Pediculosis capitis
- Overview
- Theory
- Diagnosis
- Management
- Follow up
- Resources
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
children <2 months of age
mechanical removal
Head lice rarely occur in this age group. Mechanical removal can be safely used. If a patient in this age group has head lice, the infestation is likely to be minimal and individual head lice can easily be seen as the hair is very thin. It is better to remove these few head lice by hand instead of putting newborns at risk of adverse effects from other treatments.
treatment of contacts
Treatment recommended for ALL patients in selected patient group
Household and other close contacts of infested individuals should be examined and treated if infested. Some experts recommend prophylactic treatment of household contacts, particularly siblings of the infested individual.[2]Burgess I. Human lice and their control. Ann Rev Entomol. 2004 Jan;49:457-81. http://www.ncbi.nlm.nih.gov/pubmed/14651472?tool=bestpractice.com [3]Ko CJ, Elston DM. Pediculosis. J Am Acad Dermatol. 2004 Jan;50(1):1-12. http://www.ncbi.nlm.nih.gov/pubmed/14699358?tool=bestpractice.com [4]Leung AK, Fong JH, Pinto-Rojas A. Pediculosis capitis. J Ped Health Care. 2005 Nov-Dec;19(6):369-73. http://www.ncbi.nlm.nih.gov/pubmed/16286223?tool=bestpractice.com
supportive measures
Treatment recommended for ALL patients in selected patient group
Fomite transmission is less likely than transmission by head-to-head contact, but is possible. Therefore, it is prudent to clean hair care items and bedding of the individual with infestation.[25]Burkhart CN. Fomite transmission with head lice: a continuing controversy. Lancet. 2003 Jan 11;361(9352):99-100. http://www.ncbi.nlm.nih.gov/pubmed/12531574?tool=bestpractice.com [26]Burkhart CN, Burkhart CG. Fomite transmission in head lice. J Am Acad Derm. 2007 Jun;56(6):1044-7. http://www.ncbi.nlm.nih.gov/pubmed/17187895?tool=bestpractice.com [27]Speare R, Cahill C, Thomas G. Head lice on pillows, and strategies to make a small risk even less. Int J Derm. 2003 Aug;42(8):626-9. http://www.ncbi.nlm.nih.gov/pubmed/12890107?tool=bestpractice.com
Only items, clothing, upholstered furniture, or carpeting in contact with the head of an infested person in the 24-48 hours before treatment should be considered for cleaning. Louse survival off the scalp beyond 48 hours is extremely unlikely.
Washing, soaking, or drying items at temperatures greater than 130°F (54.4°C) will kill stray lice or eggs.
Furniture, carpeting, car seats, and other fabrics or fabric-covered items can be vacuumed; pediculicide spray should not be used.
Bagging items that cannot be washed in plastic for 2 weeks is considered overkill. Extreme cleaning measures are not beneficial.[5]American Academy of Pediatrics, Nolt D, Moore S, et al. Head Lice. Pediatrics. 2022 Oct 1;150(4):e2022059282. https://publications.aap.org/pediatrics/article/150/4/e2022059282/189566/Head-Lice http://www.ncbi.nlm.nih.gov/pubmed/36156158?tool=bestpractice.com
children ≥2 months and <2 years of age
pediculicide
Permethrin 1%, or pyrethrins plus piperonyl butoxide, are first-line treatments in this patient group and are available over the counter.[7]Falagas ME, Matthaiou DK, Rafailidis PI, et al. Worldwide prevalence of head lice. Emerg Infect Dis. 2008 Sep;14(9):1493-4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2603110 http://www.ncbi.nlm.nih.gov/pubmed/18760032?tool=bestpractice.com [50]Kasai S1, Ishii N, Natsuaki M, Fukutomi H, et al. Prevalence of kdr-like mutations associated with pyrethroid resistance in human head louse populations in Japan. J Med Entomol. 2009 Jan;46(1):77-82. https://jme.oxfordjournals.org/content/46/1/77.long http://www.ncbi.nlm.nih.gov/pubmed/19198520?tool=bestpractice.com Human toxicity seems to be low in adults.[71]Tomalik-Scharte D, Lazar A, Meins J, et al. Dermal absorption of permethrin following topical administration. Eur J Clin Pharmacol. 2005 Jul;61(5-6):399-404. http://www.ncbi.nlm.nih.gov/pubmed/15947923?tool=bestpractice.com Pyrethrins have slightly higher absorption rates compared with permethrin 1%; they can cause allergic reactions in individuals sensitive to ragweed, and should be avoided in patients allergic to chrysanthemums. Because neither product is ovicidal, experts suggest treatment at days 0 and 8-10.[46]Lebwohl M, Clark L, Levitt J. Therapy for head lice based on life cycle, resistance, and safety considerations. Pediatrics. 2007 May;119(5):965-74. http://www.ncbi.nlm.nih.gov/pubmed/17473098?tool=bestpractice.com [72]Gao JR, Yoon KS, Lee SH, et al. Increased frequency of the T929I and L932F mutations associated with knockdown resistance in permethrin-resistant populations of the human head louse, Pediculus capitis, from California, Florida, and Texas. Pestic Biochem Physiol. 2003 Nov;77:115-24. https://cat.inist.fr/?aModele=afficheN&cpsidt=15252364
There is widespread resistance to these products, especially where they have been widely used over many years. Resistance patterns are complex and are usually not known for the location in which the patient lives.[51]Hunter JA, Barker SC. Susceptibility of head lice (Pediculus humanus capitis) to pediculicides in Australia. Parasitol Res. 2003 Aug;90(6):476-8. http://www.ncbi.nlm.nih.gov/pubmed/12827503?tool=bestpractice.com [52]Durand R, Millard B, Bouges-Michel C, et al. Detection of pyrethroid resistance gene in head lice in schoolchildren from Bobigny, France. J Med Entomol. 2007 Sep;44(5):796-8. https://jme.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17915510 http://www.ncbi.nlm.nih.gov/pubmed/17915510?tool=bestpractice.com [53]Bailey AM, Prociv P. Persistent head lice following multiple treatments: evidence for insecticide resistance in Pediculus humanus capitis. Australas J Dermatol. 2000 Nov;41(4):250-4. http://www.ncbi.nlm.nih.gov/pubmed/11105372?tool=bestpractice.com [54]Sendzik J, Stahlmann R. Arzneimittel gegen Kopflausbefall. Toxikologie und Wirksamkeit [in German]. Med Monatsschr Pharm. 2005 May;28(5):167-72.[55]Menegaux F, Baruchel A, Bertrand Y, et al. Household exposure to pesticides and risk of childhood acute leukaemia. Occup Environ Med. 2006 Feb;63(2):131-4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2078075 http://www.ncbi.nlm.nih.gov/pubmed/16421392?tool=bestpractice.com There are also safety concerns.[39]Cummings C, Finlay JC, MacDonald NE et al. Head lice infestations: a clinical update. Paediatr Child Health. 2024 Jan 11;23(1):e18-24. https://cps.ca/documents/position/head-lice [56]US Food and Drug Administration. FDA public health advisory: safety of topical lindane products for the treatment of scabies and lice. 2009 [internet publication]. https://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm110845.htm
Manufacturer's directions for use need to be followed closely to ensure a safe and effective outcome. Parents need to be informed and reassured that seeing live lice (nymphs) after the first treatment does not indicate treatment failure or resistance, and they should continue to administer the additional treatments at the recommended intervals.
In areas with known resistance to over-the-counter pediculicides, a prescription-only drug is recommended. Ivermectin topical lotion, or spinosad are suitable options. These products should only be used in patients ≥6 months of age.[5]American Academy of Pediatrics, Nolt D, Moore S, et al. Head Lice. Pediatrics. 2022 Oct 1;150(4):e2022059282. https://publications.aap.org/pediatrics/article/150/4/e2022059282/189566/Head-Lice http://www.ncbi.nlm.nih.gov/pubmed/36156158?tool=bestpractice.com Benzyl alcohol is also used in some countries, but is not available in the US.
Primary options
permethrin topical: (1%) apply to the hair and scalp as directed, leave for 10 minutes before rinsing
OR
pyrethrum/piperonyl butoxide topical: apply to the hair and scalp as directed, leave for 10 minutes before rinsing
Secondary options
ivermectin topical: infants ≥6 months of age: (0.5%) apply to the hair and scalp as directed, leave for 10 minutes before rinsing
OR
spinosad topical: infants ≥6 months of age: (0.9%) apply to the hair and scalp as directed, leave for 10 minutes before rinsing
treatment of contacts
Treatment recommended for ALL patients in selected patient group
Household and other close contacts of infested individuals should be examined and treated if infested. Some experts recommend prophylactic treatment of household contacts, particularly siblings of the infested individual.[2]Burgess I. Human lice and their control. Ann Rev Entomol. 2004 Jan;49:457-81. http://www.ncbi.nlm.nih.gov/pubmed/14651472?tool=bestpractice.com [3]Ko CJ, Elston DM. Pediculosis. J Am Acad Dermatol. 2004 Jan;50(1):1-12. http://www.ncbi.nlm.nih.gov/pubmed/14699358?tool=bestpractice.com [4]Leung AK, Fong JH, Pinto-Rojas A. Pediculosis capitis. J Ped Health Care. 2005 Nov-Dec;19(6):369-73. http://www.ncbi.nlm.nih.gov/pubmed/16286223?tool=bestpractice.com
supportive measures
Treatment recommended for ALL patients in selected patient group
Fomite transmission is less likely than transmission by head-to-head contact, but is possible. Therefore, it is prudent to clean hair care items and bedding of the individual with infestation.[25]Burkhart CN. Fomite transmission with head lice: a continuing controversy. Lancet. 2003 Jan 11;361(9352):99-100. http://www.ncbi.nlm.nih.gov/pubmed/12531574?tool=bestpractice.com [26]Burkhart CN, Burkhart CG. Fomite transmission in head lice. J Am Acad Derm. 2007 Jun;56(6):1044-7. http://www.ncbi.nlm.nih.gov/pubmed/17187895?tool=bestpractice.com [27]Speare R, Cahill C, Thomas G. Head lice on pillows, and strategies to make a small risk even less. Int J Derm. 2003 Aug;42(8):626-9. http://www.ncbi.nlm.nih.gov/pubmed/12890107?tool=bestpractice.com
Only items, clothing, upholstered furniture, or carpeting in contact with the head of an infested person in the 24-48 hours before treatment should be considered for cleaning. Louse survival off the scalp beyond 48 hours is extremely unlikely.
Washing, soaking, or drying items at temperatures greater than 130°F (54.4°C) will kill stray lice or eggs.
Furniture, carpeting, car seats, and other fabrics or fabric-covered items can be vacuumed; pediculicide spray should not be used.
Bagging items that cannot be washed in plastic for 2 weeks is considered overkill. Extreme cleaning measures are not beneficial.[5]American Academy of Pediatrics, Nolt D, Moore S, et al. Head Lice. Pediatrics. 2022 Oct 1;150(4):e2022059282. https://publications.aap.org/pediatrics/article/150/4/e2022059282/189566/Head-Lice http://www.ncbi.nlm.nih.gov/pubmed/36156158?tool=bestpractice.com
mechanical removal or occlusive agent
Patients who cannot or do not want to use pediculicides with a neurotoxic mode of action, or run the risk of inducing resistance, can use mechanical removal.
Mechanical removal methods include nit picking, shaving hair, or the preferred method, wet combing. Occlusive agents that may be used in this age group include petroleum jelly.
Nit picking (removal of eggs and hatched egg casing) is generally not recommended as the sole technique for eradication of an infestation. If undertaken, a fine-toothed, metal lice comb can aid in removal of the nits.[13]Meinking TL. Infestations: pediculosis. Curr Probl Dermatol. 1996;24:157-63. http://www.ncbi.nlm.nih.gov/pubmed/8743266?tool=bestpractice.com [59]Speare R, Canyon DV, Cahill C, et al. Comparative efficacy of two nit combs in removing head lice (Pediculosis capitis) and their eggs. Int J Dermatol. 2007 Dec;46(12):1275-8. http://www.ncbi.nlm.nih.gov/pubmed/18173523?tool=bestpractice.com
Wet combing involves shampooing or conditioning hair twice a week with ordinary shampoo, then vigorous combing out of wet hair with a special fine-toothed comb. Success can be variable and depends largely on good technique.[61]Bainbridge CV, Klein GL, Neibart SI, et al. Comparative study of the clinical effectiveness of a pyrethrin-based pediculicide with combing versus a permethrin-based pediculicide with combing. Clin Pediatr (Phila). 1998 Jan;37(1):17-22. http://www.ncbi.nlm.nih.gov/pubmed/9475695?tool=bestpractice.com [62]Plastow L, Luthra M, Wright J, et al. Head lice infestation: bug busting vs traditional treatment. J Clin Nursing. 2001 Nov;10(6):775-83. http://www.ncbi.nlm.nih.gov/pubmed/11822849?tool=bestpractice.com [63]Tebruegge M, Runnacles J. Is wet combing effective in children with pediculosis capitis infestation? Arch Dis Child. 2007 Sep;92(9):818-20. http://www.ncbi.nlm.nih.gov/pubmed/17715448?tool=bestpractice.com
Petroleum jelly is thought to obstruct the respiratory spiracles of the adult louse and block holes in the operculum of the eggs. About 30-40 g of standard petroleum jelly is massaged on the entire surface of the hair and scalp and left on overnight. Repeated shampooing over the following 7-10 days removes the residue, and nits should be removed.
Re-infestation can be treated as for initial infestation.
treatment of contacts
Treatment recommended for ALL patients in selected patient group
Household and other close contacts of infested individuals should be examined and treated if infested. Some experts recommend prophylactic treatment of household contacts, particularly siblings of the infested individual.[2]Burgess I. Human lice and their control. Ann Rev Entomol. 2004 Jan;49:457-81. http://www.ncbi.nlm.nih.gov/pubmed/14651472?tool=bestpractice.com [3]Ko CJ, Elston DM. Pediculosis. J Am Acad Dermatol. 2004 Jan;50(1):1-12. http://www.ncbi.nlm.nih.gov/pubmed/14699358?tool=bestpractice.com [4]Leung AK, Fong JH, Pinto-Rojas A. Pediculosis capitis. J Ped Health Care. 2005 Nov-Dec;19(6):369-73. http://www.ncbi.nlm.nih.gov/pubmed/16286223?tool=bestpractice.com
supportive measures
Treatment recommended for ALL patients in selected patient group
Fomite transmission is less likely than transmission by head-to-head contact, but is possible. Therefore, it is prudent to clean hair care items and bedding of the individual with infestation.[25]Burkhart CN. Fomite transmission with head lice: a continuing controversy. Lancet. 2003 Jan 11;361(9352):99-100. http://www.ncbi.nlm.nih.gov/pubmed/12531574?tool=bestpractice.com [26]Burkhart CN, Burkhart CG. Fomite transmission in head lice. J Am Acad Derm. 2007 Jun;56(6):1044-7. http://www.ncbi.nlm.nih.gov/pubmed/17187895?tool=bestpractice.com [27]Speare R, Cahill C, Thomas G. Head lice on pillows, and strategies to make a small risk even less. Int J Derm. 2003 Aug;42(8):626-9. http://www.ncbi.nlm.nih.gov/pubmed/12890107?tool=bestpractice.com
Only items, clothing, upholstered furniture, or carpeting in contact with the head of an infested person in the 24-48 hours before treatment should be considered for cleaning. Louse survival off the scalp beyond 48 hours is extremely unlikely.
Washing, soaking, or drying items at temperatures greater than 130°F (54.4°C) will kill stray lice or eggs.
Furniture, carpeting, car seats, and other fabrics or fabric-covered items can be vacuumed; pediculicide spray should not be used.
Bagging items that cannot be washed in plastic for 2 weeks is considered overkill. Extreme cleaning measures are not beneficial.[5]American Academy of Pediatrics, Nolt D, Moore S, et al. Head Lice. Pediatrics. 2022 Oct 1;150(4):e2022059282. https://publications.aap.org/pediatrics/article/150/4/e2022059282/189566/Head-Lice http://www.ncbi.nlm.nih.gov/pubmed/36156158?tool=bestpractice.com
children ≥2 years of age and adults
pediculicide
Permethrin 1%, or pyrethrins plus piperonyl butoxide, are first-line treatments in this patient group and are available over the counter.[7]Falagas ME, Matthaiou DK, Rafailidis PI, et al. Worldwide prevalence of head lice. Emerg Infect Dis. 2008 Sep;14(9):1493-4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2603110 http://www.ncbi.nlm.nih.gov/pubmed/18760032?tool=bestpractice.com [50]Kasai S1, Ishii N, Natsuaki M, Fukutomi H, et al. Prevalence of kdr-like mutations associated with pyrethroid resistance in human head louse populations in Japan. J Med Entomol. 2009 Jan;46(1):77-82. https://jme.oxfordjournals.org/content/46/1/77.long http://www.ncbi.nlm.nih.gov/pubmed/19198520?tool=bestpractice.com Human toxicity seems to be low in adults.[71]Tomalik-Scharte D, Lazar A, Meins J, et al. Dermal absorption of permethrin following topical administration. Eur J Clin Pharmacol. 2005 Jul;61(5-6):399-404. http://www.ncbi.nlm.nih.gov/pubmed/15947923?tool=bestpractice.com Pyrethrins have slightly higher absorption rates compared with permethrin 1%; they can cause allergic reactions in individuals sensitive to ragweed, and should be avoided in patients allergic to chrysanthemums. Because neither product is ovicidal, experts suggest treatment at days 0 and 8-10.[46]Lebwohl M, Clark L, Levitt J. Therapy for head lice based on life cycle, resistance, and safety considerations. Pediatrics. 2007 May;119(5):965-74. http://www.ncbi.nlm.nih.gov/pubmed/17473098?tool=bestpractice.com [72]Gao JR, Yoon KS, Lee SH, et al. Increased frequency of the T929I and L932F mutations associated with knockdown resistance in permethrin-resistant populations of the human head louse, Pediculus capitis, from California, Florida, and Texas. Pestic Biochem Physiol. 2003 Nov;77:115-24. https://cat.inist.fr/?aModele=afficheN&cpsidt=15252364
There is widespread resistance to these products, especially where they have been widely used over many years. Resistance patterns are complex and are usually not known for the location in which the patient lives.[51]Hunter JA, Barker SC. Susceptibility of head lice (Pediculus humanus capitis) to pediculicides in Australia. Parasitol Res. 2003 Aug;90(6):476-8. http://www.ncbi.nlm.nih.gov/pubmed/12827503?tool=bestpractice.com [52]Durand R, Millard B, Bouges-Michel C, et al. Detection of pyrethroid resistance gene in head lice in schoolchildren from Bobigny, France. J Med Entomol. 2007 Sep;44(5):796-8. https://jme.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17915510 http://www.ncbi.nlm.nih.gov/pubmed/17915510?tool=bestpractice.com [53]Bailey AM, Prociv P. Persistent head lice following multiple treatments: evidence for insecticide resistance in Pediculus humanus capitis. Australas J Dermatol. 2000 Nov;41(4):250-4. http://www.ncbi.nlm.nih.gov/pubmed/11105372?tool=bestpractice.com [54]Sendzik J, Stahlmann R. Arzneimittel gegen Kopflausbefall. Toxikologie und Wirksamkeit [in German]. Med Monatsschr Pharm. 2005 May;28(5):167-72.[55]Menegaux F, Baruchel A, Bertrand Y, et al. Household exposure to pesticides and risk of childhood acute leukaemia. Occup Environ Med. 2006 Feb;63(2):131-4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2078075 http://www.ncbi.nlm.nih.gov/pubmed/16421392?tool=bestpractice.com There are also safety concerns.[39]Cummings C, Finlay JC, MacDonald NE et al. Head lice infestations: a clinical update. Paediatr Child Health. 2024 Jan 11;23(1):e18-24. https://cps.ca/documents/position/head-lice [56]US Food and Drug Administration. FDA public health advisory: safety of topical lindane products for the treatment of scabies and lice. 2009 [internet publication]. https://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm110845.htm
Manufacturer's directions for use need to be followed closely to ensure a safe and effective outcome. Parents need to be informed and reassured that seeing live lice (nymphs) after the first treatment does not indicate treatment failure or resistance, and they should continue to administer the additional treatments at the recommended intervals.
In areas with known resistance to over-the-counter pediculicides, a prescription-only drug is recommended. Ivermectin topical lotion, or spinosad are suitable options.[5]American Academy of Pediatrics, Nolt D, Moore S, et al. Head Lice. Pediatrics. 2022 Oct 1;150(4):e2022059282. https://publications.aap.org/pediatrics/article/150/4/e2022059282/189566/Head-Lice http://www.ncbi.nlm.nih.gov/pubmed/36156158?tool=bestpractice.com Benzyl alcohol is also used in some countries, but is not available in the US.
Malathion is an organophosphate (cholinesterase inhibitor). Due to reports of cross-resistance with pyrethroids and safety concerns (it is highly flammable), it is considered a third-line treatment.[73]Meinking TL, Vicaria M, Eyerdam DH, et al. A randomized, investigator-blinded, time-ranging study of the comparative efficacy of 0.5% malathion gel versus Ovide Lotion (0.5% malathion) or Nix Creme Rinse (1% permethrin) used as labeled, for the treatment of head lice. Ped Derm. 2007 Jul-Aug;24(4):405-11. http://www.ncbi.nlm.nih.gov/pubmed/17845167?tool=bestpractice.com [74]Meinking TL, Vicaria M, Eyerdam DH, et al. Efficacy of a reduced application time of Ovide lotion (0.5% malathion) compared to Nix creme rinse (1% permethrin) for the treatment of head lice. Ped Derm. 2004 Nov-Dec;21(6):670-4. http://www.ncbi.nlm.nih.gov/pubmed/15575855?tool=bestpractice.com [75]Yoon KS, Gao JR, Lee SH, et al. Permethrin-resistant human head lice, Pediculus capitis, and their treatment. Arch Dermatol. 2003 Aug;139(8):994-1000. https://archderm.jamanetwork.com/article.aspx?articleid=479452 http://www.ncbi.nlm.nih.gov/pubmed/12925385?tool=bestpractice.com [76]Meinking TL, Serrano L, Hard B, et al. Comparative in vitro pediculicidal efficacy of treatments in a resistant head lice population in the United States. Arch Dermatol. 2002 Feb;138(2):220-4. https://archderm.jamanetwork.com/article.aspx?articleid=478698 http://www.ncbi.nlm.nih.gov/pubmed/11843643?tool=bestpractice.com Although head lice resistant to malathion are common in the UK, where it has been used for decades, the preparation available in the US contains additional ingredients that themselves have a 50% cure rate, and this may delay development of resistance in the US.
Most pediculicides can be used in pregnant women. However, all agents should be used with caution in lactation due to a lack of data. For women who want an extra margin of safety, mechanical removal or compounds with a physical mode of action can be safely used instead.
Primary options
permethrin topical: (1%) apply to the hair and scalp as directed, leave for 10 minutes before rinsing
OR
pyrethrum/piperonyl butoxide topical: apply to the hair and scalp as directed, leave for 10 minutes before rinsing
Secondary options
ivermectin topical: (0.5%) apply to the hair and scalp as directed, leave for 10 minutes before rinsing
OR
spinosad topical: (0.9%) apply to the hair and scalp as directed, leave for 10 minutes before rinsing
Tertiary options
malathion topical: (0.5%) apply to the hair and scalp as directed, leave for 8-12 hours before rinsing
treatment of contacts
Treatment recommended for ALL patients in selected patient group
Household and other close contacts of infested individuals should be examined and treated if infested. Some experts recommend prophylactic treatment of household contacts, particularly siblings of the infested individual.[2]Burgess I. Human lice and their control. Ann Rev Entomol. 2004 Jan;49:457-81. http://www.ncbi.nlm.nih.gov/pubmed/14651472?tool=bestpractice.com [3]Ko CJ, Elston DM. Pediculosis. J Am Acad Dermatol. 2004 Jan;50(1):1-12. http://www.ncbi.nlm.nih.gov/pubmed/14699358?tool=bestpractice.com [4]Leung AK, Fong JH, Pinto-Rojas A. Pediculosis capitis. J Ped Health Care. 2005 Nov-Dec;19(6):369-73. http://www.ncbi.nlm.nih.gov/pubmed/16286223?tool=bestpractice.com
supportive measures
Treatment recommended for ALL patients in selected patient group
Fomite transmission is less likely than transmission by head-to-head contact, but is possible. Therefore, it is prudent to clean hair care items and bedding of the individual with infestation.[25]Burkhart CN. Fomite transmission with head lice: a continuing controversy. Lancet. 2003 Jan 11;361(9352):99-100. http://www.ncbi.nlm.nih.gov/pubmed/12531574?tool=bestpractice.com [26]Burkhart CN, Burkhart CG. Fomite transmission in head lice. J Am Acad Derm. 2007 Jun;56(6):1044-7. http://www.ncbi.nlm.nih.gov/pubmed/17187895?tool=bestpractice.com [27]Speare R, Cahill C, Thomas G. Head lice on pillows, and strategies to make a small risk even less. Int J Derm. 2003 Aug;42(8):626-9. http://www.ncbi.nlm.nih.gov/pubmed/12890107?tool=bestpractice.com
Only items, clothing, upholstered furniture, or carpeting in contact with the head of an infested person in the 24-48 hours before treatment should be considered for cleaning. Louse survival off the scalp beyond 48 hours is extremely unlikely.
Washing, soaking, or drying items at temperatures greater than 130°F (54.4°C) will kill stray lice or eggs.
Furniture, carpeting, car seats, and other fabrics or fabric-covered items can be vacuumed; pediculicide spray should not be used.
Bagging items that cannot be washed in plastic for 2 weeks is considered overkill. Extreme cleaning measures are not beneficial.[5]American Academy of Pediatrics, Nolt D, Moore S, et al. Head Lice. Pediatrics. 2022 Oct 1;150(4):e2022059282. https://publications.aap.org/pediatrics/article/150/4/e2022059282/189566/Head-Lice http://www.ncbi.nlm.nih.gov/pubmed/36156158?tool=bestpractice.com
mechanical removal or occlusive agent
Patients who cannot or do not want to use pediculicides with a neurotoxic mode of action, or run the risk of inducing resistance, may use mechanical removal.
Mechanical removal methods include nit picking, shaving hair, or the preferred method, wet combing.
Nit picking (removal of eggs and hatched egg casing) is generally not recommended as the sole technique for eradication of an infestation. If undertaken, a fine-toothed, metal lice comb can aid in removal of the nits.[13]Meinking TL. Infestations: pediculosis. Curr Probl Dermatol. 1996;24:157-63. http://www.ncbi.nlm.nih.gov/pubmed/8743266?tool=bestpractice.com [59]Speare R, Canyon DV, Cahill C, et al. Comparative efficacy of two nit combs in removing head lice (Pediculosis capitis) and their eggs. Int J Dermatol. 2007 Dec;46(12):1275-8. http://www.ncbi.nlm.nih.gov/pubmed/18173523?tool=bestpractice.com
Wet combing involves shampooing or conditioning hair twice a week with ordinary shampoo, then vigorous combing out of wet hair with a special fine-toothed comb. Success can be variable and depends largely on good technique.[61]Bainbridge CV, Klein GL, Neibart SI, et al. Comparative study of the clinical effectiveness of a pyrethrin-based pediculicide with combing versus a permethrin-based pediculicide with combing. Clin Pediatr (Phila). 1998 Jan;37(1):17-22. http://www.ncbi.nlm.nih.gov/pubmed/9475695?tool=bestpractice.com [62]Plastow L, Luthra M, Wright J, et al. Head lice infestation: bug busting vs traditional treatment. J Clin Nursing. 2001 Nov;10(6):775-83. http://www.ncbi.nlm.nih.gov/pubmed/11822849?tool=bestpractice.com [63]Tebruegge M, Runnacles J. Is wet combing effective in children with pediculosis capitis infestation? Arch Dis Child. 2007 Sep;92(9):818-20. http://www.ncbi.nlm.nih.gov/pubmed/17715448?tool=bestpractice.com
Occlusive agents that may be used in this age group include petroleum jelly, or use of the Nuvo method.
Petroleum jelly is thought to obstruct the respiratory spiracles of the adult louse and block holes in the operculum of the eggs. About 30-40 g of standard petroleum jelly is massaged on the entire surface of the hair and scalp and left on overnight. Repeated shampooing over the following 7-10 days removes the residue, and nits should be removed.
The Nuvo method uses Cetaphil® cleanser (a hydrating emollient containing glycerin) applied to the hair and scalp, dried on with a blow-dryer, then washed out 8 hours later, with the treatment repeated once a week for 3 weeks.[69]Pearlman DL. A simple treatment for head lice: dry-on, suffocation-based pediculicide. Pediatrics. 2004 Sep;114(3):e275-9. https://pediatrics.aappublications.org/content/114/3/e275.full http://www.ncbi.nlm.nih.gov/pubmed/15342886?tool=bestpractice.com [70]Pearlman D. Cetaphil cleanser (Nuvo Lotion) cures head lice. Pediatrics. 2005 Dec;116(6):1612. http://www.ncbi.nlm.nih.gov/pubmed/16322200?tool=bestpractice.com
Re-infestation can be treated as for initial infestation.
treatment of contacts
Treatment recommended for ALL patients in selected patient group
Household and other close contacts of infested individuals should be examined and treated if infested. Some experts recommend prophylactic treatment of household contacts, particularly siblings of the infested individual. Children should not be excluded or sent home early from school because of head lice. Parents of infested children (defined by visualization of live lice) should be notified and informed that their child should be treated, ideally, before returning to school the next day. The presence of nits alone does not justify treatment.[2]Burgess I. Human lice and their control. Ann Rev Entomol. 2004 Jan;49:457-81. http://www.ncbi.nlm.nih.gov/pubmed/14651472?tool=bestpractice.com [3]Ko CJ, Elston DM. Pediculosis. J Am Acad Dermatol. 2004 Jan;50(1):1-12. http://www.ncbi.nlm.nih.gov/pubmed/14699358?tool=bestpractice.com [4]Leung AK, Fong JH, Pinto-Rojas A. Pediculosis capitis. J Ped Health Care. 2005 Nov-Dec;19(6):369-73. http://www.ncbi.nlm.nih.gov/pubmed/16286223?tool=bestpractice.com
supportive measures
Treatment recommended for ALL patients in selected patient group
Fomite transmission is less likely than transmission by head-to-head contact, but is possible. Therefore, it is prudent to clean hair care items and bedding of the individual with infestation.[25]Burkhart CN. Fomite transmission with head lice: a continuing controversy. Lancet. 2003 Jan 11;361(9352):99-100. http://www.ncbi.nlm.nih.gov/pubmed/12531574?tool=bestpractice.com [26]Burkhart CN, Burkhart CG. Fomite transmission in head lice. J Am Acad Derm. 2007 Jun;56(6):1044-7. http://www.ncbi.nlm.nih.gov/pubmed/17187895?tool=bestpractice.com [27]Speare R, Cahill C, Thomas G. Head lice on pillows, and strategies to make a small risk even less. Int J Derm. 2003 Aug;42(8):626-9. http://www.ncbi.nlm.nih.gov/pubmed/12890107?tool=bestpractice.com
Only items, clothing, upholstered furniture, or carpeting in contact with the head of an infested person in the 24-48 hours before treatment should be considered for cleaning. Louse survival off the scalp beyond 48 hours is extremely unlikely.
Washing, soaking, or drying items at temperatures greater than 130°F (54.4°C) will kill stray lice or eggs.
Furniture, carpeting, car seats, and other fabrics or fabric-covered items can be vacuumed; pediculicide spray should not be used.
Bagging items that cannot be washed in plastic for 2 weeks is considered overkill. Extreme cleaning measures are not beneficial.[5]American Academy of Pediatrics, Nolt D, Moore S, et al. Head Lice. Pediatrics. 2022 Oct 1;150(4):e2022059282. https://publications.aap.org/pediatrics/article/150/4/e2022059282/189566/Head-Lice http://www.ncbi.nlm.nih.gov/pubmed/36156158?tool=bestpractice.com
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