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menu.
Scabies in adults and children aged 1 year and over: a summary of the Pharmacy First pathway, from assessment and referral criteria to permethrin treatment and contact management.
Similar symptoms in household members, sexual partners or other close contacts1
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Or: a household member, sexual partner or close contact of someone with scabies, even without symptoms1
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A burrow appears as a thin, brown-grey line 0.2–1 cm long. On darker skin, redness may be hard to see and the rash may look darker: look closely for burrows1,3
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Itch starts 3–6 weeks after a first infestation, but within 1–3 days if the person has had scabies before3
If these features are absent: scabies less likely
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Consider eczema, dermatitis, insect bites, urticaria or folliculitis. Itch without a rash may indicate systemic disease1,3
Referral
Urgent (GP, A&E or 999 depending on circumstances)
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Systemically unwell or suspected sepsis: A&E, or 999 if life-threatening. Consider calculating a NEWS2 score ahead of signposting1,2
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Fever, spreading colour change, pain, discharge or suspected secondary bacterial infection: same-day general practice or out-of-hours service1,2
General practice
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Crusted scabies (thick, crusted or scaly skin), or immunosuppression1,2
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Suspected nodular scabies: firm, itchy, red-brown lumps, often on the genitals, groin or armpits1,2
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Pre-existing eczema or another skin condition (increased risk of sensitivity to permethrin)1,2
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Already treated for scabies in this episode, including over-the-counter treatment1,2
Living in a care home or other communal residential setting, or linked to a suspected outbreak in one (2 or more cases at the same setting in 8 weeks): refer to general practice. Suspected outbreak: health protection route1,2
Prescribe enough for two whole-body applications, 7 days apart: up to a maximum of 4 tubes for adults and children aged 12 and over, and up to a maximum of 2 tubes for children aged 1 to 11 (depending on body surface area)1,2
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Treat all household members, sexual partners from the past month and close contacts at the same time, even if they have no symptoms, each in their own consultation1,2
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Scabies from a sexual partner: consider referral to a sexual health service for partner notification and an STI check1,2
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Permethrin 5% cream is licensed from 2 months of age, but the pathway starts at 1 year2,3
Quantity per application
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Adults and children over 12: usually up to one tube (30 g). Some adults need a second tube, but no more than two tubes (60 g) per application3
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Children aged 6–12 years: up to half a tube (15 g). Children aged 1–5 years: up to a quarter of a tube (7.5 g)3
Outside the pathway
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NICE CKS lists oral ivermectin as an option, and suggests considering it for people with pre-existing eczema or another skin condition. Oral ivermectin is not listed as an option in the community pharmacy pathway1,3
Self-care and advice
Applying permethrin: advice for all patients and contacts
●
Apply to cool, dry skin over the whole body, including the neck, scalp, face (avoiding the eyes) and ears, finger and toe webs, under the nails, armpits, groin, genitals and buttocks1,2
●
Leave on overnight for 12 hours, then wash off. Reapply to any area washed during this time, such as the hands1,2,3
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Repeat the whole-body application after 7 days1,2,3
●
Parents or carers applying the cream should wear gloves to avoid irritating their own hands3
Preventing reinfestation
●
Everyone in the household, sexual partners from the past month and close contacts need treatment at the same time, even without symptoms1,2,3
●
Wash clothing, bedding and towels at 60°C or above, or seal in a bag for 72 hours1,3
Patient information
●
Provide the British Association of Dermatologists scabies leaflet (step-by-step guide) and direct people to the NHS website: scabies1,4,5
Follow up
After treatment
●
Itching may continue for up to 4 weeks after successful treatment and does not alone mean treatment failure1,3
●
Advise the person to seek further assessment (general practice or the relevant out-of-hours service) if new burrows appear, itch continues for more than 2 to 4 weeks after the second application, infection develops, or the diagnosis becomes uncertain1,3
If treatment has not worked
●
Persistent nodular lesions can last weeks to months after treatment and need specialist input: refer to general practice2,3
●
Suspected resistant scabies after re-treatment: refer to general practice1,3
NICE Clinical Knowledge Summaries. Scabies. Last revised September 2025. Management: scenario, management of scabies; prescribing information.
4
British Association of Dermatologists and British Society for Paediatric Dermatology. Scabies patient information leaflet, as linked from the Pharmacy First pathway.
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