To the Editor: We thank Davidson and colleagues1 for their comprehensive narrative review on skin infections in Australian Aboriginal children. A significant factor in both individual and mass drug administration therapy of scabies is the uncertainty regarding the safety of oral ivermectin in small children and during pregnancy. Australian guidelines state ivermectin should not be used in children aged under 5 years or who weigh less than 15 kg or in pregnant women.2 A retrospective cohort study of 170 children aged 1–64 months (median age, 15 months) or weighing under 15 kg treated with ivermectin (mean dose, 223 μg/kg) found only minor self‐limiting adverse effects in seven patients (4%).3 A review of previous literature found 60 children aged under 5 years or weighing less than 15 kg who had been treated with ivermectin at a dose range of 150–200 μg/kg for whom safety data were available.4 Only four of 60 children (7%) developed an adverse reaction, all of which were benign and transient, with no long term sequelae. A recent study of oral ivermectin (dose 400 μg/kg) in the treatment of head lice revealed no adverse effects in 54 children aged under 5 years.5 The Ivermectin Exposure in Small Children Study Group expected to commence the analysis in late 2019 of data collected from 2017 to 2019.6
Three studies totalling 363 women with inadvertent maternal exposure to ivermectin 150 μg/kg (76–85% in first trimester) for filariasis and onchocerciasis found no increased risk of congenital malformations, miscarriage or stillbirth.7 A study of 199 pregnancies with maternal treatment in the second trimester with ivermectin and albendazole, and 198 with ivermectin alone in the management of helminth infections, found no increased risk of adverse pregnancy outcomes.8 In France, the use of oral ivermectin is permitted during pregnancy and in children weighing less than 15 kg when topical therapy has failed.9 Further published data regarding the safety of ivermectin in these populations would be useful, particularly with respect to mass drug administration programs.
- 1. Davidson L, Knight J, Bowen AC. Skin infections in Australian Aboriginal children: a narrative review. Med J Aust 2020; 212: 231–237. https://www.mja.com.au/journal/2020/212/5/skin-infections-australian-aboriginal-children-narrative-review
- 2. Australian Healthy Skin Consortium. National healthy skin guideline for the prevention, treatment and public health control of impetigo, scabies, crusted scabies and tinea for Indigenous populations and communities in Australia; 1st ed. Perth: Telethon Kids Institute, 2018. https://infectiousdiseases.telethonkids.org.au/siteassets/media-images-wesfarmers-centre/national-healthy-skin-guideline-1st-ed.-2018.pdf (viewed Mar 2020).
- 3. Levy M, Martin L, Bursztejn AC, et al. Ivermectin safety in infants and children under 15 kg treated for scabies: a multicentric observational study. Br J Dermatol 2020; 1282: 1003–1006.
- 4. Wilkins AL, Steer AC, Cranswick N, et al. Question 1: is it safe to use ivermectin in children less than five years of age and weighing less than 15 kg? Arch Dis Child 2018; 103: 514–519.
- 5. Chosidow O, Giraudeau B, Cottrell J, et al. Oral ivermectin versus malathion lotion for difficult‐to-treat head lice. N Engl J Med 2010; 362: 896–905.
- 6. Worldwide Antimalarial Resistance Network. Ivermectin Exposure in Small Children Study Group. https://www.wwarn.org/working-together/study-groups/ivermectin-exposure-small-children-study-group-0. (viewed Aug 2020).
- 7. Gyapong JO, Chinbuah MA, Gyapong M. Inadvertent exposure of pregnant women to ivermectin and albendazole during mass drug administration for lymphatic filariasis. Trop Med Int Health. 2003; 8: 1093–1101.
- 8. Ndyomugyenyi R, Kabatereine N, Olsen A, Magnussen P. Efficacy of ivermectin and albendazole alone and in combination for treatment of soil‐transmitted helminths in pregnancy and adverse events: a randomized open label controlled intervention trial in Masindi district, western Uganda. Am J Trop Med Hyg 2008; 79: 856–863.
- 9. Monsel GDP, Chosidow O. Arthropods. In: Griffiths C, Barker J, Bleiker T, et al. editors. Rook's Textbook of Dermatology, 9th ed. New York: Wiley‐Blackwell; 2016: 1–55.
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