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#420 Scratching the Surface: What is the most effective treatment for scabies?


CLINICAL QUESTION
QUESTION CLINIQUE
 For adults and children with classic scabies, how effective are treatment options and what is the duration of treatment?

BOTTOM LINE
RÉSULTAT FINAL
 At 4 weeks, treatment success for scabies occurs in 89-93% of patients treated with topical permethrin 5% cream versus 72-86% treated with oral ivermectin. Permethrin should be applied to entire body (may include face and scalp), including skin folds and under nails. Two doses (day 0 and day 7-14) generally recommended, especially if mites present at 7-14 days. Pruritis can persist for weeks after treatment. Adverse effects similar between groups (4-6%).


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EVIDENCE
DONNÉES PROBANTES
  • Results statistically significant unless indicated.
  • Cluster-randomized controlled trial (RCT), (1075 participants; 289 cases with dermoscopy-confirmed clinical scabies, 786 household contacts). Topical permethrin 5% cream or oral ivermectin 200 mcg/kg (applied to entire body overnight (>8 hours), including scalp and face), on days 0 and 10. Treatment success at 28 days:1
    • Index case: 92% (permethrin) versus 77% (ivermectin), number needed to treat (NNT)=7.
    • Contacts: 94% (permethrin) versus 85% (ivermectin), NNT=11.
    • ≥1 cutaneous adverse effects (itching, burning, eczema): 4-6% (both groups).
  • Two systematic reviews (15 RCTs each, 1896-2172 participants): Oral ivermectin (200 mcg/kg, 1-3 doses) or topical permethrin 5% cream (1-3 treatments):2-3
    • Treatment success (14 RCTs, 1691 participants): 90% (permethrin) versus 86% (ivermectin), NNT=25.3
    • Other systematic review: Similar.2
    • Adverse events: No differences.
  • Limitations: Patients with crusted scabies excluded; adverse events poorly reported.
CONTEXT
CONTEXTE
  • Infestation caused by Sarcoptes scabiei Crowded environments (e.g., long-term care facilities, shelters, child-care facilities, prisons) increase transmission risk.4
  • Treatment indicated for household and sexual contacts of index cases, even if asymptomatic.4,5
  • Guidelines:4,5
    • Based on potential fomite transmission: 4,5
      • Clothing, bedding: Hot water wash, dry on hot cycle; or store in plastic for 3-7 days.
      • Vacuum mattress.
    • First line (>3 months old): Permethrin 5% cream, 1-2 treatments, 7-14 days apart.
  • Permethrin applied to entire body from neck down.5
    • Consider scalp coverage (particularly young infants/toddlers) and face.1,5
    • Overnight then wash off in morning.
  • Post-scabetic pruritis can persist for several weeks after treatment.
  • Cost (two treatments): Ivermectin $20-115 (weight-dependent), permethrin $45 (2x30g tubes).6

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Author(s)
Auteur(s)
  • Azeria Telesford MSc
  • Caitlin Finley MSc MD CCFP

1. Boralevi F, Simon G, Bernigaud C et al. BMJ. 2026;392: e086277.

2. Rosumeck S, Nast A, Dressler C. Cochrane Database Syst Rev. 2018; (4)CD012994.

3. Dhana A, Yen H, Okhovat JP et al. JAAD. 2018;17(1): 194-8.

4. Thomas C, Castillo Valladares H, Berger TG et al. JAMA. 2024;332(14): 1189-99.

5. Bugs and Drugs. Available at: https://www.bugsanddrugs.org/13c2289c-5316-4842-8e5e-ecc90dc27890. Accessed Mar 17, 2026.

6. Alberta Drug Benefit List, Alberta Human Services and the Palliative Drug Benefit Supplements Drug Price Files. Available at https://www.ab.bluecross.ca/provider/type/pharmacy/price-files.php. Accessed Mar 26, 2026.

Authors do not have any conflicts of interest to declare.