Scabies (pediatric) in Infant/Neonate
See also in: AnogenitalAlerts and Notices
Synopsis
Scabies is a parasitic infestation of the epidermis. It is caused by the obligate human parasite Sarcoptes scabiei var hominis and is transmitted via direct skin-to-skin contact and rarely by fomites. Scabies affects all ethnic groups and socioeconomic levels. It is most common in young children, and the highest prevalence is seen in children younger than 2 years. It is extremely contagious, spreading between individuals who share close contact or living spaces. Frequent outbreaks occur in schools, group homes, and orphanages where direct contact with infested individuals is common. The most common predisposing factors are overcrowding, poverty, poor nutrition, and being undomiciled. Other predisposing conditions include immunocompromised status, HIV infection, and severe intellectual or physical disability.
Symptoms and signs typically develop approximately 3 weeks after the primary infestation. The most common clinical manifestation of scabies in infants is the development of pustules, vesicles, and crusting. The palms and soles, fingers, face, and scalp are most heavily involved. Secondary impetigo and eczematization are also common. The primary symptom of infestation is pruritus, and in young infants who have not developed a coordinated itch response, this may manifest as rubbing the head against a caregiver, irritability, insomnia, and poor feeding.
Crusted scabies (formerly known as Norwegian scabies) is a variant of scabies characterized by profuse proliferation of mites within the epidermis, with subsequent widespread scaly, crusted, or hyperkeratotic papules and plaques. Pruritus may be severe but is usually minimal or absent. It is mainly seen in immunocompromised individuals.
Codes
ICD10CM:B86 – Scabies
SNOMEDCT:
128869009 – Infestation by Sarcoptes scabiei var hominis
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Differential Diagnosis & Pitfalls
- Infantile acropustulosis – Thought by many authors to be precipitated by scabies.
- Eosinophilic folliculitis of infancy – Extremely pruritic; scalp involvement may differentiate from scabies.
- Impetigo – Erythematous vesiculopustular lesions that rupture, forming the pathognomonic honey-colored crust. Lesions may involve the face, neck, and extremities. Scabies may sometimes be impetiginized, so a good history may distinguish primary versus secondary impetigo.
- Neonatal herpes – Discrete or grouped vesicles on an erythematous base, possibly with systemic symptoms. Tzanck smear from the vesicle reveals multinucleated giant cells.
- Congenital cutaneous candidiasis – Presents at birth, may affect the nails, and may be associated with placental lesions and inflammation. Potassium hydroxide (KOH) preparation of vesicular contents reveals yeast and pseudohyphae.
- Cutaneous candidiasis – Affects the intertriginous areas, especially the groin or neck, in the form of confluent erythematous patches with multiple, small satellite pustules. A KOH test from a pustular lesion reveals budding spores and pseudohyphae.
- Atopic dermatitis – Eczematous lesions with oozing on the face and flexural areas (cubital and popliteal fossa). Lichenification is seen in chronic dermatitis. Burrows are absent, and lesions are not seen in the web spaces.
- Papular urticaria – A hypersensitivity reaction to a variety of bites, such as mosquitoes, fleas, bedbugs, and mites. There may be a seasonal occurrence. Recurrent episodes of excoriated papular and urticarial lesions on the exposed parts of the extremities (extensor aspect) are the cardinal features. Absence of burrows and family history of itching differentiate this from scabies.
- Langerhans cell histiocytosis
- Insect bites
- Tinea corporis
- Leukemia or lymphoma cutis, prurigo nodularis (differential for scabies nodules)
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Last Reviewed:02/15/2023
Last Updated:04/06/2023
Last Updated:04/06/2023
Patient Information for Scabies (pediatric) in Infant/Neonate
Overview
Scabies is a common itchy rash seen in children and infants that is highly contagious. It is caused by a small bug known as a mite. (The scientific name of the mite is Sarcoptes scabiei.) The female mite typically enters the skin through skin folds, such as the space between the fingers, and burrows or invades the skin, forming a red "tract." She then proceeds to lay eggs in the skin, which will later hatch into larvae. The first sign of a scabies infection (actually it is an infestation, but the two words tend to be used interchangeably for scabies) is usually several small (1–2 mm) red, crusty bumps on the hands and feet. The skin of infants is often more exposed and more sensitive, and, therefore, these lesions can develop into large blistering lesions or pus-filled bumps. Scabies is extremely itchy because the human immune system forms an allergic reaction to the mite and the eggs that hatch.Who’s At Risk
Scabies can infect all populations. It is common among children and infants and can be spread rapidly through day cares, nurseries, and households. Scabies is spread through physical contact, and the more exposure you have to an infected person increases the risk for becoming infected yourself, which is why those living in the same household are particularly prone to becoming infected.Typically the head, neck, palms of the hands, and soles of the feet are spared from the rash.
Signs & Symptoms
Although the entire body may itch, the most common locations for the lesions of scabies in older children and adults include:- The areas between the fingers (finger webs)
- Inner wrists, inner elbows, and armpits
- Breasts of females and genitalia of males
- Navel (umbilicus)
- Lower abdomen
- Buttocks
- Backs of knees
- Trunk, arms, and legs
- Head and neck
- Palms of the hands and soles of the feet
Scabies is intensely itchy, especially at night.
Scratching the itchy lesions can create breaks in the skin, and these breaks can become infected with bacteria.
People who are exposed to scabies may not develop itchy lesions for up to 6 weeks after becoming infested, as the immune system takes some time to recognize the mites and develop an allergic response to them. However, individuals who have had scabies before may develop the rash within several days of re-exposure.
Self-Care Guidelines
Though scabies is extremely contagious, it usually requires prolonged skin-to-skin contact with a person already infested. A quick handshake or hug will not normally spread the infection. However, scabies is easily spread to sexual partners and to other members of the household. Less commonly, it may be spread by sharing towels, clothing, or bedding.Scabies requires prescription medication in order to stop the infestation. Once your child is under a doctor's care, there are steps you can take to prevent scabies from coming back:
- Mites cannot survive off the human body for more than 48-71 hours. Therefore, wash all clothing, bedding, and towels used by the infested person in the previous 72 hours in hot water and dry these items in a hot dryer.
- Vacuum all carpets, rugs, and upholstered furniture, and discard the vacuum bags.
When to Seek Medical Care
See your child's doctor for evaluation if he or she develops an extremely itchy rash. If other members of the household or your child's close contacts have similar itchy rashes, make sure they are also evaluated by a physician.Treatments
The physician may be able to diagnose scabies simply by examining your child's skin for typical lesions such as burrows. A skin scraping, called a scabies preparation, may be examined under the microscope for mites, eggs, or mite droppings (feces).In most cases of scabies, the doctor may recommend a topical cream or lotion, such as:
- Permethrin cream – Apply at night, and rinse off in the morning. Use the permethrin cream again in 1 week. Permethrin has been approved for use in infants aged 2 months or older.
- Crotamiton cream – Apply once daily for 2 consecutive days, and rinse off 48 hours after last application.
- Sulfur ointment – Apply nightly for 3 consecutive nights, and rinse off 24 hours after last application. This is often the best choice for babies and for pregnant and nursing women because it is very safe to use.
- Lindane lotion or cream – Wash the cream or lotion off after 8 hours. Lindane may be toxic to some people. Infants and young children should not be treated with lindane, nor should pregnant or breast-feeding women or people with diseases affecting the nerves (neurological diseases).
- Apply to the entire body from the neck down.
- Smear the product beneath your child's fingernails and toenails.
- Apply to body folds, including inside the navel, in the buttock crease, and between the toes.
- Ivermectin pills – Take once and then repeat 1–2 weeks later. Ivermectin should not be used for children aged younger than 5 years or who weigh less than 15 kg (about 35 lb), or pregnant or lactating women.
- Antihistamine pill.
- Antibiotic pills – If any scratched areas appear to be infected with bacteria, your physician may prescribe oral antibiotics.
Your doctor should remind you to launder towels, bed linens, and clothes used by your child in the previous 72 hours and to vacuum carpets, rugs, and upholstered furniture.
Household members, sexual partners, and anyone else with prolonged skin-to-skin contact with an infested person should also seek treatment from their doctors. Since the initial development (incubation time) for scabies infestations can be from 6–8 weeks, people may be infected with scabies, but since they do not yet feel itchy, they are unaware that they have infestation. If untreated, these close contacts could pass the mites back to your child. Ideally, everyone should be treated at the same time in order to prevent re-infestation.
References
Bolognia, Jean L., ed. Dermatology, pp.1321-1324. New York: Mosby, 2003.
Freedberg, Irwin M., ed. Fitzpatrick's Dermatology in General Medicine. 6th ed. pp.1374, 2283-2284. New York: McGraw-Hill, 2003.
Scabies (pediatric) in Infant/Neonate
See also in: Anogenital