How should I approach the treatment of scabies in a pregnant patient?

Treatment of scabies in pregnancy should not be withheld due to concerns about fetal risk. Topical permethrin 5% cream is considered safe and is the first-line treatment for classical scabies in pregnant women from 2 months of age onwards. It can be used at any stage of pregnancy without medical grounds for termination or additional fetal monitoring.

If permethrin is inappropriate (e.g., allergy), malathion aqueous 0.5% liquid may be used, although it is currently unavailable. Benzyl benzoate is generally not recommended due to lower efficacy and skin irritation risk.

All close contacts, including household members and sexual partners within the past 3 months, should also be treated simultaneously to prevent reinfestation.

Bedding, clothing, and towels should be decontaminated by washing at high temperature (≥60°C), drying in a hot dryer, dry-cleaning, or sealing in a plastic bag for at least 72 hours.

Persistent itching may continue for up to 4 weeks after successful treatment; if symptoms persist beyond 2–4 weeks or new burrows appear, retreatment should be considered.

Oral ivermectin is generally not first-line in pregnancy but may be considered in resistant cases after specialist advice.