Comparative effectiveness of permethrin and ivermectin on pruritus and psychological outcomes in scabies: a prospective cohort of 600 adults

Background Scabies is a common parasitic skin disease causing intense pruritus and psychological distress. While permethrin and ivermectin are both established first-line therapies, their comparative effects on psychological outcomes and dermatology-specific quality of life remain underexplored. This study aims to compare the effects of permethrin and ivermectin on anxiety, depression, sleep quality, and dermatology-related quality of life.Methods This multicenter cohort study included 600 adults with confirmed scabies who were treated between February and August 2025. Of these, 292 received oral ivermectin and 308 received topical permethrin. Patients who completed a full 6-week treatment course were evaluated using the Visual Analog Scale (VAS) for pruritus, Hospital Anxiety and Depression Scale (HADS), Pittsburgh Sleep Quality Index (PSQI), and Skindex-29. Between- and within-group analyses were conducted, supported by multivariate linear regression, subgroup interactions, ANCOVA, and mediation analysis.Results Both treatments significantly improved VAS, PSQI, HADS-depression, and Skindex-29 scores (p < 0.001). However, anxiety reduction (HADS-anxiety) was greater with permethrin than ivermectin (p < 0.001), a difference that remained significant after adjusting for change in pruritus. Permethrin also showed superior outcomes in emotional quality of life (Skindex-Emotions; p = 0.022). No serious adverse events were reported.Conclusions While both agents are effective, permethrin may confer greater short-term psychological benefit. These findings highlight the relevance of psychobehavioral mechanisms in scabies management beyond symptom control.