Oral ivermectin or topical permethrin: Which is better for scabies treatment?

Oral ivermectin and topical permethrin 5% cream are the most frequently used medications for treating classic scabies, but comparative data are lacking. Two Cochrane systematic reviews (published in 2007 and 2018) produced contradictory results, showing permethrin superiority or no difference in efficacy between the drugs.To further examine this issue, researchers in France investigated whether oral ivermectin or topical permethrin 5% cream can clinically cure scabies in index cases and in members of their households. The multicentre, assessor-blinded, cluster randomized clinical trial was conducted in 28 French hospitals over a five-year period. The study included index cases of adults and children weighing > 15 kg with scabies, confirmed by dermoscopy. Persons were excluded if they had received a scabicide in the preceding four weeks, or had diffuse eczema or extensive impetigo.Index cases were randomly assigned to the ivermectin group or permethrin group in a 1:1 ratio. Each member of a cluster, defined as the household of each index case, received the same treatment as the index case, except for children weighing < 15 kg who received topical permethrin 5%. Oral ivermectin was dosed at 200 μg/kg (taken with food, tablets could be crushed for children) on day 0 and day 10. Permethrin 5% cream was applied to the whole body, from head to toe, on day 0 and day 10. The cream was left on overnight (≥ 8 hours) and washed off in the morning, with emollients recommended for all participants. All household members were treated simultaneously, regardless of the presence or absence of symptoms, to avoid potential reinfestation (a subsequent source of treatment failure). All participants also received instructions on decontaminating textiles, to avoid indirect transmission of classic scabies.The primary outcome was clinical cure of the cluster (household) on day 28 (i.e., disappearance of clinical signs and symptoms of scabies for all cluster members). Secondary outcomes were index case and individual level clinical cure rate and safety. Dermatologists were used as assessors and were masked to the treatment.Key results:507 participants in 142 households (clusters) were treated with oral ivermectin and 568 participants in 147 households received topical permethrin.Cluster (household) level cure rates were 71.8% for ivermectin versus 88.5% for permethrin (–16.7 percentage point difference, 95% confidence interval [CI] –6.3 to –7.1).Secondary outcome (index case and individual level clinical cure rate) percentage point differences also showed the inferiority of ivermectin compared with permethrin for index cases (76.6% v 91.5%; percentage point difference –14.9, 95% CI –23.6 to –6.2) and participants (85.3% v 94.2%; –9.2 percentage point difference, –14.9 to –3.5).Intraclass correlation coefficients were higher for permethrin than ivermectin for all clusters (0.68, 95% CI 0.61–0.75 v 0.46, 0.37–0.56) and for cluster size > 1 (0.67, 0.60–0.74 v 0.47, 0.37–0.56).Cutaneous adverse events occurred in 11.9% of participants treated with oral ivermectin and 15.6% of participants treated with topical permethrin.The researchers conclude that the results of this cluster randomized trial of classic scabies showed the superiority of permethrin 5% cream compared with oral ivermectin in achieving clinical cure of scabies in a large population of children and adults, including index cases and their households. Despite the superiority of topical permethrin, the authors caution that when making decisions in clinical practice, factors such as adherence, ease of use, clinical tolerance or resistance to scabicides, and the skin condition of patients should be considered when prescribing treatment for scabies.Reference:Boralevi F, Simon G, Bernigaud C, et al. Oral ivermectin versus 5% permethrin cream to treat children and adults with classic scabies: multicentre, assessor blinded, cluster randomised clinical trial. BMJ 2026;392:e086277. (accessed January 27, 2026).

Oral ivermectin or topical permethrin: Which is better for scabies treatment?

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