What is the management for scabies in a baby less than 2 months old?

Management of Scabies in Infants Less Than 2 Months Old

Topical permethrin 5% cream is the treatment of choice for scabies in infants less than 2 months old, applied from the neck down (including face, scalp, palms, and soles in this age group) for 8-14 hours, then washed off. 1, 2

First-Line Treatment: Permethrin 5% Cream

• Permethrin is specifically recommended by the CDC and American Academy of Pediatrics as the preferred agent for infants and young children due to its high efficacy, low toxicity, and minimal percutaneous absorption 1, 2, 3

• Apply to all body areas from the neck down, but critically in infants <2 months, also include the face, scalp, palms, and soles since these areas are frequently involved in this age group (unlike older patients) 3

• Leave on for 8-14 hours before washing off 1, 2

• A single application is generally curative, though a second application may be considered after 1-2 weeks if live mites persist 1

• Real-world data from 57 pediatric dermatologists shows permethrin is used in 82.5% of cases in infants <2 months, with only 4.3% reporting mild side effects (itching, erythema, xerosis) and no serious adverse events 4

Alternative Treatment: Precipitated Sulfur 6%

• Precipitated sulfur 6% ointment is the main alternative when permethrin is unavailable or contraindicated 5, 2

• Apply for 3 consecutive nights 5

• This is a safe option in very young infants, though less convenient than permethrin 6

Oral Ivermectin: NOT Recommended in This Age Group

• Ivermectin is contraindicated in infants <15 kg (approximately <2 years old) due to potential neurotoxicity 1, 5, 2

• While emerging data suggests it may be safe in children 4-15 kg when used off-label, there is insufficient safety data for infants <2 months or <4 kg 7, 8

• Do not use ivermectin in this population 9, 1

Critical Management Steps Beyond Medication

Treat All Close Contacts Simultaneously

• Examine and treat all household members, caregivers, and close contacts within the preceding month, even if asymptomatic 1, 2
• Failure to treat contacts simultaneously is the most common cause of treatment failure 5

Environmental Decontamination

• Machine wash and dry all bedding, clothing, and towels using hot cycles, or dry clean 1, 2
• Alternatively, remove items from body contact for at least 72 hours (the mite cannot survive off the host longer than this) 9, 1
• Fumigation of living areas is unnecessary 9, 2

Application Technique

• Apply permethrin to all skin folds, under fingernails and toenails, and up to the edge of all body orifices 5
• In infants <2 months, ensure coverage of face, scalp, palms, and soles 3

Follow-Up and Expected Course

• Pruritus and rash may persist for up to 2 weeks after successful treatment - this does NOT indicate treatment failure 1, 2

• Reevaluate after 1-2 weeks if symptoms persist 9

• Consider retreatment only if live mites are observed or symptoms persist beyond 2 weeks 1, 2

• Postscabietic nodules may persist for months after mite clearance 3

Agents to AVOID in This Population

• Lindane is absolutely contraindicated in infants <2 months due to risk of neurotoxicity, especially after bathing or in those with extensive dermatitis 9, 1, 2

• Lindane has been associated with seizures and aplastic anemia 9

• Benzyl alcohol lotion and malathion are not appropriate for this age group 9

Common Pitfalls to Avoid

• Not treating asymptomatic household contacts leads to reinfection 5

• Applying permethrin after bathing increases absorption and potential toxicity 2

• Missing critical areas like scalp, face, palms, and soles in young infants 3

• Expecting immediate symptom resolution - pruritus takes up to 2 weeks to resolve 1, 2