Treatment of Crusted Scabies in a 2-Year-Old
For crusted scabies in a 2-year-old child, use combination therapy with topical 5% permethrin cream applied daily for 7 days then twice weekly until cure, plus oral ivermectin 200 μg/kg on days 1,2,8,9, and 15. 1, 2
Treatment Regimen
Topical Therapy
- Apply 5% permethrin cream to all areas of the body including the scalp, hairline, neck, temple, and forehead (critical in infants and young children) down to the soles of the feet 1, 3
- For crusted scabies specifically: apply daily for 7 consecutive days, then continue twice weekly until clinical cure is achieved 1, 2
- Leave cream on for 8-14 hours before washing off 1, 3
- Ensure application under fingernails and toenails 4
Oral Therapy
- Administer ivermectin 200 μg/kg orally on days 1,2,8,9, and 15 1, 2
- Give with food to increase bioavailability and epidermal penetration 1
- Important caveat: While guidelines traditionally recommend against ivermectin in children <15 kg due to neurotoxicity concerns 2, 4, recent high-quality evidence from a multicentric French study of 170 children aged 1-64 months (4-14.5 kg) showed only 4% mild adverse events with no serious toxicity 5
- The same study demonstrated 85% cure rates with doses >200 μg/kg and intervals <10 days between doses 5
Critical Management Steps
Contact and Environmental Management
- Examine and treat all household, close personal, and sexual contacts from the preceding month simultaneously, even if asymptomatic 1, 2, 4
- Failure to treat contacts simultaneously is the most common cause of treatment failure 4
- Decontaminate all bedding and clothing by machine washing/drying on hot cycle, dry cleaning, or removing from body contact for at least 72 hours 1, 4
- Fumigation of living areas is unnecessary 1, 4
Follow-Up Expectations
- Pruritus and rash may persist for up to 2 weeks after successful treatment and does not indicate treatment failure 1, 2, 4
- Only consider retreatment if symptoms persist beyond 2 weeks and live mites are observed 1, 2
Common Pitfalls to Avoid
- Never use lindane in this age group—it is contraindicated in children <10 years due to neurotoxicity risk 1, 2, 4
- Do not apply lindane after bathing, as this increases absorption and toxicity 1, 4
- Ensure permethrin is applied to the scalp and face in young children, as these areas are commonly infested in this age group but often missed 3
- Do not skip any of the scheduled ivermectin doses on days 1,2,8,9, and 15, as crusted scabies requires this intensive regimen 1, 2
Special Considerations for This Age Group
- At 2 years old, this child likely weighs <15 kg, placing them in a traditionally cautious category for ivermectin use 2, 4
- However, crusted scabies is a severe, highly contagious variant with massive mite burden that requires aggressive combination therapy 1, 2, 6, 7
- The risk-benefit analysis favors using ivermectin in this context, as topical therapy alone is often insufficient for crusted scabies 6, 7
- Monitor closely for treatment response, as immunocompromised patients have higher treatment failure rates 1