Describe the management of scabies in a neonate, in a child less than 2 years of age, an adult and a pregnant female.

Management in a Neonate (Less than 28 days)

Scabies in neonates is often acquired from close contact with infected caregivers. Management is challenging due to the neonate’s delicate skin and increased risk of systemic absorption.

• Diagnosis: Clinical diagnosis is often made based on characteristic lesions, but confirmation via skin scraping is difficult in neonates.
• Treatment: Permethrin 5% cream is generally considered the safest option, but should be used cautiously and sparingly, applied only to affected areas, and hands should be washed thoroughly after application. Avoid application to the face and scalp.
• Non-Pharmacological: Frequent bathing and gentle skin care are essential. All close contacts, including breastfeeding mothers, should be treated simultaneously.
• Monitoring: Monitor for signs of systemic absorption (irritability, lethargy).

Management in a Child Less Than 2 Years of Age

Children under two are also vulnerable to systemic absorption and require careful treatment.

• Diagnosis: Skin scraping can be attempted, but clinical diagnosis is often sufficient.
• Treatment: Permethrin 5% cream remains the first-line treatment. Application should be limited to affected areas and followed by thorough handwashing. Avoid the face, scalp, and diaper area. Lindane is contraindicated in this age group due to neurotoxicity.
• Oral Ivermectin: Not generally recommended under 15kg body weight due to safety concerns.
• Non-Pharmacological: As with neonates, frequent bathing and emollient use are important. Treat all household contacts.
• Pruritus Management: Antihistamines (e.g., hydroxyzine) can be used cautiously to manage pruritus, under medical supervision.

Management in an Adult

Adults typically present with more widespread and chronic scabies.

• Diagnosis: Skin scraping is highly recommended to confirm the diagnosis.
• Treatment:
  • Topical: Permethrin 5% cream is the first-line treatment. Apply from neck to toes, leaving on for 8-14 hours, then wash off. Repeat after 7 days.
  • Oral Ivermectin: An alternative for those who cannot tolerate topical treatment or have extensive disease. Dosage is weight-based (typically 150 mcg/kg as a single dose, repeated in 1-2 weeks).
  • Lindane: Reserved for cases refractory to other treatments due to potential neurotoxicity.
• Non-Pharmacological: All clothing and bedding should be washed in hot water and dried on a hot cycle. Items that cannot be washed should be sealed in a plastic bag for at least 72 hours.
• Pruritus Management: Topical corticosteroids and oral antihistamines can be used to manage pruritus.

Management in a Pregnant Female

Scabies management in pregnancy requires careful consideration to minimize fetal risk.

• Diagnosis: Skin scraping is preferred to avoid unnecessary medication exposure.
• Treatment:
  • Permethrin 5% cream: Considered relatively safe in pregnancy and is the preferred first-line treatment. However, systemic absorption is a concern, and use should be limited to affected areas.
  • Oral Ivermectin: Generally avoided during pregnancy due to limited safety data. If absolutely necessary, a risk-benefit assessment should be performed.
  • Lindane: Absolutely contraindicated in pregnancy due to its known teratogenic effects.
• Non-Pharmacological: Strict adherence to hygiene measures (washing clothes and bedding) is crucial.
• Monitoring: Close monitoring of the mother and fetus is essential.

Age Group	First-Line Treatment	Contraindicated Treatment	Special Considerations
Neonate	Permethrin 5% (limited application)	Lindane	High risk of systemic absorption; cautious use.
Child <2 years	Permethrin 5% (limited application)	Lindane, Oral Ivermectin (<15kg)	Avoid face, scalp, diaper area; monitor for systemic effects.
Adult	Permethrin 5% or Oral Ivermectin	Lindane (reserved for refractory cases)	Treat all household contacts; manage pruritus.
Pregnant Female	Permethrin 5% (limited application)	Lindane, Oral Ivermectin (generally avoided)	Minimize systemic absorption; risk-benefit assessment for Ivermectin.