• Initial presentation:
• Treat simultaneously (within 24 hours) all members of the household, close contacts, and sexual contacts with a topical insecticide (even in the absence of symptoms).
• Apply insecticide twice with applications one week apart.
• Use permethrin 5% dermal cream as a first-line treatment.
• Use malathion 0.5% aqueous liquid if permethrin is inappropriate (e.g. if the person has an allergy to chrysanthemums).
• Mites on clothes, bed linen, or towels can be killed by machine washing (at 50°C or above), on the day of application of the first treatment. For alternative methods see Managing scabies.
• Consider symptomatic treatment for itching.
• Treat associated eczema — see the CKS topic on Eczema - atopic.
• If itch persists 4 weeks after the second application of insecticide:
• Re-examine the person to confirm that the diagnosis is scabies.
• Consider alternative diagnoses.
• Consider the possibility that treatment failure has occurred. See Actions in treatment failure.
• If re-treatment is indicated ensure that all members of the household, close contacts, and sexual contacts are identified and re-treated simultaneously.
• Refer if:
• The diagnosis is in doubt, or after two treatment failures.
• There is a history of risk behaviour for sexually transmitted infections.
• There is an outbreak of scabies in an institution (e.g. school, prison, or nursing home): report to the Health Protection Agency.
• Seek specialist advice for:
• Children under 2 months of age (e.g. from a paediatric dermatologist).
• The management of crusted scabies (e.g. from a consultant dermatologist).

• Ask about all people with whom skin-to-skin contact has been made for a prolonged period within the previous 2 months, as all of these people are at risk of scabies and should be informed.
• In people with scabies, assess:
• The severity of the infestation.
• The severity of the symptoms (e.g. itch).
• Whether there are any secondary lesions:
• Eczema.
• Secondary infection.
• The risk of sexually transmitted infection, if appropriate (sexual partners within the previous 2 months).
• The likely source of infestation.
• If crusted scabies, consider the possibility of underlying immunodeficiency and investigate if appropriate.

• These recommendations are based on pragmatic advice and information from the Health Protection Agency [HPA, 2004].

• Simultaneously (within 24 hours) treat all members of the household, close contacts, and sexual contacts with a topical insecticide (even in the absence of symptoms).
• Encourage the family not to delay treatment.
• Pregnant or breastfeeding women should also be treated with an insecticide.
• Apply the insecticide twice, with applications one week apart.
• Consider symptomatic treatment for itching:
• Advise the person that itching may take several weeks to resolve.
• Treat associated eczema — see the CKS topic on Eczema - atopic.
• Treat scabies that has become infected with an antibiotic.
• Machine wash (at 50°C or above) clothes, towels, and bed linen, on the day of application of the first treatment.
• Advise the individual to avoid close body contact with others until their partners and close contacts have been treated.

• Keep any items of clothing that cannot be washed in plastic bags for at least 72 hours to contain the mites until they die.
• Pressing clothes with a warm iron, dry cleaning, or putting items in a dryer on the hot cycle for 10–30 minutes is also effective.
• It is not necessary to fumigate living areas or furniture, or to treat pets.

• These recommendations are based on expert advice from the published medical literature [HPA, 2005; Johnston and Sladden, 2005; Fox and Usatine, 2006].
• It is important that all contacts (symptomatic and asymptomatic), including members from the same household, are treated on the same day:
• Scabies is highly contagious and there is a latent period before symptoms develop.
• Simultaneous treatment is important as this minimizes the chances of reinfestation from an untreated contact.
• The recommendation for two applications, 7 days apart, is an unlicensed use of permethrin, and is different to the packaging information which states that a single application is sufficient. Malathion is now licensed as a course of two applications of insecticide 7 days apart [ABPI Medicines Compendium, 2007].

• 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.

• Apply the treatment to the whole body from the chin and ears downwards paying special attention to the areas between the fingers and toes and under the nails. The exceptions to this are people who are immunosuppressed, the very young and elderly people where the insecticide should be applied to the whole body including the face and scalp.
• Apply the treatment to cool dry skin (i.e. not after a hot bath).
• Allow the lotion or cream to dry before dressing.
• Wash the treatment off after prolonged contact with the skin:
• Permethrin — 8 to 12 hours.
• Malathion — 24 hours.
• Reapply treatment if it is washed off during this treatment period (e.g. after washing the hands or nappy area).

• To prevent small children and babies sucking the treatment from their hands, mittens can be worn.
• Help may be required to apply the treatment properly and special attention should be paid to the axillae, the flexor aspect of the wrists and elbows, and beneath the breasts and around the nipples in women.

• These recommendations are based on expert advice from the published medical literature and from the British Association of Dermatologists [HPA, 2005; BAD, Personal Communication, 2007].
• Treatment should not be applied after a hot bath, as this increases systemic absorption and removes the drug from its treatment site.

[Figueroa, 1998; Roberts, 2000; Scott, 2001]

• Treat itching with topical crotamiton.
• Alternatively, consider using topical hydrocortisone 1% to help reduce itch and inflammation.
• Avoid corticosteroid creams if the diagnosis is not certain, as they may mask signs and symptoms of other skin conditions, making diagnosis more difficult.
• Consider an oral sedating antihistamine (e.g. chlorphenamine or hydroxyzine) at night if the itch is interfering with sleep.

• Apply crotamiton 2–3 times a day. Crotamiton is licensed for children under 3 years old for once a day application only.
• Apply topical hydrocortisone sparingly to the affected area once or twice a day for no longer than 7 days [BNF 53, 2007].
• If creams for itching need to be applied during the application time of the insecticide, allow the insecticide to disappear into the skin or dry, before the cream or lotion for itch is applied.

• These recommendations are based on expert opinion from the medical literature [Johnston and Sladden, 2005; Heukelbach and Feldmeier, 2006].

Topical treatments

• Crotamiton cream or lotion has soothing qualities and may help to relieve itch, although no controlled studies have been published that assess its efficacy. It is licensed for the relief of itching caused by scabies.
• CKS was unable to identify any trial evidence for topical corticosteroids, but they are widely used for the treatment of scabies-related itch [BNF 53, 2007].

Oral antihistamines

• There is limited evidence that oral antihistamines are effective in treating pruritus.
• Results from a review of 16 randomized controlled trials and other studies (n = 803) suggest that neither first- nor second-generation antihistamines offer relief from itch in conditions such as atopic dermatitis [Klein and Clark, 1999].
• However, it may be useful to give a sedating oral antihistamine at night for temporary help with sleeping, to break the itch-scratch-itch cycle. Hydroxyzine is licensed for use in pruritus but chlorphenamine is not (off-label use).
• Itching is worse at night when the patient is warm.

• For women who are breastfeeding or pregnant, treat scabies with permethrin 5% dermal cream.
• Alternatively use malathion 0.5% aqueous liquid if permethrin is not appropriate (e.g. the person has an allergy to chrysanthemums).

• Breastfeeding mothers should remove the liquid or cream from the nipples before breastfeeding, and reapply treatment afterwards.

• Neither malathion nor permethrin are specifically licensed for use during pregnancy or breastfeeding, however there is no indication that either product poses any risk to the fetus or child [ABPI Medicines Compendium, 2005; ABPI Medicines Compendium, 2006].
• Both products are poorly absorbed following topical application and are widely recommended for use during pregnancy [NTIS, 1999; BASHH, 2001; Johnston and Sladden, 2005; CDC, 2006].
• There is more evidence for the effectiveness of permethrin than malathion.

• Follow-up is not generally required for people with classical scabies. However, if symptoms have not cleared within 6 weeks after the first application of treatment the person should be advised to return for reassessment.

• Treatment failure is likely if:
• The itch still persists at least 6 weeks after the first application of an insecticide (particularly if it persists at the same intensity or is increasing in intensity).
• Treatment was uncoordinated or not applied correctly.
• New burrows appear at any stage after the second application of an insecticide.

• These recommendations are based on expert opinion from the medical literature [Walker and Johnstone, 2000; Chosidow, 2006; BAD, Personal Communication, 2007].
• Itching commonly persists for several weeks after successful treatment and may become more pronounced as the body reacts to the dead mites and their waste products [HPA, 2005].

• Re-examine the person to confirm that the diagnosis is correct and look for new burrows (see Diagnosing scabies).
• Consider alternative diagnoses.
• If all contacts were treated simultaneously and treatment was applied correctly, give a course of a different insecticide:
• If permethrin 5% dermal cream was used initially then prescribe malathion 0.5% aqueous solution, OR
• If malathion 0.5% aqueous solution was used initially then prescribe permethrin 5% dermal cream.
• If contacts were not treated simultaneously or treatment was incorrectly applied, either re-treat with the same insecticide, or use a different insecticide.
• Ensure that all members of the household, close contacts, and sexual contacts are identified and re-treated simultaneously.
• Provide written advice explaining the correct application method.

• These recommendations are based on expert opinion from the medical literature [Johnston and Sladden, 2005; Chosidow, 2006].

• In addition to treating the scabies, treat the infection empirically with oral antibiotics for 7 days:
• Oral flucloxacillin is recommended for empirical treatment of staphylococcal and streptococcal skin infections.
• Oral erythromycin (or clarithromycin if erythromycin is not tolerated) is an alternative for people with penicillin allergy.

• Consider referral to a dermatologist if the diagnosis is in doubt, or after continued treatment failure (e.g. if two courses of an insecticide have failed).
• Seek specialist advice from a consultant dermatologist for the management of anyone presenting with crusted scabies. Admission may be required.
• Consider referral to a genito-urinary medicine clinic for specialist advice, diagnostic services, partner notification, and contact tracing if there is a history of risk behaviour for sexually transmitted infections:
• Contact tracing of partners from the previous 2 months should be undertaken.
• Refer institutionalised outbreaks of scabies (e.g. schools, long-stay nursing homes, and prisons) to the Health Protection Agency, as control measures are necessary to deal with all residents, staff and healthcare workers.
• Scabies is rare in children under 2 months of age. Seek specialist advice (e.g. from a paediatric dermatologist) if treatment is required for this age group.

• These recommendation are based on expert opinion from the medical literature and pragmatic advice [HPA, 2005].

• Children and adults can return to school or work after the first application of treatment has been completed.

• This recommendation is based on expert advice from the Health Protection Agency [HPA, 2005; HPA, 2006].
• Transmission ceases after the first treatment has been applied [Figueroa, 1998].
• A systematic review of the literature was carried out to determine the incubation periods, periods of infectiousness, and exclusion policies for the control of 41 communicable diseases including scabies, in school and preschools in the UK. A Medline search was carried out between 1966 and 1998. Three papers were found on scabies and it was concluded that:
• The risk of transmission was low (moderate in families).
• The exclusion period should be until treated.

• Seek specialist advice for the management of crusted scabies (e.g. from a consultant dermatologist).
• Where appropriate, investigate for an underlying immunodeficiency (e.g. suspected HIV).

• These recommendations are based on expert opinion from the medical literature [McCarthy et al, 2004; HPA, 2005; Johnston and Sladden, 2005].
• People with crusted scabies may not respond to treatment with topical insecticides alone and may require oral ivermectin in combination with a topical insecticide.
• Oral ivermectin is available on a named-person basis only.
• There is evidence that doses of ivermectin 200 micrograms/kg given 2 weeks apart are effective for treating crusted scabies, however relapses may occur in severe cases and require additional doses [McCarthy et al, 2004].