Effectiveness of scabies treatments in Italy (SCAB-net): a prospective observational study

Background: Scabies is a neglected tropical disease with a worldwide distribution. Although uncommon in high-income countries, its incidence has increased in recent years, accompanied by growing reports of treatment failure, particularly with topical permethrin. Observational data from high-income settings remain scarce. We aimed to evaluate the effectiveness of first-line scabies treatments and to identify predictors of treatment failure in Italy. Methods: SCAB-net was a national, prospective, multicentre observational study conducted in 28 Italian dermatology centres between June 20, 2024, and Dec 31, 2025. Index cases were diagnosed according to International Alliance for the Control of Scabies criteria and followed up until recovery. Treatment selection was left to the discretion of clinicians according to routine clinical practice and included permethrin 5% cream, oral ivermectin 200 μg/kg, benzyl benzoate 10–25% lotion, and their combinations. The primary outcome was clinical cure in the index case. Multivariable logistic regression was used to evaluate associations between clinical factors and recovery. Findings: Among the enrolled 1751 index cases, 1640 had complete treatment data. Benzyl benzoate monotherapy achieved the highest cure rate (84·2% [250 of 297]), significantly outperforming permethrin (42·5% [433 of 1019]; odds ratio [OR] for non-cure permethrin vs benzyl benzoate 6·85, 95% CI 4·65–10·09, p<0·0001). Cure rates with ivermectin were similar to benzyl benzoate (81·6% [449 of 550], p=0·35). Combination therapies did not significantly improve outcomes compared with benzyl benzoate alone. Environmental decontamination counselling was associated with reduced odds of treatment failure (OR 0·39; 95% CI 0·26–0·57; p<0·0001), whereas immunosuppression (OR 2·34; 1·22–4·49; p=0·010) and foreign nationality (OR 1·36; 1·05–1·75; p=0·018) were associated with increased risk. Interpretation: In this observational study from a high-income country, permethrin showed substantially reduced effectiveness compared with benzyl benzoate or ivermectin. These findings support reconsideration of current scabies treatment recommendations. Funding: None. Translations: For the Italian translation of the abstract see Supplementary Material section.