Professional Documents
Culture Documents
Alter 2018
Alter 2018
Cutaneous infections and infestations are common among tinea unguium (nails). Less frequent endemic fungal infections
children and adolescents. Ectoparasitic infestations affect such as blastomycosis, coccidiodomycosis, and histoplasmo-
individuals across the globe. Head lice, body lice, scabies, sis may present with skin findings. This article will describe
and infestations with bed bugs are seen in individuals who the epidemiology and transmission of these conditions as well
reside in both resource poor areas and in developed as their clinical manifestations. The approach to diagnosis
countries. Superficial cutaneous and mucosal candida infec- will be addressed as well as primary prevention and current
tions occur throughout the life cycle. Dermatophyte infections therapies.
of keratin-containing skin and skin structures result in tinea
capitis (scalp), tinea corporis (body), tinea pedis (foot), and Curr Probl Pediatr Adolesc Health Care 2018;48:3-25
Scabies
Scabies is caused by the eight-legged mite Sarcoptes
scabiei var. hominis, which burrows into the stratum
FIG 3. scabies on the leg of an infant.
corneum of humans causing an extremely pruritic
dermatitis. The female mite lives 4–6 weeks and lays
2–4 eggs daily, each taking approximately 10 days to The presentation of scabies infestation can be quite
mature.16 Mites are capable of surviving away from the varied among individuals but has some classic features
host for 24–36 hours in room conditions (21ºC and readily identified during examination. Patients most
40–80% relative humidity).17 The adult mite is approx- often complain of extreme pruritus associated with mild
imately 0.3–0.5 mm in length, making it almost dermatitis that results from the underlying host immune
invisible to the human eye.16 Thus, diagnosis relies response. Pruritus is typically worse at night or after a
more on clinical presentation and techniques such as hot bath or shower. Symptoms usually develop several
mineral oil prep of skin scrapings. Pruritus induced by weeks after initial infestation but can present much
infestation may lead to incessant scratching, causing sooner upon re-infestation.19 Some individuals do not
secondary bacterial infection with Streptococcal or mount a significant immune response and are therefore
Staphylococcal species. S. scabiei is also capable of asymptomatic carriers. Classic areas of infestation and
infesting other mammals, causing Sarcoptic mange in dermatitis include the interdigital webspaces of the
livestock.16 hands and feet, flexural wrists, axillae, breasts, penis,
According to the Global Burden of Disease Study in scrotum, and buttocks. However, infants are susceptible
2010, the estimated worldwide prevalence of scabies is to infestation on all body surfaces including the head
100 million.18 While the exact prevalence in the United and may present with an atypical distribution and
States is not known, it is certainly a common diagnosis morphology. Classic skin findings include erythematous
encountered in primary care and dermatology clinics. papules, excoriations and linear burrows, sometimes
Scabies is transmitted by intimate personal contact with a barely visible black “dot” at one end. Vesico-
including sexual contact and less so by fomites such as pustules on the hands and feet or papulonodules on the
clothing and bed linens.16 It can be particularly head and/or extremities of an infant should also raise
problematic in places where people live in close clinical suspicion for scabies infestation (Fig 3). Secon-
quarters or areas plagued by poor sanitation. Although dary impetiginization by group A Streptococcus or
the sequelae of scabies infestation can include impetigo Staphylococcus aureus results from scratching, with
and superficial skin infections, the scabies mite is not yellow crusting frequently visible on physical examina-
known to act as a vector for infectious disease.19 tion. In immunocompromised individuals, such as those
Permethrin 1% (Nix®) is the treatment of choice for was found to be insufficiently effective to warrant use
head lice infestation. The cream rinse is applied to for head lice infestation in a 1995 systemic review.37
shampooed hair and rinsed off after 10 min.33,34 Treat- Banned in California since 2002 (due to concerns of
ment can be repeated in 1 week. Synthetic pyrethroids, contamination of waste water), lindane has a boxed
such as permethrin (Nix® and generics), have the same warning of serious adverse events including death.38
mechanism of action as pyrethrins, but are more Seizures and other serious complications have been
environmentally stable and remain active for 2 weeks reported in children due to inappropriate use or inten-
following application.33 They have much less mamma- tional ingestion of the medication.33,34 Resistance of
lian toxicity than treatment with certain other therapies head lice to lindane is widespread.36 Some sources,
such as malathion (an organophosphate) or lindane (an including the American Academy of Pediatrics, rec-
organochloride that is no longer recommended). They ommend against use for treatment of head lice.40 If
do not need to be avoided in individuals with plant used, it should be restricted to those who have failed or
allergies. Permethrin 5%, used for treatment of scabies, are unable to tolerate other approved therapies and
has been used off-label as a pediculicide in treatment- should be used with extreme caution in infants,
resistant cases. It can be applied to the scalp for children, elderly adults, immunosuppressed individu-
several hours or overnight, then rinsed off. There are als, those on anticonvulsants, pregnant females and
concerns regarding the reported decline in efficacy of nursing mothers.33,38
permethrin due to rapid growth of documented world- Malathion 0.5% (Ovide® and Prioderm®) is an organo-
wide resistance.33,35,37,39 A shared site of action with phosphate which irreversibly inhibits acetylcholinester-
dichlorodiphenyltrichloroethane (DDT) and wide- ase. Lotion is applied to the hair and rinsed off 8–12
spread use are likely factors contributing to this loss hours later. Malathion has high ovicidal activity but
of therapeutic efficacy.37 should be re-applied if live lice are noted 7–10 days after
Lindane (γ-hexachlorocyclohexane), first registered initial application. The product is malodorous and
in the 1950s, acts by causing neuronal hyperstimula- flammable; it can cause respiratory depression if ingested.
tion followed by paralysis and death of the louse. It has Use of a hair dryer or curling iron after application should
low ovicidal activity.33,34 It is available as a shampoo be avoided.40 Skin irritation, including second-degree
which is rinsed out after a 10-min application. Repeat burns and eye irritation, can occur with use.33,37 Safety
application is recommended in 7–10 days. Lindane has not been demonstrated in children under 6 years of
TABLE 2. Recommended dosing regimens for pediatric tinea capitis (including kerion*)
Medication Recommended dosing Monitoring Notes
Griseofulvin • 20–25 mg/kg once daily (microsized) No monitoring generally necessary in • Preferred therapy.
for 6–12 weeks, or 10–15 mg/kg normal healthy children
• Superior for Microsporum infections.
once daily (ultramicrosized) for 6–12
weeks. • Available in tablets or liquid.