How effective is permethrin topical for treating scabies. What are the common side effects of permethrin cream. How should permethrin be applied to treat scabies effectively. What are alternative treatments for scabies if permethrin is ineffective. How long does it take for permethrin to eliminate scabies mites and eggs.

Understanding Scabies: Causes, Symptoms, and Diagnosis

Scabies is a highly contagious skin infestation caused by tiny mites called Sarcoptes scabiei. These microscopic parasites burrow into the upper layers of the skin, causing intense itching and a distinctive rash. But what exactly causes scabies, and how can you recognize its symptoms?

The primary cause of scabies is direct, prolonged skin-to-skin contact with an infected person. This often occurs within households, between sexual partners, or in crowded living conditions. The mites can survive for 48-72 hours without a human host, making it possible (though less common) to contract scabies from infested bedding, clothing, or furniture.

Recognizing scabies symptoms is crucial for early diagnosis and treatment. The most common signs include:

• Intense itching, especially at night
• A pimple-like rash, often in a line or track
• Tiny blisters or scales
• Sores caused by scratching

These symptoms typically appear 2-6 weeks after initial exposure in people who have never had scabies before. For those who have had previous infestations, symptoms may develop within 1-4 days.

Diagnosing scabies can be challenging, as the rash may resemble other skin conditions. Healthcare providers often make a diagnosis based on symptoms and visual examination. In some cases, they may take a skin scraping to examine under a microscope for mites, eggs, or fecal matter.

Permethrin Topical: A First-Line Treatment for Scabies

Permethrin topical is widely considered the first-line treatment for scabies infestations. This synthetic pyrethroid insecticide works by paralyzing and killing scabies mites and their eggs. But how effective is permethrin, and what do patients need to know about using it?

Permethrin 5% cream is highly effective against scabies when used correctly. Studies have shown cure rates of 87-97% with a single application. However, many healthcare providers recommend a second application after 7-14 days to ensure complete eradication of the infestation.

To use permethrin effectively:

1. Apply the cream to clean, dry skin from the neck down to the soles of the feet
2. Pay special attention to areas between fingers and toes, under nails, and in skin folds
3. Leave the cream on for 8-14 hours (usually overnight)
4. Wash off thoroughly with soap and water

It’s important to note that while itching may persist for several weeks after treatment, this doesn’t necessarily indicate treatment failure. The dead mites and their waste products can continue to cause an allergic reaction in the skin.

Side Effects and Precautions When Using Permethrin

While permethrin is generally well-tolerated, it can cause side effects in some individuals. Understanding these potential reactions can help patients use the medication safely and effectively. What are the most common side effects of permethrin topical?

The most frequently reported side effects include:

• Mild burning or stinging sensation
• Itching (which may temporarily worsen after application)
• Numbness or tingling
• Redness or swelling

In rare cases, more severe reactions may occur, such as severe burning, blistering, or signs of an allergic reaction. Patients should seek medical attention if they experience these symptoms.

Certain precautions should be taken when using permethrin:

• Avoid contact with eyes, mouth, and mucous membranes
• Do not use on broken skin or open wounds
• Consult a healthcare provider before using on children under 2 months old or during pregnancy
• Inform your doctor of any other medications you’re taking to avoid potential interactions

By following these guidelines, patients can maximize the effectiveness of permethrin while minimizing the risk of adverse effects.

Alternative Treatments for Scabies: When Permethrin Isn’t Enough

While permethrin is highly effective for most cases of scabies, some patients may require alternative treatments. This could be due to permethrin resistance, allergies, or treatment failure. What other options are available for treating scabies?

Several alternative treatments can be considered:

1. Ivermectin: An oral medication that can be particularly useful for crusted (Norwegian) scabies or widespread infestations
2. Crotamiton: A topical medication that can be used as an alternative to permethrin, though it may be less effective
3. Lindane: A prescription lotion or shampoo, used as a second-line treatment due to potential neurotoxicity
4. Sulfur ointment: An older treatment that can be effective, especially for infants or pregnant women
5. Benzyl benzoate: A topical treatment used in some countries, particularly for resistant cases

The choice of alternative treatment depends on various factors, including the severity of the infestation, the patient’s age and health status, and local treatment guidelines. A healthcare provider can help determine the most appropriate alternative based on individual circumstances.

Managing Scabies Outbreaks: Beyond Individual Treatment

Effectively managing scabies outbreaks requires more than just treating infected individuals. A comprehensive approach is necessary to prevent reinfestation and control the spread of scabies within communities. What steps should be taken to manage a scabies outbreak?

Key elements of outbreak management include:

• Simultaneous treatment of all household members and close contacts, even if they don’t show symptoms
• Thorough cleaning and decontamination of the environment
• Education about scabies transmission and prevention
• Follow-up examinations to ensure complete eradication

Environmental decontamination is crucial in preventing reinfestation. This involves:

1. Washing all clothing, bedding, and towels used in the past 3 days in hot water and drying on high heat
2. Sealing items that can’t be washed in plastic bags for at least 72 hours
3. Vacuuming carpets and upholstered furniture thoroughly

In institutional settings like nursing homes or schools, additional measures may be necessary, such as implementing isolation procedures and coordinating treatment schedules to break the cycle of transmission.

Preventing Scabies: Strategies for Individuals and Communities

While treating scabies is important, preventing infestations in the first place is ideal. Understanding and implementing effective prevention strategies can help individuals and communities reduce the risk of scabies outbreaks. How can scabies be prevented?

Key prevention strategies include:

• Practicing good personal hygiene
• Avoiding prolonged skin-to-skin contact with individuals who have scabies
• Refraining from sharing personal items like clothing, towels, or bedding
• Promptly treating diagnosed cases and their close contacts
• Implementing regular skin checks in high-risk settings

In healthcare settings, additional precautions may include:

1. Using appropriate personal protective equipment (PPE) when caring for infected patients
2. Implementing contact precautions for diagnosed or suspected cases
3. Educating staff about scabies recognition and prevention

By combining individual preventive measures with community-wide strategies, the risk of scabies transmission can be significantly reduced.

Living with Scabies: Coping Strategies and Support

Dealing with a scabies infestation can be physically and emotionally challenging. The persistent itching, social stigma, and anxiety about reinfestation can take a toll on an individual’s well-being. How can patients cope with the challenges of living with scabies?

Several strategies can help manage the physical and emotional impact of scabies:

• Following treatment instructions meticulously to ensure complete eradication
• Using over-the-counter antihistamines or topical corticosteroids to manage itching (under medical supervision)
• Keeping nails short and clean to minimize skin damage from scratching
• Seeking support from friends, family, or support groups
• Practicing stress-reduction techniques like meditation or deep breathing

It’s important to remember that post-scabies itch can persist for several weeks after successful treatment. This doesn’t necessarily indicate treatment failure or reinfestation. Patients should consult their healthcare provider if they’re concerned about ongoing symptoms.

Education plays a crucial role in coping with scabies. Understanding the condition, its treatment, and prevention can help alleviate anxiety and empower patients to take control of their health. Healthcare providers should offer clear, comprehensive information and be available to address patients’ concerns throughout the treatment process.

Addressing Scabies Stigma: Promoting Understanding and Compassion

Despite being a common and treatable condition, scabies often carries a significant social stigma. This can lead to feelings of shame, isolation, and reluctance to seek treatment. How can we address the stigma associated with scabies and promote a more compassionate approach?

Strategies for reducing scabies stigma include:

• Educating the public about scabies transmission, emphasizing that it’s not related to poor hygiene
• Encouraging open communication about skin health and infestations
• Promoting empathy and support for those affected by scabies
• Addressing misconceptions and myths about the condition
• Ensuring confidentiality and respect in healthcare settings

Healthcare providers play a crucial role in addressing stigma. They can:

1. Use non-judgmental language when discussing scabies
2. Provide clear, factual information about the condition
3. Offer emotional support and reassurance to patients
4. Advocate for patients in workplace or school settings if needed

By fostering a more understanding and compassionate approach to scabies, we can encourage earlier diagnosis and treatment, ultimately reducing the spread of infestations and improving outcomes for affected individuals.

Permethrin topical for Scabies Reviews

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My granddaughters caught head lice at school so I bought this product which usually has a good reputation for being good at eradication two bottles I bought and used them has per the instruction there infestation is as bad as ever and only combing is keeping them under control I wonder if there was any agent in these bottles at all

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Scabies

Scabies

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• Scabies

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Baby suffering from Scabies in the United Republic of Tanzania.

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Basic facts

• Human scabies is a parasitic infestation caused by Sarcoptes scabiei varhominis
• An estimated 200 million people in the world are infected with scabies at any given time
• Up to 10% of children in under-resourced areas have scabies
• Scabies is distributed throughout the world, mainly in hot tropical countries and in areas with high population density

Human scabies is a parasitic infestation caused by Sarcoptes scabiei var hominis. The microscopic mite enters the skin and lays eggs, eventually triggering an immune response in the host that results in severe itching and a rash. Scabies can be exacerbated by bacterial infections leading to the development of skin ulcers, which in turn can lead to more severe complications such as sepsis, heart disease, and chronic kidney disease. In 2017, scabies and diseases caused by other ectoparasites were listed as neglected tropical diseases (NTDs) in response to requests from Member States and recommendations from the WHO Strategic and Technical Advisory Group on NTDs.

Magnitude of the problem

Scabies is one of the most common skin diseases and accounts for a significant proportion of skin diseases in developing countries. It is estimated that over 200 million people in the world are infected with scabies at any given time, but more work is needed to better estimate this burden. According to recent publications on scabies, prevalence rates range from 0.2% to 71%.

Scabies is endemic in many resource-poor tropical areas, where average prevalence rates in children are estimated to be 5-10%. Re-infections are widespread. The heavy burden of scabies and its complications comes at a high cost to health systems. Although isolated cases occur in high-income countries, outbreaks of scabies in health care settings and vulnerable communities result in significant economic costs to national health services.

Scabies is prevalent throughout the world, but the most vulnerable populations – young children and the elderly in under-resourced communities – are particularly susceptible to scabies infection and secondary complications. Infection rates are highest in countries with hot tropical climates, especially in communities where people live in conditions of overcrowding and poverty and access to treatment is limited.

Symptoms

Scabies mites penetrate the top layer of the skin where adult females lay their eggs. After 3-4 days, larvae appear from the eggs, which develop into adult ticks in 1-2 weeks. After 4-6 weeks, the patient develops an allergic reaction to the proteins and feces of the mites in the scabies, which causes severe itching and a rash. Most people are infected with 10-15 mites.

Patients usually experience severe itching, and tick-like burrows and vesicles appear in the interdigital spaces, on the wrists, on the upper and lower extremities and in the lumbar region. In infants and young children, the rash may be more widespread and involve the palms, soles of the feet, ankles, and sometimes the scalp. Inflammatory scabies nodules can be found in adult men on the penis and scrotum, and in women in the mammary glands. Due to the fact that symptoms develop some time after the initial infection, itch moves can be detected in people who have had close contact with an infected person who have not yet developed itching.

People with crusted scabies develop thick, scaly scabies on their skin that may spread more widely, including on the face.

Immunocompromised people, including people with HIV/AIDS, can develop a special form of the disease called crusted (Norwegian) scabies. Crusted scabies is a hyperinfection, in which the number of mites reaches several thousand and even millions. The mites spread widely and lead to crusting, but often do not cause significant itching. If left untreated, this disease is characterized by high mortality from secondary sepsis.

The effects of mites on the immune system, as well as the direct effects of scratching, can lead to bacterial contamination of the skin, leading to the development of impetigo (skin ulcers), especially in tropical conditions. Impetigo may be complicated by deeper skin infections such as abscesses or severe invasive diseases, including sepsis. In tropical settings, skin infection associated with scabies is a common risk factor for kidney disease and possibly rheumatic heart disease. Signs of acute kidney injury can be found in up to 10% of scabies-infected children in under-resourced areas, and in many cases these symptoms persist for years after infection, leading to irreversible kidney damage.

Transmission

Scabies is usually spread from person to person through close skin contact (eg, living together) with an infected person. The risk of transmission depends on the level of infection, with the highest risk coming from contact with individuals suffering from crusting scabies. The likelihood of transmission from contact with contaminated personal items (eg clothing and bedding) is low for common scabies, but high for crusted scabies. Given the asymptomatic period of infection, transmission may occur before symptoms appear in the initially infected person.

Treatment

Initial treatment of infected individuals includes the use of topical scabicides such as 5% permethrin, 0.5% water-based malathion, 10-25% benzyl benzoate emulsion, or 5-10% sulfur ointment. Oral ivermectin is also highly effective and has been approved in several countries. The safety of ivermectin in pregnant women or children weighing less than 15 kg has not been established, so ivermectin should not be used in these populations until further safety data are available. With effective treatment within 1-2 weeks, pruritus usually increases, and persons undergoing treatment should be informed about this.

Since there may be no symptoms in the early stages of a new infestation, and since anti-scabies drugs do not kill the eggs of the parasite, best results are achieved by treating all family members at the same time and re-treatment at a time appropriate to the chosen drug.

WHO activities

WHO is collaborating with Member States and partners to develop scabies control strategies and outbreak response plans. WHO recognizes that the burden of disease and the risk of long-term complications need to be better defined, and that scabies control strategies need to be linked to interventions to facilitate rapid and cost-effective implementation. WHO is working to have ivermectin included on the WHO Model List of Essential Medicines when it is next updated. In addition, WHO is taking steps to ensure that quality and effective medicines are available to countries in need.

what it looks like, symptoms, signs and treatment

Scabies: a definition of the disease

Scabies (or, scientifically, scabies) is a common contagious skin disease.

In the last decade in Russia, the incidence of scabies is officially kept at the level of 18-45 cases per 100 thousand people. But it can be much higher, since people do not go to the doctor: they try to cope with the disease on their own or are ashamed of their symptoms.

Scabies agent

The cause of the disease is the scabies mite Sarcoptes scabiei, which feeds on flakes of dead skin. It spends most of its life in the skin, and appears on the surface only for mating.

The size of an adult tick is approximately 0.1 mm. The parasite has a powerful jaw, with the help of which it gnaws tunnels in the skin

As a rule, mating of ticks occurs in the evening. After it, the males die, and the females gnaw through human skin and make scabies in it, in which they lay 2-4 eggs. The hatched larvae come to the surface of the skin and penetrate into the hair follicles and flakes of the epidermis (upper layer of the skin). After a couple of days, they molt and become nymphs, and then they become adults, ready to mate.

Characteristics of the scabies mite Sarcoptes scabiei:

• the tick quickly dies in the external environment: it is unable to absorb water from the air, therefore it dies from moisture deficiency;
• for the parasite, temperatures above 55 degrees are detrimental;
• adult females can penetrate the skin only in the most sensitive areas, and larvae – in any, due to their small size;
• is usually infected by females and larvae at the same time.

Ways of transmission of scabies

There are two ways of transmission of scabies – direct and indirect.

Direct infection with scabies occurs during close bodily contact. There are known cases of tick transmission from an infected person to a healthy person even during a strong handshake.

Indirect infection with scabies occurs without direct contact with an infected person. This can happen in a bathhouse, a hotel, an entrance and in other places where many people touch the same objects on which ticks are located.

Usually scabies is infected in orphanages, boarding schools, hostels, barracks, prisons – wherever people live in a large group.

The risk of contracting scabies is higher in places where people work and live in small groups

Incubation period for scabies

The incubation period for scabies depends on whether infection has occurred with adult scabies mite or its larvae.

When infested with larvae, the first symptoms may appear after 10-14 days – this is how long it takes for the mites to mature. And when infected with already fertilized females, there may not be an incubation period at all: the females will immediately begin to dig scabies and lay eggs in them in order to breed as soon as possible.

Types of scabies

Typical scabies – the most common, accompanied by excruciating itching, scabies, nodules and blisters on the skin. The characteristic symptom of the disease – itching – usually appears 10-14 days after infection. Itching intensifies in the evening and at night, it is at this time that scabies mites are active.

For the treatment of typical scabies, scabicides are prescribed – drugs that destroy mites and their larvae. The illness usually resolves within 2-3 weeks.

Clean scabies mostly occurs in people who shower or bathe in the evening. They have almost no nodules and blisters on their skin, strong scratching and bloody crusts.

Treatment for clean scabies is the same as for typical scabies. With the right choice of drugs and compliance with all the doctor’s recommendations, recovery occurs in 2-3 weeks.

Norwegian (crustal) scabies is a rare and highly contagious form of the disease. It was first identified by Norwegian doctors in 1848 in patients with leprosy (leprosy).

As a rule, Norwegian scabies occurs in immunocompromised people, in patients with Down’s syndrome, HIV, dementia, oncological diseases, as well as in patients taking hormonal and cytotoxic drugs for a long time.

With Norwegian scabies, vesicles, nodules, cracks form on the skin, and then – rough crusts – gray-yellow or brown-black. Such crusts can, like a shell, cover large areas of the skin and prevent a person from moving normally. In the lower layers of the crusts, sinuous depressions are visible – scabies. When removing the crusts, extensive weeping erosions are exposed. Between the layers of crusts, a huge number of mites are found – up to 200 individuals in one square centimeter (for comparison: with typical scabies, there are usually no more than 10-15 of them).

Norwegian scabies can cause a micro-epidemic – when all family members, health workers and patients who are in the same room become infected with the disease.

Treatment of Norwegian scabies is long and takes place in two stages. First, the doctor removes the crusts from the patient’s skin (sometimes local anesthesia is required), then prescribes anti-scabies, which will need to be used for a long time.

Scabies without burrows is less common than typical and is usually found in people who have been in contact with people with scabies. With such scabies, infection with scabies mite larvae occurs. Symptoms of the disease: single nodules and inflammatory vesicles on the skin.

Scabies without burrows usually resolves in 2 weeks, is treated in the same way as typical scabies – anti-scabies drugs.

Scabious lymphoplasia – manifested by intensely itchy flat rounded bluish-purple nodules, which are most often localized on the trunk (buttocks, abdomen, in the axillary region), as well as on the elbows and genitals in men, mammary glands in women. The basis of the disease is the reaction of the body to the waste products of the tick. This happens in people who suffer from scabies for a long time.

After complete therapy, the rash may resolve in 2 weeks to 6 months.

Scabious erythroderma occurs in people who have been treated for a long time (up to 3 months) with typical scabies with corticosteroid ointments, antipruritic and sedative drugs. The disease is manifested by many itch moves that occur even in atypical places (between the shoulder blades, on the head, on the face). At the same time, itching is mild, and patients do not comb the skin, but rub it with their palms.

Treatment of scabious erythroderma is quite long – up to 6 weeks may be required until complete recovery.

Pseudosarcoptic mange is a type of scabies that affects dogs, pigs, horses, rabbits, wolves, foxes and other animals. Pseudosarcoptic mange can only be contracted from animals. It is not transmitted from person to person.

The incubation period is several hours. There are no scabies, since the mites do not breed on an unusual host and only partially burrow into the skin, causing itching. The rashes are concentrated on open areas of the skin and look like blisters, blisters, bloody crusts and scratches.

Pseudosarcoptic mange often resolves on its own after cessation of contact with the affected animal. If the symptoms recur or persist for several days, you should consult a doctor to make an accurate diagnosis.

Symptoms of scabies

The main symptom of scabies is unbearable itching, which intensifies in the evening and at night.

Itching runs along the burrows. They look like straight or curved lines that rise above the skin. The color of the lines can be dirty gray or whitish gray. Length – 5-7 mm.

Most often, itch moves are found on the wrists, feet, male genital organs, in the interdigital spaces.

The skin of a person infected with scabies usually has blisters and nodules. In about a third of cases, young males and females of the parasite are found in them. You can see them with the naked eye: ticks look like white or yellowish dots the size of a poppy seed.

Nodules with mites are located in the area of ​​hair follicles. Bubbles are more often between the fingers, on the wrists.

The main symptom of scabies is excruciating itching

Complications of scabies

Complications of scabies in the form of dermatitis and secondary pyoderma occur in approximately 50% of patients.

Dermatitis is an inflammation of the skin, which is manifested by redness, burning, tingling, itching, swelling of the affected area. Secondary pyoderma is a purulent-inflammatory skin disease caused by bacteria.

Less often against the background of scabies develops microbial eczema – inflammation of the skin of an allergic nature caused by microbes.

Skin changes in scabies complicated by the addition of a secondary infection:

• staphylococcal impetigo – inflammation of the hair follicle caused by staphylococcus aureus;
• deep folliculitis – damage to the deep sections of the hair follicle, which leads to purulent inflammation;
• furunculosis – acute purulent-necrotic inflammation of the hair follicle, sebaceous gland and surrounding tissues;
• impetigo – vesicular-pustular rash;
• paronychia – inflammation of the periungual fold.

Scabies in children

As a rule, children become infected with scabies in a direct way – through prolonged contact with the skin of an infected person. This happens when sleeping in the same bed, contact games, using shared toys. In addition, children can catch scabies in crowded groups – in orphanages, camps, hospitals, sports clubs, swimming pools. Teenagers are infected with scabies during sexual intercourse.

The course of scabies in children is usually more pronounced than in adults. Complications develop more often – microbial eczema, pyoderma (purulent-inflammatory skin lesions), impetigo (vesicle-pustular rashes), paronychia (inflammation of the periungual roller).

Symptoms of scabies in children:

• severe itching that worsens in the evening and at night;
• rash;
• scabies;
• nodules and vesicles on the skin.

Symptoms of scabies in children are usually more pronounced than in adults

In infants and young children, rashes can be located on any area of ​​the skin – including the face, scalp, palms and soles. The rash in babies often begins to get wet, there are multiple grouped vesicles in the lesions, scabious lymphoplasia of the skin.

In school-age children and adolescents, scabies affects the hands, feet, elbows, buttocks, genitals, intergluteal folds.

Diagnosis of scabies

The diagnosis of scabies is made by a doctor – a dermatologist, therapist or infectious disease specialist – on the basis of an examination and complaints of the patient.

A clear sign of the disease is pruritus, which becomes unbearable in the evening and at night. Other symptoms that make it possible to suspect the disease are characteristic linear scratches and nodules on the skin.

Skin scrapings can confirm the diagnosis of scabies. However, it should be borne in mind that there may not be ticks in the biomaterial if the person has washed himself thoroughly before visiting the doctor.

Another way to detect a mite in a laboratory or clinic is to apply a drop of 40% lactic acid to the suspected itch, nodule, vesicle. Lactic acid loosens the epidermis well, and after a few minutes it can be carefully scraped off, placed on a glass slide and examined under a microscope.

The tick extraction method is also used. In this case, the doctor opens the blind end of the itch with a needle. The female is attached to the needle. Then the doctor takes the needle out of the itch along with the female and immerses it in a drop of water or 40% lactic acid. Then microscopy is performed.

Treatment of scabies

There are three ways to treat scabies: specific, prophylactic and trial.

Specific treatment is given to patients with symptoms of the disease and a clinically confirmed diagnosis. Scabicides are used – drugs that destroy the scabies mite and its larvae.

Prophylactic treatment is performed according to epidemiological indications – in scabies. However, people may not have symptoms.

Such treatment is indicated for everyone who has been in contact with an infected person: family members, sexual partners, nannies and nurses, members of close groups in orphanages, boarding schools, hostels, prisons, barracks.

Trial treatment is performed only in cases where the patient has symptoms of scabies, but the causative agent – scabies mite – is not detected. If after the use of anti-scabies drugs a positive effect occurs, then the diagnosis of “scabies” is considered confirmed.

Anti-scabies preparations

Ointments, emulsions, aerosols are used to kill scabies mites.

Basic scabicides – scabicides:

• preparations containing esdepalletrin, a neurotoxic insect poison. Contraindicated in pregnant women, as well as in patients with bronchial asthma and obstructive bronchitis;
• benzyl benzoate (ointment, emulsion): 20% for adults and 10% for children from 3 to 7 years;
• sulfuric ointment 33%. The drug is contraindicated in children under 3 years of age. Has an unpleasant smell, stains clothes. Possible skin irritation, longer treatment;
• permethrin 5% (emulsion). The drug is not recommended for use in children under 1 year old, patients with liver and kidney diseases, lactating women;
• crotamiton 10% (cream, lotion). Pregnant women can use the medicine only according to strict indications. In addition, the drug is contraindicated in children under 12 years of age.

The doctor prescribes the drug regimen. Self-medication can be hazardous to health.

General rules for the use of anti-scabies:

• apply drugs in the evening, with bare hands, not with a tissue or swab;
• rub preparations thoroughly into palms and soles;
• change underwear and bed linen after completion of the course;
• to simultaneously treat everyone who is in the focus of infection.

The doctor may give the patient antihistamines or topical corticosteroids to relieve itching. Both of them are usually used in a short course.

If itching does not resolve within a week, it may be necessary to re-treat the skin with scabicide preparations after thoroughly washing the patient with soap and a washcloth.

Prognosis and prevention

With proper and timely treatment, the prognosis of scabies is favorable.