Permethrin Dosing for Pediatric Scabies
For pediatric patients with scabies, apply permethrin 5% cream to all areas of the body from the neck down (including scalp, hairline, neck, temple, and forehead in infants and young children) and wash off after 8-14 hours, with one application generally curative. 1, 2
Standard Dosing Regimen
- Apply permethrin 5% cream to the entire body from neck down, washing off after 8-14 hours 1, 3, 2
- One application is generally curative in most cases 2
- Approximately 30 grams is sufficient for an average adult; adjust proportionally for pediatric body surface area 2
Critical Pediatric-Specific Considerations
Application Sites by Age
- Infants and young children require application to the scalp, hairline, neck, temple, and forehead in addition to the body, as these areas are commonly infested in this age group 1, 2, 4
- Older children and adults typically require neck-down application only, though scalp involvement can occur and may necessitate scalp-to-toes application 4
Age-Specific Safety
- Permethrin is safe and effective in children ≥2 months of age per FDA labeling 2
- For infants <2 months, permethrin remains off-label but has been demonstrated safe and well-tolerated in clinical practice, with successful treatment in seven infants without adverse effects even with repeated applications 5
- Permethrin is specifically recommended for infants and young children over alternative agents like lindane or ivermectin 1, 3
Important Clinical Pitfalls to Avoid
Common Treatment Failures
- Inadequate application is a leading cause of treatment failure; ensure thorough massage into all skin surfaces 2
- Failure to treat the scalp and head in infants leads to persistent infestation 1, 4
- Not treating all close contacts simultaneously results in reinfection 3, 6
Post-Treatment Expectations
- Persistent pruritus after treatment is common and rarely indicates treatment failure; it is not an indication for retreatment 2
- Approximately 75% of patients with persistent itching at 2 weeks will have resolution by 4 weeks 2
- Retreatment is indicated only if demonstrable living mites are present after 14 days 2
Contraindications in Pediatrics
- Lindane should NOT be used in children <10 years due to neurotoxicity risk, including seizures and aplastic anemia 1, 3
- Ivermectin should NOT be used in children <10 years per CDC guidelines 1
Efficacy Data
- Permethrin 5% cream achieved 89% cure rate at 4 weeks in pediatric patients aged 2 months to 5 years, significantly superior to crotamiton (60% cure rate, P=0.002) 7
- Two applications of permethrin provided 85% cure rate at 4-week follow-up in a larger pediatric study 8
Environmental Management
- Decontaminate bedding and clothing by machine washing/drying on hot cycle, dry cleaning, or removing from body contact for ≥72 hours 1, 3, 6
- Treat all household and close contacts within the preceding month, even if asymptomatic 3, 6
- Fumigation of living areas is unnecessary 3
Special Populations
Pregnant/Lactating Mothers
- Permethrin is the preferred agent for pregnant and lactating women, considered safe with no evidence of teratogenicity 1, 6, 2
Immunocompromised Children
- Closer monitoring is necessary as these patients are at increased risk for treatment failure and may require combination therapy 3