Dear Parents, Students and Staff,

The following article was recently published in The Journal of School Nursing and
includes detailed information about everything you ever wanted to know about head lice.
Please take the time to read this (without scratching if possible!) and contact us in the
clinic if you have any questions! Thank you.
From the Clinic Staff
From Dermatology Nursing

Head Lice: Diagnosis and Therapy

Gabriel J. Martinez-Diaz, MD; Anthony J. Mancini, MD
Authors and Disclosures
Posted: 10/28/2010; Dermatology Nursing 2010 Jannetti Publications, Inc.

Abstract and Introduction

Etiology and Pathophysiology
Clinical Manifestations
Diagnosis
Treatment
Patient Education
Conclusion
References
Abstract and Introduction
Abstract
Children worldwide are commonly infected with head lice, or pediculosis capitis. The
epidemiology, etiology, clinical manifestations, diagnosis, and preventive and treatment
modalities for managing head lice in children are reviewed.
Introduction
Head lice, also known as pediculosis capitis, has a worldwide prevalence of up to 60%
(Falagas, Matthaiou, Rafailidis, Panos, & Pappas, 2008). It is caused by the head louse ,
Pediculosishumanus var. capitis, which may infest children of any age, but most
frequently those between 3 and 12 years of age in the United States (Falagas et al., 2008).

African Americans are less commonly infested, which may be due to the twisted nature of
the hair shaft, the use of hair pomades, or the diameter and shape of their hair shafts,
which may make grasping of the shaft more difficult (Diamantis, Morrell, & Burkhart,
2009; Frankowski & Weiner, 2002; Ko & Elston, 2004; Rubeiz & Kibbi, 2009). Although
traditionally believed to be associated with low socioeconomic status, poor hygiene,
longer hair, or frequency of shampooing or brushing, head lice infestation is not
dependent on these variables. The human head louse does not transmit disease, but can be
socially stigmatizing and places a significant burden on patients, parents, and society. The
annual direct and indirect costs of head lice infestations in the United States are estimated
to be in the hundreds of millions of dollars (Clore & Longyear, 1990; Frankowski &
Weiner, 200 2; West, 2004).
Etiology and Pathophysiology
The head louse is 12 mm long, wingless, and white -to-gray in color, living on average 30
days. It has a long, dorso-ventrally flattened, segmented abdomen with 3 pairs of clawed
legs. The louse inserts its mo uthparts into the skin to feed on the blood of the human host
every 4 6 hours. In doing so, it injects saliva, which results in an inflammatory reaction
with resultant pruritus. Head lice move rapidly, traveling up to 23 cm/min, by grasping
hairs and generally remaining close to the scalp (Ko & Elston, 2004). The female head
louse lays eggs at night and can produce as many as 10 eggs per day. There is a
predilection for the posterior hairline and post - auricular areas, and the eggs are
deposited at the base o f the hair shafts, within 12 mm of the scalp. The nit is attached
with highly insoluble cement. The end of the nit is topped with a tough but porous cap
known as the operculum. This structure allows for gas exchange while the nymph
develops in the casin g (Rubeiz & Kibbi, 2009). The nit requires optimum conditions of 30
C and 70% humidity to hatch within an average time frame of 810 days; the incubation
period may be longer at lower temperatures, and hatching usually does not occur if the
temperature is lower than 22 C. Nits may survive for as long as 1 month away from the
human host. After incubation, the nymph is hatched and undergoes three stages (first,
second, and third "instar forms") of development before reaching its adult form 8 10 days
later (Frankowski & Weiner, 2002; Janniger & Kuflik, 1993; Rubeiz & Kibbi, 2009). In
general, nits located close to the scalp are viable and unhatched, although in warmer
climates, viable ones may be found several inches away from the scalp (American
Academy of Pediatrics [AAP], 2009).

Direct head-to-head contact is a common mode of transmission of head lice, but indirect
transmission via fomites (such as brushes, combs, hair accessories, bedding, helmets, and
headgear) is also well established (Burkhart & Burkhart, 2007). This fomite transmission
contributes to the challenging cycle of head lice infestation. While hair length or frequency
of grooming do not generally influence susceptibility to head lice infestation, cultures
where hair grooming is performed frequ ently (such as in the United States) tend to have
no more than a dozen live lice, in comparison to cultures with lessfrequent grooming
practices, where a hundred or more live lice may be noted with an infestation (Frankowski
& Weiner, 2002).
Clinical Manifestations
Children with head lice may initially be asymptomatic. However, itching, which is
confined to the scalp, and which may become quite severe in intensity, is common and is
traditionally the first clinical symptom. Nits are attached by the louse to hair shafts, within
a few millimeters from the scalp, and can often be found in the occipital and posterior
auricular regions of the head. It is often easier to observe nits (which appear as oval shaped, white-to-tan-to-gray eggs firmly attached to the h air shaft) than adult crawling
lice. Other possible manifestations of a head lice infestation include excoriations,
secondary impetiginization, pyoderma with or without hair loss, cervical
lymphadenopathy, conjunctivitis, fever, malaise, and occasionally a diffuse morbilliform
hypersensitivity eruption (AAP, 2009; Janniger & Kuflik, 1993; Mumcuoglu, Klaus, Kafka,
Teiler, & Miller, 1991).
Diagnosis
The diagnosis of head lice is made easily with the identification of live lice, either via
inspection of the scalp or when combed from the hair after wetting it. Visual inspection for
live lice without combing can be challenging, as the head louse crawls rapidly and likes to
avoid light (Bacot, 1917). The identification of nits attached to hair shafts does not confirm
active disease, but if they are within 1 cm of the scalp, an active infestation is more likely
(AAP, 2009; British Medical Journal Publishing Group, 2009; "Getting the Bugs Out," 2009;
Janniger & Kuflik, 1993; Mumcuoglu et al., 1991; Namazi, 2003; Vander Stichele et al.,
2002). The diagnosis of lice can sometimes be confirmed with the use of a hand lens or
microscope. Table 1 lists the differential diagnosis of nits. The ability to easily slide off
debris, scales, and hair casts usually helps to distinguish most of these mimickers from
true nits, which are firmly cemented to the hair shafts.

Treatment
Treatment for head lice is recommended for individuals diagnosed with an active
infestation, and prophylactic therapy is recommended for bedmates and immediate
members of the household of the infested index patient (AAP, 2009). All close contacts
should be examined, and those with evidence of an active infestation should also be
treated. Treatment of all contacts of the infested patient who require therapy should be
done concurrently, so as to minimize the transmission cycle (Centers for Dis ease Control
and Prevention [CDC], 2008; Diamantis et al., 2009; Namazi, 2003).
Table 2 lists the most commonly utilized therapies for head lice infestation. Several of
these are discussed briefly below. Environmental decontamination, an important adjunct
to treatment as well as prevention, is discussed in the Patient Education section.
Over-the-counter Medications Pyrethrins, naturally derived from chrysanthemum extract,
cause neurotoxicity and eventu al paralysis of head lice by interfering with sodium
transport (Ko & Elston, 2004). The addition of pyrethrins to piperonyl butoxide provides
synergism, as the latter interferes with metabolism of the former, thereby extending its
half life (Lebwohl, Clark, & Levitt, 2007). This class includes such agents as Pronto,
Rid, and A200, among others. Treatment failures may be seen and depend on the local
lice resistance patterns.
Prescription Medications Since 1995, lindane has been designated as a "second -line"
treatment, meaning it should be used only when other first-line treatments for lice have
failed (Thomas et al., 2006). The efficacy of lindane, an organochloride compound, has
decreased in recent years because of increasing lice resistance. Lindane is g enerally not as
effective as other treatments and there have been concerns about its safety (West, 2004;
Zargari et al., 2006). Overuse, misuse, or accidental ingestion of lindane can result in
toxicity to the brain and other parts of the nervous system; for this reason, it is
recommended this agent be considered only in patients who have failed treatment with, or
cannot tolerate other pediculicidal medications that pose less risk. The CDC recommends
against the use of lindane in premature infants, pregnant or breast-feeding women,
individuals with a history of seizures or irritated skin/sores on the scalp, and infants,
children, the elderly, or persons who weigh less than 110 pounds (CDC, 2008). Lindane
use has been banned in the state of California since 2 002 (Humphreys et al., 2008).
Malathion is an organophosphate (acetylcholinesterase inhibitor) that works by causing
respiratory paralysis in the louse (Elston, 2005). Malathion 5% lotion (Ovide) kills live
lice and their eggs, and is approved for use in children 6 years of age and older. Treatment
with malathion has a favorable efficacy profile, given low observed resistance, and is

highly effective. In the United States, lice have become increasingly resistant to
pyrethroids and lindane, but not to malat hion (Meinking et al., 2004). Resistance to
malathion has been reported in the United Kingdom, however (Silverton, 1972).
Benzyl alcohol 5% lotion (UlesfiaTM) is a new addition to the prescription lice therapy
market in the United States. This product is the first FDA-approved, non-neurotoxic
prescription product for treating head lice, and works via physical blockage of the
respiratory mechanism of head lice. Although head lice have evolved the ability to close
their breathing spiracles upon exposure to pot entially suffocating substances, benzyl
alcohol 5% lotion stuns these spiracles open, so that the mineral oil vehicle can obstruct
them and the lice die from asphyxiation (Shionogi Pharma, Inc., 2010). This prescription
product provides a non -neurotoxic pediculicidal alternative for parents who are
concerned about the use of those agents.
Daily removal of lice and their nits from a child's hair may be accomplished with a metal
nit comb. "Nit combing," considered a mechanical type of lice therapy, is helpful as an
adjunctive measure, but most studies suggest that it is not as effective as chemical agents,
especially when used as monotherapy (Diamantis et al., 2009; Ko & Elston, 2004). Nit
combing after treatment with a pediculicide is helpful, because none of the pediculicidal
agents are 100% ovicidal. Removal of nits is tedious and time consuming but may be
attempted for aesthetic reasons, to decrease diagnostic confusion, or to decrease the
chance of self -reinfestation (AAP, 2009). Several products have been suggested as helpful
in loosening the cement that adheres nits to hair shafts. These include dilute vinegar, 8%
formic acid, and some enzymatic nit removal systems.
Some systemic antihelminthic agents and antibiotics have been used off -label for the
treatment of head lice. Use of these medications is generally considered only for severe or
resistant infestations where topical medications have failed or are ineffective (AAP, 2009;
Elston, 2005; Roberts, 2002). The antihelminthic agents reported have included
albendazole, levamisole, and ivermectin (Akisu, Delibas, & Aksoy, 2006). Albendazole has
been used in a single dose or as a 3 -day course of 400 mg daily, with a repeated single
dose of albendazole 400 mg after 1 week (Akisu et al., 2006). Levamisole at a dose of 3.5
mg/kg once daily was suggested to be effective against pediculosis upon administration
for 10 days (Nutanson, Steen, Schwartz, & Janniger, 2008). Ivermectin, the most frequently
considered of the antihelminthic drugs, is an oral agent that is FDA-approved for
onchocerciasis and strongyloidiasis. It has been used in a single oral dose of 200
micrograms/kg, repeated in 710 days, and has been demonstrated to be effective against
head lice (Dourmishev, Dourmishev, & Schwartz, 2005). However, given its potential
neurotoxicity when crossing the blood-brain barrier, it has been recommended ivermectin

be avoided in children weighing less than 15 kg. The FDA has not approved ivermectin as
a pediculicidal agent (Dourmishev et al., 2005; Lebwohl et al., 2 007; Roberts, 2002).
Trimethoprim/sulfamethoxazole (TMP/SMX), which reportedly kills symbiotic bacteria in
the gut flora of the head louse thereby interfering with its ability to synthesize B vitamins,
has been suggested as being effective against head lice, albeit not approved by the FDA for
this use (AAP, 2009; Frankowski & Weiner, 2002). One small study suggested this
antibiotic demonstrated synergistic activity when used in combination with permethrin
1%, when compared with either agent alone (Hipolito, Mallorca, Zuniga-Macaraig,
Apolinario, & Wheeler-Sherman, 2001). Use of this agent should be balanced with the risk
of severe, life -threatening allergic reactions (e.g., Stevens-Johnson or drug
hypersensitivity syndromes).
Alternative Medications The alternative treatments most often discussed for head lice are
occlusive agents. The most commonly used products in this category are petroleum jelly,
olive oil, butter, and fatcontaining mayonnaise. Un fortunately, lice have evolved
mechanisms to evade the int ended effect (asphyxiation) of these agents. In addition, these
treatments tend to be messy and meet with low acceptance on the part of patients and
parents. Shaving of the scalp has been proposed as a treatment option for lice, but may not
be acceptable f or school-aged children, especially girls.
Patient Education
Since head lice are transmitted primarily person -to-person, avoidance of head-to-head
contact is important. In addition, combs, brushes, hats, and other headgear can also
transmit lice, so sharing of these items should be strongly discouraged, especially i n
places where close contact is likely, such as schools, camps, and daycare centers. Hair
grooming items used by an infested person, if not discarded, should be de -infested by
soaking them in hot water (of at least 130 F) for 5 10 minutes. Washable clothing and
linens should be laundered with a minimum water temperature of 50 C or with a dry
cycle for at least 40 minutes (West, 2004). Items that are not washable, such as stuffed
animals, should be sealed in plastic bags for 2 weeks or dry-cleaned.
Upholstered furniture can be vacuumed. Fumigation of the household is not necessary,
and these products can be toxic if inhaled or absorbed through the skin (AAP, 2009; CDC,
2008).
Children identified as having head lice should be referred for treatment and excluded
from school only until the recommended treatment has been completed. According to the
Committee on Infectious Diseases of the American Academy of Pediatrics, "no -nit"

policies, whereby schools and child -care institutions require children be free of nits before
they return, have not been effective in controlling pediculosis capitis transmission and are
not recommended (AAP, 2009) Additionally, children should not be excluded or sent
home early from school because of head lice. Instead, parents should be notified of the
infestation and requested to have their child treated before returning to school on the day
after treatment (AAP, 2009). School contacts should not be treated prophylactically, but
should be notified and evaluated for infestation. Caregiver s who have prolonged skin-toskin contact with students infested with lice, though, may benefit from prophylactic
treatment (CDC, 2008).
Conclusion
Head lice infestation is a common yet benign problem of childhood. Head lice may be
transmitted by direct head-to-head contact or fomites, most notably hair grooming items
and headgear. Although the head louse does not transmit disease, the infestation can be
socially stigmatizing for both the patient and his/her family. The diagnosis is made by
direct visualiza tion of live lice or nits attached to hair shafts within 1 cm from the scalp.
Treatment of head lice can be challenging. Available treatment options include over the counter and prescription products, as well as some alternative therapy options. Efficacy
and safety should be the primary drivers of treatment choice. Education of both the family
and school or day -care professionals is paramount to successfully combating the cycle of
head lice transmission.