ORIGINAL

ARTICLES
Comparison of Permethrin-Based Treatment Strategies against Scabies in
Infants and Young Children
Katharina Riebenbauer1, Philipp B. Weber, MD1, Andrea Haitel, MD2, Julia Walochnik, PhD3, Julia Valencak, MD1,
Damian Meyersburg, MD4, Tamar Kinaciyan, MD1, and Alessandra Handisurya, MD1

Objective To optimize the permethrin-based therapies for scabies infestations in infants and young children, the
efficacies of 3 different regimens were evaluated.
Study design The retrospective analysis encompassed 85 infants and children aged <4 years with scabies. The
children had received either topical permethrin 5% on the entire body on days 1/8, on days 1/8/15, on days 1/8/15
plus interim applications restricted to hands and feet on days 2/3/4//9/10/11, or alternative treatments.
Results The intensified regimen, consisting of full-body permethrin applied on days 1/8/15 and hands/feet on days
2/3/4//9/10/11, resulted in cure of scabies in 73.5% of the cases. The cure rates were significantly greater
compared with full-body permethrin given on days 1/8, which led to eradication in 44%, and were greater compared
with the clearance in children who had received full-body permethrin on days 1/8/15 (53.8%) or alternative treat-
ments (60%). For patients in whom permethrin had previously been applied, the intensified regimen resulted in
eradication of scabies in 71.4% of the cases, compared with 30% and 55.6% after full-body permethrin on days
1/8 and 1/8/15, respectively.
Conclusions The intensified regimen of full-body permethrin plus interim applications on hands/feet, which aims
at reducing the number of mites present on the frequently heavily infested palmoplantar sites in addition to the stan-
dard entire body application, appears efficacious in curing scabies in young children. (J Pediatr 2022;245:184-9).

S
cabies, an infectious disease caused by infestation of the skin by the ectoparasitic mite Sarcoptes scabiei var. hominis,
affects an estimated 200 million people worldwide.1 Disproportionately high prevalence rates are reported in pediatric
age groups, particularly in children younger than 2 years.2,3
The clinical presentation of scabies varies depending on age. In adults, scabies is characterized by an intensely pruritic
erythematous papular eruption, which affects the interdigital spaces of the fingers, wrists, axillae, genitalia, and buttocks,
whereas the head, palms, and soles often are spared.4 In contrast, in infants and young children, the head (including scalp,
face, and neck) as well as palms, soles, ankles, and dorsal feet are commonly involved (Figure 1, A-H).5 In addition, these
patients often present with a variety of skin lesions, comprising papules, vesicles, pustules, and nodules, as well as
excoriated eczematous areas.6 Due to the divergent clinical presentations and the frequent absence of itch, scabies can be
difficult to diagnose in the young population.
A range of therapeutic agents exist for scabies, although availability and prescription preferences vary among countries.3,7-11
The scabicides encompass mainly topical agents, such as permethrin 5%, benzyl benzoate 6.25%-25%, crotamiton 5%-10%,
malathion 0.5%, lindane, tea tree oil 0.002%-2%, or sulfur 2%-25%, and the only systemic compound, ivermectin.3 However,
limitations in availability as well as authorization issues hamper the treatment of children, and many medications are not
approved for infants or newborns.
Permethrin, a synthetic pyrethroid with scabicidal and ovicidal activity, disrupts the function of the voltage-gated sodium
channels in the neuronal membrane of the mites, resulting in paralysis and death.12 Permethrin is highly effective against scabies
and well-tolerated without major side-effects, as it is minimally absorbed
through the skin and rapidly eliminated, thus exerting minimal systemic pres-
ence in humans.4,7,13,14 Hence, it is recommended as a first-line therapy for adults 1
From the Department of Dermatology, Medical
2
15,16 University of Vienna, Vienna, Austria; Department of
and children in many countries. Pathology, Medical University of Vienna, Vienna, Austria;
3
Molecular Parasitology, Institute of Specific Prophylaxis
We frequently have observed persistent infestations in infants and young chil- and Tropical Medicine, Medical University of Vienna,
4
dren, despite the use of guideline-conforming scabicidal therapies and hygienic Vienna, Austria; and Department of Dermatology and
Allergology, University Hospital Salzburg of the
15
measures. In particular, the children’s palms and feet often were infested heavi- Paracelsus Medical University Salzburg, Salzburg,
Austria
ly with numerous mites (Figure 1, D-H; Video 1, available at www.jpeds.com) Supported by the Austrian Science Fund. The funding
and refractory to therapy, which in turn may represent a source for agency had no role in the study design, data collection,
data analysis, data interpretation, or manuscript prepa-
reinfestations for their close contacts. To optimize the treatment strategy for ration. The authors declare no conflict of interest.

infants and young children, the efficacies of 3 different permethrin-based 0022-3476/ª 2022 The Author(s). Published by Elsevier Inc. This is an
regimens in eradicating scabies were retrospectively evaluated and compared open access article under the CC BY license (http://creativecommons.
org/licenses/by/4.0/).
in this age group. https://doi.org/10.1016/j.jpeds.2022.02.016

184

Methods
This retrospective cohort study (EK1990/2019) was approved
by the Ethics Committee of the Medical University of Vienna,
Austria, and conducted in accordance with the Helsinki
Declaration of 1975, as revised in 1983. The study population
comprised 83 children aged younger than 4 years who pre-
sented to the Department of Dermatology, Medical Univer-
sity of Vienna, Austria, with scabies, between January 2017
and November 2020 (Table I). Two of the 83 children,
who became reinfested within the study period after
dermoscopy-verified eradication of infestation and a
disease-free period of several weeks, were reintroduced into
the study cohort and their primary and reinfestations
analyzed individually, resulting in a final number of 85
analyzed cases.
Diagnosis of scabies infestation in our study population was
made by direct visualization of the mites through microscopic
examination of skin scrapings or dermoscopy and/or by
clinical assessment of scabietic lesions and burrows plus
corresponding anamnestic features, such as positive contact
history and scabies-associated itch.17 Patient characteristics
extracted from the medical records comprised sex, age at
presentation, numbers and types of antiscabietic therapies
(including therapies before presentation), and treatment
outcome. All therapeutic decisions were made independent
of the study. Response to treatment was evaluated when
children presented 2-4 weeks after completion of therapy.
Follow-up visits within the first 2 weeks after therapy were
Figure 1. Scabietic lesions in infants and young children aged less than 4 years of age affecting the A, back; B, arm and axillary
region; C, head; D, dorsum of foot and toes; E and F, soles; and G and H, palms.
Volume 245  June 2022
not considered due to lack of informative value regarding
disease activity. Cure was defined as disappearance of lesions,
absence of new lesions, and lack of dermatoscopically visible
mites. The presence of itch was not included in the definition
of cure, as it is difficult to assess in young children and to
discriminate active infestation-associated vs postscabietic itch.
Treatment Groups and Evaluation
The following treatment groups were evaluated for their
efficacy against scabies: topical permethrin 5% cream for
the entire body on days 1/8, as recommended in the
European guideline for the management of scabies15;
full-body topical permethrin 5% cream on days 1/8/15; an
intensified treatment regimen, consisting of topical
permethrin 5% cream for the entire body on days 1/8/15
plus additional applications of permethrin restricted to
hands and feet on days 2/3/4//9/10/11; and alternative
treatments, which included nonaforementioned applications
of permethrin 5% cream, therapies with crotamiton, benzyl
benzoate or ivermectin, and combination therapies of
different scabicides. However, the numbers of individual
alternative treatments were too low to allow valid
conclusions, hence, they were subsumed into a single
treatment group.
When persistence of scabies infestation was observed in a
patient after completion of therapy at the respective
follow-up visit, a repeat treatment was performed, which
on occasion consisted of a different scabicide and/or
regimen, depending on the decision of the respective
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THE JOURNAL OF PEDIATRICS  www.jpeds.com
Table I. Study cohort characteristics
Overall cohort size, No. 85
Sex, No. (%)
Male 53 (62.4%)
Female 32 (37.6%)
Age, y, range, mean (SD) 0.1-3.8, 1.5 (1.1)
Age group, y, No. (%)
0-<1 34 (40.0%)
1-<2 26 (30.6%)
2-<3 14 (16.5%)
3-<4 11 (12.9%)
Previous therapies, No. (%)
None 19 (22.4%)
Permethrin 43 (50.6%)
Permethrin + benzyl benzoate 1 (1.2%)
Permethrin + ivermectin 5 (5.9%)
Unknown 17 (20.0%)
attending physician. To ensure that antecedent applica-
tion(s) with the respective regimen was/were included in
the analyses, each child who had received the respective
regimen was evaluated within the appropriate treatment
group. If this particular regimen resulted in eradication of
scabies, the case was defined as “cured from disease.” If erad-
ication of scabies infestation was caused by another subse-
quent treatment regimen, the case was regarded as “failure”
with regard to the analyzed treatment group.
Statistical Analyses
For the statistical analyses the c2 test was performed employ-
ing SPSS Statistics for Windows, version 24 (IBM Corp). In
addition, to determine the independent impact of age
(grouped into <2 years vs ³ 2 years), treatment regimen
(the intensified treatment regimen vs all other treatments),
sex, and antecedent permethrin-based therapies on the
therapy outcome of our study cohort, logistic regression
analyses were performed in a forward manner. All P values
were 2-sided and considered statistically significant when
<.05; ORs with 95% CIs were reported when applicable.
Results
The demographics of the study population comprising a total
of 85 cases are shown in Table I. Infants aged younger than
1 year constituted the largest subpopulation, followed by
infants aged 1 to younger than 2 years. Before presentation,
the majority of the study population already had been
treated for scabies by primary healthcare providers,
pediatricians, dermatologists, or in other hospitals, but
without evident success. Of the known previous therapies,
monotherapy with permethrin had most frequently been
prescribed to the pretreated children, followed by
combination therapy consisting of permethrin and ivermectin.
Efficacy of the Antiscabietic Treatments
At the end of the study period, scabies infestations were suc-
cessfully eradicated in 76.5% (65/85) of the study cohort,
which comprises all 3 permethrin-based treatment groups
186
Volume 245
as well as the alternative treatment group. In the remaining
23.5% (20/85), persistent disease activity was noted at the
end of the study. Despite providing appropriate antiscabietic
therapies and detailed information on the hygienic
procedures, therapy failure was a frequently observed
phenomenon, and in more than one-half of the study cohort,
the first therapeutic intervention failed, necessitating
repeat therapy.
Comparison of the Efficacy of 3 Different
Permethrin-Based Therapies
To optimize the therapeutic strategy for scabies-infested in-
fants and young children, 3 different permethrin-based regi-
mens and alternative strategies were evaluated for their
efficacies (Table II, available at www.jpeds.com). In our
study cohort consisting of 85 cases, 29.4% received
permethrin on the entire body on days 1/8. Full-body
treatment on days 1/8/15 was administered to 30.6% of the
cases. In particular children, who had presented with severe
scabietic involvement of hands and feet, received
permethrin on the entire body surface on days 1/8/15 and
additional applications restricted to hands and feet on the
interim days 2/3/4//9/10/11. This intensified permethrin-
based therapy was given to 40% of the cases. Alternative
treatments were received by 29.4% of the study cohort. Of
note, a case could belong to more than 1 treatment group
due to the different treatment regimens administered
independently from this study and the frequently observed
treatment failures that required repeat treatments.
Comparison of the different treatment groups revealed
that full-body permethrin application on days 1/8 resulted
in cure of scabies in 44% of treated children. Improvement
of the cure rate to 53.8% was achieved by full-body
permethrin treatment on days 1/8/15. However, the intensi-
fied treatment strategy, consisting of full-body permethrin on
days 1/8/15 and interim applications on hands and feet on
days 2/3/4//9/10/11 emerged as the most successful regimen
in this study cohort, leading to scabies eradication in 73.5%
of treated cases. Importantly, this intensified regimen
proved significantly better compared with the other 3
antiscabietic strategies (P = .039) as well as to the 2 other
Table II. Efficacies of the different antiscabietic
treatment groups
Eradication of
scabies in treated cases
Treated cases (at end of study)
Treatment groups Total No. (%) Total No. (%)
Permethrin day 1/8 25*/85 (29.4%) 11/25 (44.0%)
Permethrin day 1/8/15 26*/85 (30.6%) 14/26 (53.8%)
Permethrin day 1/8/15 34*/85 (40.0%) 25/34 (73.5%)
+ hands/feet day
2/3/4//9/10/11
Alternatives 25*/85 (29.4%) 15/25 (60.0%)
*Of note, one case can belong to different treatment groups due to the necessity of repeat treat-
ments.
Riebenbauer et al
June 2022
Table III. Treatment efficacies after antecedent
permethrin therapy
Cases with
permethrin
pretreatments
Treatment groups Total No. (%)
Permethrin day 1/8 10*/49 (20.4%)
Permethrin day 1/8/15 18*/49 (36.7%)
Permethrin day 1/8/15 28*/49 (57.1%)
+ hands/feet day
2/3/4//9/10/11
Alternatives 13*/49 (26.5%)
*Of note, one case can belong to different treatment groups due to the necessity of repeat treat-
ments.
permethrin-based therapies of days 1/8 and 1/8/15 without
additional applications of permethrin on hands and feet
(P = .024). The intensified regimen was more efficacious in
curing the scabies-infested children than the conventional
2-day regimen on days 1/8 (P = .022) and improved the
outcome compared with full-body application on days
1/8/15 (P = .113). The alternative options were moderately
successful and cured scabies infestations in 60%.
In the logistic regression analyses, the variable “intensified
treatment vs all other treatments” were found to improve the
model (P = .042, OR 2.500, 95% CI 1.032-6.057), whereas
neither age nor sex was of significance.
Efficacy of the Different Permethrin-Based
Treatment Strategies after Antecedent Permethrin
Therapies
We assessed whether antecedent permethrin administration
could have an impact on the outcome of subsequent
permethrin-based therapies, such as increased treatment fail-
ures possibly indicating development of mite resistance to
this scabicide. In our study cohort, 57.6% (49/85) of the chil-
dren had received antecedent therapies with permethrin-
containing therapies. These had been prescribed before
presentation in our clinic. The 2 children in our study cohort
who became reinfested after a disease-free latency period
initially were treated successfully with permethrin on either
day 1/8 or days 1/8/15 with additional applications on hands
and feet by the physicians of our clinic.
At the end of the study, the majority, 81.6% (40/49), of
the permethrin-pretreated cases were cured successfully
(Table III). No association was found between antecedent
permethrin treatments and therapy outcome in our study
population (P = .596). In the 49 permethrin-pretreated
cases, full-body application of permethrin on days 1/8 and
1/8/15 was administered to 20.4% and 36.7% of cases,
respectively. The intensified regimen was received by 57.1%
of the pretreated cases. In 26.5% of the cases, alternative
therapies were administered. As repeat treatments were
frequently necessary, 1 case could be incorporated into 1 or
more treatment groups.
Comparison of Permethrin-Based Treatment Strategies against Scabies in Infants and Young Children
ORIGINAL ARTICLES
Full-body permethrin on days 1/8 resulted in eradication
of scabies in 30% of the pretreated cases. Administration of
permethrin on days 1/8/15 showed a greater success rate of
Treatment 55.6% in the pretreated children. However, treatment
success in pretreated outcome was best with the intensified regimen, where
cases (at end of study)
cure was achieved in 71.4% of the permethrin-pretreated
Total No. (%)
cases. This intensified regimen was significantly superior
3/10 (30.0%) compared with the standard 2-day (P = .021) and better
10/18 (55.6%)
20/28 (71.4%)
than the 3-day (P = .270) full-body regimens. The
alternative treatments were efficacious in 53.8% of the
pretreated cases.
7/13 (53.8%)
Discussion
In children, the prevalence of scabies is estimated to be
approximately 5%-10%, and infants and children younger
than 2 years constitute a particularly vulnerable population.1-3
In this age group, infestations may be more frequent, owing to
the increased proximity to other infected individuals, the chil-
dren’s thinner skin, and/or immaturity of the immune sys-
tem.18 However, inherent limitations to the use of scabicides
hamper management in infants and young children. For
instance, in Austria, permethrin has not received marketing
authorization for use in infants younger than the age of
3 months, although topical therapy with permethrin was re-
ported to be safe in infants aged younger than 2 months.19
Benzyl benzoate is contraindicated in infants younger than
1 year due to the reported toxicity of its metabolite, benzyl
alcohol, in neonates, which is suspected to cause “infant gasp-
ing syndrome.”10 Systemic administration of ivermectin is not
approved for use in infants less than 15 kg body weight due to
potentially serious neurotoxic adverse events caused by pene-
tration of the substance through the perceived immature
blood–brain barrier and reports of ivermectin-induced neuro-
toxicity in animals.11
Although international and national guidelines for the
management of scabies are available,15,16,20 treatment failures
frequently have been reported. The intensified permethrin-
based regimen presented herein employs 2 strategies to
achieve cure in infants and young children: first, mites,
nymphs, larvae, and eggs are targeted by full-body applica-
tion of permethrin on days 1/8/15 on the entire body,
including the head; second, additional reduction of mite
numbers on the predilection sites of palms and soles is
achieved by interim permethrin applications on days 2/3/
4//9/10/11 to these regions. Hence, this strategy may help
minimize the frequently observed skin irritation after full-
body permethrin application while allowing the scabicide
to repeatedly penetrate the thicker corneal structure of the
palms and soles and to more efficiently destroy mites. It is
conceivable that the children’s palms and soles, which are
frequently heavily infested, represent an internal source for
mites that survive a full-body application and remigrate to
other sites which had already been treated, during the
application-free interval. This may partially account for the
greater cure rates seen with the intensified regimen compared
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THE JOURNAL OF PEDIATRICS  www.jpeds.com
with the full-body regimen on days 1/8/15 without interim
hands/feet application.
The issue of mite resistance and/or tolerance to certain sca-
bicides is controversial.12,21-25 Surprisingly, the majority of
our subjects, who had received previous permethrin-
containing therapies without success, showed clearance of in-
festations with 1 of the 3 permethrin-based regimens used in
the study. This suggests that mite resistance to permethrin
may be less likely and/or that the causes for therapy failure
may relate to insufficient adherence to treatment, inadequate
implementation of hygienic measures, or deficiencies in the
treatment procedures. This also may be supported by the
observed inverse correlation of treatment attempts and treat-
ment successes. In total, 134 antiscabietic treatments were
administered in our study cohort. In our study, population
cure was achieved after an average of 2 (1, range 1-5) treat-
ments, persistently infested children had received an average
of 1.4 (0.8) antiscabietic treatments at the end of study,
indicating that treatment adherence may be lower during
the first treatment(s) and may increase with the number of
treatment attempts and/or duration of symptoms.
Our study has some limitations. Although 146 children
younger than the of age of 4 years had presented with scabies
at our department during the study period, information
regarding treatment outcome was missing for 63 (43.2%)
cases. In addition, given the retrospective nature of this
study, interventions regarding choice of therapy were not
possible and different treatment regimens were prescribed
to our study cohort based on the choice of the treating physi-
cian. Numerous physicians, however, preferred administra-
tion of the intensified treatment predominantly to children
with scabies with more severe involvement of palms and soles
or a history of treatment failure(s). Furthermore, the retro-
spective nature of the study did not allow concise assessment
of treatment adherence, duration, and intensity of symptoms
or correct implementation of the hygienic measures. Adverse
events were not specifically addressed; however, no major
side effects aside from skin irritation were documented in
the medical records of the study cohort. Given these limita-
tions, future randomized prospective studies are needed to
further explore the effectiveness of the different regimens.
A beneficial impact of repeated permethrin applications
could not be demonstrated in young adults.22 In contrast, in
the current study cohort of infants and young children, con-
cerned parents might adhere more strictly to treatment instruc-
tions, which may partially account for the better outcome. No
major issues regarding lack of compliance of the parents were
documented, despite the more intense care required, especially
for the intensified regimen. It might be easier to thoroughly
apply topical agents to children than to oneself without leaving
untreated gaps, eg, on the back. Permethrin is generally pack-
aged into tubes of 30 g, the standard amount prescribed for one
application to an adult. Perhaps the parents of our study cohort
used more than the recommended amount of 7.5 g of cream for
children up to 5 years, whereas for adults the 30 g might not
suffice to cover the entire skin.
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Volume 245
In our study population, 1.7-fold more boys were afflicted
with scabies than girls. Certain viral diseases, such as respira-
tory syncytial, measles, or mumps virus infections, are more
common and more severe in male than in female chil-
dren.26,27 Similarly, a male predominance in the incidence
of bacterial lower respiratory tract infections and parasitic
diseases has been reported.26,28 The reason for the greater
prevalence of scabies in males in our cohort is unknown
and does not reflect the birth rate in Austria, where the ratio
of live-born boys to girls was stable between 1.049 and 1.069
during 2015-2019.29 Although skin thickness at this age does
not differ between the sexes, the influence of sex hormones
on the Th1/Th2 cytokine pattern or the presence of estrogen
receptors on lymphocytes and macrophages could influence
the susceptibility to infectious disorders, including scabies.30
Possible future therapeutic options for scabies in infants
include the macrocyclic lactone moxidectin, which has
shown high effectiveness against Sarcoptes scabiei in vitro
and in animal models and is currently being evaluated for
use against human scabies.31,32 Off-label administration of
ivermectin to infants of <15 kg body weight was reported
to be well-tolerated.14,33-36 However, until such systemic
(or other topical) scabicides are proven efficacious and safe
for use in young children, the data presented herein suggest
that the permethrin-based intensified treatment regimen
may be beneficial in the treatment of severely infested infants
and young children, particularly with extensive involvement
of palms and soles. n
The authors thank Sonja Dorfer, MSc, Marcus Lisy, MD, Nikolaus
Urban, and Sarah Ahmed, MD, for excellent technical help; these
individuals have no conflicts of interest.
Submitted for publication Nov 16, 2021; last revision received Jan 22, 2022;
accepted Feb 9, 2022.
Reprint requests: Alessandra Handisurya, MD, Department of Dermatology,
Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
E-mail: alessandra.handisurya@meduniwien.ac.at
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