Alternatives to Permethrin If You Can't Fill Your Prescription

Permethrin is the CDC's and AAP's first-line treatment for both scabies and head lice — but it's not always available, and resistance is a growing concern. Whether your pharmacy is out of stock or permethrin simply hasn't worked after two full treatment cycles, there are solid alternatives your provider can prescribe.

Here's a breakdown of the best FDA-approved alternatives to permethrin, organized by what you're treating.

Alternatives to Permethrin for Scabies

1. Oral Ivermectin (Stromectol / Generic Ivermectin)

Oral ivermectin is the most commonly prescribed alternative to permethrin for scabies in the US. It's a single pill (dosed at 200 mcg/kg of body weight), usually taken in two doses 14 days apart. Clinical trials show it has similar efficacy to permethrin after 2 weeks, though permethrin provides faster initial symptom relief in the first week.

Rx required: Yes

Cash price: ~$15-40 for generic with GoodRx

Best for: Adults and children over 15 kg (33 lbs); those who can't tolerate topical therapy; institutional outbreaks; crusted (Norwegian) scabies

Not for: Children under 15 kg, pregnant women, or breastfeeding mothers without explicit provider guidance

2. Crotamiton 10% Cream or Lotion (Eurax)

Crotamiton is an FDA-approved topical scabicide that also relieves itching — a useful bonus since itching after permethrin treatment can persist for weeks. It's applied to the entire body on two consecutive nights, then washed off 48 hours after the second application.

Rx required: Yes

Efficacy: Generally considered less effective than permethrin but a valid alternative when permethrin is unavailable or fails

Best for: Patients with significant itching; those who cannot take oral ivermectin

3. Sulfur Ointment (Precipitated Sulfur 6-10%)

Sulfur ointment is the oldest treatment for scabies and is still used today in resource-limited settings or for patients who cannot use permethrin or ivermectin. It is not FDA-approved for scabies, but is considered safe — including in pregnant women and infants under 2 months. It's typically applied nightly for 3 consecutive nights. Compounding pharmacies can prepare it.

Alternatives to Permethrin for Head Lice

4. Spinosad (Natroba)

Spinosad is a prescription topical treatment for head lice that is highly effective against permethrin-resistant lice. It's applied to dry hair and scalp for 10 minutes, then rinsed off. One application is usually curative — unlike permethrin, you often don't need to repeat treatment.

Best for: Permethrin-resistant lice; children aged 4 and older

Drawback: More expensive than permethrin (brand-name Natroba can cost $200+ without insurance)

5. Malathion 0.5% Lotion (Ovide)

Malathion (brand: Ovide) is FDA-approved for head lice and is recommended by the CDC when permethrin resistance is suspected. It is applied to dry hair and left on for 8-12 hours. It is highly flammable while wet — patients should not use hair dryers or be near open flames after application.

Rx required: Yes

Not for: Children under 6 years; pregnant or breastfeeding women without provider consultation

6. Benzyl Alcohol 5% Lotion (Ulesfia)

Benzyl alcohol lotion (Ulesfia) is FDA-approved for head lice in patients aged 6 months and older. It works by asphyxiating lice rather than affecting the nervous system — meaning there's no cross-resistance with permethrin. It requires two treatments 7 days apart.

When Should You Try an Alternative?

Consider an alternative to permethrin when:

Permethrin is not available at any pharmacy near you

You have tried two full courses of permethrin and live mites or lice are still present after 14 days

You are allergic to pyrethrins or chrysanthemums

You have an infant under 2 months old (permethrin is not approved in this age group)

Bottom Line

Permethrin is still the go-to first-line treatment for scabies and head lice — but if you can't find it or it hasn't worked, effective alternatives exist. Talk to your doctor about oral ivermectin, crotamiton, or spinosad as appropriate for your situation. If you're still trying to locate permethrin, medfinder can help you find which pharmacies have it in stock near you.