Pediatric Dermatology Vol. 7 No.

3 205-207

Scalp Infestation by Phthirus pubis

in a 6-Week-Old Infant
Bruce S. Silburt, M.D., C.C.F.P.,* and Wanda L. Parsons, M.D., C.C.F.P.f
* Family practitioner, Guelph. Ontario. Canada, and tAssistant Professor of Family Medicine, Memorial
University of Newfoundland, St. John's, Newfoundland, Canada

Abstract: This case report describes a 6-week-oid infant with a Phthi-

rus pubis infestation of the scalp, tt is beiieved this patient is the first
reported case in this age group. Treatment is discussed, as are tiie family
dynamics that put this infant at risk. The authors address the possible
association between infestation and chiid abuse.

Pediculosis pubis, or crab lice infestation by
Phthirus pubis, is primarily a sexually transmitted
disease (STD) of adults, but has been described as a
cause of preadolescent blepharitis (1). In children,
the infestation can sometimes involve the scalp
margins (2). We report an infant with an isolated
scalp infestation who was treated together with his
family.
CASE REPORT
A 34-year-old Caucasian female was seen initially
with a primary complaint of abdominal fullness,
leading to the diagnosis of a 20-week gestation. Her
prenatal care was subsequently marked by a crab
lice infestation in her pubic region, and a similar but
disseminated infestation was present in her partner.
The couple were tobacco smokers and alcohol
abusers. living in a multifamily. crowded home, and
they proved difficult to treat due to compliance
problems. Eventually, however, the woman was
cleared of the infestation using RID (pyrethrins and
piperonyl butoxide in a petrolatum distillate vehi-
cle) and a nonprescribed pubic shave. Physical ex-
amination and appropriate cultures to detect the
STDs often associated with crab lice (gonorrhea,
syphilis, Trichomonas, condylomata acuminata, and
Chlamydia) were negative in both patients. The
man would not return for follow-up.
The woman went into labor spontaneously at
term and was delivered of a healthy male by cesar-
ean section for failure to progress. There were no
problems in hospital. The child was bottle-fed, and
the mother returned to work. At 6 weeks of age a
facial "rash" was noted in the infant, and close in-
spection showed a widespread, eczematized. exco-
riated eruption over the forehead, and preauricular
and scalp regions. Eyelashes and eyebrows were
uninvolved. Further inspection revealed nits and
crab lice throughout the scalp, which were con-
firmed by microscopic assessment of the insect.
The mother again had nits in the pubic area and
again her STD screen was negative. Her partner de-
nied any responsibility for the infestation and would
no longer consent to examination or to participation
in any further health care maneuvers. The infant was
treated with RID and retreated one week later when
at least one crab louse was still seen.
At the time of initial treatment, the mother was
given instructions and precautions regarding treat-

Address correspondence to Wanda L. Parsons, M.D.,

C.C.F.P.. Discipline of Family Practice. Memorial University of
Newfoundland, St. John's, Newfoundland, Canada, AlB 3V6.

205
 206 Pediatric Dermatology Vol. 7 No. 3 September 1990
ing herself and her partner (and any undisclosed in-
timates) with lindane (Kwellada). and was advised
to use the shampoo at the same time the baby was
treated with RID. The infant's eruption resolved
and his skin was essentially clear one week after the
final treatment. The problem has not recurred over
the subsequent year. Search for an extrafamiiial in-
fection source was fruitless.
It was learned from the male partner's sister,
with whom the family lived, that the man and
woman had a major problem with alcohol abuse.
The family had also begun to refuse entry to the
public health nurse who had been visiting weekly
since the infestation was first diagnosed. We felt
that the functional integrity of the family was in
grave jeopardy, and a home visit was made by one
of us (BSS) and the office nurse.
A family conference and subsequent telephone
interviews confirmed at least one episode of physi-
cal abuse meted out to the mother (she had a black
eye at one office visit). At no time was abuse or ne-
glect of the child revealed by history or physical ev-
idence. He was noted to be thriving, with normal
developmental milestones and social responsive-
ness. Social service and public health agencies, who
had been involved since the first diagnosis of the
infestation, agreed with this assessment. Although
the sister prevailed on her brother to seek treatment
for alcoholism, the family left the area and is now
lost to follow-up.
DISCUSSION
Descriptions of crab lice infestations in the pediatric
age group have usually been limited to the eye-
lashes and the peripheral scalp area of older chil-
dren. This case occurred in an infant, involved the
entire scalp region, and was associated with high
risk based on prior infestation of the parents.
The crab louse is a fairly immobile, blood-
sucking ectoparasite that spends most of its time at-
tached to hair, truly resembling a crab. It prefers
coarse, widely spaced hair and is rather host depen-
dent, surviving less than 12 hours on its own (2).
Because of the immobility of the crab louse, it was
suggested that the area of involvement points to the
mode of transmission (3). When a child is affected,
transmission is likely a result of intimate contact
with a parent (4). In infants and children, who have
no pubic hair, the eyelashes and peripheral scalp
are thought to be a suitable environment as they are
most similar to pubic hair. The head of the infant is
also a possible site for the louse.
Kwellada, used according to instructions, is rec-
ommended for adults who have no contraindica-
tions. Caution should be exercised in the quantity
prescribed, since often the unused portions are self-
prescribed for an array of itches and lesions. It is in
this situation that the well-described toxicities
might supervene. Although it is the preferred treat-
ment in adults, Kwellada carries some precautions
when used in pregnant women or lactating mothers
and infants. In these patients, pyrethrins have been
advised.
Pyrethrins are derived from an extract from the
flowers of the chrysanthemum family (1) and are
currently available in Canada in combination with
an enhancing agent, piperonyl butoxide. in a petro-
latum distillate vehicle as RID. The compound is
left in place for 10 minutes and washed off. Eye-
lashes are treated with plain petrolatum three to flve
times a day for one week (2), although a single treat-
ment of 10% to 20% fluorescein (5) has been suc-
cessful. The usual clothing and linen treatments
(high heat and dry cycle, or plastic bagging for one
month) are aiso advised.
The discovery of pediculosis pubis in an adult
mandates a search for the common STDs (2). In a
child one must also consider the possibility of
abuse. As reported by Scott and Esterly. crab lice
infestation of the eyelashes in a 4-year-old girl led to
the diagnosis of sexual abuse by the mother's boy-
friend (6). Often, however, the source of infestation
is not found. In the series of six children reported
by Goldman, the youngest of whom was age 19
months, a source was never found despite detailed
tracing efforts (7).
Nevertheless, the discovery of crab lice in an in-
fant or child should raise the suspicion of neglect or
sexual abuse. Certainly, the crab louse infestation
of this infant was an important sign leading to the
discovery of family dysfunction that put the boy at
risk. As is often the case, however, the underlying
psychosocial malady was much more resistant to
treatment than the infestation.
ACKNOWLEDGMENTS
The authors thank Dr. J. E. Brown for photogra-
phy. V. Laing-Smith for home visits, and Corina
Bickford and Yvonne Fowler for secretarial assis-
tance,
REEERENCES
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diatr Dermatol I984;2(l):74-79.
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