Get Your Head in the Game: Revised Head Lice Clinical Review

May 1, 2015

Get Your Head in the Game: Revised Head Lice Clinical Review

  1. Mary Wu Chang, MD

No healthy child should be excluded from school because of head lice or nits.

  1. Mary Wu Chang, MD

Head lice are not a health hazard, do not signify poor hygiene, and do not cause spread of any disease. However, social stigma, ostracization, and mandated school absence are problematic. Recent treatment costs have been estimated at $1 billion/year. These authors present a revision of the 2010 clinical report on head lice published by the American Academy of Pediatrics to clarify current diagnosis and treatment protocols and guide the management of children with head lice.

Lice are transmitted by direct head-to-head contact; lice crawl, they can't jump or fly. Lice survive for <1 day off the scalp. Nits (eggs) attached >1 cm from the scalp are unlikely to be viable and cannot hatch at temperatures lower than those near the scalp. Therefore, indirect transmission is uncommon.

Other key points to keep in mind:

  • No healthy child should be excluded from school because of head lice or nits. No-nit policies for return to school should be abandoned.

  • Do not treat a child unless live lice or eggs (not just empty nit cases) are present.

  • 1% permethrin and pyrethrins (over the counter) are very safe, inexpensive, and remain the first-line treatment for active infestations, unless resistance in the community is proven. These products are not ovicidal; thus at least two treatments are required at proper intervals (day 0 and day 9, or day 0, 7, and 13–15 days).

  • Manual removal of lice/nits (wet-combing), although time-consuming, is an alternative to the topical treatment, but it requires close surveillance and repeat efforts weekly for at least three treatments.

  • Benzyl alcohol 5% can be used in children older than 6 months, and malathion 0.5% can be used in children older than 2 years. Spinosad and topical ivermectin are effective alternatives, but they are very expensive.

  • Other treatments include the off-label use of scabicides — topical (permethrin, crotamiton) or oral (ivermectin).

  • Alternative approaches are found in abundance on the internet but are unproven and may result in treatment failure or even cause contact dermatitis (e.g., essential oils).

Comment — Dermatology

In February 2015, the caretaker of an 18-month-old girl treated her for head lice by applying mayonnaise to the scalp and covering it with a plastic bag, a home remedy often found on the internet. The child was left unattended for some time, the bag slid over her face, and she suffocated to death. This tragedy underscores the need for proper education of parents, schools, and the community about head lice.

Comment — Pediatrics and Adolescent Medicine

  1. Deborah Lehman, MD

Because children actively infected with head lice have likely been infected for several weeks, barring them from school is not likely to reduce classroom transmission and will only increase absenteeism. “No-nit” policies are outdated and are not in the best interest of children or public health. Physicians should review the approved treatments (pediculicides and alternative therapies) but be wary of unproved and potentially harmful treatments for this medically benign condition.

Editor Disclosures at Time of Publication

  • Disclosures for Mary Wu Chang, MD at time of publication Consultant / Advisory board Pierre Fabre; Valeant Speaker’s bureau Pierre Fabre

Citation(s):

Reader Comments (1)

Kelly Gardiner PhDc, PMHNP, CSN, BC Other Healthcare Professional, Psychiatry, CMH

As a school nurse, we recommended 100% pure mayo on the head (shower cap over it) for about 5 hours while vacuuming the house or sleeping (not safe if too young). For the nits, a flat curling iron as close to roots as possible form roots to tips each section (fries the eggs). Not sure why this isn't standard???

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