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• Topical permethrin or lindane

• Sometimes oral ivermectin

Primary treatment is topical or oral scabicides (see table Treatment Options for Scabies). Permethrinis the 1st-line topical drug.

Older children and adults should apply permethrin or lindane to the entire body from the neck down and wash it off after 8 to 14 h. Permethrin is often preferred because lindane can be neurotoxic. Treatments should be repeated in 7 days.

For infants and young children, permethrin should be applied to the head and neck, avoiding periorbital and perioral regions. Special attention should be given to intertriginous areas, fingernails, toenails, and the umbilicus. Mittens on infants can keep permethrin out of the mouth. Lindane is not recommended in children < 2 yr and in patients with a seizure disorder because of potential neurotoxicity.

Precipitated sulfur 6 to 10% in petrolatum, applied for 24 h for 3 consecutive days, is safe and effective and usually used in infants < 2 mo of age.

Ivermectin is indicated for patients who do not respond to topical treatment, are unable to adhere to topical regimens, or are immunocompromised with Norwegian scabies. Ivermectin has been used with success in epidemics involving close contacts, such as nursing homes.

Close contacts should also be treated simultaneously, and personal items (eg, towels, clothing, bedding) should be washed in hot water and dried in a hot dryer or isolated (eg, in a closed plastic bag) for at least 3 days.

Pruritus can be treated with corticosteroid ointments and/or oral antihistamines (eg, hydroxyzine 25 mg po qid). Secondary infection should be considered in patients with weeping, yellow-crusted lesions and treated with the appropriate systemic or topical antistaphylococcal or antistreptococcal antibiotic.

Symptoms and lesions take up to 3 wk to resolve despite killing of the mites, making failed treatment due to resistance, poor penetration, incompletely applied therapy, reinfection, or nodular scabies difficult to recognize. Skin scrapings can be done periodically to check for persistent scabies.

Treatment Options for Scabies

• Risk factors for scabies include crowded living conditions and immunosuppression; poor hygiene is not a risk factor.

• Suggestive findings include burrows in characteristic locations, intense itching (particularly at night), and clustering of cases among household contacts.

• Confirm scabies when possible by finding mites, ova, or fecal pellets.

• Treat scabies usually with topical permethrin or, when necessary, oral ivermectin.