Itchy rashes in children: scabies, impetigo and ringworm

Most itchy rashes in children are not serious, but three common ones need the right treatment: scabies (tiny mites under the skin), impetigo (a bacterial skin infection) and ringworm (a fungal infection). All three spread to other people. Scabies needs the whole family treated together, and ringworm should never be treated with steroid mixture creams. Here are the questions parents ask Dr Dutta most.

What does scabies look like on a child?

Scabies causes very itchy small bumps and short, thin lines on the skin. The itch is usually worst at night.¹

In older children, the rash is common between the fingers, on the wrists, arms, legs, around the waist and in the groin.^1,2 The thin lines are burrows, where the mite tunnels under the skin.

Babies and toddlers often get a wider rash, which can involve the palms, the soles, the ankles and at times the scalp.¹ Babies may be fussy, sleep badly and rub their hands and feet together. On brown skin the spots can be harder to see, but you can often feel them.²

How do I know if it is scabies and not something else?

The biggest clue is an intensely itchy rash that is worse at night, with other people in the family itching too.

Doctors usually diagnose scabies by looking at the skin, without tests.¹ The itch often starts weeks after the mites arrive, usually 4 to 6 weeks after infestation.¹ So the person who brought scabies home may not have been itching at the time.

Other causes of itchy rashes in children include eczema, insect bites, heat rash and hives. If you are not sure, show a doctor before buying creams.

How does scabies spread?

Scabies spreads mainly through close skin contact, for example between people living in the same home.¹

It is very common in crowded homes, hostels and joint families where children share beds. Clothes and bedding rarely spread ordinary scabies.¹ Away from human skin, the mites usually die within 2 to 3 days.¹

Scabies is not a sign of a dirty home. Anyone can get it.² Pets do not spread human scabies.²

What is the treatment for scabies in children?

The usual treatment is permethrin 5% cream.^1,3,4 A cream or lotion is applied over the whole body and the treatment is repeated 7 days later.²

Apply it to cool, dry skin from the neck down, including between fingers and toes, under the nails, and in skin folds. Leave it on for the time written on the pack, usually overnight, then wash it off. NHS advice includes the scalp and face, avoiding the area around the eyes.²

A Cochrane review found permethrin cream cleared scabies slightly faster than ivermectin tablets at one week. By 2 to 4 weeks, the two worked about equally.³ Ivermectin tablets should not be given to children weighing less than 15 kg.¹

The treatment does not kill eggs, which is why the second application a week later matters.¹

How do I treat scabies in a baby?

Permethrin 5% cream is the usual first choice for babies over 2 months old, but a doctor should check any baby under 2 years before you start.^4,2

In babies, apply the cream to the whole body, including the scalp, face, palms and soles, but keep it away from the eyes and mouth. Babies often lick their hands, so put on cotton mittens or socks while the cream is on.

A small study of infants whose scabies did not clear found that extra applications to just the hands and feet helped. Kicking and fist clenching probably rub the cream off these areas.⁵ Ask your doctor whether your baby needs this.

Never use old-style lotions such as lindane on a baby. Check every cream with your paediatrician.

Why does the whole family need scabies treatment?

Because family members can carry the mites before they start itching. If only the itchy child is treated, the mites come straight back from someone else.

WHO advises treating everyone in the household, even people without symptoms.¹ NHS advice is that everyone should be treated at the same time, on the same day.²

In a joint family, this means grandparents, the maid who carries the baby, and cousins who share a bed. This is the step most families skip, and it is the most common reason scabies "keeps coming back".

Why is my child still itching after scabies treatment?

It is normal for itching to continue for a few weeks after treatment, even when the mites are dead.² The itch can even get worse for 1 to 2 weeks after starting treatment.¹

This happens because the skin is still reacting to dead mites and their waste. Moisturisers and an antihistamine from your doctor can help. Do not keep re-applying permethrin on your own, as this irritates the skin.

See your doctor if the itch is still there 2 to 4 weeks after the treatment has finished, or if new burrows appear.²

Do I need to wash all the clothes and bedding for scabies?

Yes. Wash bedding, towels and clothes that touched the child's skin in hot water, and dry them in strong sunlight or a hot dryer.¹

Things that cannot be washed, such as soft toys, can be sealed in a plastic bag for a week.¹ Do this on the day you apply the first treatment. Sweep and clean the rooms after treatment.¹ There is no need to throw anything away.

What is impetigo and what does it look like?

Impetigo is a bacterial skin infection, common in young children. It starts as red sores or blisters that burst and leave crusty, golden-brown patches, like cornflakes stuck to the skin.⁶

It usually appears around the nose and mouth and on the hands, and the patches can grow and spread to other parts of the body.⁶ It often starts in skin already broken by a cut, an insect bite, eczema or scabies.⁶ Scratching scabies is a common way impetigo starts in tropical countries.¹

Some children get larger fluid-filled blisters, called bullous impetigo.⁶

How is impetigo treated?

A small patch of impetigo is treated with a cream. Widespread impetigo may need a cream or antibiotic medicine by mouth, and a child with blisters or who is unwell needs medicine by mouth.⁷

For a small area, NICE suggests hydrogen peroxide 1% cream first, and a short course of antibiotic cream if that is not suitable.⁷ In India, doctors usually prescribe mupirocin or fusidic acid cream. A Cochrane review found these two creams work equally well, and as well as or better than antibiotics by mouth.⁸

Gently soak off the crusts with warm water before applying the cream. Use it for the full course, even if the sores look better.⁶ Using antibiotic creams again and again breeds resistance, so do not keep a tube at home "for next time".⁷

Is impetigo serious?

Usually not. With treatment, impetigo often clears in a few days.⁶

But see a doctor rather than a chemist for a baby aged 11 months or younger.⁶ NICE also advises specialist advice for babies with bullous impetigo, and hospital care if there are signs of a deeper infection such as cellulitis (red, hot, swollen, painful skin).⁷

Rarely, skin infections from the streptococcus germ, often after scabies, can lead to kidney inflammation.¹ Puffy eyes, a swollen face, or red or cola-coloured urine a few weeks after skin sores need a doctor promptly.

What is ringworm on a child's skin?

Ringworm is a fungal infection of the skin, not a worm. It usually looks like a ring-shaped, scaly, itchy patch that slowly grows outwards.⁹

It can appear anywhere, including the scalp, where it can cause patchy hair loss.⁹ It spreads through close contact with infected people or animals and through shared towels, combs and bedsheets.⁹ Hot, humid Kolkata weather, sweaty clothes and tight synthetic fabrics make it more likely.

Why is ringworm so hard to cure in India now?

India has seen a big rise in ringworm that is long-lasting, keeps coming back and responds poorly to usual treatment. Indian skin specialists describe this as an unprecedented increase over recent years.¹⁰

Many of these stubborn cases have been altered by steroid creams.¹⁰ Stopping treatment as soon as the itch fades, and sharing towels and clothes within the family, also keep it going.

Why shouldn't I use steroid combination creams for ringworm?

Because steroids make the fungus worse. Combination creams that mix a steroid with an antifungal and an antibiotic calm the itch at first, but the ringworm spreads and returns.

The Indian Association of Dermatologists strongly discourages steroid creams for ringworm, whether used alone or mixed with other drugs.¹⁰ In an Indian study of steroid-altered ringworm, most cases (78%) had been started on these creams by a pharmacist, and betamethasone was the commonest steroid used.¹¹

Steroid creams on a child's skin, especially the face and groin, can also thin the skin and leave marks. Please read the label. If a cream contains "betamethasone", "clobetasol" or another "-sone", do not use it for ringworm unless a doctor has told you to.

How is ringworm treated in children?

Ringworm on the body is treated with a plain antifungal cream, used every day for up to 4 weeks, and continued for the full time even after the rash fades.⁹ For widespread or long-standing ringworm on the body, Indian skin specialists recommend antifungal tablets from a doctor along with the cream.¹⁰

Indian experts suggest continuing the cream for 2 weeks after the skin looks clear.¹⁰ Ringworm on the scalp usually needs antifungal tablets and shampoo from a doctor.⁹ Creams alone cannot reach the fungus in the hair roots.

• Keep the skin dry, especially skin folds.
• Use loose cotton clothes and change sweaty clothes quickly.
• Give each child their own towel, and wash towels and sheets often.
• Check pets for patches of missing fur.⁹

Are scabies, impetigo and ringworm contagious? When can my child go back to school?

All three are contagious, but children can usually return to school soon after starting treatment.

• Scabies: children aged 5 and over can return once treatment has started. Under-5s can return to nursery 24 hours after the first treatment.²
• Impetigo: it stops being contagious 48 hours after starting treatment. Without treatment it can stay contagious for 7 to 21 days.⁶
• Ringworm: it is fine to go to school once treatment has started.⁹

Tell the teacher, so other cases can be picked up early.

Could the itchy bumps be insect bites instead?

Yes, often. Mosquito, bedbug and flea bites cause itchy red bumps, usually in groups on uncovered skin such as the arms, legs and face.

Unlike scabies, bites do not usually affect the finger webs, and other family members may not itch. Some children react strongly to bites and get crops of firm, itchy bumps that come and go through the monsoon.

Scratched bites can become infected and turn into impetigo, so keep them clean with soap and water.⁶ Check mattresses for bedbugs, and use bed nets and safe repellents.

When should I take my child's rash to a doctor?

See a doctor if:

• your baby is under 2 years and you think it is scabies²
• your baby is under 1 year and has impetigo⁶
• sores are spreading, or skin around them is red, hot, swollen or painful⁷
• your child has a fever or seems unwell with the rash
• itching continues 2 to 4 weeks after scabies treatment²
• ringworm is on the scalp, or has not improved with antifungal cream⁹
• puffy eyes, a swollen face, or dark or red urine appear after skin sores

Go to hospital urgently if your child has a rash with high fever and looks very unwell, or has a rash that does not fade when you press a glass on it.