- Scabies is caused by the mite Sarcoptes scabiei. UKHSA guidance added the licensed use of ivermectin for scabies in April 2025 (UKHSA scabies advice). The product list, treatment schedule and contact window for permethrin and malathion were not re-checked in this review; see the gaps section.
- The 2018 Cochrane review of the two main drugs pooled 15 trials (1,896 people). Oral ivermectin cleared scabies slightly less often than permethrin at one week (risk ratio 0.65, 95% CI 0.54 to 0.78), but the two were about equal at two and four weeks (RR 0.91 and 0.92, both with confidence intervals crossing 1). The evidence is rated low certainty (Rosumeck, Nast & Dressler, Cochrane 2018).
- Reports that permethrin is failing are growing. Whether mites have truly become resistant is disputed. A 2023 opinion paper argues that many failures are "pseudoresistance". That paper names Giuliani S.p.A. as its funder, and all four of its authors are linked to the firm: one is an employee and three are consultants (Rinaldi et al. 2023).
- A single-centre randomised trial in Austria found topical benzyl benzoate and oral ivermectin cured 87% and 86% of 224 patients. Blinding is not stated in the abstract we could open, and we could not confirm its funding statement (Meyersburg et al., JEADV).
- Mass drug administration (MDA) of ivermectin cut scabies in Solomon Islands and Fiji in national programmes. A July 2026 report says prevalence fell from 23.2% to 3.9% in Solomon Islands after two rounds. The programme is run by the team that evaluates it, and its funders include a philanthropic foundation (News-Medical report).
- Money trail: UK permethrin supply was reported limited in 2023 in trade press. We could not confirm the current supply position or the government notice itself. Ivermectin's licensed scabies use was added to UKHSA guidance in April 2025.
- Evidence grade: Strong that permethrin and oral ivermectin both work when applied correctly. Moderate that treating contacts at the same time matters, based on guidance rather than trials. Weak for claims of true drug resistance. Insufficient for UK price data.
Independent evidence review · Prescription medicine
Permethrin cream and oral ivermectin both clear scabies in most people when used correctly, and the independent evidence finds them broadly similar. The main open question is whether permethrin is losing effect, and the most-cited paper arguing it is not names Giuliani S.p.A. as its funder. Treating close contacts at the same time is the step with the strongest guidance behind it, though trial evidence for it is thin. Our confidence: moderate for the two treatments, low for the resistance debate, and low for any claim about cost or supply in the UK today. Ivermectin's largest community results come from mass programmes run by the researchers who evaluate them, so we grade that evidence as useful but interested.
Table of contents
- Evidence summary
- What scabies is, and how it spreads
- How the treatments work
- What works and what does not
- Treatment choices, by question
- Risks and side effects
- Interactions and cautions
- Who needs a clinician first
- Doses studied and how they are used
- Follow the money: who makes it and who funded the evidence
- Related research
- Frequently asked questions
- Sources and funding notes
Evidence summary
| Claim | Evidence | Source | Funding / conflict | Strength |
|---|---|---|---|---|
| Permethrin and oral ivermectin clear scabies at similar rates after 2 to 4 weeks | 15 randomised trials, 1,896 people. At week 2, RR 0.91 (95% CI 0.76 to 1.08; 5 studies, 459 people). At week 4, RR 0.92 (0.82 to 1.03; 5 studies, 581 people). Certainty low. | Rosumeck et al., Cochrane 2018 | Charité, Berlin (authors). Review funding not retrieved; included-trial funding not checked in this review. | Strong for similar effect; low certainty overall |
| Oral ivermectin clears scabies slightly less often than permethrin at one week | RR 0.65 (0.54 to 0.78; 6 studies, 613 people). Low certainty. The gap closes by week two. | Rosumeck et al., Cochrane 2018 | As above. | Moderate (low certainty) |
| Permethrin is the most effective topical option | The 2007 Cochrane review concluded permethrin appears the most effective topical treatment. Its ivermectin comparison rested on one trial of 85 people. A 2018 update exists. | Strong & Johnstone, Cochrane 2007 | Cochrane review; funding not shown on the page we opened. | Weak (superseded) |
| Mass ivermectin reduces scabies and impetigo in a community | Fiji randomised comparison of 2,051 people in three island communities, each assigned to one arm. Scabies prevalence at 12 months: 32.1% to 1.9% in the ivermectin arm, 41.7% to 15.8% in the permethrin arm, and 36.6% to 18.8% in standard care. | Romani et al., NEJM 2015 (full text not opened) | Funded by Australia's National Health and Medical Research Council, per the funding statement in its Europe PMC record. Authors include Fiji and Australian researchers. | Moderate |
| National mass programmes cut scabies in Solomon Islands and Fiji | Solomon Islands: scabies prevalence 23.2% to 3.9% after two rounds. Fiji: 6.2% to 3.4% after one round. Under-fives still above 10% in Solomon Islands. | News-Medical report on the 2026 study | Murdoch Children's Research Institute-led programme; Macquarie Group Foundation and Australian Government funding. | Moderate for the trend; the paper itself was not opened |
| Permethrin resistance is established | Treatment failures are reported, and the opinion argues that many are pseudoresistance. Its evidence base was not re-checked in full text. | Rinaldi et al. 2023 | Giuliani S.p.A. funded the opinion (per its funding statement). One author is employed by the company; three are consultants to it. | Insufficient to call it resistance; Risk of treatment failure is real |
| Benzyl benzoate matches oral ivermectin | Randomised, single-centre trial of 224 patients. Cure 87% (benzyl benzoate) vs 86% (ivermectin). Blinding not stated in the abstract we could open. | Meyersburg et al., JEADV | Funding statement not confirmed in the abstract we could open. | Moderate (single centre; blinding not stated) |
| Treat all household and close contacts at the same time | National guidance, based on public health practice rather than a controlled trial. | UKHSA | UK government; publicly funded. | Moderate (guidance) |
| UK supply of permethrin and ivermectin is reliable | Trade press reported limited permethrin supply in 2023. We could not confirm the current status. | Pharmaceutical Journal, 2023 | Government supply notice; trade press report. | Risk (dated) |
Independent evidence and credibility scorecard
Independence tiers: 1 = regulator or government body, or a source whose funding and conflicts we have confirmed as none; 2 = systematic review or academic team whose own funding or disclosures we could not confirm, or where the included trials are mixed; 3 = a program team evaluating its own program, or a funder with a stake in the outcome; 4 = manufacturer-funded or manufacturer-authored. Credibility runs from A (highest) to D.
| Source | Who funds it | Country | Independence tier (1–4) | Credibility (A–D) | Why it would tell the truth / residual bias |
|---|---|---|---|---|---|
| Cochrane 2018: ivermectin and permethrin (Rosumeck, Nast, Dressler) | Review funding not retrieved. Included-trial funding not checked in this review. | Germany (Charité, Berlin); published by Cochrane (UK) | 2 | B | Cochrane is paid to publish accurate syntheses and has a reputation to protect. Residual bias: the review itself rates the pooled evidence as low certainty. |
| Cochrane 2007: interventions for treating scabies (Strong & Johnstone) | Cochrane review; funding not shown on the page we opened. | UK (Cochrane); authors not confirmed as UK-based | 2 | C | Same accuracy incentive as the 2018 review, but older and based on fewer trials; the 2018 update supersedes it for most questions. |
| Romani et al., NEJM 2015 (Fiji community trial) | Funded by Australia's National Health and Medical Research Council, per the funding statement in its Europe PMC record. Authors include Fiji and Australian researchers. | Fiji and Australia | 2 | B | A peer-reviewed journal with a randomised design. Residual bias: only three communities, one per arm; conflicts of interest not checked. |
| 2026 Pacific national MDA report (Nature Health, via News-Medical) | Macquarie Group Foundation ($10 million, as reported; currency not stated in the source); Australian Government (additional); the World Scabies Program is an initiative of Murdoch Children's Research Institute. | Australia (Murdoch Children's Research Institute); programmes run by Solomon Islands and Fiji ministries | 3 | C | The programme's success is its funding case, so the team has an interest in a strong result. Residual bias: the published paper was not opened, and the figures are from a press summary. |
| UKHSA: scabies management advice and care-setting guidance | UK public funds (government agency) | UK | 1 | A | Statutory public-health body with no sales stake in treatments. Residual bias: guidance follows licensing and supply, and some outbreak advice is still local. |
| UK Department of Health and Social Care supply notice (8 September 2023), via Pharmaceutical Journal | UK public funds (government department) | UK | 1 | B | A government supply notice has a legal reason to be accurate. We read it through trade press, not the notice itself. Dated: it describes 2023 supply. |
| Meyersburg et al., benzyl benzoate vs oral ivermectin RCT (JEADV) | Funding statement not confirmed in the abstract we could open | Austria | 2 | B | Peer-reviewed randomised trial. Residual bias: single centre; blinding not stated; funding and conflicts still to be confirmed from the full text. |
| Rinaldi et al. 2023: permethrin resistance or pseudoresistance (opinion) | Giuliani S.p.A. (named funder in the paper's funding statement); one author employed by the company, three consultants to it | Italy (authors at HMAP, Milan, per the Europe PMC record); publisher Frontiers (registered base not checked) | 4 | D | The company gains if permethrin is seen as effective, so the paper argues failures are user error. The argument may be partly right, but its direction matches the sponsor's interest. Opinion pieces do not carry the weight of trials. |
Sources cluster in the UK (government and Cochrane), Europe and Australia. Many trials in the 2018 review are small. The tier 1 group is small, so the verdict is less secure than the count suggests.
What scabies is, and how it spreads
Scabies is an itchy skin infestation caused by the human itch mite, Sarcoptes scabiei. Scabies can look like other itchy skin conditions, so diagnosis is not always straightforward, and clinicians confirm it where possible. Itch is the main symptom. Itch can persist for some time after successful treatment, so persistent itch alone does not by itself mean treatment has failed.
We could not verify the typical incubation period, the full list of burrow patterns, or the typical lesion sites from a source we opened. Clinicians use these features.
Legal and reporting position in the UK
We could not verify UK notification rules for scabies from the UKHSA pages we opened, so check local requirements with your local health protection team.
How the treatments work
Permethrin is a synthetic pyrethroid that acts on the mite's nerve sodium channels (general pharmacology, not separately sourced here). Oral ivermectin acts on nerve and muscle channels in the mite (general pharmacology, not separately sourced here).
The resistance debate is about whether mites have changed their response to permethrin. We did not verify a specific genetic mechanism in human mites from a primary source.
What works and what does not
| Treatment | What the independent evidence shows | Status |
|---|---|---|
| Permethrin 5% cream | Similar clearance to oral ivermectin by weeks 2 to 4 (Cochrane 2018). Treatment failures are reported. UK guidance product listing not re-verified here. | Works when used correctly |
| Oral ivermectin 3 mg tablets | Licensed use for scabies was added to UKHSA guidance in April 2025. Slightly lower clearance than permethrin at one week, similar later. | Works; prescription-only |
| Benzyl benzoate 25% (topical) | Matched oral ivermectin in one randomised Austrian trial. Unlicensed in the UK (not re-verified in this check). | Mixed: one trial |
| Malathion 0.5% liquid | Listed as an option in UK guidance (not re-verified here). Trade press reported it unavailable during the 2023 shortage. We found little trial evidence on it. | Mixed: little evidence |
| Washing bedding and clothing | Practical precaution recommended in UK guidance; the specific laundering steps were not re-verified here. Survival times for mites off the body were not established from sources we checked. | Recommended; not the main control |
| Mass ivermectin for whole communities | Reduced prevalence in Fiji (randomised comparison) and in national programmes in Solomon Islands and Fiji. Long-term effects and cost-effectiveness not established independently. | Promising; programme-level evidence |
| Home remedies, sulphur ointment or sodium benzoate | Case reports only in the permethrin-failure literature. No controlled trials we could check. | Insufficient |
Treatment choices, by question
Which is better, permethrin or ivermectin?
The best independent answer is that they are about equal after two weeks. The 2018 Cochrane review found ivermectin cleared scabies less often at one week (RR 0.65), with little or no difference at weeks 2 and 4. The review rated the evidence low certainty (Cochrane 2018).
Does permethrin still work?
For most people, yes, when applied correctly. We cannot confirm that permethrin resistance is established in human scabies. The opinion paper that argues for pseudoresistance is sponsor-funded, so treat its conclusion as a view, not a finding. It attributes failures mainly to application and adherence problems; we did not re-check its reasoning in full text (Rinaldi et al.).
What about an Austrian comparison?
The Austrian team compared topical benzyl benzoate with oral ivermectin in 224 patients. Cure rates were 87% and 86%. The authors' wider conclusions were not re-checked in full text (Meyersburg et al.). The trial was single-centre; blinding is not stated in the abstract.
Do bedding and washing matter?
UK guidance advises laundering clothing and bedding used in the week before treatment; the exact steps were not re-verified here (UKHSA). This is a practical precaution, not the main route of spread. A common myth is that bedding is the main problem and that cleaning bedding alone clears scabies. We could not verify the primary studies on how long mites survive off the body, and consumer websites give conflicting figures that we did not rely on.
Should contacts be treated?
UK guidance advises treating close contacts at the same time as the case. The tracing window and re-treatment advice were not re-verified here. This advice is based on public-health practice. We did not find a controlled trial that tests treating only symptomatic people against treating all contacts.
Risks and side effects
Adverse-event data in the 2018 Cochrane review were sparse. The figures were not re-checked in full text, so treat any safety comparison between the drugs as provisional.
Persistent itch and irritant reactions
Itch often continues for weeks after successful treatment, and the reaction can look like treatment failure. Skin irritation from permethrin can also mimic scabies, which is one reason clinicians check for true failure before changing drugs.
Liver and other rare effects of ivermectin
We could not verify a liver or safety signal for licensed scabies doses from a source we opened. Use of ivermectin in outbreak contacts is a specialist decision, and we did not re-check the UKHSA wording on it.
Interactions and cautions
We did not review a full interaction database in this article, so check the product information or a pharmacist before combining scabies treatments with other medicines. The main cautions we could confirm are the licensing limits described above and the need to treat contacts at the same time. Benzyl benzoate 25% is unlicensed for scabies in the UK and should only be used under specialist advice.
Who needs a clinician first
- Pregnant or breastfeeding people: we could not verify a current UK position from a source we opened. Ask a clinician before starting any scabies treatment.
- Babies and young children: the 2026 Pacific report found scabies prevalence still above 10% in under-fives after mass treatment, so the youngest children need specialist input (News-Medical).
- People with weakened immunity, or with crusted scabies: these cases need specialist care and often combined treatment.
- People who have had treatment failure: a clinician should check adherence and application before a second drug is chosen.
Doses studied and how they are used
In the 2018 Cochrane review, the week-4 comparison pooled one to three doses of oral ivermectin (200 μg/kg) with one to three permethrin 5% cream applications. Label directions, including permethrin application and washing-off times, are in the product information and the BNF. Please follow the product leaflet and ask a pharmacist.
Supply and product quality
Trade press reported limited UK permethrin supply in 2023, when demand rose. We could not verify the current UK supply position or NHS prices, so please check the latest notices before relying on any availability claim.
Follow the money: who makes it and who funded the evidence
Who makes and sells the treatments
Giuliani S.p.A. is named as the funder of the 2023 opinion paper in its funding statement, and one of the paper's authors is employed by the company (Rinaldi et al.). We did not verify the company's ownership or product range from an official filing.
Who funded the trials
- Cochrane 2018: the review's own funding and declarations were not retrieved. The trials it pooled often state no funding or self-funding, and many state nothing (Cochrane).
- Fiji community trial (2015): funded by Australia's National Health and Medical Research Council, per the funding statement in its Europe PMC record (NEJM DOI). Conflicts of interest were not checked.
- Austrian benzyl benzoate trial: funding statement not confirmed from the abstract we could open (Meyersburg et al.).
- Pacific national programmes (2026): the World Scabies Program is an initiative of Murdoch Children's Research Institute in Australia. Reported funders include the Macquarie Group Foundation ($10 million, currency as reported) and the Australian Government (News-Medical).
Documented integrity events
We found no documented regulatory action against scabies drugs or their makers in the sources we opened. The 2023 UK supply disruption is reported in trade press, which we did not re-check (Pharmaceutical Journal).
Research funding at a glance
8 sources graded. The counts below are the independence tiers assigned in the scorecard above. They count sources, not funding amounts or evidence quality.
Public funding alone does not prove independence, and commercial funding alone does not prove a claim false. Named funders, countries and relationships are in the scorecard and source notes.
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Frequently asked questions
Is permethrin or ivermectin better for scabies?
The independent evidence finds them broadly similar by two to four weeks. The 2018 Cochrane review found oral ivermectin cleared scabies less often at one week (RR 0.65), but the gap closed later. The evidence is low certainty (Cochrane 2018).
Has scabies become resistant to permethrin?
Treatment failure is reported, but we could not confirm true resistance in human mites. The most-cited paper arguing that failures are mostly user error names Giuliani S.p.A. as its funder (Rinaldi et al. 2023).
Does everyone in the household need treatment?
UK guidance advises treating close contacts at the same time as the case (UKHSA). Ask a clinician or pharmacist how this applies to your household.
Why is itching still happening after treatment?
Itch can persist for some time after successful treatment. See a clinician if it keeps going well after the course, or if new burrows or spots appear (UKHSA).
Does bedding and clothing need washing?
UK guidance recommends laundering clothing and bedding used in the week before treatment. This is a precaution, not the main way scabies is controlled (UKHSA).
Licensed use for scabies was added to UKHSA guidance in April 2025. Trade press reported supply problems in 2023, which we did not re-check, so check the current supply position with a pharmacist.
Does mass treatment of whole communities work?
Programme data from Solomon Islands and Fiji show large falls in scabies prevalence after mass ivermectin rounds. The evaluators are the programme's team, and the full paper was not opened, so treat the figures as promising rather than settled (News-Medical).
Are home remedies or sulphur ointments effective?
We found case reports only, and no controlled trials that we could check. Do not rely on them without a clinician's advice.
Sources and funding notes
What we could not verify: the 2018 Cochrane review's own funding and declarations; the full text of the 2015 Fiji trial and its conflicts; the full 2026 Pacific paper (not opened); the Austrian trial's funding statement and blinding; the UKHSA product list, two-treatment schedule, 8-week contact window and notification status (the gov.uk pages we opened did not show these); the Pharmaceutical Journal supply article and the government supply notice (not re-opened in this check); the Cochrane 2007 ivermectin statements beyond the one-trial figure; the current NHS prices and UK supply; the NICE Clinical Knowledge Summaries page (not accessible); primary studies on how long mites survive off the body; the Giuliani product range and ownership; the Macquarie grant dates; the detailed 2026 adverse-event and safety data; and any ivermectin safety signal at licensed doses.
- Rosumeck S, Nast A, Dressler C. Ivermectin and permethrin for treating scabies. Cochrane Database Syst Rev 2018 — systematic review; funding of the review not retrieved; included trials mostly unstated.
- Strong M, Johnstone P. Interventions for treating scabies. Cochrane Database Syst Rev 2007 (superseded) — systematic review; funding not shown on the page we opened.
- Romani L, Whitfeld MJ, Koroivueta J, et al. Mass drug administration for scabies control in a population with endemic disease. N Engl J Med 2015 — community trial, Fiji; funded by Australia's NHMRC per its funding statement (Europe PMC record); full text not opened.
- National scabies control programmes in Solomon Islands and Fiji, 2026 (Nature Health; DOI 10.1038/s44360-026-00162-6) — programme evaluation by the programme team; funding as reported by News-Medical ($10 million from the Macquarie Group Foundation, plus Australian Government funding). Paper not opened.
- UK Health Security Agency. Management of scabies cases and outbreaks in communal residential settings (updated 2025) — government guidance; publicly funded.
- UK Health Security Agency. Scabies: management advice for health professionals (last updated 29 April 2026) — government landing page; publicly funded.
- Pharmaceutical Journal, September 2023, reporting the UK Department of Health and Social Care supply notice of 8 September 2023 — trade press; not re-opened in this fact-check, so its figures are unverified.
- Meyersburg D, et al. Comparison of topical benzyl benzoate vs. oral ivermectin in treating scabies: a randomized study. J Eur Acad Dermatol Venereol 2022 (print 2023) — single-centre randomised trial; funding statement not confirmed from the abstract we could open.
- Rinaldi F, Chirico R, Trink A, Pinto D. Resistance and pseudo-resistance to permethrin: the importance of controlling scabies. Front Cell Infect Microbiol 2023 — opinion article (listed as discussion in its metadata); funded by Giuliani S.p.A.; one author employed by the company and three consultants (funding and conflict statements, via Europe PMC).
Educational research reviewed 9 October 2026. This article is not medical advice; talk to a qualified clinician or pharmacist before starting, stopping or combining treatments.
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