What is the best treatment for a baby with a scalp infection?

Treatment of Baby Scalp Infections

For bacterial scalp infections in infants, systemic antibiotics targeting Gram-positive organisms (particularly Staphylococcus aureus and beta-hemolytic Streptococcus) are required, with surgical drainage being essential for any abscess formation. 1, 2

Initial Diagnostic Considerations

The etiology of scalp infection in infants determines treatment approach:

• History of fetal scalp electrode placement mandates evaluation for gonococcal scalp abscess, which requires blood, CSF, and abscess aspirate cultures on chocolate agar before initiating therapy 3, 1, 4
• Bacterial infections present with purulent drainage, crusting, erythema, warmth, and tenderness and require systemic antibiotics 2
• Fungal infections (tinea capitis) present with scaling, alopecia, and lymphadenopathy but are rare in neonates 3, 5
• Seborrheic dermatitis presents with scaling and erythema without purulence and responds to topical antifungals 6

Treatment Algorithm by Infection Type

Gonococcal Scalp Abscess (if fetal scalp electrode used)

Ceftriaxone 25-50 mg/kg/day IV or IM in a single daily dose for 7 days is the CDC-recommended treatment, extending to 10-14 days if meningitis is documented 3, 1, 4, 2. This represents the highest priority guideline-based recommendation for this specific scenario.

• Hospitalization is required for evaluation of disseminated infection (sepsis, arthritis, meningitis) 3
• Obtain cultures from blood, CSF, and abscess aspirate on chocolate agar before treatment 3, 1
• Alternative regimen: Cefotaxime 25 mg/kg IV or IM every 12 hours for 7 days 3

Bacterial Scalp Infections (Non-Gonococcal)

For localized bacterial infections without systemic signs:

• First-line oral therapy: Flucloxacillin (penicillinase-resistant penicillin) targeting S. aureus and Streptococcus 7
• Alternative agents: Cefalexin or cefadroxil (broader coverage, once-daily dosing) 7, 8
• Treatment duration: 7 days is adequate despite traditional 10-day courses 7

For moderate-to-severe infections with systemic signs:

• Empiric IV therapy with ceftriaxone (advantage of once-daily dosing for potential outpatient management) 7
• Alternative: Vancomycin plus piperacillin-tazobactam or carbapenem 2

Scalp Abscesses

Incision and drainage is the primary and essential treatment, with antibiotics added only if systemic signs are present 1, 2, 7:

• Multiple counter-incisions are preferred over single long incisions to prevent step-off deformities 2
• If S. aureus confirmed as methicillin-susceptible (MSSA), dicloxacillin 25-50 mg/kg/day divided into 4 oral doses may be used after drainage 1
• Antibiotics alone are insufficient for localized purulent infections 1

Tinea Capitis (Fungal)

While rare in neonates 5, if diagnosed:

• Systemic antifungal therapy is required as topical therapy alone is inadequate 3
• Griseofulvin 15-20 mg/kg/day for 6-8 weeks (licensed for children in many countries, more effective against Microsporum species) 3
• Terbinafine 62.5 mg/day (for infants <20 kg) for 2-4 weeks (more effective against Trichophyton species) 3
• One case report documented successful topical treatment in a 16-day-old with bifonazole 1%, but this is not standard practice 5

Seborrheic Dermatitis

• Topical antifungal agents (ketoconazole) are mainstay of therapy 6
• Topical corticosteroids only for short-term use due to adverse effects 6
• Note: Selenium sulfide safety and effectiveness have not been established in infants per FDA labeling 9

Critical Pitfalls to Avoid

• Never rely on topical antibiotics alone for bacterial scalp infections—systemic therapy is required 2, 7
• Never prescribe antibiotics for simple abscesses without drainage—incision and drainage is definitive treatment 1, 2
• Never miss gonococcal infection in infants with history of fetal scalp electrode placement—this requires urgent evaluation and specific treatment 3, 4
• Never use topical therapy alone for tinea capitis—the infection invades the hair shaft and requires systemic treatment 3, 5
• Always obtain cultures before initiating therapy when possible to guide antibiotic selection and identify resistance patterns 2, 7

MRSA Considerations

Consider MRSA coverage if:

• Prior MRSA infection
• Failure of initial therapy
• High local MRSA prevalence 2

For community-acquired MRSA in well infants, clindamycin or trimethoprim-sulfamethoxazole may be used, but close observation for adverse effects is required 7.