A 32-year-old woman presents with severe pruritus, worse at night, affecting the interdigital spaces, flexural surfaces, and genitalia. Burrows are visible on examination. She lives in a joint family with 8 members. What is the most appropriate next step in management?

Explanation

## Management Principles in Scabies **Key Point:** Scabies is a highly contagious parasitic infestation with an incubation period of 2–6 weeks. Simultaneous treatment of all household contacts is essential to prevent reinfection and break the transmission cycle. ### Why Simultaneous Household Treatment is Mandatory **High-Yield:** In a joint family setting, treating only the index patient will result in reinfection from untreated contacts. The mite can survive 48–72 hours on fomites; therefore, environmental decontamination (washing bedding, clothing, towels at ≥60°C or dry cleaning) is equally critical. ### Standard First-Line Regimen | Agent | Dose | Application | Advantages | |-------|------|-------------|------------| | Permethrin 5% cream | Apply to entire body except face | Leave on for 8–14 hours, repeat after 1 week | First-line in non-pregnant, non-immunocompromised | | Benzyl benzoate 10–25% | Apply to entire body | Leave on for 12–24 hours, repeat after 1 week | Cheaper, effective, safe in pregnancy | | Sulfur 5–10% | Apply to entire body | Leave on for 24 hours, repeat for 3 days | Safe in infants, pregnant women, immunocompromised | **Clinical Pearl:** Permethrin 5% is the gold standard in most guidelines because of superior efficacy, low toxicity, and rapid action. In India, benzyl benzoate remains widely used due to cost. ### Fomite Decontamination 1. Wash all bedding, clothing, and towels in hot water (≥60°C) or dry clean. 2. Items that cannot be washed should be sealed in a plastic bag for 1–2 weeks (mites die without a host). 3. Furniture and floors do not require special disinfection if routine cleaning is done. **Warning:** Failure to treat household contacts is the most common reason for treatment failure and recurrence in scabies. ### Post-Treatment Follow-up - Pruritus may persist for 2–4 weeks despite successful mite eradication (due to residual mite antigens and host inflammation). - If new burrows or lesions appear after 2 weeks, repeat treatment is indicated. - Patients should be counseled that itch alone does not indicate treatment failure.