A 9-month-old infant has vesiculopustular lesions on the palms and soles, plus the face and neck, with linear burrow lesions on the hands and wrists. What is the treatment?

A 9-month-old infant has vesiculopustular lesions on the palms and soles, plus the face and neck, with linear burrow lesions on the hands and wrists. What is the treatment?

• A. Ivermectin 200 mcg/kg for 7 to 14 days, along with symptomatic treatment for itching
• B. Permethrin 5% cream for 7 days with ivermectin 200 mcg/kg
• C. Treatment of all family members except the infant with permethrin 5% cream and ivermectin
• D. Permethrin 5% cream applied to face, neck, and body and rinsed off in 8 to 14 hours

Answer: (D)

This presentation is classic for scabies in an infant, where the rash and burrows involve the face and neck in addition to the hands and feet. The best approach is a topical scabicide that is safe for young children and capable of treating mites on the entire body, including the face. Permethrin 5% cream is first-line for infants. It’s applied all over the body from the neck down, and in babies you treat the face and neck as well, taking care to avoid the eyes and mucous membranes. After a contact time of 8 to 14 hours, the cream is washed off. This regimen delivers effective contact with the mites and their eggs while remaining safe for a 9‑month‑old. A second treatment is often considered after about a week if symptoms persist. Why the other approaches aren’t ideal here: systemic ivermectin is generally avoided in infants because of safety concerns and dosing uncertainty at this age and weight; combining ivermectin with permethrin isn’t routinely needed for an initial infantile infestation; and excluding the infant from treatment or only treating others in the household would leave the infant untreated and at risk for ongoing infection and reinfestation. So, applying permethrin 5% cream to the face, neck, and body with an 8–14 hour contact time is the appropriate choice.

This presentation is classic for scabies in an infant, where the rash and burrows involve the face and neck in addition to the hands and feet. The best approach is a topical scabicide that is safe for young children and capable of treating mites on the entire body, including the face.

Permethrin 5% cream is first-line for infants. It’s applied all over the body from the neck down, and in babies you treat the face and neck as well, taking care to avoid the eyes and mucous membranes. After a contact time of 8 to 14 hours, the cream is washed off. This regimen delivers effective contact with the mites and their eggs while remaining safe for a 9‑month‑old. A second treatment is often considered after about a week if symptoms persist.

Why the other approaches aren’t ideal here: systemic ivermectin is generally avoided in infants because of safety concerns and dosing uncertainty at this age and weight; combining ivermectin with permethrin isn’t routinely needed for an initial infantile infestation; and excluding the infant from treatment or only treating others in the household would leave the infant untreated and at risk for ongoing infection and reinfestation.

So, applying permethrin 5% cream to the face, neck, and body with an 8–14 hour contact time is the appropriate choice.