Scabies Treatment, Step by Step
Three things decide whether it works, and none of them is which product you use — full coverage, the second application, and treating everyone on the same day.
Part of the Complete Scabies Guide.
Key fact: Scabies treatment fails for three reasons, and none of them is the medicine: not covering the whole body, not repeating after 7 days, and not treating everyone at the same time. Get those three right and almost any licensed product works.
Which treatment
| Permethrin 5% cream | Malathion 0.5% aqueous liquid | |
|---|---|---|
| Position | First line | Second line — if permethrin is unsuitable or has not worked. Sold as Derbac-M |
| Coverage | Whole body from the jaw down | Whole body including face, neck, scalp and ears |
| Leave on for | 8 to 12 hours — usually overnight | 24 hours |
| Applications | Two, exactly 7 days apart | |
| Pregnancy and breastfeeding | Generally the preferred option | Discuss first |
Permethrin's coverage extends to the face, neck, scalp and ears as well in children under 2, older adults, and anyone immunosuppressed, because those are the groups in whom scabies affects the head.
Before you start
- Get enough product. An adult needs roughly 30 to 60g of cream per application — typically a full 30g tube or more each time, and there are two applications. Running out halfway is a common reason for failure
- Coordinate the household so everyone applies on the same evening
- Apply to cool, dry skin. Not straight after a hot bath or shower — warm skin increases absorption into the bloodstream and reduces how long it stays where it is needed. Wait until you have cooled down
- Cut nails short and clean under them, since mites shelter there
- Plan the timing — overnight suits permethrin; malathion's 24 hours needs more thought
How to apply it
| Step | What it involves |
|---|---|
| Start at the jawline | Or from the scalp down if you are using malathion, or are in one of the groups needing head coverage |
| Work downwards, systematically | Neck, shoulders, arms, trunk, back, buttocks, genitals, legs, feet. Do not skip anywhere that looks normal — mites are not only where the rash is |
| Use a mirror or a second person | For the back, which is otherwise reliably missed |
| Include the fiddly places | Between every finger and toe, under the nails, in the navel, behind the ears, in the groin folds, under the breasts, between the buttocks |
| Leave it on for the full time | 8 to 12 hours for permethrin, 24 for malathion. Washing it off early is a wasted application |
| Reapply to the hands after washing them | Every time. Hands are where the mites concentrate and the cream is most easily removed |
| Wash it off thoroughly | At the end of the period, then change into clean clothes and clean bedding |
The spots everyone misses
- Under the fingernails and toenails — use a brush to work cream underneath
- The back, particularly between the shoulder blades
- The soles of the feet, and between the toes
- The genitals and the skin between the buttocks — commonly affected, commonly skipped out of embarrassment
- Behind the ears and along the jawline
- The navel
- Skin folds — under breasts, in the groin, under an overhanging abdomen
The second application
Seven days after the first. It is not optional and it is not a top-up.
Eggs already laid in the skin are relatively protected and hatch over the following days. The first application kills the mites; the second kills what has hatched since, before those reach the age at which they can lay eggs of their own. Skipping it lets the cycle restart, and the resulting recurrence usually gets blamed on reinfection from outside.
Everyone repeats on the same day too. A household that staggers its second applications is a household that keeps passing scabies between its members.
Treating everyone at once
- Everyone living in the household, symptoms or not
- All sexual contacts from the past 8 weeks
- Close contacts — anyone with prolonged skin-to-skin contact, such as a regular carer, a partner who does not live with you, or a child who shares a bed elsewhere
- On the same day, both times
The 8-week window exists because it can take that long for symptoms to appear. Someone entirely symptom-free may well be infested, and treating the visibly itchy people only is the single commonest reason a household cannot get rid of it.
Telling contacts is awkward. It is also the difference between one round of treatment and six months of recurrence.
Bedding and clothing
Unlike head lice, this genuinely matters here — mites survive a day or two off a person — but only briefly and only on the treatment days.
- On the day of each application: wash bedding, towels and recently worn clothing at 60°C or hotter, and tumble dry hot if you can
- What cannot be washed hot: dry-clean, or seal in a plastic bag for at least 72 hours
- Vacuum mattresses, upholstery and carpets once
- That is enough. Daily deep cleaning for weeks is unnecessary and exhausting
Pregnancy, babies and older adults
Get advice before treating if the person is under 2 months old, if you are pregnant or breastfeeding, if there is widespread crusting or scaling, or if the immune system is weakened. Permethrin is generally the preferred option in pregnancy and breastfeeding, and in babies, older adults and immunosuppressed people the cream must also cover the face, neck, scalp and ears — which changes the application and the amount needed.
For breastfeeding, cream on the breasts is usually washed off before feeding and reapplied afterwards — worth confirming with whoever supplies the treatment.
If it has not worked
| Possibility | What to do |
|---|---|
| It is post-treatment itch, not failure | By far the commonest. Itch continues for 2 to 4 weeks after the mites are dead. See still itching afterwards |
| Incomplete coverage | Back, feet, nails, genitals. Repeat properly rather than switching product |
| Second application missed or late | Complete the course |
| Contacts not treated | Treat everyone, same day, both applications |
| Washed off early, or applied to hot skin | Reapply correctly |
| Genuine treatment failure | New burrows or new spots appearing more than 2 to 4 weeks after the second application. Switch to the alternative agent and get assessed |
| Crusted scabies | Thick crusted plaques, often with little itch. Needs specialist treatment |
Frequently Asked Questions
How do you apply scabies cream properly?
To cool, dry skin, covering the whole body from the jaw down, working systematically so nothing is missed, including between the fingers and toes, under the nails, the navel, the genitals, the back and the soles. Leave permethrin on 8 to 12 hours or malathion 24 hours, reapply to the hands every time they are washed, then wash off and change into clean clothes and bedding.
Why do you need two scabies treatments 7 days apart?
Eggs already laid in the skin are relatively protected and hatch over the following days. The first application kills the mites and the second kills what has hatched since, before they are old enough to lay eggs themselves. Skipping the second application lets the cycle restart.
How much scabies cream do you need?
An adult needs roughly 30 to 60g per application, so typically a full 30g tube or more each time, and there are two applications. Running out halfway through an application is a common reason treatment fails.
Should you have a hot bath before applying scabies cream?
No. Apply to cool, dry skin. Hot skin increases absorption of the treatment into the bloodstream and reduces how long it remains where it is needed. If you have bathed, wait until you have cooled down fully before applying.
Do I need to wash all the bedding?
Yes, but only on the treatment days. Wash bedding, towels and recently worn clothing at 60°C or hotter on the day of each application, tumble drying hot where possible. Items that cannot be washed hot can be dry-cleaned or sealed in a plastic bag for at least 72 hours. Daily deep cleaning for weeks is unnecessary.
References
- NHS. Scabies. nhs.uk
- National Institute for Health and Care Excellence. Clinical Knowledge Summary: Scabies. cks.nice.org.uk
- Nottinghamshire Area Prescribing Committee. Scabies: guidance for primary care. nottsapc.nhs.uk
- IUSTI. European guideline for the management of scabies. iusti.org
- UK Health Security Agency. Health protection in children and young people settings, including education. gov.uk
Medical disclaimer: This article is for informational purposes only and does not constitute medical advice. Scabies treatment must be applied to the whole body and repeated after 7 days, and everyone in the household needs treating at the same time. Always read the leaflet supplied with your own product. Always consult a qualified healthcare professional for diagnosis and treatment. In a medical emergency, call 999.