• Use permethrin 5% dermal cream as a first-line treatment.
• Use malathion 0.5% aqueous liquid if permethrin is inappropriate (e.g. the person has an allergy to chrysanthemums).
• For children under 2 months old, seek specialist advice from a paediatric dermatologist.
• Scabies is rare in children under 2 months old.
• If malathion is used, an aqueous preparation is preferred to the alcohol-based lotion.

• Children under 6 months old require a prescription for an insecticide to treat scabies.
• If parents prefer to purchase an insecticide over the counter:
• Malathion 0.5% aqueous liquid can be purchased for children over 6 months old.
• Children under 2 years old require a prescription for permethrin 5% dermal cream.

• These recommendations are based on evidence from a Cochrane systematic review, randomized controlled trials (RCTs), uncontrolled trials, and expert opinion from the medical literature [HPA, 2005; Johnston and Sladden, 2005].

Recommended treatments:

• Permethrin:
• There is evidence from one systematic review and a subsequent RCT that permethrin 5% is highly effective at achieving clinical and parasitic cure of scabies within 28 days of treatment.
• Permethrin 1% cream rinse (licensed for head lice) has been associated with treatment failure [Cox, 2000].
• Malathion:
• There is limited evidence from uncontrolled trials that malathion is effective for treating scabies. These studies found that malathion 0.5% left on the skin for 24–48 hours cured 70–80% of people within 2–4 weeks [Hanna et al, 1978; Thianprasit and Schuetzenberger, 1984]. Malathion is widely used to treat scabies and is recommended by the Health Protection Agency [HPA, 2005].
• Aqueous preparations are easier to apply than alcohol-based lotions. Alcohol-based lotions cause irritation of excoriated skin and the genitalia.

Treatments not recommended:

• Benzyl benzoate:
• Benzyl benzoate 25% is less effective than permethrin or malathion. It requires repeated applications (twice a day for 2–3 days, repeated after 10 days), irritates the skin, and can produce a burning sensation, which all reduce compliance [Heukelbach and Feldmeier, 2006].
• Crotamiton:
• Crotamiton 10% cream or lotion is less effective than permethrin [Walker and Johnstone, 2000], and is rarely used in the UK for treating scabies because of its poor efficacy [DTB, 2002b]. However, it may help to relieve the itch caused by scabies.
• Oral ivermectin:
• Ivermectin is available on a named-person basis and has been used in combination with topical treatments for the treatment of hyperkeratotic (crusted or Norwegian) scabies infestation that does not respond to topical treatment alone [HPA, 2005].
• Lindane:
• Lindane has been withdrawn from the UK market. It is effective for treating scabies, but neurotoxicity (particularly seizures) has been reported in infants, children, and among those with widespread skin damage (e.g. eczema) [McCarthy et al, 2004].
• Lindane is systemically absorbed when applied topically, especially when applied to damaged skin. Systemic absorption is higher in infants and small children.