior benefit of benzoyl benzoate. In addition, cure rates with ivermectin were lower than reported in other studies.

Adverse effects – Local skin irritation and pruritus are potential adverse effects [23,24].

Topical sulfur — Topical precipitated sulfur is relatively inexpensive and primarily used for the treatment of neonates and pregnant individuals. The mechanism of action is thought to involve keratolytic effects and scabicidal properties [25] (see 'Special populations' below):

Administration – In the United States, sulfur must be compounded. Concentrations of 2 to 10% are typical. A typical regimen for adults consists of 8 or 10% precipitated sulfur in petrolatum. Lower concentrations (eg, ≤6%) are typically used for infants [26].

Sulfur ointment is applied overnight, rinsed off, and reapplied similarly for three consecutive days. Treatment may be repeated in 7 to 14 days in an attempt to improve efficacy [25].

Efficacy – Data on the efficacy of topical sulfur are limited [26-28]. An open-label trial in which 100 children were treated with either 10% sulfur ointment applied for seven consecutive nights or 0.3% gamma benzene hexachloride gel as a single overnight application repeated after one week found similar efficacy for achieving clinical cure (absence of new lesions and healing of all old lesions in 92 and 91 percent of patients, respectively) and parasitic cure (absence of parasites on skin scraping in 83 and 84 percent of patients, respectively) after four weeks [27]. In an uncontrolled study in which 124 children with scabies residing in orphanages received four applications of either 5 or 10% precipitated sulfur in petrolatum over three consecutive days, 71 percent of the 102 children available for follow-up after four weeks achieved cure (no new lesions, healing of all original active lesions, and negative skin scraping) [26].

Adverse effects – Adverse effects include a burning sensation, skin erythema, and malodor [26,27].

Topical ivermectin — Ivermectin 1% lotion has been used for the treatment of scabies. Ivermectin binds to glutamate-gated chloride channels in invertebrate nerve and muscle cells, leading to increased permeability of cell membranes to chloride ions, hyperpolarization of nerve or muscle cells, and paralysis and death [29]. Although other forms of topical ivermectin are available for the treatment of rosacea and head lice, ivermectin 1% lotion is not available in the United States:

AdministrationIvermectin 1% lotion is applied to all body sites from the neck down. The drug is washed off after 8 to 14 hours. Application should be repeated after one week for patients with persistent symptoms [7].

Efficacy – Topical ivermectin 1% lotion appears to have efficacy for scabies [30-32]. An open-label, randomized trial (n = 315) that compared permethrin 5% cream, ivermectin 1% lotion, and oral ivermectin (200 mcg/kg) supports efficacy of topical ivermectin [30]. Patients were assessed weekly for four weeks after initial treatment, with repetition of the same treatment up to week 3 if clinical cure (resolution of visible, scabietic lesions but not necessarily pruritus) was not achieved. At the end of the second week after initial treatment, clinical cure rates for permethrin, topical ivermectin, and oral ivermectin were 99, 100, and 63 percent, respectively, and all groups achieved a clinical cure rate of at least 99 percent by the end of the third week. No adverse effects occurred in patients treated with topical ivermectin.

Adverse effects – Topical ivermectin appears to be well tolerated. Local skin irritation or burning sensations are potential adverse effects.

Spinosad — Spinosad is a topical agent that causes fatal neuronal excitation in insects. In 2021, the US Food and Drug Administration (FDA) approved spinosad 0.9% topical suspension for the treatment of scabies in adults and children four years of age and older:

AdministrationSpinosad 0.9% suspension should be shaken well prior to application [33]. Proper application involves rubbing the product into the skin to completely cover the skin from the neck to the soles of the feet. Patients with a balding scalp should also apply spinosad to the scalp, hairline, forehead, and temples.

Spinosad should be allowed to dry on the skin for 10 minutes prior to putting on clothing. The product should be left on the skin for at least six hours before showering or bathing.

EfficacySpinosad has demonstrated efficacy for scabies in two phase 3, placebo-controlled, randomized trials [34]. In the trials, 206 households with a total of 533 adults and children were randomly assigned to a single six- to eight-hour application of spinosad 0.9% topical suspension or vehicle [34]. Efficacy analyses performed for the youngest members of each household at day 28 in the first trial showed complete cure (a combination of clinical and microscopic cure) in 82 of 105 patients (78 percent) in the spinosad group and 40 of 101 patients (40 percent) in the vehicle group.

The relative efficacy of spinosad compared with permethrin and oral ivermectin is unclear.

Adverse effectsSpinosad is generally well tolerated. In the randomized trials, adverse events considered related to spinosad use included burning sensations and dry skin, each occurring in less than 1 percent of patients.

Other therapies — Additional topical treatment options for scabies include crotamiton, malathion, and lindane [1,7]. These therapies appear to be less effective than permethrin and oral ivermectin [12]:

Crotamiton – The treatment regimen for crotamiton is not standardized. The drug can be applied to the entire body from the chin down (including under the fingernails), reapplied 24 hours later, and washed off 48 hours after the last application [35]. Regimens consisting of application for up to five successive days or longer have also been utilized [2]. In randomized trials, crotamiton has appeared less effective than permethrin [5,36].

Malathion – A single application of malathion 0.5% lotion is typically performed. Malathion is applied to the skin at night and washed off after 8 to 12 hours [1]. Disadvantages of malathion include flammability of the product and relatively high cost.

Data on malathion are limited. In a trial that randomly assigned 340 patients with scabies to two applications of either ivermectin 1% lotion or malathion 0.5% lotion separated by one week followed by retreatment (if needed), cure rates for ivermectin and malathion were 68 and 44 percent, respectively, at week 2 and 85 and 68 percent, respectively, at four weeks [31]. Case series also suggest efficacy [5].

Lindane – Use of lindane has fallen out of favor due to risk for systemic toxicity (eg, seizures, death) [1,7]. European and Japanese guidelines recommend against use of this therapy [1,2]. Lindane lotion or cream is not available in the United States. (See "Pediculosis capitis", section on 'Lindane toxicity'.)

Lindane should be used only as an alternative therapy in patients who cannot tolerate other therapies or when other therapies have failed [7]. A thin layer of lindane 1% (1 oz of lotion or 30 g of cream) is applied to all areas of the body from the neck down and thoroughly washed off after eight hours [7].

Crusted scabies — Crusted scabies presents with plaques or papules with overlying, prominent, adherent scale and crusts (picture 3A-E). Erythema may also be present:

Preferred initial therapy – Combination treatment with permethrin and oral ivermectin is the preferred first-line treatment for crusted scabies. Treatment with permethrin alone requires repeated applications, and the failure rate is significant. Oral ivermectin combined with topical therapy has appeared effective in case reports and case series [37-40].

We agree with the United States Centers for Disease Control and Prevention's combination regimen for the treatment of crusted scabies [14]:

Permethrin 5% cream applied every two to three days for one to two weeks

and

Oral ivermectin (200 mcg/kg/dose) given for three, five, or seven nonconsecutive days depending on severity of infestation (approximately days 1, 2, and 8; approximately days 1, 2, 8, 9, and 15; or approximately days 1, 2, 8, 9, 15, 22, and 29)

The application procedure for permethrin is similar to the procedure for classic scabies. (See 'Permethrin' above.)

Other interventions – Topical benzyl benzoate (25% for adults, 10 or 12.5% for children) is an alternative to permethrin [1,25]. (See 'Benzyl benzoate' above.)

Concomitant use of topical keratolytic creams (eg, ammonium lactate 12% lotion for the body or urea 10% cream for the hands and feet in adults) may help to reduce crusting [14].

The use of lindane is contraindicated in patients with crusted scabies due to risk for toxicity [7]. (See "Pediculosis capitis", section on 'Lindane toxicity'.)

Special populations

Children — Given its high efficacy and safety, permethrin is our preferred therapy for children (algorithm 1). However, topical sulfur, which is considered safe in infants, is typically used for the treatment of infants under the age of two months because of lack of regulatory approval for permethrin use in infants in this age group. (See 'Permethrin' above and 'Topical sulfur' above.)

A survey study documents active use of permethrin for young infants in the clinical setting despite the uncertainty about safety [41]. Among 57 dermatologists (including 48 pediatric dermatologists) who responded to a survey about scabies treatment for infants under the age of two months, 47 (83 percent) reported experience with use of permethrin, and 38 (67 percent) considered permethrin the preferred therapy for infants in this age group.

Safety data for spinosad are limited to children who are at least four years old. Lindane should not be given to children under the age of 10 years because of risk for systemic toxicity [7]. (See "Pediculosis capitis", section on 'Lindane toxicity' and 'Spinosad' above.)

Treatment with oral ivermectin is not recommended for children who weigh less than 15 kg [1]. The safety of oral ivermectin has not been determined in this population. Although a retrospective study of the efficacy and tolerability of oral ivermectin for scabies in infants under 15 kg found that 12 of 14 achieved resolution of clinical features of scabies within one month and documented few adverse events [42], additional data are needed before use of this drug in infants with scabies can be recommended. (See 'Oral ivermectin' above.)

Guidance on the use of benzyl benzoate in infants varies. Whereas some sources support safety of a 6.25% concentration for use on infants [25], avoidance in infants has also been recommended [22].

Pregnant individuals — Permethrin is considered safe for use in pregnant and lactating patients and is a preferred treatment (algorithm 1) [7]. Systemic absorption is low, and the drug is metabolized quickly.

Second-line treatments for pregnant individuals include topical sulfur and benzyl benzoate [1,43]. Although risk associated with oral ivermectin may be low, data on use in this population are limited [7]. Lindane is contraindicated in pregnancy [25].

TREATMENT OF PRURITUS — Antihistamines may improve pruritus, which may persist for up to four weeks after successful treatment [44]. We typically prescribe a nonsedating antihistamine (eg, loratadine, cetirizine, fexofenadine) during the day and a sedating antihistamine (eg, hydroxyzine, diphenhydramine) at night. (See "Pruritus: Therapies for generalized pruritus", section on 'Role of antihistamines' and "Pharmacotherapy of allergic rhinitis", section on 'Oral antihistamines'.)

After the eradication of mites, medium- or high-potency topical corticosteroids (table 1) can be prescribed to control itching [45]. In severe cases, patients can be treated with an oral glucocorticoid taper over one to two weeks, starting with 40 to 60 mg of prednisone daily for adults.

Symptoms should progressively improve with adequate therapy. If symptoms worsen despite adequate treatment, the possibility of re-exposure or an alternative diagnosis should be considered. (See 'Recognition of cure and treatment failure' below.)

RECOGNITION OF CURE AND TREATMENT FAILURE — The state of pruritus and skin lesions is the primary measure for recognizing likely cure or treatment failure. Reassessment is warranted when these findings persist for more than four to six weeks after the completion of treatment (algorithm 1):

Findings consistent with cure – Therapy is likely successful if active lesions resolve and nocturnal pruritus ceases by one week after treatment [1]. Some pruritus often persists for two to four weeks after successful treatment.

Patients with persistent pruritus or active skin lesions – Pruritus extending beyond four weeks may indicate persistent infestation or reinfestation. Postscabetic nodules, treatment-related irritant or allergic contact dermatitis, and misdiagnosis are other potential causes of persistent pruritus. (See "Scabies: Epidemiology, clinical features, and diagnosis", section on 'Differential diagnosis' and 'Nodules' below and "Allergic contact dermatitis in children" and "Clinical features and diagnosis of allergic contact dermatitis" and "Irritant contact dermatitis in adults".)

Mite resistance to the prescribed treatment is considered a rare cause of treatment failure [25]:

Patient assessment – The assessment of patients with persistent pruritus or active skin lesions should include a careful history (to ensure correct administration of the prescribed therapy and review symptoms and risk factors for reinfestation) and a physical examination (to assess for findings supportive of persistent scabies or alternative diagnoses). Visual inspection for burrows and performance of a scabies preparation to identify scabies mites, eggs, or feces is helpful for confirming persistent infestation. (See "Scabies: Epidemiology, clinical features, and diagnosis", section on 'Examination for mites'.)

Management – Patients in whom clinical or microscopic findings support persistent infestation require retreatment. The best approach to retreatment has not been established. When permethrin or oral ivermectin therapy fails and the reason for failure is unclear, we switch to the other therapy (eg, from permethrin to oral ivermectin) or treat with both agents simultaneously. If this intervention fails and persistent scabies is confirmed, we proceed to an alternative antiscabietic therapy (eg, topical sulfur). (See 'Alternative therapies' above.)

COMPLICATIONS — Potential complications of scabies include secondary infection and cutaneous nodules.

Secondary infection — Secondary bacterial infections should be treated with appropriate systemic antibiotics. Streptococcal infections associated with scabies have resulted in glomerulonephritis [46]. (See "Scabies: Epidemiology, clinical features, and diagnosis", section on 'Complications'.)

Nodules — Nodules from scabies may persist after the eradication of mites. Dermoscopy may be helpful for identifying patients with residual, active disease [47] (see "Scabies: Epidemiology, clinical features, and diagnosis", section on 'Classic scabies'):

Topical or intralesional corticosteroids – Nodules can be treated with once- or twice-daily application of a potent topical corticosteroid for two to three weeks or intralesional injection of a corticosteroid such as triamcinolone acetonide (5 to 10 mg/mL) (table 1) [48]. Intralesional corticosteroid injections may also be useful for nodules that fail to respond adequately to topical corticosteroid therapy. The injection volume should just make the lesion blanch; typically, 0.1 mL per nodule is adequate. Cutaneous atrophy is a potential side effect of topical intralesional corticosteroid therapy. (See "Topical corticosteroids: Use and adverse effects", section on 'Adverse effects' and "Intralesional corticosteroid injection", section on 'Adverse effects and pitfalls'.)

Other therapies – Limited data suggest that topical calcineurin inhibitors may be beneficial. Improvement of nodules after treatment with topical tacrolimus 0.03% ointment has been documented in a small case series, and topical pimecrolimus appeared effective in a case report [49,50]. Resolution of nodules following cryotherapy has also been reported [51]. Additional studies are needed to confirm the efficacy of these treatments.

CONTACTS AND ENVIRONMENT

Overview — The onset of symptoms of scabies is often delayed for several weeks; therefore, close personal contacts may have active scabies even in the absence of symptoms. As a result, simultaneous treatment of cohabitants and individuals with prolonged physical contact is generally practiced to avoid an endless cycle of transmission and reinfestation [52]. However, high-quality, randomized trials to confirm the efficacy of this practice and to determine the best treatment regimen are lacking [53]. Close personal contacts are typically treated with the same regimens used for classic scabies. (See 'Classic scabies' above.)

Environmental measures are suggested with the goal of minimizing risk for transmission or reinfestation. Scabies mites generally do not survive for more than two to three days away from human skin. Therefore, such measures are focused on items and areas in contact with the patient over the preceding several days.

General environmental measures include laundering or sequestering items that came in close, prolonged contact with the individual who is infested and adequate cleaning of rooms inhabited by patients with crusted scabies. A more aggressive approach is indicated in institutional settings to minimize risk for transmission to other patients and staff [9].

Fomite transmission is most likely to occur in the setting of crusted scabies, given the associated high mite burden (up to millions of mites). (See "Scabies: Epidemiology, clinical features, and diagnosis", section on 'Transmission'.)

Application of pesticides is not indicated in either the home or institutional setting.

Community setting — Scabies in the community setting warrants treatment of close contacts and environmental measures:

Contacts – The patient and cohabitants or other individuals who have had prolonged skin-to-skin contact in the preceding six weeks should be treated simultaneously. Because symptoms of scabies may be delayed for up to six weeks in individuals who are newly infested, the absence of symptoms does not confirm the absence of infestation.

Ideally, the patient should inform and encourage such contacts to seek medical attention for treatment [54]. Although commonly practiced, treatment of cohabitants without an examination performed by the prescribing clinician is controversial. Local policies regarding the legality of this practice (ie, expedited partner therapy) vary [55].

Environment – In addition, items used within the preceding several days (clothing, linens, stuffed animals, etc) can be machine washed and dried using the heat cycle or removed from body contact for at least 72 hours [7]. Dry cleaning is an alternative. Rooms used by patients with crusted scabies should be thoroughly cleaned and vacuumed.

Institutional setting — In the institutional setting, a diagnosis of scabies should trigger heightened awareness to facilitate the identification and treatment of additional individuals with scabies. In the setting of multiple individuals with classic scabies or at least one patient with crusted scabies, the institution should implement an institution-wide education program about scabies. Notification of the local health department is indicated if there is the potential for spread beyond the institution [9].

The United States Centers for Disease Control and Prevention provides detailed recommendations for the management of scabies in institutional settings [56]. Local health departments are another useful resource:

Classic scabies – Suggested general management measures for asymptomatic individuals who are or have been in contact with a patient with classic scabies include [9]:

Adherence to appropriate infection control measures when handling patients (eg, avoidance of direct skin-to-skin contact, use of gloves when providing hands-on care, handwashing after providing care)

Treatment of staff, other patients, and household members who had prolonged skin-to-skin contact with the patient

Offering of treatment to household members of staff who are receiving treatment for scabies

Avoidance of skin-to-skin contact with the patient until at least eight hours after treatment

Laundering of clothing and bedding of the affected patient with a washing machine and dryer utilizing hot water and hot dryer cycles

Routine cleaning and vacuuming of the room after the patient is discharged from the room

Crusted scabies – Rapid identification and treatment of crusted scabies is essential to minimize dissemination of the infestation. Institutional infection control personnel should be contacted immediately, and the patient should be isolated from other patients in the institution. Suggested general management measures following a diagnosis of crusted scabies include [9]:

Prompt involvement of institutional infection control personnel.

Isolation of the affected patient from other patients.

Assignment of a dedicated care team for the patient to minimize exposure of staff, if feasible.

Strict contact precautions, including avoidance of direct skin-to-skin contact with the patient and use of protective gowns, gloves, and shoe covers, until the patient has been treated and a scabies preparation is negative.

Frequent cleaning of the patient's room to remove contaminated scales and crusts; thorough cleaning and vacuuming of the room after the patient is discharged from the room.

Laundering of clothing and bedding with a washing machine and dryer utilizing hot water and hot dryer settings; utilization of protective clothing and gloves by laundry personnel.

Treatment of all individuals (eg, staff, visitors, family members/caregivers) who came in direct physical contact with the patient or clothing, bedding, or furniture.

Offering of treatment to household members of staff who are receiving scabies treatment.

Endemic scabies — Mass drug administration, which involves repeat administration of single doses of therapeutic agents to the entire community, has been shown to be an effective control strategy for scabies in hyperendemic areas [57]. Oral ivermectin is our preferred intervention given the drug's efficacy and ease of administration:

The Skin Health Intervention Fiji Trial (SHIFT), involving three island communities with a scabies prevalence >20 percent, compared the efficacy of three approaches: mass administration of a single dose of oral ivermectin 200 mcg/kg of body weight, mass administration of a single dose of topical permethrin, and standard treatment (topical permethrin treatment only for persons with scabies and their contacts) [13]. Participants with scabies received a second dose of the assigned medication after 7 to 14 days. The primary outcome was the change in the prevalence of scabies and impetigo from baseline to 12 months. At 12 months, the prevalence of scabies had declined by 94 percent in the ivermectin group (95% CI 83-100 percent), 62 percent in the permethrin group (95% CI 49-75 percent), and 49 percent in the standard care group (95% CI 37-60 percent). The prevalence of impetigo was reduced by 67, 54, and 32 percent in the three groups, respectively. Adverse effects were mild but more common in the ivermectin group than in the permethrin group (16 versus 7 percent).

RETURN TO WORK OR SCHOOL — Individuals with classic scabies can return to work, child care, or school the day after the first treatment [9]. This is appropriate provided treatment has been administered correctly and the patient agrees to complete the prescribed course of treatment.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Scabies".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Scabies (The Basics)")

Beyond the Basics topics (see "Patient education: Scabies (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Treatment overview – Scabies is a common cutaneous infestation caused by the mite Sarcoptes scabiei. Management involves:

Eradication of the infestation

Management of pruritus

Management of complications

Treatment of close personal contacts

Implementation of environmental measures to minimize transmission and recurrence of infestation (see 'Introduction' above)

Overview of antiscabietic therapies – Scabies may be treated with topical or oral therapies. The major options for topical therapy include permethrin (preferred), benzyl benzoate, precipitated sulfur, spinosad, and ivermectin. Use of lindane has fallen out of favor due to risk for systemic toxicity. Oral ivermectin is available for systemic treatment. (See 'Treatment options' above.)

Treatment of classic scabies – Classic scabies, the most common presentation of scabies, can be treated with either topical or oral therapy (figure 1 and picture 2A-E and algorithm 1).

For patients with classic scabies, we suggest topical permethrin for initial treatment rather than topical benzoyl benzoate, sulfur, crotamiton, malathion, or lindane based upon data that suggest greater efficacy of permethrin (Grade 2B). High efficacy and safety support the preferred use of permethrin therapy.

Oral ivermectin is an alternative initial treatment for nonpregnant adults who prefer oral treatment, cannot tolerate permethrin, or are unable to apply topical therapy. Spinosad and topical ivermectin are additional options for topical therapy that have not been proven superior to permethrin therapy. (See 'Classic scabies' above.)

Treatment of crusted scabies – For patients with crusted scabies (picture 3A-E), we suggest combination therapy with permethrin and ivermectin rather than either therapy alone (Grade 2C). The duration of treatment is dependent upon the severity of infestation. (See 'Crusted scabies' above.)

Recognition of cure and treatment failure – Signs of successful treatment include resolution of active skin lesions and nocturnal pruritus one week after the completion of treatment (algorithm 1). However, some pruritus often persists for up to four weeks after successful treatment. Examples of causes of pruritus beyond this period include treatment failure, treatment-related skin irritation or contact dermatitis, reinfestation, and misdiagnosis. (See 'Recognition of cure and treatment failure' above.)

Close contacts – The onset of symptoms may be delayed for several weeks after infestation. Thus, asymptomatic individuals who have been in close personal contact with a patient with classic scabies may have active scabies. Patients with confirmed scabies and close contacts should be treated simultaneously. (See 'Contacts and environment' above and 'Community setting' above.)

Environmental measures – Scabies mites typically cannot survive for more than two to three days when separated from human skin. Clothing or bedding items used within the preceding three days by the individual who is infested should be machine washed with hot water and machine dried with a heat cycle. Dry cleaning items or removing items from body contact for at least 72 hours is an alternative. Rooms used by individuals with crusted scabies should be cleaned and vacuumed. (See 'Contacts and environment' above and 'Community setting' above.)

Scabies in the institutional setting – Occurrences of scabies in institutional settings require prompt attention to minimize risk for transmission to other individuals. A rapid response is particularly important in the setting of crusted scabies. (See 'Institutional setting' above.)

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Topic 114369 Version 10.0

References

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