PA23 A case of neonatal scabies

Abstract A premature baby of male origin, 28 weeks (corrected to 36 + 1) of age, developed a scaly dry and scanty pustulation and crusting affecting his posterior torso (sparing of his buttocks), with neck and right-palm involvement. He was admitted under the neonatology team with a complex background history of severe lung disease, prolonged conjugated hyperbilirubinaemia with hepatomegaly, recent Escherichia coli sepsis and a haemodynamically stable patent duct arteriosus. The neonatal intensive care unit team were initially concerned regarding a potential herpes simplex virus (HSV) infection. However, subsequent HSV polymerase chain reaction was negative and aciclovir was therefore ceased. Empirical treatment with flucloxacillin and gentamycin was also stopped due to no evidence of ongoing infection. There was concern about a scabies manifestation, after further discussion with the parents revealed that there had been an outbreak at the start of the year in their household and that the baby’s father had not been treated. The mother demonstrated her hands, which had been itching. She thought was due to eczema but clinically there was evidence of burrows and vesicles on the palms of her hands bilaterally in keeping with the diagnosis of scabies. The initial diagnosis made by the paediatric dermatology team was that the rash did resemble possible erythema toxicum neonatorum. However, the new history of close contacts with scabies, and also the migration of the rash now involving the head, neck and extremities, made a scabies infestation more likely. Skin scrapings were not performed. Following a dermatology consultant-led multidisciplinary team approach the decision was made to apply permethrin 5% to the baby below the neck area and to wash it off 10–12 h later. Within 24 h, the baby’s rash had cleared completely and he no longer was irritated by its presence. All contact members were also treated. Neonatal scabies is a rare entity, and due to its atypical presentation the diagnosis is often delayed. Here we present an immunocompromised neonate who was successfully treated with permethrin 5%. Skin lesions can include erythematous papules, nodules and crusts, and in the absence of positive skin scrapings a careful history and examination of close contacts should lead to the eventual diagnosis.