Scabies: Management - UpToDate https://www.uptodate.com/contents/scabies-management?search=escabio...

Authors: Beth G Goldstein, MD, Adam O Goldstein, MD, MPH

Section Editors: Robert P Dellavalle, MD, PhD, MSPH, Moise L Levy, MD, Ted Rosen, MD
Deputy Editor: Abena O Ofori, MD

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Dec 2017. | This topic last updated: Sep 29, 2017.

INTRODUCTION — Scabies is a cutaneous infestation caused by the mite Sarcoptes scabei. Classic scabies is typically
characterized by an intensely pruritic eruption with small, often excoriated, erythematous papules in sites such as the
fingers, wrists, axillae, areolae, waist, genitalia, and buttocks. Crusted scabies, a less common clinical variant, typically
presents with scaly, crusted, fissured plaques and primarily occurs in immunocompromised individuals. (See "Scabies:
Epidemiology, clinical features, and diagnosis".)

The successful management of scabies involves the eradication of mites from the affected person, management of
associated symptoms and complications, assessment for additional individuals who may require treatment, and
implementation of measures to minimize transmission and recurrence of infestation. Factors such as the clinical variant,
patient characteristics, and the setting of infestation influence the selection of interventions.

The management of scabies will be reviewed here. 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, crusted, or endemic scabies) and patient population (see 'Special populations' below). Treatment of
both the patient and close personal contacts is suggested to prevent recurrent infestation. (See 'Contacts and environment'
below.)

Classic scabies — 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, United Kingdom, and Australia [3]. Benzyl
benzoate, topical sulfur, crotamiton, lindane, and topical ivermectin are examples of other treatments. (See 'Other agents'
below.)

First-line therapies — Topical permethrin is highly effective for scabies, with cure rates in randomized trials
approximating or exceeding 90 percent [4,5]. Oral ivermectin is an alternative first-line treatment that may be less effective
than permethrin but has the advantage of ease of administration. Special considerations are warranted for young children
and pregnant women. (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].

● 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. Thirty grams is usually sufficient 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 [6,7].
However, the relative efficacy of one versus two applications of permethrin has not been studied.

● Efficacy – High-quality trials comparing scabies treatments are limited [4,5]. In a systematic review and meta-analysis
of randomized trials, topical permethrin appeared more effective than oral ivermectin, topical crotamiton, and topical
lindane [4].

● Adverse effects – Permethrin 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

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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. Oral ivermectin is not a recommended first-line treatment for pregnant or
lactating women and children who weigh less than 15 kg. (See 'Special populations' below.)

● Administration – Ivermectin therapy for classic scabies consists of a 200 mcg/kg single dose followed by a repeat
dose after one to two weeks [8-10].

● 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) [11]. In addition,
randomized trials have suggested that a single dose of ivermectin 200 mcg/kg is as or more effective than a single
application of 1% lindane but less effective than a single application of permethrin [4]. In one randomized trial, two
doses of ivermectin achieved equivalent cure rates to a single application of permethrin [12].

● Adverse effects – Oral ivermectin is generally well tolerated in patients treated for scabies; most reports of severe
adverse effects have occurred in patients with helminthic infections [13,14]. The validity of an isolated report of
increased deaths among residents of a nursing home treated with oral ivermectin for scabies has been questioned
[15-17].

Other agents — Additional topical treatment options for scabies include benzyl benzoate, topical sulfur, lindane, and
crotamiton [1,3,8,18]. These agents have not been shown to be more effective than topical permethrin [4,5]. Topical
ivermectin is a newer, albeit high-cost, agent that appears to have efficacy for scabies [19-21]. In an open-label, randomized
trial that compared permethrin, topical ivermectin, and oral ivermectin, cure rates for permethrin and topical ivermectin were
similar [19].

Benzyl benzoate (10 or 25%) is commonly used in resource-limited countries because of the drug's low cost. Treatment
regimens vary; the drug may be applied once daily at night on two consecutive days, with a repeat treatment cycle after
seven days [1]. Benzyl benzoate is not available in the United States.

Topical sulfur (6 to 33%) is primarily used for the treatment of neonates and pregnant women. Sulfur ointment is applied
overnight for three consecutive days. (See 'Special populations' below.)

Use of lindane has fallen out of favor due to risk for systemic toxicity (eg, seizures, death) [1,8]. Lindane should be used
only as an alternative therapy in patients who cannot tolerate other therapies or when other therapies have failed [8]. 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 [8]. European and Japanese guidelines recommend against use of this therapy [1,2]. (See
"Pediculosis capitis", section on 'Lindane toxicity'.)

The treatment regimen for crotamiton is not standardized. The drug can be applied to the entire body from the chin down,
reapplied 24 hours later, and washed off 48 hours after the last application [22]. Regimens consisting of application for up to
five successive days or longer have also been utilized [2].

Crusted scabies — Combination treatment with permethrin and oral ivermectin is considered the preferred first-line
treatment for crusted scabies [6,10]. Treatment with permethrin alone requires repeated applications, and the failure rate is
significant. In case reports and case series, oral ivermectin combined with topical therapy has been effective [23-26].

We agree with the United States Centers for Disease Control and Prevention's combination regimen for the treatment of
crusted scabies [8]:

● Topical 5% permethrin or topical 5% benzoyl benzoate applied daily for seven days, then twice weekly until cure

AND

● Oral ivermectin (200 mcg/kg/dose) given on days 1, 2, 8, 9, and 15

Patients with severe infestations may require longer courses of oral ivermectin, with two additional doses (given on days 22
and 29) [6,27].

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

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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 [9,28,29].
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) [9]. 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 (95% CI 83-100 percent) in the
ivermectin group, 62 percent in the permethrin group (95% CI 49-75 percent), and 49 percent (95% CI 37-60 percent) in the
standard-care group. 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).

Special populations

Children — Given its high efficacy and safety, permethrin is our preferred therapy. However, topical sulfur 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. Lindane should not be given to children under the age of 10 years because of risk for systemic
toxicity [8].

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 [30], additional data are needed before use of this drug in infants with scabies can be
recommended.

Pregnant women — Permethrin is considered safe for use in pregnant and lactating women and is a preferred treatment
[8]. Systemic absorption is low, and the drug is metabolized quickly.

Second-line treatments for pregnant women include topical sulfur and benzyl benzoate [1,31]. Although risk associated with
oral ivermectin may be low, data on use in this population are limited [8].

Assessment for cure and treatment failure — Therapy is likely successful if active lesions resolve and nocturnal pruritus
ceases by one week after treatment [1]. Of note, some pruritus often persists for two to four weeks after successful
treatment.

Common causes for pruritus beyond four weeks include treatment failure and treatment-related skin irritation or contact
dermatitis [18]. Treatment failure may result from poor adherence to the treatment regimen, resistance, or reinfestation. If
resistance appears to be the most likely cause of treatment failure, treatment with an alternative antiscabietic agent should
be attempted [18]. Other causes of persistent pruritus include delusional infestation (also called delusional parasitosis) and
unrelated skin disease.

When persistent active scabies is suspected, a physical examination and scabies preparation can aid in detecting active
infestation. (See "Scabies: Epidemiology, clinical features, and diagnosis", section on 'Diagnosis'.)

SYMPTOMS AND COMPLICATIONS — The management of scabies should include treatment of associated conditions
such as pruritus, secondary infection, and cutaneous nodules.

Pruritus — Antihistamines may improve pruritus, which may persist for up to four weeks after successful treatment [18]. We
typically prescribe a nonsedating antihistamine during the day and a sedating antihistamine at night. (See "Pruritus:
Overview of management", section on 'Antihistamines'.)

After eradication of mites, medium- or high-potency topical corticosteroids (table 1) can also be prescribed to control itching
[32]. 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

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possibility of re-exposure or an alternative diagnosis should be considered. (See 'Assessment for cure and treatment failure'
above.)

Secondary infection — Pyoderma should be treated with appropriate systemic antibiotics. Streptococcal infections
associated with scabies have resulted in glomerulonephritis [33]. (See "Scabies: Epidemiology, clinical features, and
diagnosis", section on 'Complications'.)

Nodules — Nodules from scabies may persist after eradication of mites. Dermoscopy may be helpful for identifying patients
with residual active disease [34]. (See "Scabies: Epidemiology, clinical features, and diagnosis", section on 'Classic
scabies'.)

Nodules can be treated with once- to twice-daily application of a potent topical steroid for two to three weeks or intralesional
injection of a corticosteroid such as triamcinolone acetonide (5 to 10 mg/mL) (table 1) [35]. 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 "General principles of dermatologic therapy and topical
corticosteroid use", section on 'Side effects' and "Intralesional injection", section on 'Side effects, complications, and
pitfalls'.)

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 [36,37]. Resolution of nodules following cryotherapy also has been reported [38]. Additional studies
are needed to confirm the efficacy of these treatments.

CONTACTS AND ENVIRONMENT — 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 [39]. However, high-quality randomized trials to confirm the efficacy of this practice and to determine the
best treatment regimen are lacking [40]. Close personal contacts are typically treated with the same regimens used for
classic scabies. (See 'Classic scabies' above.)

In addition, 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 infested individual 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 [7]. 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 — We treat the patient and cohabitants or other individuals who have had prolonged skin-to-skin
contact in the preceding six weeks simultaneously because symptoms of scabies may be delayed for up to six weeks in
newly infested individuals. In addition, items used within the preceding several days (clothing, linens, stuffed animals, etc)
can be placed in a plastic bag for at least three days or washed with hot water and then ironed or dried in a hot dryer [8]. 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 potential for spread beyond the institution
[7].

Suggested general management measures for asymptomatic individuals who are or have been in contact with a patient with
classic scabies include [7]:

● Adherence to appropriate infection control measures when handling patients (eg, avoidance of direct skin-to-skin

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contact, handwashing)

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

● 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,
dry cycles

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

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 [7]:

● 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) who came in direct physical contact with the patient or
clothing, bedding, or furniture.

The United States Centers for Disease Control and Prevention provides detailed recommendations for the management of
scabies in institutional settings [41]. Local health departments are another useful resource.

RETURN TO WORK OR SCHOOL — Individuals with classic scabies can return to work, child care, or school the day after
the first treatment [7]. 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

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

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• Eradication of mites from the affected person

• Management of associated symptoms and complications

• Assessment for additional individuals who may require treatment

• Implementation of measures to minimize transmission and reinfestation (see 'Introduction' above)

● Classic scabies, the most common presentation of scabies, can be treated with either topical or oral therapy. We
suggest topical permethrin or oral ivermectin for first-line treatment of adults (Grade 2B). We suggest treating crusted
scabies with a combination of permethrin and ivermectin (Grade 2C). (See 'Classic scabies' above and 'Crusted
scabies' above.)

● Signs of successful treatment include resolution of active skin lesions and nocturnal pruritus one week after treatment.
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, persistent infestation,
or reinfestation. (See 'Assessment for cure and treatment failure' above and 'Pruritus' above.)

● Nodules that persist after eradication of mites can be treated with potent topical corticosteroids or intralesional
corticosteroid injections. (See 'Nodules' above.)

● The onset of symptoms from scabies may be delayed for several weeks after infestation. Thus, individuals who have
been in close personal contact with a patient with classic scabies may have active scabies even in the absence of
symptoms. We suggest treating patients and individuals who have had prolonged skin-to-skin contact with patients with
classic scabies simultaneously (Grade 2C). (See 'Contacts and environment' above.)

● 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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