Permethrin

Permethrin: Using Scabies Cream Correctly — Head to Toe, Everyone at Once

As a 5% cream, permethrin is the first-choice treatment for scabies. The cream reliably kills the mites — provided it covers the whole skin without gaps, is left on long enough and all close contacts are treated at the same time. Most treatment failures are not down to the active ingredient but to the organisation.

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Contents

  1. At a glance: technical data sheet
  2. How it works: a nerve poison for mites, hardly absorbed in humans
  3. Dosing: how much cream for whom
  4. Treatment night: from head to toe
  5. Side effects and the itching afterwards
  6. Everyone at once: close contacts, repeat treatment, laundry
  7. Interactions: condoms, other creams, the environment
  8. When it does not go away: treatment failure and alternatives
  9. Special situations: babies, pregnancy, breastfeeding, care homes
  10. Permethrin experiences: what patients really ask
  11. FAQ: Common questions about permethrin

1. At a glance: technical data sheet

PropertyDetails
Active ingredientPermethrin
ATC codeP03AC04
Drug classPyrethroid; medicine against scabies mites (scabicide)
Dosage forms5% cream for scabies (e.g. InfectoScab); lower-strength permethrin solutions for head lice are separate products used differently
Half-lifeOf little relevance for use: only a very small amount is absorbed through the skin and it is broken down quickly in the body
Maximum amount per applicationGuide values: adults and adolescents over 12 up to 30 g, children aged 6 to 12 up to 15 g, children aged 2 months to 5 years up to 7.5 g
Onset of actionMites die during the contact time of at least 8 hours; itching can persist for up to four weeks
Prescription status5% cream is prescription only
Special featureClose contacts are treated at the same time; the RKI (Robert Koch Institute, Germany's public health institute) recommends repeating the treatment after 7 to 10 days
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2. How it works: a nerve poison for mites, hardly absorbed in humans

Permethrin is a pyrethroid, a synthetic derivative of the pyrethrins found in chrysanthemum flowers.¹ It paralyses the nervous system of insects and mites by keeping the sodium channels of their nerve cells open. The scabies mites, which dig their burrows in the top layer of the skin, die as a result.

In humans the effect is quite different: only a very small amount is absorbed through the skin, and this is quickly broken down in the body into inactive components. That is why it is so well tolerated — including in pregnant women and young children, for whom there are otherwise few alternatives. The Robert Koch Institute (RKI) still names permethrin as the first-choice treatment for scabies.²

How scabies develops, what it looks like and how it is diagnosed is described in the article on the condition, scabies. Here the focus is on what happens between the prescription and recovery: using the cream correctly.

The way it works leads to the three rules on which treatment depends:

  • Where there is no cream, mites survive. Permethrin only works where it has been applied. A gap between the fingers or under the nails is enough for a relapse.
  • The cream needs time. According to the package leaflet, it must be left on for at least eight hours; washing during this time shortens the effect at exactly that spot.¹
  • Anyone not treated will reinfect others. Mites move back and forth between close contacts. A person who has been treated perfectly is quickly reinfested by an untreated partner.

3. Dosing: how much cream for whom

The following amounts are the guide values from the package leaflet and are not a recommendation for use — the product, amount and number of applications are set by the treating practice.¹

Age groupGuide value per applicationNote
Adults and adolescents over 12Up to 30 g (one 30 g tube or half a 60 g tube)Tall adults sometimes need more — better enough than too thin
Children aged 6 to 12Up to 15 gTreat the head and face too, leaving out the area around the mouth and eyes
Children aged 2 months to 5 yearsUp to 7.5 gUp to 23 months only under close medical supervision
Babies under 2 monthsNo dose recommendationOnly on medical advice
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The package leaflet stresses that these are guide values that can be adjusted according to body surface area.¹ For a family of several people this means in practice: there must be enough cream for every person and every application. If you “share” the tube with your partner, you often both end up applying it too thinly. For the repeat treatment, see section 6.

4. Treatment night: from head to toe

Treatment usually takes place in the evening so that the cream can work overnight. The basics of applying creams are explained in the guide Applying creams correctly; for permethrin, this is the routine:¹,²

  1. Trim and clean your nails. Mites and eggs like to sit under the fingernails, where they get to through scratching.
  2. Do not bathe just beforehand. According to the RKI, the skin should not be wet for about 30 minutes before applying. If it was wet, dry it well and let it cool down.
  3. Adults: from the neck to the soles of the feet. Apply the cream thinly but without gaps to the whole body — including the neck, the back of the neck, the palms of the hands and the soles of the feet. According to the package leaflet, the head and face can be left out if there are no affected areas there.
  4. Children and people over 65: the head and face too. In these groups the face, ears and scalp are also treated; the area around the eyes and mouth is left out. Children should not lick the cream off their hands; thin gloves can help if needed.
  5. Take extra care with the problem areas. Between the fingers and toes, under the nails, wrists, elbow creases, armpits, nipples, belly button, external genitals and buttocks — this is where mites prefer to sit.
  6. Let it soak in and put on fresh clothes. Let the cream soak in for a few minutes, then put on fresh nightwear and go to a freshly made bed.
  7. Leave it on for at least eight hours. Do not shower or bathe during this time. If you need to wash your hands or clean your intimate area, apply the cream there again afterwards.¹
  8. Shower thoroughly in the morning. Then fresh clothes, towels and bed linen again — and wash the textiles you used (section 6).
Get some help. Covering your own back with cream without any gaps is almost impossible. According to the package leaflet, anyone helping should wear disposable gloves.¹ In families, it has proven useful for everyone to apply cream to each other on the same evening — that also takes care of the “everyone at once”.
Not in the eyes, mouth or mucous membranes. The cream is for the skin only and must not be swallowed. Avoid contact with the eyes, nose and throat, mucous membranes in the genital area and open wounds; if contact happens by accident, rinse thoroughly with water. If cream has been swallowed, for example by a toddler, get medical advice or contact the poison emergency line (Giftnotruf); more in Medication overdose: what to do.

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5. Side effects and the itching afterwards

Permethrin cream is usually well tolerated. The most common complaints affect the skin — and are often hard to tell apart from the symptoms of scabies itself.¹

Side effectFrequency according to the package leafletWhat helps
Itching, redness, tingling, stinging, burning, dry skinCommonFollow-up care with moisturising, lipid-replenishing products and oil baths; can also come from the scabies itself
HeadacheRareUsually temporary
Skin abrasions, inflammation of hair follicles, lighter patches of skinVery rareHave it checked by a doctor if it gets worse
Breathing difficulties in sensitive or allergic people (described for pyrethroids)Very rareIf you are short of breath, call 112 (emergency number in Germany) immediately; if you have asthma, mention it beforehand
Contact-allergic skin reactions with itching, redness, blisters or wheals, also beyond the treated areaNot knownGet it checked by a doctor; do not use again after a severe reaction
NauseaNot knownUsually temporary
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The itching stays — and that is usually not a failure

This is the point where many people despair: the cream has been applied, the mites are dead — and it keeps itching, sometimes even more. According to the package leaflet, itching and rash can persist for up to four weeks after treatment. The cause is a reaction of the immune system to the dead mites and their waste in the skin, known as post-scabies eczema.¹,²

  • Do not simply apply more: using more permethrin on your own because of the itching irritates the skin further. The package leaflet requires you to talk to the practice before applying it again.
  • Look after your skin: moisturising, lipid-replenishing creams and oil baths ease the dryness after treatment.
  • For the eczema: according to the RKI, post-scabies eczema is treated with cortisone creams — which one and for how long is decided by the practice. Background in the cortisone guide.
  • Warning signs of a relapse: new mite burrows, new bumps in typical places or itching that gets worse again after a few weeks instead of fading — then go for a check-up.

More on persistent itching and dry skin in the symptom articles.

When you need help immediately. Shortness of breath, tightness in the chest, swelling of the face or neck after applying the cream: wash the cream off and call 112 (emergency number in Germany) immediately. Widespread, weeping or pus-filled areas of skin, fever or red, hot skin after scratching suggest a bacterial infection and should be treated by a doctor promptly.

6. Everyone at once: close contacts, repeat treatment, laundry

Permethrin works reliably when it is used correctly. That scabies nevertheless “comes back” so often is frequently due to three organisational gaps: close contacts are treated too late or not at all, the repeat treatment is skipped, or the laundry is forgotten.

Who is treated as well

According to the RKI, people with scabies and their close contacts are always treated at the same time — even if the contacts do not have any symptoms yet.² The reason: after a first infection, it takes two to five weeks before the itching starts. During this time someone is infested but does not notice. Close contacts are people with prolonged skin-to-skin contact over a large area, for example by sharing a bed, as partners, cuddling children or giving personal care to someone who needs it. With ordinary scabies, shaking hands or a brief hug is usually not enough for transmission.²

If treating everyone at the same time is not possible, the RKI says close contacts should be treated within a few days and avoid close physical contact until then. After treatment, the RKI recommends avoiding close physical contact for about another 36 hours.² The package leaflet puts it this way: all contacts, especially family and partners, should see a doctor as soon as possible; the practice decides on their treatment.¹

Once or twice?

Here the sources differ. The InfectoScab package leaflet states that one application is usually enough, with a repeat after 14 days if the infestation persists or returns.¹ In its current guide, the RKI, on the other hand, generally recommends a repeat after 7 to 10 days.² The background is increasing reports of mites that are less sensitive to permethrin, and the concern that with a single application some mites survive, for example from eggs that only hatch afterwards. The European guideline also describes repeat schedules.³ How often you treat is decided by your practice — what matters is that all close contacts follow the same schedule on the same day.

Laundry and household items

Scabies mites survive away from the skin only for a limited time: according to the RKI, at room temperature and normal humidity they probably remain infectious for at most about two days, and for less time in warmth.² This leads to the following measures:

WhatMeasure according to the RKI
Bed linen, towels, underwear, clothing in contact with the skinWash at a minimum of 50 °C for at least 10 minutes, or alternatively use a tumble dryer or hot steam
Non-washable textiles, shoes, soft toysPack in plastic bags or film and store for 72 hours at a minimum of 21 °C; in dry air, for example next to a radiator, 48 hours is enough
Alternative for small itemsFreeze for 5 hours at below −10 °C
Upholstered furniture, mattresses, carpetsVacuum thoroughly; with ordinary scabies, no insecticides are needed in the home
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The package leaflet is stricter: clothing, bed linen and towels should be changed daily for four days and washed at a minimum of 60 °C.¹ Both aim at the same thing: textiles that were in direct contact with the skin in the days before treatment should not pass surviving mites back.

Nursery, school, work. Under the German Infection Protection Act, children with scabies may only return to communal facilities after proper treatment. According to the RKI, readmission is possible after the first correct application of a topical scabies treatment; this does not apply to crusted scabies. Proof of the medical prescription is recommended.²

7. Interactions: condoms, other creams, the environment

Because hardly any permethrin reaches the body, no interactions with tablets are known. Other things listed in the package leaflet are more relevant in practice:¹

CombinationConsequenceWhat to do
Latex condoms and diaphragmsParaffin and white soft paraffin in the cream can impair how latex products work and therefore how safe they areAvoid sex during the contact time — advisable anyway because of the risk of infection; see Medications and contraception
Other creams, ointments, lotionsCan dilute the cream or interfere with its effect in those areasDo not apply anything else during the contact time; skincare only after showering it off
Cortisone creams for the eczemaIntended follow-up treatment for the itchingOnly when prescribed by a doctor and after the permethrin application
Allergy to chrysanthemums or other plants of the daisy familyCross-reaction possibleOnly use after talking to the practice
Aquariums, terrariums, bodies of waterPermethrin is harmful to insects and to aquatic animals such as fishAvoid contact; do not dispose of leftovers via the toilet or sink
AlcoholNo interaction knownNo particular restrictions
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The cream also contains cetostearyl alcohol and sorbic acid, which can cause local skin irritation such as contact dermatitis.¹ Background on such additives in the guide Excipients and intolerances; how to dispose of leftover medicines correctly is explained in Disposing of medications.

A word about animals: permethrin is also found in some tick and flea treatments for dogs. It is highly toxic to cats. So do not let cats lick freshly treated skin, and keep the tube out of their reach. Incidentally, human scabies mites are not transmitted by pets, and mites from animals cause at most temporary skin reactions in humans.

If you use several skin products, allergy tablets for the itching and long-term medicines at the same time, the brite interaction check helps you keep track.

8. When it does not go away: treatment failure and alternatives

If it is still itching four weeks after treatment, or itching again, or new mite burrows appear, an honest search for the cause is worthwhile before a new prescription. The most common reasons are:

  • Reinfection: a close contact was not treated or was treated too late — the most common reason of all.
  • Gaps in application: too little cream, hands not re-treated after washing, areas such as the soles of the feet, nails or genital area left out, showering too early.
  • No repeat treatment, even though one was planned.
  • Reduced sensitivity of the mites: according to the RKI, there are increasing reports of mite populations that are less sensitive to permethrin. Permethrin nevertheless remains the first choice; if a poor response is suspected, other medicines can be considered.²
  • Not scabies at all: not every itchy skin rash is scabies. Eczema, atopic dermatitis, hives or a drug allergy can look similar; the practice can detect mites with a dermatoscope or in a skin scraping.
First line Topical
Permethrin 5% cream
First-choice treatment; overnight for at least 8 hours, repeated according to the practice's schedule.²,³
Alternatives For failure, intolerance or special situations
Ivermectin (tablet)
Taken as a single dose based on body weight, repeated if necessary; practical when many people are affected, for example in care homes. Not the first choice for young children or in pregnancy.²,³
Benzyl benzoate
Applied to the skin on three consecutive days and washed off on the fourth day; for children in a lower concentration. Often stings on the skin.²
Crotamiton
Applied to the skin on three to five consecutive days.²

A special form is crusted scabies (scabies crustosa), with thick crusts and very large numbers of mites, mainly in people with a weakened immune system or high care needs. It is highly contagious and is usually treated with a combination of topical treatment and ivermectin tablets under medical, often inpatient, care; the hygiene rules are much stricter.² The German S1 guideline on scabies dates from 2016 and is currently being revised; for treatment details, the RKI refers to the guideline of the German Dermatological Society (DDG).²,⁴ Which alternative is right is decided by the treating practice.

9. Special situations: babies, pregnancy, breastfeeding, care homes

Babies and toddlers

According to the package leaflet, permethrin is only used in babies under two months on medical advice; up to the age of 23 months, treatment should take place under close medical supervision because experience is limited.¹ In babies and toddlers, scabies often looks different: it also appears on the head, face, palms of the hands and soles of the feet, sometimes with blisters. That is why these areas are treated too, leaving out the mouth and eyes. Tips on handling medicines in children in the guide Medications for children.

Pregnancy

According to the package leaflet, extensive experience in pregnant women has shown no evidence of harmful effects; as a precaution, permethrin should only be used during pregnancy on a doctor's instructions.¹ Embryotox describes permethrin as the treatment of choice for scabies in pregnancy, because hardly any active ingredient is absorbed and what is absorbed is broken down quickly.⁵ More in the guide Medications during pregnancy.

Breastfeeding

Here the recommendations differ. As a precaution, the package leaflet advises a five-day break from breastfeeding after use.¹ Embryotox, on the other hand, sees no reason to restrict breastfeeding and also names permethrin as the treatment of choice while breastfeeding; if the breast was treated, it is cleaned thoroughly before feeding.⁵ Discuss with the practice which approach you will follow — and remember that a breastfed baby is a close contact and must be treated too. More in Medications while breastfeeding.

Care homes, shared accommodation, older people

In care facilities, scabies often spreads unnoticed, because itching can be weaker in older people and skin changes look different. According to the package leaflet, in people over 65 the face, ears and scalp are also treated.¹ In outbreaks, the local public health office (Gesundheitsamt) is usually involved so that residents and staff are treated at the same time. More on the organisation in the guide Medications in care homes.

Asthma and eczema

According to the package leaflet, the cream can worsen the symptoms of asthma or eczema.¹ Let the practice know beforehand if this applies to you, and keep your reliever inhaler to hand.

10. Permethrin experiences: what patients really ask

“I treated myself three weeks ago, and it is still itching.”

This is common and usually post-scabies eczema: a reaction to the dead mites, which according to the package leaflet can last up to four weeks. What matters is how it develops. If the itching slowly eases and no new bumps or burrows appear, this suggests the treatment worked. If it gets worse again after improving, or new burrows appear between your fingers, it needs to be seen at the practice — before you apply cream again.

“My partner has no symptoms. Do they really have to take part?”

Yes, if you have close skin contact, for example sleeping in the same bed. After an infection it takes weeks before the itching starts. Anyone who does not get treated now can carry mites without knowing it and pass them back after your treatment. According to the RKI, close contacts are always treated at the same time, even without symptoms. This also applies to sexual partners outside the household.

“I washed my hands during the night. Was it all for nothing?”

No, but on your hands the contact time has been interrupted. According to the package leaflet, the cream is reapplied to the hands and wrists after hand washing; the same applies to the buttocks and genital area after using the toilet. The hands are one of the mites' favourite places — this is exactly where care pays off.

“There are five of us. Do I have to disinfect the whole flat?”

No. With ordinary scabies, according to the RKI it is enough to wash the textiles that touched the skin in recent days on a hot cycle or pack them in plastic bags for three days, and to vacuum upholstery thoroughly. Insect sprays in the home are not needed. Much more important is that all five are treated with cream on the same evening, each person gets their own sufficient amount and everyone takes part in the repeat treatment according to the agreed schedule.

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FAQ: Common questions about permethrin

The cream is applied in the evening, thinly but without gaps, to the whole body: in adults from the neck to the soles of the feet, in children and older people also to the face, ears and scalp, leaving out the eyes and mouth. Particular care is taken with the spaces between the fingers and toes, the nails, wrists, armpits, genital area and buttocks. After at least eight hours, it is showered off.
According to the package leaflet, at least eight hours, ideally overnight. You should not bathe or shower during this time. If you wash your hands or intimate area in between, the cream is applied there again.
According to the package leaflet, one application is usually enough; if the infestation persists or returns, it is repeated after 14 days. In its current guide, the Robert Koch Institute generally recommends a repeat after 7 to 10 days. Which schedule applies is decided by the treating practice.
After an infection, it takes two to five weeks before itching starts. Contacts can therefore be infested without noticing and pass the mites back after treatment. That is why, according to the RKI, close contacts such as partners and family members are treated at the same time, even without symptoms.
The itching is often the body's reaction to the dead mites in the skin and, according to the package leaflet, can last up to four weeks. This is usually not a treatment failure. New mite burrows or itching that gets worse again after improving should, however, be checked by a doctor before applying cream again.
According to the RKI, textiles that have been in contact with the skin are washed at a minimum of 50 degrees for at least ten minutes. Anything that cannot be washed is stored in a sealed plastic bag at room temperature for 72 hours. Upholstery is vacuumed thoroughly; with ordinary scabies, insect sprays in the home are not needed.
Embryotox describes permethrin as the treatment of choice for scabies during pregnancy and breastfeeding, because hardly any active ingredient is absorbed. The package leaflet recommends using it in pregnancy only on a doctor's instructions and advises a five-day break from breastfeeding after treatment. Discuss the approach with your practice.
According to the package leaflet, there are guide values from the age of two months. In younger babies it is only used on medical advice, and up to the age of 23 months treatment should take place under close medical supervision.

Sources

  1. Package leaflet for InfectoScab® 5% cream (permethrin 50 mg/g), INFECTOPHARM, as of June 2021, sections 1 to 6; the SmPC was not freely available at the time of writing — German source. patienteninfo-service.de
  2. Robert Koch Institute: RKI guide to scabies (RKI-Ratgeber Skabies), as of May 2025 — German source. rki.de
  3. Salavastru CM et al.: European guideline for the management of scabies. Journal of the European Academy of Dermatology and Venereology 2017;31:1248–1253. doi.org
  4. S1 guideline Diagnosis and treatment of scabies (Deutsche Dermatologische Gesellschaft, the German Dermatological Society; AWMF register number 013-052, as of 2016, under revision) — German source. register.awmf.org
  5. Embryotox — German pharmacovigilance and advisory centre for embryonic toxicology (Charité Berlin): permethrin in pregnancy and breastfeeding. Accessed 2026. embryotox.de

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Medical disclaimer: This article is for general information and does not replace medical advice, diagnosis or treatment. Do not use permethrin without a medical diagnosis, treat close contacts at the same time after talking to the practice, and do not apply more cream on your own if the itching persists. The cream must not get into the eyes, mouth or onto mucous membranes and must not be swallowed; if you have shortness of breath or swelling of the face, call 112 (emergency number in Germany) immediately. The choice of medicine and the dose are always set individually by the treating practice. Last updated: November 2026.