What is the recommended treatment for a child with scabies?

Treatment of Scabies in Children

Permethrin 5% cream is the first-line treatment for children with scabies, applied to all areas of the body from the neck down (including scalp, hairline, neck, temple, and forehead in infants) and washed off after 8-14 hours. 1, 2, 3

First-Line Treatment: Permethrin 5% Cream

• Apply permethrin 5% cream to the entire body from the neck down, ensuring thorough coverage of all skin folds and creases 1, 3
• In infants and young children, also treat the scalp, hairline, neck, temple, and forehead since these areas are commonly infested in this age group 3
• Leave on for 8-14 hours before washing off with a bath or shower 1, 3
• One application is generally curative, though a second treatment may be needed after 1-2 weeks if live mites persist 3
• Permethrin is safe and effective even in infants younger than 2 months, with minimal side effects reported (primarily mild itching, erythema, or xerosis) 4

Why Permethrin is Preferred for Children

Permethrin demonstrates superior efficacy compared to alternatives, with cure rates of 89% at 4 weeks versus 60% for crotamiton 5, 6. It has low mammalian toxicity, minimal percutaneous absorption, and virtually no allergic side effects 7. The medication is rapidly metabolized in the skin and excreted in urine 7.

Alternative Treatment: Crotamiton 10% Cream

• Use crotamiton 10% cream if permethrin is unavailable or not tolerated 1, 8
• Apply to entire body from chin down nightly for 2 consecutive nights 9, 8
• Wash off 24 hours after the second application 9, 8
• Crotamiton is less effective than permethrin, with cure rates of only 60-65% at 4 weeks 5, 6

Oral Ivermectin Option

• Oral ivermectin (200 μg/kg) with a repeat dose after 2 weeks is an alternative first-line option, particularly useful for treatment failures or institutional outbreaks 1, 2
• Must be taken with food to increase bioavailability 1, 2

Critical Contraindications in Children

AVOID lindane in children under 10 years of age due to risk of neurotoxicity, seizures, and aplastic anemia 9, 1, 2. Lindane should never be used after bathing (increases absorption) or in children with extensive dermatitis 9, 1.

Essential Environmental and Contact Management

• Treat all household and close contacts simultaneously within the preceding month, even if asymptomatic 1, 2
• Decontaminate bedding and clothing by machine washing/drying on hot cycle, dry cleaning, or removing from body contact for at least 72 hours 9, 1, 2
• Fumigation is unnecessary 9, 1
• Trim fingernails short and apply medication under nails, as mites commonly hide there 1, 8

Follow-Up and Treatment Failure Management

• Pruritus may persist for up to 2 weeks after successful treatment and does not indicate treatment failure 1, 2, 3
• Retreatment is indicated only if live mites are observed after 14 days or symptoms persist beyond 2 weeks 1, 2, 3
• Common causes of treatment failure include:
  • Failure to treat all close contacts simultaneously 1, 2
  • Inadequate application of topical treatment (missing skin folds, under nails) 1, 2
  • Reinfection from untreated contacts or contaminated fomites 1, 2
  • Not repeating ivermectin dose after 2 weeks if using oral therapy 1, 2

Special Considerations for Infants

• Permethrin is safe for infants of all ages, including those younger than 2 months 4
• Always include scalp and face treatment in infants, as these areas are commonly affected 3
• Sulfur 6% ointment (applied nightly for 3 nights) is an alternative for very young infants if there are concerns about permethrin, though it is less cosmetically elegant 1