Scabies in children 
Review 
SCABIES IN CHILDREN 
N. Kecelj-Leskovec and B. Podrumac 
SUMMARY 
Scabies is a persistent, contagious pruntlc skin eruption caused by cutaneous infestation with the mite 
Sarcoptes scabiei. Usually parents and children are infected at the same tirne, because scabies infestations are 
transmitted mostly by direct contact. The peak incidence of scabies in children, which have been treated at 
the University Department of Dermatology in Ljubljana from 1990 to 1997, was observed from 1993 to 1995 
with approximately 163 cases per year. History, clinical features, and laboratory examinations are important 
for diagnosis. Clinical features are different in infants and in children, because infant's skin is stili immature. 
The lesions in infants are of a more exudative character. They can be detected almost everywhere on the 
skin, important sites are soles, palms, face and scalp. Variants of scabies, differential diagnosis and treatment 
of scabies in children are reviewed. We should consider the diagnosis of scabies whenever the patient has 
persistent papulovesicular Iesions, the itch worsening at night, and there are additional cases involving other 
persons at home. 
KEYWORDS 
scabies, children, infants, epidemiology, clinical features, differential diagnosis, treatment, Slovenia 
WHAT IS SCABIES? 
It is a persistent, contagious pruritic skin eruption 
caused by cutaneous infestation with the mite Sarcoptes 
scabiei (1,2). The female burrows into the stratum 
corneum of epidermis, Iays her eggs, and dies after 
one month. The eggs hatch, the new generation 
matures in 14 days, when the cycle is repeated. The 
mite and its excrements cause severe pruritus (2). 
184 
THE INCIDENCE OF SCABIES IN 
SLOVENJA 
Reliable data on the incidence of scabies in 
Slovenia are available since 1971 due to the well-
organized dermatological care and the reporting sys-
tem. The peak incidence was reached in 1972 (8646 
cases). There was a second peak in 1982 (4412 
cases). The yearly incidence of over 1000 cases stili 
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Scabies in children 
persists. It seems that the majority of cases have 
been imported by guest workers from certain regions 
outside Slovenia (3). 
The incidence of scabies in children, which have 
been treated at the University Department of Dermato-
logy in Ljubljana from 1990 to 1997, is shown in 
figure l. The peak incidence is seen from 1993 to 
1995 and is about 163 cases per year. 
HOW IS SCABIES RECOGNIZED? 
History, clinical features, and laboratory examinations 
are important for diagnosis (2,4 ). Patients complain 
of severe and persistent itch, worsening after bathing 
and at night. Frequently a whole household is 
infested (2,4). 
Local hypersensitivity to the female scabies mite 
is assumed to cause a release of inflammatory 
mediators, giving rise to an itching rash. The rash 
consists of pruritic papules, which may be superficially 
excoriated. Later secondary infection with pustule 
formation and crusting is common (1,2). 
Clinical features are different in infants and in 
children. The sites of predilection in children and 
adults are located in interdigital folds of the hands, 
volar sites of wrists, extensor sites of elbows, axillary 
areas, central abdomen (periumbilical area), areola 
of the nipple in females, genitalia especially in boys, 
buttocks, and the anterior side of thighs (1,2,4). 
The infant's skin is still immature; therefore the 
lesions are of a more exudative character. We can 
find them almost everywhere on the skin, important 
sites are soles, palms, face and scalp (5-7). 
Demonstration of the acarus is made by scraping 
the burrows to reveal the female mite, the eggs or 
faecal material under the microscope. All cases of 
presumed scabies in which the acarus has not been 
identified and which do not respond to therapy, 
should be reassessed and a biopsy considered (1,2,4). 
V ARIANTS OF SCABIES 
Brownish-red nodules develop as a consequence 
of foreign-body type granulomatous inflammation in 
cases where the infestation is of a long duration. 
They are seen on covered parts of the body ( axillary 
areas, shoulders, genitalia, and buttocks ... ) and usually 
persist for months after therapy (1,2,8). 
Clean scabies can arise in those who observe a 
high standard of hygiene with severe and persistent 
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itch, though there are only minimal skin lesions. In 
such cases the diagnosis is rather difficult, therefore 
laboratory examinations must be repeated (1-3). 
In patients who are immunocompromised, mentally 
retarded, or have an impaired sensibility the Norwegian 
scabies can develop. Additionally to typical lesions 
erythematous plaques with scales and crusts are 
present. Sites that are usually spared are also involved. 
Such patients are very contagious due to the large 
number of mites (1,2,5,6,8). 
DIFFERENTIAL DIAGNOSIS 
The most common misdiagnoses of scabies in infants 
are: 
- impetigo of palms and soles 
- dermatitis atopica 
- dermatitis seborrhoica 
- incontinentia pigmenti m the first vesiculobullous 
stage 
- histiocytosis X 
The most common misdiagnoses of scabies in children 
are: 
- coritact dermatitis 
- impetigo contagiosa 
- strophulus infantum 
- ictus insecti 
- juvenile dermatitis herpetiformis 
- pediculosis corporis 
- rare cases of animal scabies (1,2,4,5). 
~ 200 
i 
0::150 o 
il 
.Q 
~ 100 z 
so 
o 
1990 1991 1992 1993 1994 1995 1996 1997 
years 
j fl adults 11111 children 1 
Figure 1. The incidence of scabies in children and 
adults treated at the University Departrnent of Dermatology 
in Ljubljana from 1990 to 1997. 
185 
Scabies in children 
Figure 2. Exudative lesions everywhere on the skin in 
an infant. 
Figure 4. Lesions on the cheeks, the trunk and the 
axillary area. 
186 
Figure 3. Lesions on the soles in an infant. 
Figure 5. Nodules on genitals of an infant. 
acta dermatovenerologica A.P.A. Vol 7, 98, No 3-4 
Scabies in children 
TREATMENT 
The most useful acaricides are 1 % gamma benzene 
hexachloride - lindan, malathion, 5% permethrin 
and 10% krotamiton. Lindan should be used with 
precaution to avoid its excess penetration into the 
skin and should not be used to treat infants, young 
children, and pregnant or lactating women (9). Sulphur 
preparations, such as 5% - 20% sulphur ointments, 
permethrin, and krotamiton are recommended for 
infants. It is essential that the entire body from the 
neck to the soles be treated. This procedure can be 
repeated after 24 hours once or twice (for krotamiton 
5 - 7 days). 24 hours after the last application the 
patient should bathe, and ali clothing and bed linen 
should be washed (2,4,5,9) . 
Ali household and other close contacts should be 
treated at the same tirne as the patient, even if they 
are asymptomatic (2,4). 
At the end of the treatment we have to repeat 
laboratory examination to confirm recovery from 
infes ta tion. 
CONCLUSION 
We can see that scabies is stili a fairly frequent 
skin disease. Usually parents and children are infested 
at the same tirne, because scabies infestations are 
transmitted mainly by direct contact ( 4,5). 
We should consider scabies whenever the patient 
has persistent papulovesicular lesions, with the itch 
worsening at night, and additional cases involving 
other persons at home (2,4). 
REFERENCES 
l. Braun - Falco O. Epizoonoses. In: Braun - Falco 
O, Plewig G, Woljf HH et al. Dennatology 3rd ed, 
Springer - Verlag, Berlin 1991, 255-8. 
2. MacKie RM. Cutaneous Infestations. In: MacKie 
RM. Clinical Dennatology 4th ed, Oxford University 
Press, New York 1997, 134-7. 
3. Kralj B, Kansky A, Žgavec B et al. Scabies in 
Slovenia during the 1971-95 Period. Acta Dennatoven 
APA. 1997,· 6: 35-8. 
4. Sayers CP. Arthropod bites and stings. In: Fitzpatrick 
JE, Aeling JL. Dennatology Secrets, Hanley & Belfus, 
Philadelphia 1996, 227. 
5. Hurwitz S. Insect bites and parasitic infestation. In: 
Hurwitz S. Clinical Pediatric Dennatology, W B. Saunders 
Company, Philadelphia 1993, 405-24. 
6. Harper l. Infestations. In: Harper l . Handbook of 
Pediatric Dennatology, Butterworth & Co, London 
1985, 63-7. 
7. Paller AS. Scabies in infants and small children. 
Semin Dennatol 1993; 12 (1) : 3-8. 
8. Grassi AM. Bites and Infestations. In: Olbricht SM, 
Bigby ME, Amdt KA. Manual oj Clinical Problems in 
Dennatology Js' ed, Little Brown & Company, Boston 
1992, 157-8. 
9. Brown S, Becher J, Brady W Treatment of Ectopara-
sitic Infections: Review of the English - Language 
Literature, 1982-1992. Ciin Inf Dis 1995; 20 (Suppl 
1): S104-9. 
AUTHORS, ADDRESSES 
Nada Kecelj-Leskovec MD, Department of Dermatology, University Medica! Center, Zaloška 2, 
1525 Ljubljana, Slovenia 
Božana Podrumac MD, Head Pediatric Dermatology, same address 
acta de1matovenerologica A.P.A. Vol 7, 98, No 3-4 187