Scabies in Children: Symptoms, Treatment & Prevention Guide

What Is Scabies and What Causes It?

Scabies is a skin infestation caused by the human itch mite (Sarcoptes scabiei var. hominis), a tiny eight-legged parasite that burrows into the top layer of skin to lay eggs. The mites and their waste products trigger an allergic reaction that causes intense itching. Scabies affects approximately 200 million people worldwide at any given time.

Scabies is one of the most common skin conditions in the world, affecting people of all ages, races, and socioeconomic backgrounds. The condition is caused by a microscopic mite called Sarcoptes scabiei var. hominis, which is visible only under magnification. These tiny parasites, measuring just 0.3-0.4 millimeters in length, have evolved specifically to live on human skin and cannot survive on other animals or surfaces for extended periods.

When a female mite lands on human skin, she burrows into the outermost layer (the stratum corneum) using her specialized mouthparts and front legs. Once inside, she creates tunnel-like structures called burrows, where she lives for her entire 30-60 day lifespan. Each day, the female mite lays 2-3 eggs in these burrows, which hatch into larvae within 3-4 days. The larvae then mature through nymph stages before becoming adult mites, ready to start the cycle again.

The number of mites on an infected person is surprisingly low in typical cases. Most people with scabies have only 10-15 mites on their entire body at any given time. Despite this small number, the intense itching and skin reactions they cause can be extremely distressing. This is because the symptoms are not caused by the mites themselves, but by the body's allergic reaction to the mites, their eggs, and their fecal matter (called scybala).

Scabies Has Nothing to Do with Hygiene

One of the most important things to understand about scabies is that it has absolutely nothing to do with personal cleanliness or hygiene. Scabies mites do not discriminate based on how often someone bathes or how clean their home is. The condition spreads through prolonged skin-to-skin contact with an infected person, making it equally common in all socioeconomic groups and living situations.

Unfortunately, there is still significant stigma associated with scabies due to misconceptions about its connection to poor hygiene. This stigma can prevent people from seeking treatment promptly and can cause unnecessary embarrassment and distress. Healthcare providers emphasize that scabies is simply a parasitic infection that can affect anyone, similar to head lice or other common infestations.

What Are the Symptoms of Scabies in Children?

The main symptoms of scabies include intense itching that worsens at night, thin gray or brown burrow tracks on the skin, small red bumps or blisters, and scratch marks from itching. In children under 2 years, scabies can affect the head, face, palms, and soles, unlike older children where these areas are typically spared.

The symptoms of scabies can vary depending on whether it is a first-time infection or a reinfestation. Understanding these symptoms is crucial for early detection and treatment, as the condition is highly contagious and can spread rapidly through households, schools, and childcare settings.

Intense Itching, Especially at Night

The hallmark symptom of scabies is severe, relentless itching known as pruritus. This itching is typically described as the worst patients have ever experienced and significantly impacts quality of life. The itching tends to be most intense at night and during warm conditions, such as after a bath or while lying under blankets. This nocturnal pattern is thought to be related to the increased activity of female mites during warm, dark conditions, as well as the body's natural immune rhythms.

The itching is caused by an allergic reaction to the mites, their eggs, and their waste products. When these substances come into contact with the immune system, the body releases histamine and other inflammatory chemicals, resulting in the intense itching sensation. Importantly, the itching can occur anywhere on the body, not just where the mites are located, because it is an allergic response affecting the entire immune system.

Burrow Tracks and Skin Changes

Scabies burrows are one of the most distinctive signs of the condition, though they can be difficult to spot without training or magnification. These burrows appear as thin, gray, brown, or skin-colored lines on the surface of the skin, typically measuring about 1 centimeter in length. They may have a slightly raised, thread-like appearance and often have a tiny black dot at one end, which is the mite itself.

In addition to burrows, scabies causes various other skin changes. These include small red bumps (papules), tiny blisters (vesicles), scratch marks (excoriations) from intense itching, and in some cases, crusty patches or sores. Secondary bacterial infections can develop when scratching damages the skin, leading to impetigo or other skin infections that require additional treatment.

Where Scabies Appears on the Body

The location of scabies lesions differs based on age, which is important for diagnosis. In older children and adults, scabies mites prefer certain areas of the body where the skin is thin and has folds. Common sites include the webbing between fingers, wrists, elbows, armpits, waistline, buttocks, and genital area. Notably, scabies in older children and adults typically spares the head, face, neck, palms, and soles.

However, in infants and young children under 2 years of age, the pattern is quite different. Scabies can affect any area of the body, including the head, face, neck, scalp, palms, and soles of the feet. This is why treatment protocols for young children include application to these areas, which are usually skipped in older patients.

Delayed Onset of Symptoms

One of the most challenging aspects of scabies is that symptoms don't appear immediately after infection. In a first-time infestation, it typically takes 2-6 weeks for the body to develop the allergic sensitization that causes itching. During this period, the infected person is already contagious and can spread scabies to others, even though they have no symptoms themselves.

In people who have had scabies before, the immune system is already sensitized to the mites' proteins. In these cases, symptoms can develop within 1-4 days of reinfestation, as the allergic response is triggered much more quickly. This is why some people notice symptoms almost immediately after contact with an infected person, while others may take weeks.

Crusted (Norwegian) Scabies

A severe form of scabies called crusted scabies (formerly known as Norwegian scabies) can occur in people with weakened immune systems, including those with HIV/AIDS, cancer, or those taking immunosuppressive medications. In crusted scabies, the body fails to mount an effective immune response, allowing the mite population to explode from the typical 10-15 mites to thousands or even millions.

Crusted scabies presents very differently from classic scabies. Instead of typical burrows and bumps, patients develop thick, crusty scales on the skin that are packed with mites. Surprisingly, itching may be minimal or absent in crusted scabies because the immune system is too compromised to react. This form is extremely contagious and requires aggressive treatment under medical supervision.

When Should You See a Doctor for Scabies?

See a doctor if your child has persistent itching especially at night, if you notice burrow-like lines on the skin, or if a close contact has been diagnosed with scabies. Medical evaluation ensures proper diagnosis and treatment, as other conditions can mimic scabies symptoms.

While scabies is often suspected based on symptoms and history of exposure, a medical evaluation is important for several reasons. First, other skin conditions such as eczema, contact dermatitis, insect bites, and certain rashes can cause similar symptoms. A healthcare provider can examine the skin carefully and may perform tests to confirm the diagnosis.

Second, prescription treatments may be needed in some cases, particularly for infants, pregnant women, or those who don't respond to over-the-counter treatments. A doctor can recommend the most appropriate treatment based on your child's age, health status, and severity of infestation.

Situations Requiring Medical Attention

• Persistent itching: If you or your child has been itching for several days, especially if it worsens at night
• Known exposure: If someone in your household or a close contact has been diagnosed with scabies
• Visible skin changes: If you notice thin lines, bumps, or blisters on the skin, particularly between fingers, on wrists, or in skin folds
• Infants and young children: Scabies in babies requires careful diagnosis and appropriate treatment selection
• Signs of infection: Redness, warmth, pus, or increasing pain around scratched areas may indicate secondary bacterial infection
• No improvement after treatment: If itching persists at the same intensity more than 2-4 weeks after treatment
• Immunocompromised individuals: Those with weakened immune systems need prompt medical care for suspected scabies

If you live with or have had close contact with someone diagnosed with scabies, you should be treated even if you don't have symptoms. This is because you may be infected but in the pre-symptomatic period, and treating everyone simultaneously prevents reinfection.

How Does Scabies Spread?

Scabies spreads primarily through prolonged skin-to-skin contact lasting several minutes. Casual contact like handshakes rarely transmits scabies. Transmission through bedding or clothing is uncommon but possible if items were recently used by an infected person. Scabies spreads even before symptoms appear.

Understanding how scabies spreads is essential for preventing transmission and properly managing outbreaks. The scabies mite moves slowly and cannot jump or fly, which means transmission requires direct contact between skin surfaces for an extended period, typically several minutes or longer.

Direct Skin-to-Skin Contact

The primary mode of scabies transmission is prolonged direct skin contact with an infected person. Activities that commonly lead to transmission include sleeping in the same bed, sexual contact, extended cuddling or holding, and caring for young children or elderly individuals. The mites crawl from one person's skin to another during this close contact.

Brief, casual contact such as handshakes, hugs, or sitting next to someone is generally insufficient for transmission. The mites need time to move between hosts, which is why quick interactions rarely result in infection. This means that scabies doesn't typically spread through normal classroom activities, public transportation, or other casual social interactions.

Transmission Through Objects (Fomites)

While scabies can survive off the human body for up to 2-3 days under optimal conditions, transmission through contaminated objects is much less common than direct contact. However, it can occur with items that have had recent, close contact with an infected person's skin, such as bedding, towels, and clothing worn directly against the skin.

The risk of transmission through fomites increases with crusted scabies, where the high number of mites makes environmental contamination more significant. In typical scabies cases with only 10-15 mites, the chance of mites being shed onto surfaces is relatively low.

Contagious Period

A person with scabies can spread the infestation to others from the moment they are infected, even before symptoms appear. This is one reason scabies can spread so easily through households and communities before anyone realizes there is a problem. The contagious period continues until treatment is completed and the mites are eliminated.

After proper treatment with permethrin or another scabicide, patients are generally considered non-contagious after the medication has been on the skin for the recommended duration (usually 8-14 hours). This means children can typically return to school or daycare the day after treatment.

How Is Scabies Diagnosed?

Scabies is diagnosed through visual examination of the skin, looking for characteristic burrows and distribution patterns. Definitive diagnosis can be made by identifying mites, eggs, or fecal matter under microscopy after skin scraping. Dermoscopy (a magnified skin examination) can also visualize mites and burrows.

Accurate diagnosis of scabies is important because the treatment involves applying medication to the entire body and treating all close contacts, which can be burdensome if done unnecessarily. At the same time, missing a scabies diagnosis can lead to prolonged suffering and continued spread of the infestation.

Clinical Examination

The first step in diagnosing scabies is a thorough examination of the skin. Healthcare providers look for the characteristic burrow tracks, which appear as thin, slightly raised, wavy lines on the skin surface. They also examine the distribution pattern of skin lesions, noting whether they appear in the typical locations for scabies based on the patient's age.

The healthcare provider will also take a detailed history, asking about the nature and timing of itching (particularly whether it worsens at night), any known contacts with scabies, and whether other household members have similar symptoms. This information helps differentiate scabies from other itchy skin conditions.

Dermoscopy

Dermoscopy is a non-invasive diagnostic technique that uses a handheld device with magnification and specialized lighting to examine the skin more closely. With dermoscopy, trained clinicians can often visualize the scabies mite itself, which appears as a small dark triangular structure at the end of a burrow (the "delta wing jet" sign). This technique is painless and can provide rapid confirmation of scabies.

Skin Scraping and Microscopy

The definitive diagnosis of scabies is made by identifying mites, eggs, or fecal pellets (scybala) under a microscope. To obtain a sample, the healthcare provider gently scrapes a burrow or suspicious area with a scalpel or curette, places the material on a glass slide with mineral oil, and examines it under magnification.

While finding mites or eggs confirms the diagnosis, a negative scraping does not rule out scabies. Because infected individuals typically have only 10-15 mites, they can be difficult to find even with careful examination. In cases where scabies is strongly suspected but cannot be confirmed, healthcare providers may recommend presumptive treatment.

Referral to a Specialist

In some cases, particularly when the diagnosis is uncertain or when standard treatments have failed, your child may be referred to a dermatologist (skin specialist). Specialists have additional expertise and tools for diagnosing challenging cases and can provide guidance on alternative treatments if needed.

How Is Scabies Treated in Children?

Scabies is treated with topical medications applied to the entire body, most commonly permethrin 5% cream. The cream is applied from neck to toes (including head in infants), left on for 8-14 hours, then washed off. A second treatment is typically needed 7-10 days later to kill newly hatched mites. All close contacts must be treated simultaneously.

Effective treatment of scabies requires not only applying the appropriate medication correctly but also treating all close contacts and decontaminating the environment. Failure to address all these aspects can lead to treatment failure and reinfestation.

First-Line Treatment: Permethrin 5% Cream

Permethrin 5% cream is the most commonly recommended first-line treatment for scabies worldwide. It is a synthetic pyrethroid that kills mites and their eggs by disrupting their nervous system. Permethrin is safe for use in children 2 months of age and older and is available over-the-counter in many countries.

The effectiveness of permethrin is well-documented, with cure rates of 89-98% in clinical studies. It is generally well-tolerated, with mild skin irritation being the most common side effect. The medication has minimal systemic absorption and is considered safe during pregnancy and breastfeeding, though medical guidance should be sought.

How to Apply Scabies Treatment Correctly

Proper application of scabies medication is crucial for successful treatment. Here is a step-by-step guide:

1. Bathe first: Give your child a bath or shower with lukewarm water. Pat the skin dry completely. The skin should be cool and dry before application.
2. Apply to the entire body: For children over 2 years, apply the cream from the neck down to every inch of skin. For infants and children under 2, also apply to the scalp, face (avoiding eyes and mouth), and ears.
3. Pay attention to all areas: Make sure to apply medication between fingers and toes, under fingernails and toenails (use a nail brush to work it in), in skin folds, the belly button, and the genital area.
4. Leave on for 8-14 hours: The medication should remain on the skin for the recommended time, typically overnight. If hands are washed during this period, reapply cream to the hands.
5. Wash off thoroughly: After the recommended time, have your child bathe or shower to remove the medication.
6. Repeat in 7-10 days: Apply a second treatment 7-10 days after the first to kill any mites that have hatched from eggs since the initial treatment.

Alternative Treatments

If permethrin is not suitable due to allergy, age, or other factors, alternative treatments include:

• Benzyl benzoate: An older treatment that is effective but can cause skin irritation. Often used as a second-line option.
• Sulfur ointment (5-10%): The oldest treatment for scabies, still used in some regions. Safe for infants under 2 months and pregnant women. Must be applied for 3 consecutive nights.
• Crotamiton 10% cream: Less effective than permethrin but may be used in certain situations. Applied daily for several days.
• Ivermectin (oral): A prescription medication taken by mouth, usually as two doses one week apart. Effective and convenient, but not approved for children under 15 kg in some countries.

Treating All Close Contacts

One of the most critical aspects of scabies management is treating all close contacts simultaneously, even those without symptoms. This includes all household members, regular caregivers, and any sexual partners of adolescents or adults. Because scabies can be transmitted before symptoms appear, contacts may be incubating the infection without knowing it.

If close contacts are not treated, they can reinfect the treated patient, creating a cycle of reinfestation that is frustrating and difficult to break. Everyone should apply treatment at the same time (usually the same evening) to prevent this cycle.

How Should You Clean Your Home After Scabies?

Wash all bedding, towels, and clothing used in the past 3 days in hot water (60°C/140°F or higher) and dry on high heat. Items that cannot be washed should be sealed in a plastic bag for 3-5 days. Vacuum carpets and upholstered furniture. Extensive cleaning or pesticide spraying is not necessary for typical scabies.

Environmental decontamination is an important part of scabies treatment, though it is often overemphasized. Because scabies mites can only survive 2-3 days away from human skin, measures primarily need to address items that have had recent contact with the infected person.

Washing and Laundering

On the day of treatment, wash all the following items that have been used in the past 3 days:

• Bed linens, pillowcases, and blankets
• Towels and washcloths
• Underwear and clothing worn close to the skin
• Pajamas and sleepwear

Wash these items in hot water (at least 60°C/140°F) and dry them on the highest heat setting for at least 20 minutes. The combination of hot water and heat from drying is effective at killing mites and their eggs.

Items That Cannot Be Washed

For items that cannot be washed in hot water or dried on high heat, seal them in a plastic bag for 3-5 days. This includes items like stuffed animals, throw pillows, shoes, and delicate clothing. After this period, any mites present will have died from starvation.

Additional Cleaning Measures

Vacuum carpets, rugs, and upholstered furniture thoroughly. This helps remove any mites that may have been shed onto these surfaces. After vacuuming, dispose of the vacuum bag or empty the canister outside the home.

It is not necessary to use pesticide sprays, foggers, or fumigants for scabies. These products are ineffective against scabies mites and may pose health risks, particularly for children. The simple measures described above are sufficient for typical scabies infestations.

What to Expect After Scabies Treatment

Itching commonly persists for 2-4 weeks after successful treatment as the body continues to react to dead mites and debris in the skin. This is normal and does not mean treatment failed. Use hydrocortisone cream and antihistamines to manage itching. Seek medical advice if itching is unchanged after 4 weeks or if new burrows appear.

Many parents become concerned when their child continues to itch after scabies treatment. Understanding what to expect after treatment can help reduce anxiety and prevent unnecessary retreatment.

Post-Scabietic Itching

The itching associated with scabies is caused by an allergic reaction to the mites and their waste products, not by the mites crawling in the skin. Even after all mites are killed by treatment, the dead mites, eggs, and fecal matter remain in the skin until the outer skin layer naturally sheds and renews itself. This process takes 2-4 weeks.

During this time, the allergic reaction continues, causing ongoing itching. This "post-scabietic itch" or "post-scabietic dermatitis" is completely normal and should gradually improve over several weeks. The itching should become progressively less severe, even if it doesn't disappear immediately.

Managing Post-Treatment Itching

Several measures can help manage itching during the post-treatment period:

• Hydrocortisone cream: Over-the-counter hydrocortisone 1% cream can be applied to itchy areas to reduce inflammation and itching. Follow the product directions for frequency of application.
• Oral antihistamines: Antihistamines such as diphenhydramine (Benadryl) or cetirizine (Zyrtec) can help reduce itching, especially at night. Sedating antihistamines may help with sleep.
• Cool baths and moisturizers: Lukewarm baths followed by fragrance-free moisturizers can soothe irritated skin. Avoid hot water, which can worsen itching.
• Keep nails short: Short, clean fingernails reduce skin damage from scratching and lower the risk of secondary infection.

When to Seek Follow-Up Care

Contact your healthcare provider if:

• Itching has not improved at all after 2-3 weeks of treatment
• New burrows appear more than 2 weeks after completing treatment
• Other family members develop new symptoms despite being treated
• Signs of skin infection develop (spreading redness, pus, increasing pain, fever)

Return to School and Activities

Children can typically return to school or daycare after completing the first treatment application, usually the day after treatment. Once the medication has been on the skin for the recommended time (8-14 hours), the child is no longer considered contagious. However, notify the school or daycare about the diagnosis so they can monitor for other cases.

How Can You Prevent Scabies?

Prevent scabies by avoiding prolonged skin-to-skin contact with infected individuals, treating all household members when one person is diagnosed, and properly laundering potentially contaminated items. There is no vaccine for scabies, and good hygiene alone does not prevent transmission.

While there is no foolproof way to prevent scabies, understanding how it spreads can help reduce the risk of infection and prevent outbreaks within families and communities.

Avoiding Transmission

The most effective way to prevent scabies is to avoid prolonged skin-to-skin contact with anyone who has or may have the condition. This can be challenging because infected individuals may be contagious for weeks before they develop symptoms. However, if you know someone has scabies, avoid close physical contact until they have completed treatment.

Prompt Treatment and Contact Tracing

When scabies is diagnosed in one family member, prompt treatment of all household members and close contacts is essential to prevent spread. This "mass treatment" approach breaks the cycle of transmission and prevents the pingpong effect of family members reinfecting each other.

Community Settings

In settings like schools, daycare centers, and nursing homes, scabies outbreaks can affect multiple people. In these situations, public health authorities may become involved to coordinate treatment efforts and prevent further spread. If your child's school notifies you of a scabies case, watch for symptoms and consult a healthcare provider if you have concerns.